Cesarean Delivery on maternal request - ACOG Guidelines

Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations:

• If a patient’s main motivation to elect a cesarean delivery is a fear of pain in childbirth, obstetrician-gynecologists and other obstetric care providers should discuss and offer the patient analgesia for labor, as well as prenatal childbirth education and emotional support in labor.


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


• After exploring the reasons behind the patient’s request and discussing the risks and benefits, if a patient decides to pursue cesarean delivery on maternal request, the following is recommended:
  
  
  
  • In the absence of other indications for early delivery, cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.
  
  
  • Given the high repeat cesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery.
  
  
  
  

With the exception of three outcome variables with moderate-quality evidence (maternal hemorrhage, maternal length of stay, and neonatal respiratory morbidity), all remaining outcome assessments considered by the 2006 National Institutes of Health Consensus panel were based on weak evidence. This significantly limits the reliability of judgments regarding whether an outcome measure favors either cesarean delivery on maternal request or planned vaginal delivery.

Two outcome variables had moderate-quality evidence, and both were short-term maternal variables. The frequency of postpartum hemorrhage associated with planned cesarean delivery is less than that reported with the combination of planned vaginal delivery and unplanned cesarean delivery. Compared with vaginal delivery, cesarean delivery (planned or otherwise) requires a longer hospital stay.

There are limited studies on cesarean delivery on maternal request and neonatal outcomes. The risk of respiratory morbidity, including transient tachypnea of the newborn, respiratory distress syndrome, and persistent pulmonary hypertension, is higher for elective cesarean delivery compared with vaginal delivery when delivery is earlier than 39–40 weeks of gestation.

In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended. After exploring the reasons behind the patient’s request and discussing the risks and benefits, if a patient decides to pursue cesarean delivery on maternal request, the following is recommended: in the absence of other indications for early delivery, cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks; and given the high repeat cesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery.