Public Release: 

Should Doctors Perform An Elective Caesarean Section On Request?

BMJ

(Yes, as long as the woman is fully informed)

(Maternal choice alone should not determine method delivery)

Rates of Caesarean section are rising and mothers' requests for elective Caesarean section in an uncomplicated pregnancy are not uncommon - the reasons for which are unclear. Performing a Caesarean section when it is not clinically indicated has traditionally been considered inappropriate but views may be changing, as reported by Sara Paterson-Brown from Queen Charlotte's and Chelsea Hospital in London and Olubusola Amu and colleagues from Leicester General Hospital in this week's BMJ.

Evidence as to the pros and cons of Caesarean or vaginal birth is incomplete; but for a Caesarean section the prevalence of hysterectomy due to haemorrhage is ten times that of a vaginal delivery and the risk of maternal death (including non-elective Caesarean sections) is up to 16 times greater. In those women who wanted a vaginal birth there may also be feelings of "inadequacy, guilt and failure in not completing a natural process [and a Caesarean] may affect bonding between mother and infant, particularly if the operation was conducted under general anaesthetic". The risks of vaginal birth include damage to the pelvic floor, trauma to the urethral and anal sphincters, long term predisposition to genital prolapse and urinary and anal incontinence. Also a significant risk of labour is that of fetal death (one in 1500 babies weighing more than 1500g).

Armed with this information Sara Paterson-Brown says women and obstetricians are increasingly sympathetic to the concept of Caesarean section as a means of avoiding problems. This is supported by the fact that 31 per cent of London female obstetricians with an uncomplicated singleton pregnancy at term would choose an elective Caesarean section for themselves and half of those women who have already had a Caesarean section would choose to have another. She argues that, having encouraged professionals to respect womens' choices, we should not be critical of them just becausethey are not what was expected, and concludes that prophylactic Caesarean section can no longer be considered clinically unjustifiable - it now forms part of accepted medical practice.

Olubusola Amu and colleagues argue that women's requests for a particular mode of delivery, for fear of the consequences of the other method, are not necessarily rational. They stress that choice is a human right and the crucial element is that it is informed. The authors say: "Conflicts between maternal and fetal interests are potentially complex, ethically and emotionally, and difficult to resolve." Amu et al conclude that doctors, midwives and childbirth educators must give full and honest advice and encourage the active participation of patients in order that a safe and logical informed decision can be reached about the method of delivery.

Contact:

Sara Paterson-Brown, Consultant in Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, London

Dr Ibrahim Bolaji, Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, Grimsby Hospital, Grimsby (Dr Bolaji is on holiday until 24 August 1998)

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