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Clinical Crossroads
Clinician's Corner
May 8, 2013

Elective Cesarean Delivery on Maternal Request

Author Affiliations
 

Clinical Crossroads Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.

Author Affiliations: Dr Ecker is Professor, Harvard Medical School, and Director of Quality Assurance, Clinical Obstetric Research and Maternal Fetal Medicine Fellowship in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, Boston.

JAMA. 2013;309(18):1930-1936. doi:10.1001/jama.2013.3982
Abstract

Importance Some pregnant women prefer cesarean delivery and request it without maternal or fetal indication rather than proceeding with a plan for vaginal delivery.

Objective To review approaches for counseling women who ask for cesarean delivery without maternal or fetal indication (known as cesarean delivery on maternal request [CDMR]).

Evidence Review An Agency for Healthcare Research and Quality evidence report of studies published after 1990, a 2006 National Institutes of Health state-of-the-science conference report, and published literature were examined.

Findings The prevalence of CDMR in the United States is not precisely known but probably occurs in less than 3% of all deliveries. Most practicing obstetricians have received requests for CDMR from patients. Compared with a plan for vaginal delivery, CDMR may be associated with lower rates of hemorrhage, maternal incontinence, and rare but serious neonatal outcomes. However, CDMR is associated with a higher risk of neonatal respiratory morbidity. Adverse consequences of CDMR may be manifested only in future pregnancies. Repeated cesarean deliveries have higher rates of operative complications, placental abnormalities such as placenta previa and accreta, and consequent gravid hysterectomy.

Conclusions and Relevance There is no immediate expectation for CDMR to reduce the health risks of mothers or infants. Accordingly, counseling and decisions regarding CDMR should be made after considering a woman's full reproductive plans.

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    1 Comment for this article
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    Better identification of specific CDMR risks is needed - and possible
    Pauline M Hull | Editor, electivecesarean.com
    I agree that maternal request should involve an individualized consultation of risks and benefits; however, it's very important that these risks and benefits are discussed in the appropriate context, and relevant to current recommendations for CDMR.For example, this article states, "CDMR is associated with a higher risk of neonatal respiratory morbidity", but research suggests that this higher risk is only for surgeries performed earlier than the recommended 39+ gestational weeks. If recommendations are appropriately followed, respiratory risk is not necessarily higher for CDMR compared with a trial of labor.Health professionals need to be very careful not to attribute risks to CDMR that are not directly relevant, and unfortunately in many hospitals this is not always the case. Emergency cesarean risks are often mixed with planned risks, and the short- and long-term risks of surgeries at different gestational ages are frequently mixed together too. In terms of ensuring greater clarification of specific CDMR risks and benefits in the future, and in the knowledge that there is strong opposition to a randomized clinical trial, a very simple method of gathering information would be to ensure that hospitals capture CDMR births in their collection of birth data and corresponding health outcomes. The outcomes of women and babies in healthy pregnancies who chose CDMR with those who chose a trial of labor can then be compared.
    CONFLICT OF INTEREST: Co-author of Choosing Cesarean, A Natural Birth Plan
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