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Let's face it—someone is trying to get away with something. To simply suggest that we should routinely “offer” elective cesarean delivery, at term, to all pregnant women ( 1) is not based on any sound scientific evidence that would support its benefits. This ultimate intervention (cesarean section), which is relatively dangerous and potentially life-threatening (compared with vaginal delivery), interferes with a normal physiologic process (labor) that we have no right to circumvent without evidence of compelling benefit. The compelling benefits simply are not present in most pregnancies. Indeed, vaginal delivery probably benefits fetuses, at least in terms of removal of lung water and decreasing transient tachypnea of the newborn ( 2), and subdural or cerebral hemorrhage is less in spontaneous vaginal delivery than elective cesarean delivery before labor ( 3).

Why are we treating pregnancy as a disease? “Offering” cesarean delivery or consenting to perform it electively at term is irresponsible, dangerous, and ultimately unfair to many women. The lack of fairness centers about informed consent. Like it or not, in medical care a great deal of perceived power and influence is present, and the advice of physicians is seriously heeded by many under our care. Are we truly able to relate all of the surgical risks of cesarean delivery versus a vaginal delivery to the majority of patients? I would suggest that only a small number truly understand the relative risks. The less informed woman is merely agreeing to our recommendation without true knowledge of the consequences. This is inherently unfair and a blatant misuse of power.

Fortunately, a sensible and knowledgeable woman will see through this guise and reject the offering. Insufficient scientific evidence is available to support routine elective cesarean delivery, and she will seek the normal physiologic process (labor) to protect herself. Less educated, more fearful, or less aware women will comply, however, consenting to scheduled cesarean delivery rather than proceeding to labor, and herein lies the societal unfairness of this wayward recommendation. Physicians have a duty to “First, do no harm.”

In their article Gamble and Creedy have analyzed the literature that deals with the issue of “women's request for a cesarean section” ( 4). This careful analysis of the literature alerts caregivers to what they instinctively already know: far fewer women truly request cesarean birth than has been intimated in several literature reports. Practitioners must raise their suspicions of the motives of the researchers and those who are asking the questions. Remember the physics principle —the presence of the observer affects the outcome of the experiment.

This only makes sense to practitioners who strive to provide good quality health care to women. At least in the upper midwest United States, a request to forego labor (before the start of labor at least) and proceed to cesarean delivery is very rare indeed. We have, however, all heard the requests (and resisted them to various degrees) as labor has proceeded.

The slow evolution of the labor nursing staff in an obstetric unit that adopts a practice with a high percentage of labor epidurals has been observed. Eventually, the labor nurses are less able to handle any patient in pain. It often becomes the nurse who calls for the labor epidural first, before the woman has requested it. Epidural analgesia has been “sold” to childbearing women and applied in very high numbers without a truly informed discussion of its risks, including a higher rate of cesarean delivery for dystocia.

This sad scenario may well occur with elective cesareans; practitioners will eventually be unable to handle any degree of labor, or worse, a vaginal delivery. What is a vaginal examination or a presenting part? What is this pulsating mass in the vagina? Cord? Face? Breech?

What would the motivations be for caregivers to recommend elective cesarean delivery before labor? What would their life be like? It would not be all bad. We would all get more sleep! We could lay off all the labor nurses and fire all the midwives. We could stop using so much penicillin for vaginal B streptococcus colonization. We would have probably fewer cystoceles and rectoceles in older women. Maybe we could charge more money for fewer hours of work and sweat and waiting. We would not need obstetricians; we could simply use all general surgeons for these operations!

However, we would have more dead mothers. One more is too many. We would also treat far more cases of endometritis, wound infections, and deep venous thromboses. Women would die from pulmonary emboli and hemorrhage (accreta) ( 5). These are problems we could not avoid.

Simply put, it is not worth it. Who is trying to get away with something and for what reason? Stay the course of the normal physiologic process. Use cesarean delivery for truly indicated obstetric conditions and no more. It is medically inappropriate, unfair, and unethical to offer anything less.

References

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  2. References
  • 1
    Harer WB. Patient choice cesarean. ACOG Clin Rev 2000;5(2):1, 13 16.
  • 2
    DeMott RK & Sandmire HF. The Green Bay Cesarean Section Study I. The physician factor as a determinant of cesarean birth rates. Am J Obstet Gynecol 1990;162:1593 1602.
  • 3
    Towner D, Castro MA, Eby-Wilkins BS, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341:1709 1714.
  • 4
    Gamble JA & Creedy DK. Women's request for cesarean section: A critique of the literature. Birth 2000;27(4):256 263.
  • 5
    American College of Obstetricians and Gynecologists.Evaluation of Cesarean Delivery.Washington, DC:Author,2000; 5.