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Cesarean Delivery on maternal request – ACOG Guidelines


Cesarean Delivery on maternal request – ACOG Guidelines

American College of Obstetricians and Gynecologists, ACOG has released its latest recommendations on Cesarean Delivery on maternal request.

]There is an overall increase in the incidence of cesarean delivery globally. In addition to this, there has been a simultaneous upsurge in cesarean delivery on maternal request which has contributed to the overall increase in the cesarean delivery rate. Cesarean delivery on maternal request is not a well-recognized clinical entity and it is estimated that 2.5% of all births in the United States are cesarean delivery on maternal request.Cesarean delivery on maternal request often engenders ethical concerns regarding patient and health care provider autonomy.

The available information that compared the risks and benefits of cesarean delivery on maternal request and planned vaginal delivery does not provide the basis for a recommendation for either mode of delivery. When a woman desires a cesarean delivery on maternal request, her health care provider should consider her specific risk factors, such as age, body mass index, the accuracy of estimated gestational age, reproductive plans, personal values, and cultural context. 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.

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.

For more details click on the link: www.acog.org

Source: With inputs from ACOG

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  1. Of late child birth turned out to be a politico economic issue , leave alone a social issue. with the advances in civilisation, and culture, as well as the increasing safety of surgical procedures, a surgical procedure which used to be a last resort had now become a choice . any number of examples can be quoted from the plastic surgery, metabolic surgery etc. proponents of ethics cry hoarse when the intervention with the normal process of child birth is altered as per the mothers choice, forgetting that planned parent hood is as natural or unnatural as Cesarian on demand. politics and economics take a tangent course to curb the rights of woman who is going to give birth and snatch away the choice of child birth from her. ,Most of these policemen of ethics do not understand that the ethics differ from time to time and place to place and individual to individual. the politicians try to encash on the issue at the cost of the physicians as usual. The ceasarian rates or quoted incorrectly for each hospital rather than the whole population. Neonatal mortality is not talked about while crying hoarse on the recent increase in the cesarian rates. For example the cesarian rates in the African continent is only 2% but what about the maternal and fetal mortality?!. How many women in the world has access to safe delivery and close monitoring of the fetus during the delivery ? less than 40% of the women all over the world get a qualified medical attendant for delivery. when the proponents of legal abortion claim about the rights of women to carry on with pregancy why dont they give the women the same right to give birth to her babe as per his choice? Contrary to expectations One in 5 women delver by cesarian section in UK. The politics of the whole issue is that the moment the mothers right to choose the way she delvers, the govts have to ensure that the facilities for the same are to be provided, Governments fear this situation and are not willing to spend extra money on creating such facilities with in the reach of the common woman. THe issue is also related to the power the women vields in the society. all the powerful and financially competent women choose to deliver by LSCS. what is not discussed in such forum is the uncertainity and pain the mother has to undergo while undergoing the delivery vias naturalis. How many women have access to painless delivery? Finally with the increase in the small family norms each pregnancy is preceous and the modern day empowered woman can choose the way she gives birth to her childe either vias naturalis or through LSCS.

  2. user
    Dr.Michael Klein December 29, 2018, 5:19 am

    Transient tachypnea is also increased at 39 plus weeks as well as other respiratory morbidity in newborn.