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Caesarean Section for All Patients?
N. Fisk
Institute of Reproductive and Developmental Biology, Imperial College, Hammersmith
Hospital Campus & Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London,
United Kingdom
Caesarean section rates over recent decades have widely been
condemned as being too high. Certainly their doubling over the last 20 years
followed, rather than mediated, sharp declines in maternal and perinatal
mortality. Their huge variation in the developed world (6-38%) cannot be
explained on obstetric grounds, and numerous analyses have shown that the
chief determinants of two- to three-fold differences within countries are the
woman's insurance, her choice of obstetrician, and socio-economic status. It
thus became obstetric dogma that all obstetricians should strive to achieve
vaginal delivery, and prevent unnecessary caesareans. But what is the ideal
rate? Figures ranging from 9-15% have been proposed but based on scant
evidence.
In direct contrast to the above, one third of female obstetricians in a survey in
the mid-1990’s indicated that they would choose to be delivered always by
elective caesarean section, in the absence of any medical indication.1 Their
views were presumably influenced by the safety of modern elective caesarean
section under epidural anaesthesia, thrombo-prophylactic and antibiotic cover,
which is now arguably as safe as an attempt at vaginal delivery. Most wished to
prevent long-term damage to their pelvic floor, and 39% in addition wanted to
prevent damage to their baby. So what are the arguments? More recently the
same question was posed to US obstetricians, 46% of whom wanted a non
indicated caesarean section.2
Vaginal delivery is the major aetiological factor for stress incontinence,
prolapse and anal incontinence in women. Recent functional and structural
studies of the pelvic floor indicate that many women, even the majority,
damage their pelvic floor as a direct result of vaginal delivery, and around one
third develop symptoms of incontinence, especially after assisted vaginal
delivery. Around 40% of women have long-term incontinence of urine, flatus or
stool,3 and it has been estimated, that in the USA women have a lifetime risk of
11% needing an operation for prolapse or incontinence.4 It is not possible to
predict accurately which women will require assisted delivery, and which
women will suffer these complications. The chief risk factor thus appears
primiparity, and pre-emptive caesarean section a not illogical preventative
strategy.
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Allowing women to labour vaginally is also associated with not inconsequential
fetal risks, including intrapartum death (ca.1 in 1700),5 intrapartum acquired
hypoxic ischaemic encephalopathy (1 in 1750),6 intrapartum acquired cerebral
palsy (1 in 4000),7 and the greatest risk, stillbirth at term prior to labour (1 in
550).8 Although these figures may be adjusted up or down depending on the
various data sources, cumulatively the fetal risks of vaginal delivery exceed 1 in
500. In contrast, the average woman would request elective caesarean section at
a much lower risk of 1 in 4000.9 A recent national survey in the UK indicated
that 92% of women wanted to be delivered by the route that was safest for the
baby: the same survey showed that 54% of obstetricians thought that was by
caesarean section.10
If obstetricians increasingly regard abdominal delivery as preferable, at
least for themselves, how should they respond to the low risk woman who asks
for a caesarean section? Editorials in the 1980’s argued that such requests
should be denied.11,12 We let women choose freely their method of
contraception, whether to avail themselves of prenatal diagnosis and
termination of pregnancy, their pregnancy care provider and setting, their
analgesia and birth position, and whether or not to breastfeed, yet some argue
that refusing such requests is not paternalism.13 Indeed the Ethics Committee of
FIGO, our international body, deemed in 1999 that caesarean section for
medical reasons was not ethically justified. In contrast, surveys now show that a
clear majority of obstetricians would acquiesce to informed requests.10,14
Should all women be offered an elective caesarean section? Clearly this is not
currently appropriate or achievable for all patients. Further, there are risks to
caesarean section, especially the small but important risk of abnormallypositioned or adherent placentation with recurrent abdominal delivery.15 Even
this, however, needs to be offset against the avoidance of pelvic surgery in later
life. Then there is the increased relative risk of respiratory distress with
prelabour caesarean at 38/9 weeks,16 although this is usually treatable with
good outcome, unlike unexplained intrauterine death at or after the same
gestational age.8
To inform this debate, there is urgent need for good research data on the
relative long-term outcomes of vaginal versus elective caesarean delivery.
Patient choice is having its greatest effect where there is an increased chance of
intrapartum emergency caesarean section, such as in primigravida needing
induction, in the elderly primigravida, and in the presence of twins or a prior
caesarean section, and the women is planning only two children. It is now clear
from the Term Breech Trial that elective caesarean section is safest for breech
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deliveries.17 Although many obstetricians had considered vaginal breech
delivery safe, this multicentre international randomised controlled trial showed
that only seven caesareans were required in low perinatal mortality countries to
prevent one serious adverse neonatal outcome.17 Similar trials of elective
abdominal versus vaginal delivery are now planned for twins, and those with a
single previous caesarean section, but is it not now time for a “term cephalic
trial”?
There are further reasons why the CS rate is destined to rise further.
Firstly, women in the developed world are reproducing later in life, and rising
age correlates linearly with section rates18,19 Next, babies are getting bigger, as
are their mothers.20 Indeed, anthropologically man is the only mammal in which
the fetal head almost entirely occupies the maternal pelvis, and has and is
evolving away from a reliance on vaginal birth.21 Finally, the litigation costs
resulting from vaginal delivery continue to rise exponentially, with annual
premiums in some jurisdictions exceeding half a million dollars per
obstetrician, and settlements encroaching on 8 figures. One wonders how much
longer society, and particular health care providers, will continue to be able to
afford vaginal delivery.
Patient choice is assuming greater importance in maternity care, and in
this light efforts to reduce the caesarean section rate further seem doomed.
Medical opinion on this issue is changing with recent editorials arguing that a
further rise in rates is not only to be expected, but may be desirable.22, 23 The
assumption that caesarean section rates are too high is no longer tenable, and
reducing rates may be counter to maternal and fetal interests. Caesarean rates in
the twenty first century will be driven up by consumer demand,24 and will
almost certainly exceed 50%.
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OLSEN AL, SMITH VJ, BERGSTROM JO, COLLING JC, CLARK AL.
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