Obstetrics is simultaneously blessed and cursed by the fact that so many elements of patient care can be quantified. As we move to electronic records, our ability to correlate seemingly unrelated elements will increase. Historically, we have focused on short-term, gross relationships between factors believed to influence the outcomes of different obstetrical practices. However, it would not surprise me to find a meaningful correlation between obstetrical outcome and the wheel bases of the cars in the patients’ parking lot divided by their ages. Similarly, the number of native teeth in a gravida’s mouth may be a valid predictor of prematurity and/or macrosomia and fetal outcome. I have not seen any studies on these topics. Nor have I seen a prospective analysis of maternal-fetal outcomes based on the signs of the zodiac at birth—one of the reasons some patients in China press for elective cesarean. I am simply emphasizing the importance of developing indicators for quality of care based on lifelong health outcomes for both mother and baby, as these would be far more meaningful than cesarean rates alone.
Protecting the pelvic floor
Urogynecologists are amassing impressive evidence of the ravages to the pelvic floor caused by vaginal birth, as well as the apparent protective effect of elective cesarean.7 This information also is leaking out to the public. In the United States, Europe, China, and Japan, most women now have only 1 or 2 babies.8 These women frequently take a long-range view of their health, as they anticipate living into their 80s. Many hope to avoid the bowel and bladder-control problems their mothers and aunts experienced. The result is an increasing number of requests—even demands—for elective cesarean delivery. I expect this trend to intensify before there is a reversal.
For women who will have only 1 or 2 children, the risks of repeated cesareans are minimal.
In the past, injury to the pelvic floor often took years to manifest itself, so physicians were comfortably past the statute of limitations before it was detected. Today, transanal ultrasound can demonstrate such injury in the postpartum period.9 The physician who denies a patient’s request for cesarean section to preserve her pelvic integrity is now at risk if she has postpartum evaluation demon strating subclinical injury that may cause problems in a few years.
In the absence of compelling indications for one approach over another, we should respect our obstetrical patients’ opinions.
The experience of labor and vaginal delivery has lost the luster once accorded it. Given the choice, most women prefer epidural anesthesia to the pains of labor and vaginal birth. A recent survey showed that only 43% of obstetrical patients would feel deprived of an important life experience if they were delivered by cesarean.10
For women who will have only 1 or 2 children, the recognized risks of repeated cesareans are minimal. The risk of uterine rupture prior to labor also is low, as are the risks of placenta previa and accreta.
When the long-term costs of living with and/or treating pelvic-floor disorders are considered, the lower risk and expense traditionally associated with vaginal delivery probably disappears. Our patients are increasingly aware that pelvic-floor dysfunction need not be the inevitable price of motherhood.
Conclusion
A final thought for those who believe that “nature’s way” is best: Without obstetrical care, we would revert to the almost 1% maternal mortality rate that has been the norm throughout history. As evidence-based interventions further refine obstetrical care, the benefits of cesarean section for both mother and baby will continue to increase. We should not deny patients these benefits simply because of historical bias.
I am not advocating cesarean on demand. No physician should be obligated to acquiesce to a patient’s capricious demand. But neither should the patient be forced to follow the physician’s command, as historically has been the case. To avoid a conflict, these issues should be discussed early in prenatal care and revisited as pregnancy progresses. Two questions should be answered as soon as possible: Would the patient agree to cesarean delivery for the sole indication of possible fetal benefit? Would the obstetrician perform a cesarean on request in the absence of a clear medical indication? If either party cannot accept an answer of “No,” the patient should be advised to seek care elsewhere.
We also should remember that patients have greater and greater access to valid information via the Internet, making them more eager to participate in decision-making. Thus, we should assess patients carefully and share our findings with them as objectively as possible. In the absence of compelling indications for one approach over another, we should respect their opinions.