ELECTIVE C-SECTION

Elective cesarean section:
a new dividing line for OBs

By Cindy Starr, MS, RPh

Should women be permitted to request a C/S? Physicians on both sides of the debate offer cogent arguments. What they say can help you shape your own approach.

How might you respond to a pregnant patient who, after two uneventful vaginal deliveries, asks you to deliver her third baby via a scheduled cesarean section? Timing is a concern—she must ask someone to care for her older children during her hospital stay, and she needs to attend some upcoming business meetings. However, she has also heard that vaginal delivery might increase her risk of stress incontinence later in life.

After considering the scenario, ob/gyn Kimberly Biss of St. Petersburg, Fla., says, "Until elective primary C/S becomes the standard of care, I will not honor that patient's request. I would have a hard time justifying the delivery route if the patient died of a complication or postoperative pulmonary embolism. I do have patients with incontinence who were delivered by C/S in their reproductive years. Does not the weight of the pregnant uterus weaken the pelvic floor?"

James H. Bell, an ob/gyn from Long Beach, Calif., would explain to the patient that the procedure carries greater morbidity and mortality and would not help with future continence since she has had two prior vaginal deliveries. "If she persists, I'd have her get a second opinion," he adds. Like Bell, ob/gyn John Luce would suggest another physician, noting, "My one maternal death in 36 years was from disseminated intravascular coagulation after a routine repeat C/S."

Other ob/gyns think elective C/S is a rational idea. Donald L. Block of Atlanta, Ga., for instance, says that it is available in other parts of the world, notably South America. "More and more evidence is emerging that there are serious perineal and vaginal consequences of vaginal delivery," Block says. "I believe that in 5 to 10 years, the standard will be patients' choice. Since insurers will not cover the patient decision, it is fair for the patient to pay the extra costs."

Peter D. Martelly, an ob/gyn from Fall River, Mass., thinks elective c-section should be offered to patients and covered by insurers. "If we could all agree on a standard of care and this patient met that standard, I would have no problem doing it," he says. "Women have elective cosmetic surgery, and some procedures are potentially as risky as a c-section. There doesn't seem to be a great deal of concern as long as the patient is willing to pay. The impetus to promote vaginal birth after cesarean (VBAC) is largely driven by cost savings arguments." Another ob/gyn, Laurence F. Mack of Massapequa, N.Y., would allow the patient to choose after a lengthy discussion of her concerns. "I would explain the risks and benefits of scheduled primary c-section, scheduled induction of labor, and awaiting natural labor," he says. "I would then encourage vaginal delivery."

Escalating C/S rates

Although opinions on the subject are diverse, it's clear that C/S rates are higher than they've been since such data first became available in 1989.¹ In 2001, the national rate rose 7%, so that C/S accounted for 24.4% of all births, compared to 22.9% reported in 2000. The increase cannot be attributed to regional phenomena—more cesarean deliveries were performed in every state and the District of Columbia than in the previous year. Overall, the primary C/S rate rose from 16.1% to 16.9%, while the rate of VBAC dropped from 20.6% to 16.5% (Figure 1).

C-sections are more prevalent in other parts of the world. When researchers tabulated the data for all hospitals in Chile, they found a C/S rate of 40%.² However, of births taking place in private hospitals, 59% were C/S deliveries. The situation is similar in other countries, including Brazil (32% vs. 35.9% in private hospitals) and Mexico (31.3% vs. 51.8% in private hospitals). According to W. Benson Harer, Jr., chief of staff at Riverside County Regional Medical Center in Moreno Valley, Calif., and a past president of the American College of Obstetricians and Gynecologists, about 50% of deliveries in China's largest cities and in Taiwan are by C/S. "And in England," he adds, "there is a big move toward elective C/S. As much as 20% of all cesarean deliveries at some of the private hospitals in London are clearly elective."

Nobody can say exactly what proportion of US C/S is elective. Rather, physicians like Brent W. Bost, a private practitioner in Beaumont, Tex., are noticing that more patients are broaching the subject with them. "I've had an occasional patient come in with a fear of delivery, and in the last 5 years or so, there has been a surge in the number of women who are asking about the connection between childbirth and incontinence," Bost says. "I have lots of patients who want a C/S."

Nonetheless, one national goal set by the US Department of Health and Human Service's Healthy People 2010 program is to reduce the C/S rate among low-risk women—those carrying a single full-term fetus in vertex presentation—following an uncomplicated pregnancy. HHS would like to see the rate drop from a 1998 baseline of 18% of live births among women giving birth for the first time to 15% of live births in this group by the year 2010. A corresponding objective is to lower the repeat cesarean rate among low-risk women who have had a prior C/S from the 1998 baseline of 72% of live births to 63% of live births.

ACOG also suggests a benchmark of 15.5% in nulliparous women who are at 37 weeks' or more gestation and are carrying one fetus in the vertex position.³ The recommended VBAC benchmark rate is 37% among multiparous women who have had one prior low-transverse C/S, as long as they are at 37 weeks or more with a single fetus in the vertex position. Harer believes the current rates, although higher, are acceptable. "If you take that 15.5% rate and add in all the other things that happen, such as breeches, twins, placenta previa, and abruption, you'll end up with a C/S rate that's in the low 20th percentile—and that's exactly where the nation is," Harer says. "The Healthy People goal is based on worldwide data that came out of the 1970s and early 1980s, and it just doesn't fit with modern medicine."

Balancing risks and benefits

Both Dr. Bost and Dr. Harer say that once a woman understands the risks and benefits of each route, she should then be able to decide what risk she wants to accept for herself and her baby, a point of view that is far different from promoting elective C/S. Harer notes. "I think a lot of senior conservative obstetricians just intuitively have grown up with the idea that a low c-section rate is good," he remarks. "I used to be one of them."

Now, though, Harer says no evidence indicates that any method of delivery is safer than an elective C/S at 39 weeks. "A lot of people believe it's in the fetal interest because you eliminate the risks of birth damage, fetal distress, and emergency c-section," he explains. At the same time, studies indicate that techniques currently used in vaginal delivery can injure the pelvic floor, eventually leading to stress incontinence, pelvic organ prolapse, or fecal incontinence.

Risk factors for such damage include family history, the size of your baby, a previous episiotomy with extension, use of oxytocin, use of forceps, and a prolonged second phase of labor, says Bost, adding that the risk increases with each delivery. Having assessed the potential value of scheduled elective C/S as a means for preventing such complications, he deems the prevalence numbers astounding. "Thirty to 50% of all women who deliver vaginally have stress incontinence or pelvic organ prolapse," the physician reports.⁴ "Perhaps 90% of that is preventable by scheduled c-section." As labor progresses, the protective effect of ensuing surgery diminishes. In addition, Bost believes some amount of stress incontinence stems just from carrying a fetus, particularly in women who have twins or triplets.

When Bost first fielded requests for a C/S, he told patients that he could not do surgery without a medical indication. "I then did some research and realized that patients for whom I had delivered, say, a third baby were now leaking urine 10 years after. Vaginal delivery that was such a welcome relief at the end of a long day may not have been such a good deal after all. I don't badger patients into a c-section, but I think it's important that I inform them so they have an input into the decision," he continues.

After struggling with all the arguments for and against elective C/S, Peter S. Bernstein, Associate Professor of Clinical Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, says "I'm not one of those people who is on an adamant crusade to stop elective c-sections, but in the spectrum, I fall on the side that thinks they aren't a good idea." The risk involved in a scheduled elective primary c-section done at 39 weeks is generally low; emergency procedures obviously tend to be more hazardous since they are performed under less controlled circumstances. "Why not allow women to take that risk, especially given the fact that a very, very small number of women will have their babies die in utero between 39 weeks, when we would otherwise have done the c-section, and 42 weeks, when we tend to induce labor?" he asks. "My conclusion is that that's not good enough to justify it."

Among his concerns is the chance that infants might inadvertently be delivered too soon. Also worrisome are increasing rates of placenta accreta and placenta previa, dangerous complications that occur more frequently in women who have had a previous C/S. "One of the biggest issues is that attitudes are swinging back toward once a c-section, always a c-section," Bernstein remarks. "And every additional procedure increases a woman's risk of a bad outcome, including placenta accreta, placenta previa, uterine rupture, excessive blood loss, and damage to internal organs." What's more, surgical delivery is not necessarily going to avert pelvic problems for all women, he asserts, citing a study that found a 30% prevalence of stress incontinence in a cohort of nulliparous, primarily postmenopausal nuns.⁵ "It's adopting an unproven intervention with known risks," he says. "If we start allowing this, there'll be no going back."

A report on maternal mortality in the United Kingdom between 1994 and 1995 indicated that women undergoing elective C/S had almost three times the case fatality rate as those delivering vaginally (58.5 per million versus 20.6 per million); the case fatality rate for emergency C/S—182 per million—was nearly nine times higher than that for vaginal deliveries.⁶ These so-called direct deaths "are from obstetric complications of the pregnant state, from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above." They exclude those occurring in women with a pre-existing illness. "Numbers can be very deceptive, because they include women who've died from a medical complication, not the c-section," Bost says.

Still, Robert Weinfeld, a Georgia ob/gyn who treats women who are serving in the US Army and those who are married to enlisted men, would be unwilling to perform a purely elective c-section. "Even though maternal deaths from delivery in either mode are quite rare, the woman who has a major abdominal procedure is always going to be at risk of greater morbidity or mortality from infection, blood loss, or postoperative pulmonary embolus," he says. "During my residency, one of the most influencing factors in my life as a practicing physician was the death of a young woman from a pulmonary embolism 1 week after a repeat c-section."

What's right for you?

Whether the question of elective C/S becomes a major issue for you appears to depend somewhat on patient demographics. Bernstein, who also serves as medical director of Obstetrics and Gynecology at the Comprehensive Family Care Center of Montefiore Medical Center in the Bronx, N.Y., does not get many such requests from his low-income patients. "I have friends in private practice in Manhattan and Greenwich, Conn., and they are starting to have some patients ask for it, especially professional women." All in all, those who want scheduled C/S are likely to have more money, more education, and adequate medical insurance. The same is true in South America, where higher C/S rates are found among women of the upper socioeconomic classes; yet poor women in those countries actually have greater obstetric risk.²

One peril that cannot be ignored, Dr. Harer says, is the medical-legal risk to you if a patient's strong appeal for a particular mode of delivery is denied and something goes wrong. "It puts the doctor at significant risk if there is an adverse result," he points out. That's an opinion all physicians seem to share. "If a baby died or was permanently injured after the mother insisted on a c-section and I refused, I'd be unlikely to win a subsequent case no matter how correct I was in delivering that baby vaginally," Dr. Weinfeld says. "As you look at this issue, the pressure put on by the legal system can't be ignored," agrees Peter A. Schwartz, Chair of the Department of Ob/Gyn at Reading Hospital and Medical Center in Reading, Pa., and past chair of ACOG's Ethics Committee. "Practice is moving in the direction of allowing women to make their own decisions."

Even so, the physician believes that for most women, vaginal birth is a better option than C/S. Two years ago, Reading's ob/gyn department scrutinized the matter and determined it was inappropriate to allow patients to choose. A pair of physicians debated the question in front of perhaps 100 ob/gyns and other specialists, all of whom were asked to vote at the end of the discussion. "It was probably about 70:30 against elective c-section," Schwartz recalls. "I'm guessing that if we had the same debate today, it would probably be 50:50 or maybe tipping in the other direction. We have had one elective c-section. The patient was an OB, so she had a strong enough argument. At this point, we're leaving it up to the patient and the clinician."

Cost considerations

Cost concerns also crop up when weighing the potential merits and drawbacks of elective C/S. After evaluating cost differences between elective C/S and attempted labor and delivery at his local hospital, Bost concluded that the procedure would have minimal effect on the total cost of patient care. The least expensive method was vaginal delivery without labor induction or an epidural anesthetic. For nulliparous women, the cost was an estimated 6.2% lower than that of elective C/S; for multiparous women, 24.8% cheaper. But a failed attempt at labor that culminated in C/S was 48.6% more costly than a scheduled pro- cedure in nulliparous women; 40.3% more costly in multiparous women. "I don't see any reason why cost would ever stand in the way of this decision," Bost says. "As a matter of fact, in Texas we have 3-day hospitals where you could do a C/S at a tremendously lower cost because there is less overhead than in a big hospital."

When the expenses do surpass those of a vaginal delivery, patients should pick up the tab, Schwartz suggests. "If you want to have an elective c-section though medicine says a vaginal delivery is in your best interest, why should all the other people in your risk pool pay the extra expense?" he says. "A co-pay should cover the excess cost." As far as your earnings are concerned, Harer would like physicians to earn the same fee regardless of how the delivery was accomplished. Many insurers have already removed any significant differential. This tactic could in some ways tempt physicians to do more c-sections, Schwartz remarks. A scheduled procedure on a given day means less disruption to the office routine, let alone your private time. It's also more cost-effective as it usually requires less time than labor and delivery.

Don't expect researchers to delineate the pros and cons of elective C/S any time soon. The many birth-related variables sprawl beyond the confines of any possible clinical trial. Whatever you decide to do, ensure that your patients are thoroughly informed and that all decisions are well documented (see "Put it in writing"). "You can come down on either side of this issue reasonably," Schwartz says. "The major ethical issue is to remove any personal bias that you have; you're not doing it because you have a dinner date you don't want to miss, you're getting paid more, or you fear the lawyers. Decide whether an elective c-section is a reasonable alternative based on your view of the scientific facts. If you do that, then I think it's fair to be a physician that refuses to allow an elective c-section—or that provides them. You make the decision."

REFERENCES

1. Martin JA, Park MM, Sutton PD. Births: Preliminary data for 2001. National Vital Statistics Reports; Vol 50, No 10. Hyattsville, Md: National Center for Health Statistics. 2002.

2. Belizan JM, Althabe F, Barros FC, et al. Rates and implications of caesarean sections in Latin America: ecological study. Br Med J. 1999;319:1397-1400.

3. Evaluation of Cesarean Delivery. Washington DC, The American College of Obstetricians and Gynecologists, Task Force on Cesarean Delivery Rates. 2000.

4. Bost BW. Should elective cesarean birth be offered at term as an alternative to labor and delivery for prevention of complications, including symptomatic pelvic prolapse, as well as stress urinary and fecal incontinence? Paper presented at: Annual Clinical Meeting of the The American College of Obstetricians and Gynecologists; San Francisco, Calif., 2000.

5. Buchsbaum GM, Chin M, Glantz C, et al. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol. 2002;100:226-229.

6. Hall MH, Bewley S. Maternal mortality and mode of delivery. Lancet. 1999;354:776.

7. Vaginal birth after previous cesarean delivery. Washington, DC: The American College of Obstetricians and Gynecologists; ACOG Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 5, 1999.

8. Smith GC, Pell JP, Cameron AD, et al. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA. 2002;287:2684-2690.

Ms. Starr is a freelance medical writer and editor.

Put it in writing

Lee Johnson, a health-care lawyer specializing in risk management in Mount Kisco, N.Y., can recall a number of cases where physicians, after repeatedly being urged to limit the number of cesarean sections performed, were sued because they had not opted for a surgical delivery. In such cases, it doesn't seem to matter much if the physician's actions were medically justified. "The jury sees a sick baby and says maybe this baby would have been okay if only the physician had done something earlier," she says. "There's no such thing as a win with a sick baby. Somebody has to pay."

So what kind of trouble do you risk if you perform a scheduled elective C/S? "The definition of medical malpractice comes down to whether there is a deviation from a recognized standard of care," says Steven I. Kern, a lawyer with Kern, Augustine, Conroy, and Schoppmann in Bridgewater, N.J. and Lake Success, N.Y. "If there is a recognized standard that says that a woman in particular circumstances is justified in having a c-section, and the woman is fully informed as to the risks and benefits of a c-section versus vaginal delivery, then the doctor should be on pretty firm ground. On the other hand, if you can't find any support in the literature for doing the c-section under those conditions and something goes wrong, you're going to be hung out to dry, no matter what advice you gave the patient and how much you tried to talk her out of it."

If, however, an honest disagreement exists within the medical community, then you haven't deviated from a standard of care because there really is none, Kern continues. Still, you should be able to demonstrate that a significant minority of the specialty accepts what you're doing. An example is the woman who voluntarily undergoes mastectomy in an effort to avoid breast cancer. "You create informed consent so that the patient has full knowledge of all options," he advises. "Provide all of the reasons for and against a strategy and then let the patient decide, so long as the patient's decision isn't contrary to good medical practice."

When crafting an informed consent, indicate that the patient has been told the pros and cons attending each delivery method, has been provided with a copy of the recommendations of the American College of Obstetricians and Gynecologists, understands who ACOG is and the organization's rationale, and has nonetheless chosen to have a c-section, Kern says. Also make sure to document the patient's reasons for her decision and any available medical support for it.

 

Cindy Starr. Elective cesarean section: a new dividing line for OBs. Contemporary Ob/Gyn Jun. 2, 2003;48:76-86.