Should a primary cesarean section be performed on a low-risk primigravida at 10 weeks gestation based on patient preference alone?

From the Guidelines

The physician should not perform a cesarean delivery based solely on the patient's request without medical indications. While patient autonomy is important, cesarean delivery carries significant risks including increased bleeding, infection, longer recovery time, and complications in future pregnancies such as placenta accreta, uterine rupture, and abnormal placentation 1. The American College of Obstetricians and Gynecologists recommends vaginal delivery for most pregnancies, as it typically results in shorter hospital stays, lower infection rates, and fewer complications.

Key Considerations

• The patient's concern about pelvic floor disorders is valid, but vaginal delivery is not the only risk factor, and many women deliver vaginally without developing these issues.
• Preventive measures such as pelvic floor exercises, appropriate labor management, and selective use of episiotomy can reduce risks.
• The physician should continue counseling the patient throughout pregnancy, possibly involving a urogynecologist to discuss pelvic floor concerns, and reassess the delivery plan as the pregnancy progresses.
• According to the European Society of Cardiology, vaginal delivery is recommended as the first choice in most patients, and cesarean delivery should be considered for obstetric indications or for patients with specific medical conditions 1.
• A study published in the American Journal of Obstetrics and Gynecology in 2018 found that cesarean delivery has associated risk and benefit profiles for both processes of unscheduled or scheduled surgery, and that the overall maternal morbidity was higher for cesarean delivery compared to vaginal birth 1.

Risks and Benefits

• The risks associated with cesarean delivery, including increased bleeding, infection, and complications in future pregnancies, should be carefully considered.
• The benefits of vaginal delivery, including shorter hospital stays, lower infection rates, and fewer complications, should also be taken into account.
• The patient's individual circumstances and medical history should be carefully evaluated to determine the best course of action.

Recommendation

The physician should recommend a vaginal delivery as the primary option, while also addressing the patient's concerns and providing counseling and support throughout the pregnancy. This approach balances respect for patient autonomy with the physician's obligation to recommend the safest delivery method based on medical evidence 1.

From the Research

Cesarean Delivery on Maternal Request

• The patient's request for a primary cesarean delivery is based on her mother's experience with urinary and fecal incontinence after vaginal deliveries 2, 3, 4, 5, 6.
• Studies have shown that cesarean delivery may reduce the risk of urinary incontinence and pelvic organ prolapse compared to vaginal delivery 4, 5, 6.
• However, cesarean delivery on maternal request also carries potential risks, including a longer maternal hospital stay, increased risk of respiratory problems for the infant, and greater complications in subsequent pregnancies 2, 3.

Risks and Benefits of Cesarean Delivery

• The risks of cesarean delivery on maternal request include uterine rupture, placental implantation problems, and the need for hysterectomy in future pregnancies 2, 3.
• The benefits of planned cesarean delivery compared to planned vaginal delivery include a decreased risk of hemorrhage and transfusion, fewer surgical complications, and a decrease in urinary incontinence during the first year after delivery 2.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management and should not be performed before a gestational age of 39 weeks 2, 3.

Patient Autonomy and Informed Decision-Making

• The patient has the right to make an informed decision about her care, including the option of cesarean delivery on maternal request 2, 3.
• The physician should discuss the risks and benefits of cesarean delivery with the patient and ensure that she understands the potential complications and consequences of her decision 2, 3.
• The patient's autonomy and decision-making capacity should be respected, even if the physician is uncomfortable with her request 2, 3.