Caesarean delivery on maternal request

Caesarean delivery on maternal request (CDMR), is a form of an elective caesarean section, where the the conduct of a childbirth via a caesarean section (CS, or c-section) is dictated not by medical necessity or obstetrical indication but specifically the request of the pregnant patient.^[1]

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Over the last century, delivery by CS has become increasingly safer. The indications for delivery by CS therefore could become "softer", and the move to perform CS on request can be viewed as an extension of this development. It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by.^[1]

The movement for CDMR may have started in Brazil.^[2] The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth.^[3] Furthermore, with women living longer, concern about damage to the pelvic floor organs by vaginal delivery adds an additional dimension to the issue. Such damage could lead to a relaxation in the ligaments that hold the pelvic organs in place; urinary incontinence can become a consequence.

When women with an extreme fear of childbirth undergo a CS, it is debatable have an indication or a CDMR.

A meeting of experts sponsored by the NIH in March, 2006 attempted to address the medical issues and found "insuffient evidence to evaluate fully the benefits and risks" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand.^[1] The available evidence suggests certain differences as follows:

Proponents for CDMR will point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby.^[1] Furthermore, there is some evidence that urinary stress incontinence as a long-term result of damage to the pelvic floor is increased after vaginal birth. However, this is usually due to incorrect pushing (directed, with a woman lying on her back) and not from childbirth itself. When women are able to push in upright positions stress incontinence usually does not result. Opponents to ECS feel that it is not natural, that the costs are higher, infection rates are higher, hospitalization longer, and rates for breastfeeding decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk. Further, babies born after a vaginal delivery tend to be at a lower risk for the infant respiratory distress syndrome.^[1]

Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is significantly higher (1.77 vs. 0.62 per 1,000 live births) in babies born by CS. The authors propose that the compression of the fetal lungs during the birthing process may be one of the factors that is beneficial for subsequent survival; this effect is missing when the baby is delivered by CS.^[4] A study published in the February 13, 2007 issue of the Canadian Medical Association Journal found that women that have "planned" cesareans had an overall rate of severe complications more than three times that of women that planned vaginal deliveries.^[5]

References

1. ^ ^{a b c d e} NIH (2006). "State-of-the-Science Conference Statement. Cesarean Delivery on Maternal Request". Obstet Gynecol 107: 1386-97, also [1].
2. ^ Finger (2003). "Caesarean section rates skyrocket in Brazil. Many women are opting for caesareans in the belief that it is a practical solution.". Lancet 362: 628. PMID 12947949.
3. ^ Minkoff (2004). "Ethical dimensions of elective primary cesarean delivery.". Obstet Gynecol 103: 387-92. PMID 15166864.
4. ^ MacDorman (2006). "and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts". Birth 33(3): 175-82. PMID 16948717.
5. ^ Liu, Shiliange, Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term Canadian Medical Association Journal, February 13, 2007; 176 (4).

• NIH Cesarean Conference: Interpreting Meeting and Media Reports