1. Elective Primary Cesarean Section Paul Wendel, MD Associate Professor Residency Director UAMS Department of Obstetrics & Gynecology

2. Patient choice Patient choice Maternal request Maternal request On demand On demand All refer to primary cesarean section in the absence of medical/obstetrical indications.

3. Concept Origins: Most recently traced to 1985 Stimulated by medicolegal case involving intrapartum fetal neurologic injury Stimulated by medicolegal case involving intrapartum fetal neurologic injury Authors discussed “prophylactic cesarean section” ‘at term’ Authors discussed “prophylactic cesarean section” ‘at term’ Notion of informed consent for route of delivery was introduced Notion of informed consent for route of delivery was introduced C-section offered as a means of avoiding the risks associated with vaginal delivery C-section offered as a means of avoiding the risks associated with vaginal delivery Feldman, GB Prophylactic cesarean at term? NEJM 1985; 312 pp. 1264-67

5. Patient Perspective Elective cesarean sections currently account for 4-18% of all c-sections.

6. Why do Women ask for C-Sections? Extreme tocophobia (fear of childbirth) Death (patient or baby) Fetal injury Genital tract injury

7. When Psychotherapy was employed by trained professionals to address tocophobia: 2/3 women ultimately chose vaginal birth 2/3 women ultimately chose vaginal birth These same women… Ultimately viewed their birth experience as good Ultimately viewed their birth experience as good

8. Physicians’ Perspective Several studies have been done in UK, New Zealand, Ireland, Canada, Israel regarding physicians’ and midwives’ attitudes toward “elective c-section” Several studies have been done in UK, New Zealand, Ireland, Canada, Israel regarding physicians’ and midwives’ attitudes toward “elective c-section” 7-30% of OB/GYN’s and 4.4% of midwives preferred c- sections for themselves if female or their partner if male 7-30% of OB/GYN’s and 4.4% of midwives preferred c- sections for themselves if female or their partner if male 62-81% reported a willingness to perform c-sections on demand 62-81% reported a willingness to perform c-sections on demand

9. Physicians’ Perspective (con’t) Similar to their patients, obstetricians cited the following as reasons leading to primary elective c-sections: Similar to their patients, obstetricians cited the following as reasons leading to primary elective c-sections: Fear of childbirth 27% Fear of childbirth 27% Perineal injury 80-95% Perineal injury 80-95% Fetal injury 24-39% Fetal injury 24-39% Anal or urinary incontinence 81-83% Anal or urinary incontinence 81-83% Sexual dysfunction 58-59% Sexual dysfunction 58-59% Convenience 17-39% Convenience 17-39% Control 39% Control 39% Pain 7% Pain 7%

10. Attitudes of Urogynecologist’s & MFM’s to Elective C-sections Survey was distributed by UNC via web base Survey was distributed by UNC via web base 53% of SMFM/AUGS members responded 53% of SMFM/AUGS members responded

11. Survey Results Overall, 65% of physicians would perform an elective primary cesarean section Overall, 65% of physicians would perform an elective primary cesarean section Compared with other countries: Compared with other countries: 69% England 69% England 67% Australia/New Zealand 67% Australia/New Zealand

12. AUGS / SMFM Survey Comparison 80% of AUGS members vs. 55% of SMFM members for primary elective c-section 80% of AUGS members vs. 55% of SMFM members for primary elective c-section 45% of AUGS and 9.5% of SMFM members would choose a primary c-section for themselves or their partners 45% of AUGS and 9.5% of SMFM members would choose a primary c-section for themselves or their partners

13. Ethical Principles Can an elective c-section for an uncomplicated pregnancy be ethically justified? Can an elective c-section for an uncomplicated pregnancy be ethically justified? Decision making based on: Decision making based on: Beneficence Beneficence Nonmaleficence Nonmaleficence Autonomy Autonomy Justice Justice Voracity Voracity

14. Ethical Principles Beneficence: physicians responsibility to promote the patients’ health/welfare Beneficence: physicians responsibility to promote the patients’ health/welfare Nonmaleficence: complimentary principle refers to the physician’s obligation to do no harm to the patient Nonmaleficence: complimentary principle refers to the physician’s obligation to do no harm to the patient Autonomy: obligates the physician to discuss reasonable alternatives and elicit a decision within the framework of informed consent Autonomy: obligates the physician to discuss reasonable alternatives and elicit a decision within the framework of informed consent

15. Ethical Principles Typically, patients retain a “negative right” (right to decline care) but do not hold a “positive right” (the right to demand care that may be unnecessarily risky or medically unproven).

16. Ethical Principles Justice: requires that a physician treat patients fairly and make decisions that consider societal good with respect to limited health resources Justice: requires that a physician treat patients fairly and make decisions that consider societal good with respect to limited health resources Voracity: refers to truthfulness in patient counseling Voracity: refers to truthfulness in patient counseling

17. Committee of the Ethical Aspects of Human Reproduction of the International Federation of Obstetrics and Gynecology (FIGO) in 1999 issued a report regarding c-section for non- medical reasons:  C-section was a surgical procedure  Greater allocation of resources for c-section  Vaginal delivery was safer in long/short term for mother/fetus  Elective c-section was not ethically justified

18. American College of OB/GYN Committee on Ethics (2003) If a patient requests cesarean section after informed counseling and the physician believes it will promote the overall health of patient and fetus, “…the elective c-section is ethically justified.” If the physician disagrees, the patient should be referred to another provider.

19. Medical Issues Historically, c-sections have a higher risk of maternal mortality than vaginal delivery. However, most studies do not adjust for:  Elective vs. emergency c-section  Contributing medical/obstetric conditions

20. Cape Town, South Africa 1975-1986 Compared maternal mortality from elective c-section vs. vaginal delivery: Compared maternal mortality from elective c-section vs. vaginal delivery: Elective c-section – 23/100,000 Elective c-section – 23/100,000 RR = 3.8 Vaginal – 6/100,000 Vaginal – 6/100,000

21. Study (1954-1985) assessed c-section related mortality rate in Massachusetts Death rate C-sections - 5.9/100,000 vs. Vaginal delivery - 10.8/100,000 Saches and Colleagues (1988)

22. Washington State 1987-1996 Large retrospective study addressed postpartum mortality among primiparas (adjusting for age, marital status, preeclampsia): C-section 6.8/100,000 vs. Vaginal delivery 8.2/100,000 *Limited datasets suggest that elective cesarean sections and vaginal deliveries do not increase direct maternal death.

23. Maternal Morbidities Discussions of puerperal complications must make distinctions between c-sections performed before and after labor and between spontaneous and operative vaginal deliveries.

24. Washington State Retrospective Study 2000 Association between delivery method and maternal re-hospitalization within 60 days of delivery:  Spontaneous vaginal delivery – 10/1000  Operative vaginal delivery – 12/1000  Cesarean section – 17/1000

25. Philadelphia 1994-1997 Retrospective Study Hospital readmissions by delivery route within 60 days of delivery:  C-sections – 35.6/1000  Operative vaginal delivery – 29.5/1000  Spontaneous vaginal delivery – 17.7/1000 *Study did not distinguish between c-sections with and without labor.

26. Randomized Multicenter Trial of Management of Breech at Term Peripartum Maternal Morbidity Planned Cesarean section – 41/1041 (3.9%) Planned Vaginal delivery – 33/1042 (3.2%) *No differences between groups:  Hemorrhage  Genital tract injury  Wound breakdown  Infection

27. Fetal Morbidity Original premise: C-section at term would avoid intrapartum fetal neurologic injury Original premise: C-section at term would avoid intrapartum fetal neurologic injury Data suggests fetal neurologic injury affects 2-3/1000 intrapartum events Data suggests fetal neurologic injury affects 2-3/1000 intrapartum events 3,000 – 5,000 elective cesarean sections would be needed to avoid one such injury.

28. C-section Rate (mid 1970’s – present) Pooled data from these countries have shown significant rise of c-section rates: SwedenCanadaEnglandIreland AustraliaDenmarkNorwayU.S.  Cerebral palsy rates have remained stable internationally  C-section is not neuroprotective for the fetus

29. Birth Injury Available data suggests that “pre-labor” cesarean section does not offer a clear fetal benefit with respect to intracranial, brachial plexus, or fracture injury. May increase the risk of laceration injury in the infant.

30. Conclusion The debate over elective c-sections is growing. The debate over elective c-sections is growing. Obstetrician should be aware of the issues and their colleagues’ beliefs. Obstetrician should be aware of the issues and their colleagues’ beliefs. No adequate study has compared elective c-sections and planned SVD. No adequate study has compared elective c-sections and planned SVD. In the absence of data, professional organizations will have different opinions on ethical acceptability. In the absence of data, professional organizations will have different opinions on ethical acceptability.

31. Conclusion Available data, though not robust, suggests that overall maternal and perinatal mortality, short- and long-term maternal and neonatal morbidity favor a vaginal delivery.