Do women usually prefer a cesarean (C-section) or a vaginal delivery?

From the Guidelines

Most women prefer vaginal delivery over cesarean section when given the choice, as it is associated with less blood loss and infection risk compared to caesarean delivery. Vaginal delivery is recommended as the first choice in most patients, according to the European Society of Cardiology guidelines 1. The guidelines suggest that vaginal delivery is associated with fewer complications, such as venous thrombosis and thrombo-embolism, compared to cesarean delivery.

Key Considerations

• Vaginal delivery is generally preferred due to its benefits, including shorter hospital stays, quicker recovery times, and fewer complications for future pregnancies.
• However, cesarean delivery may be considered for obstetric indications or for patients with certain medical conditions, such as dilatation of the ascending aorta >45 mm, severe aortic stenosis, or severe heart failure 1.
• The decision between vaginal and cesarean delivery should be individualized, taking into account the patient's medical status, previous birth experiences, and personal preferences.
• It is essential to note that medical necessity often determines the delivery method, with cesarean sections being essential in cases of fetal distress, abnormal positioning, maternal health complications, or other situations where vaginal delivery poses significant risks.

Medical Necessity

• Cesarean delivery should be considered for patients on oral anticoagulants in pre-term labor, patients with Marfan syndrome and an aortic diameter >45 mm, patients with acute or chronic aortic dissection, and those in acute intractable heart failure 1.
• The guidelines also suggest that cesarean delivery may be considered in Marfan patients with an aortic diameter 40–45 mm 1.

Patient Preferences

• Women's preferences for delivery method vary based on individual circumstances, previous birth experiences, cultural factors, and medical considerations.
• Some women may prefer cesarean delivery due to fear of labor pain, previous traumatic vaginal birth experiences, or concerns about pelvic floor damage.

From the Research

Cesarean Delivery vs Vaginal Delivery

• The American College of Obstetricians and Gynecologists recommends a plan for vaginal delivery in the absence of maternal or fetal indications for cesarean delivery, as it is considered safe and appropriate 2.
• However, some women may still prefer cesarean delivery, and their healthcare provider should consider their specific risk factors, such as age, body mass index, and reproductive plans, when discussing the risks and benefits of cesarean delivery on maternal request 3.
• The risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the infant, and greater complications in subsequent pregnancies, including uterine rupture, placental implantation problems, and the need for hysterectomy 2.
• On the other hand, planned cesarean delivery may have some short-term benefits, such as a decreased risk of hemorrhage and transfusion, fewer surgical complications, and a decrease in urinary incontinence during the first year after delivery 2.

Breech Presentation and Delivery

• Breech presentation is a common malpresentation, and management of breech presentation has been a contentious issue, with a lowering threshold for cesarean section in recent years 4.
• However, vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used, such as frank breech only, estimated fetal weight of 2500-3500 g, and adequate pelvimetry without hyperextended head 4, 5.
• A study found that vaginal breech delivery cannot always be avoided, and in selected patients, it remains a viable option, with no statistically significant differences in maternal and fetal outcomes compared to cesarean deliveries 5.

Guidelines and Recommendations

• The International Federation of Gynaecology and Obstetrics provides good practice recommendations for cesarean delivery, including a checklist of staff and tools for safe on-site cesarean delivery, and defines labor, second stage length, and status before an arrested labor is confirmed 6.
• The American College of Obstetricians and Gynecologists also provides guidelines for cesarean delivery on maternal request, including recommendations for counseling and discussing the risks and benefits with patients 3.