Should a primiparous patient be allowed to choose elective cesarean delivery?
I believe the answer is yes.
It’s a question of ethics rather than science. As long as the woman’s decision reflects both informed consent for cesarean section and informed refusal of attempted vaginal delivery, her autonomy should be respected—provided the physician’s ethical obligation of beneficence would not be compromised.
Informed consent, in which the patient accepts the likely risks and benefits of a proposed therapy in relation to those of possible alternatives, is well ingrained in our practice. Informed refusal is a more recent concept in which the patient exercises the right not to follow a therapy that would be the physician’s choice.1 As for the obligation of beneficence, it requires that my participation does good—or at least minimizes harm.
In obstetrics, the historical paradigm is for all patients to attempt vaginal delivery unless the physician identifies 1 or more indications for cesarean section. Such indications usually are based on short-term assessments. In recent decades, they primarily have focused on risks to the fetus. Yet, the pregnant woman and her baby face risks regardless of what is or isn’t done. Those risks are variable, poorly quantifiable, incomparable, and highly subjective in relative valuations. Fortunately, with good prenatal care, they all are low.
Our patients are increasingly aware that pelvic-floor dysfunction need not be the inevitable price of motherhood.
In the absence of a high probability of a clearly defined risk, do physicians and/or third-party payers—or even courts of law—have the right to impose their value judgments on the patient? Let’s say the gravida decides that a 5% risk of incisional infection today is more acceptable than a 5% risk of surgery for urinary incontinence in 20 years. Who is to judge that her decision is wrong, especially if her risk of undergoing an emergency cesarean or traumatic operative delivery after a failed attempt at vaginal birth ranges from 15% to 20%? As the ethics committee of the International Federation of Gynecology and Obstetrics (FIGO) states: “Only the woman can decide if the benefits to her of a procedure are worth the risks and discomfort she may undergo.”2
Autonomy is the individual’s right to self-determination. In democracies, it is particularly esteemed in regard to one’s body. I treasure that right for myself and feel obligated to accord it to others. The FIGO ethics committee shares this sentiment, concluding that “no woman should be forced to undergo an unwished-for medical or surgical procedure in order to preserve the life or health of her fetus, as this would be a violation of her autonomy and fundamental human rights.”2 An ACOG opinion echoes this statement.3
The welfare of the fetus
The issue is complicated by the presence of a second patient—the fetus. After all, the physician’s obligation of beneficence extends to the infant too. In discussing treatment options, the physician must educate the patient and her partner about the risks and benefits to the fetus as well as the mother. The obstetrician’s advocacy for the baby may be minimal or extend to enlist the full weight of the law to supercede that of the mother.
Tradition suggests that mothers will unhesitatingly sacrifice their welfare in the interest of their babies. In other words, a woman accepts a duty of beneficence to her child that may supercede her own self-interest. Thus, if a woman is advised to undergo cesarean because of the dangers of persisting in labor, she will agree to do so out of concern for her child. Unfortunately, this is not always the case. Some women will refuse cesarean delivery despite a clear threat to the fetus from continued labor. In such cases, physicians and hospitals have sometimes asked the courts to compel the mother to submit to surgery.
The evidence suggests that a “normal”—i.e., easy, spontaneous—delivery carries less risk than a cesarean section for both mother and child. Unfortunately, we cannot predict who will have such a delivery when 10% to 25% of attempted vaginal deliveries end with cesareans for medical indications. When a vaginal delivery must be completed operatively, it poses the most serious risks to the fetus and increases maternal risks as well. Compare the rates of intracranial hemorrhage in cesareans without labor to a number of other options, including cesarean in labor (Table 1).4
There is an increasing consensus that elective cesarean provides better outcomes for very-low-birth-weight babies delivered at less than 28 to 30 weeks’ gestation. At the other end of the spectrum is the large infant. While better care and nutrition lead to bigger babies, these deliveries involve a greater risk of shoulder dystocia and/or failure to progress. Although we are fast approaching a time when three-dimensional ultrasound, coupled with pelvimetry, will allow us to estimate the risks of fetopelvic disproportion more accurately, there is still considerable margin for error.