In a healthy term singleton pregnancy with no prior uterine surgery or complications, is a cesarean delivery performed solely at the mother's request advisable?

Cesarean Delivery on Maternal Request: Not Advisable for Healthy Term Pregnancies

In a healthy term singleton pregnancy without medical or obstetric indications, cesarean delivery on maternal request should not be recommended; vaginal delivery is the safer and more appropriate option. 1, 2

Primary Recommendation

The American College of Obstetricians and Gynecologists explicitly states that in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. 1, 2 This recommendation prioritizes both maternal and neonatal morbidity and mortality outcomes, as well as long-term quality of life considerations.

Evidence-Based Rationale

Maternal Risks of Cesarean on Request

Immediate postpartum complications:

• Cesarean delivery increases postpartum infection rates 5-7 times compared to vaginal delivery 3
• Postpartum fever occurs in 6.7% of cesarean deliveries versus 1.1% of vaginal deliveries 3
• Higher rates of endometritis, wound infection, and pneumonia 3
• Longer maternal hospital stay 1

Future pregnancy complications (the most concerning risks):

• Progressive increase in placenta previa risk (1-2% per cesarean) 4, 1
• Escalating placenta accreta risk (0.25-3% and increasing with each subsequent cesarean) 4, 1, 2
• Uterine rupture risk in subsequent pregnancies (22 per 10,000 births) 3
• Increased risk of gravid hysterectomy with each repeat cesarean 1, 2
• Chronic wound pain affects 15.4% at 3-6 months postpartum 3
• Secondary infertility reported in up to 43% of women 3

Neonatal Risks

• Increased respiratory problems for the infant, particularly if performed before 39 weeks 1, 2
• Risk of iatrogenic prematurity with scheduled cesarean delivery 3

Limited Short-Term Benefits

While cesarean delivery shows some short-term benefits compared to planned vaginal delivery (including women who ultimately require cesarean in labor), these include decreased hemorrhage/transfusion risk, fewer surgical complications, and reduced urinary incontinence in the first year 1. However, these modest benefits do not outweigh the significant maternal risks, especially for women planning multiple children.

Clinical Decision Algorithm

Step 1: Explore the underlying reason for the request

• Fear of childbirth is the predominant reason for maternal request 5
• Address specific concerns through counseling 5, 2

Step 2: Provide comprehensive risk-benefit counseling

• Emphasize long-term health consequences for mother and baby 5
• Specifically counsel that cesarean delivery on maternal request is not recommended for women desiring several children 1, 2
• Discuss that the relative risk of any postpartum complication is 1.85 for elective cesarean versus vaginal delivery 3

Step 3: Offer alternatives

• Ensure effective pain management is available (cesarean should not be motivated by unavailability of pain relief) 1
• Provide access to counseling programs for fear of childbirth 5

Step 4: If patient persists after counseling

• Consider patient-specific risk factors: age, BMI, accuracy of gestational age, reproductive plans, personal values, and cultural context 2
• Do not perform before 39 weeks gestational age in the absence of other indications 1, 2
• Ensure explicit informed consent documenting discussion of risks 4

Critical Caveats

The most important pitfall: Performing cesarean delivery on maternal request for women planning multiple children exposes them to exponentially increasing risks of life-threatening placental complications with each subsequent pregnancy 1, 2. The cumulative risk of placenta accreta spectrum and need for hysterectomy makes this particularly inadvisable.

Timing matters: If cesarean on maternal request is ultimately performed, it must not occur before 39 weeks to avoid neonatal respiratory morbidity 1, 2.

Inadequate evidence: The literature on cesarean delivery on maternal request is limited and derived primarily from observational studies; well-designed prospective trials comparing planned vaginal delivery to planned cesarean on maternal request do not exist 4. Given this uncertainty and the known risks, the default recommendation must favor the physiologically normal route of vaginal delivery.

Strength of Recommendation

This is a strong recommendation based on guideline-level evidence from ACOG 1, 2, supported by systematic analysis of maternal morbidity data 3 and long-term reproductive health outcomes 4. The balance of evidence clearly favors vaginal delivery for maternal and neonatal safety, particularly when considering quality of life across the reproductive lifespan.