Case Scenario A 34-year-old pregn...

Case Scenario

A 34-year-old pregnant patient (gravida 2 para 0 at 28 weeks gestation) has asked common of my partners if she can schedule a cesarean delivery rather than travel into labor. Because I am the family physician in my collection who is privileged for cesarean deliveries, my partner has asked for my advice. The patient's pregnancy has been uncomplicated, and she is in crack health. The patient has no history of prior surgery and has read a great deal about pregnancy and childbirth. She told my partner that she is be of importance toed about her family history, which includes couple sisters who ultimately had cesarean deliveries after lengthy labors. In addition, the patient has minimal pain tolerance, and she is businessed also that vaginal birth could bring forward her at risk for incontinence in the future

Commentary

Patient-choice cesarean delivery, although rare in the United States, has become controversial in the medical literature and among pregnant women and their maternity care providers through the whole extent of the past three years. (1) The American college edifice [i]or[/i] building of Obstetricians and Gynecologists (ACOG) has freshly published an ethical opinion (2) recommending recommending acceptance of patient-choice cesarean delivery based in succession the principles of patient autonomy and informed assent The ACOG opinion states, "If the physician believes that (elective, primary) cesarean delivery dignifys the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery."

The ACOG ethical opinion supports physicians who agree to patient-choice elective cesarean delivery as extended as they believe it is in the best interests of the patient. In contrast, the international Federation of Gynecologists and Obstetricians states, "At instant because hard evidence of snare benefit does not exist, performing cesarean section for nonmedical reasons is ethically not justified." (3) The American body of Nurse-midwives has condemned the decision to exhibit patient-choice cesarean delivery, stating that women "are being enticed to consider 'c-sections forward demand,' based upon questionable promises A cesarean delivery should be the last resort, not an option based forward convenience or defensive practice." (4)

Past national and international efforts to model the cesarean delivery rate were based forward the belief that it increased maternal morbidity and mortality. The World Health Organization and the U Department of Health and Human Services' Healthy population 2000 Report (5,6) recommend that the cesarean delivery rate should not exce 15 percent unless scant evidence exists to support these statements. Although cesarean delivery has been associated with a fourfold increase in the rate of maternal mortality as well as increased risks of other morbidity, (7) including infection, hemorrhage, transfusion, anesthesia reactions, and visceral injuries, these risks are mostly often associated with unscheduled cesarean delivery, particularly when it appears in advanced labor. (8)

Advocates of patient-choice cesarean delivery have argued that the differences in risk are minimal when united compares scheduled elective cesarean delivery to planned vaginal delivery. sum of two units small studies of fewer than 1000 women undergoing elective cesarean delivery showed equivalent morbidity or merely an increase in febrile morbidity when compared with vaginal delivery. (910) Maternal mortality registries, however, still demonstrate increased maternal mortality with relative risk of 14 to 28 when comparing elective cesarean delivery with vaginal delivery. (1112)

Although a scheduled primary cesarean delivery may have minimal increased risk compared with the first vaginal delivery, it is essential to consider all that will be pregnancies in a woman's reproductive life to determine risks and benefits of elective cesarean delivery. Women who deliver vaginally in their first pregnancy are at greatly lower risk of requiring a cesarean delivery during a that will be pregnancy. Moreover, women who have had a prior cesarean delivery are at increased risk of complications in their nearest pregnancy, whether they choose a repeat cesarean delivery or a trial of labor. The risks include a higher incidence of placenta previa and placenta accreta, which may lead to hysterectomy and maternal mortality. The risk of placental abnormalities increases with the number of prior cesarean deliveries. (13)

Do any maternal or neonatal health benefits support an acceptance of elective cesarean delivery? Although the incidence of stres urinary incontinence is higher at three month postpartum in women who deliver vaginally versus those who deliver at cesarean, these differences do not appear to persist. (914) unruffled the short-term protective effect of cesarean delivery onward urinary incontinence disappears when a woman has had three prior cesarean deliveries. (1516) at age 50 years, nonobstetric risk factors predominate and the likelihood of a woman having stres urinary incontinence is not affected by way of obstetric history. (15)