What to do when patients request cesareans

Physicians should recommend that their patients plan for vaginal deliveries rather than cesarean deliveries if there are no maternal or fetal indications for a cesarean. This is the position stated in a new committee opinion from the American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice.

Committee Opinion No. 559: Cesarean Delivery on Maternal Request appears in the April 2013 issue of Obstetrics & Gynecology.

Noting that the rate of cesarean delivery has reached 32.9% of births in the United States, the opinion writers state, “[t]he incidence of cesarean delivery on maternal request and its contribution to the overall increase in the cesarean delivery rate are not well known, but it is estimated that 2.5% of all births in the United States are cesarean delivery on maternal request.”

In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended, according to the opinion.

In cases in which cesarean delivery on maternal request is planned, the committee recommends that the delivery not be performed before a gestational age of 39 weeks. The opinion writers state that cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management.

“Cesarean delivery on maternal request particularly is not recommended for women desiring several children,” they write, because the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.

“Critical life experiences (eg, trauma, violence, or poor obstetric outcomes) and anxiety about the birth process” may prompt a patient’s request for a cesarean delivery, note the opinion authors. “If [the patient’s] main concern is a fear of pain in childbirth, then prenatal childbirth education, emotional support in labor, and anesthesia for childbirth should be offered.”