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Clinical Crossroads | Conferences With Patients and Doctors| Clinician's Corner

Elective Cesarean Delivery on Maternal Request

Jeffrey Ecker, MD
JAMA. 2013;309(18):1930-1936. doi:10.1001/jama.2013.3982.
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Published online

Importance Some pregnant women prefer cesarean delivery and request it without maternal or fetal indication rather than proceeding with a plan for vaginal delivery.

Objective To review approaches for counseling women who ask for cesarean delivery without maternal or fetal indication (known as cesarean delivery on maternal request [CDMR]).

Evidence Review An Agency for Healthcare Research and Quality evidence report of studies published after 1990, a 2006 National Institutes of Health state-of-the-science conference report, and published literature were examined.

Findings The prevalence of CDMR in the United States is not precisely known but probably occurs in less than 3% of all deliveries. Most practicing obstetricians have received requests for CDMR from patients. Compared with a plan for vaginal delivery, CDMR may be associated with lower rates of hemorrhage, maternal incontinence, and rare but serious neonatal outcomes. However, CDMR is associated with a higher risk of neonatal respiratory morbidity. Adverse consequences of CDMR may be manifested only in future pregnancies. Repeated cesarean deliveries have higher rates of operative complications, placental abnormalities such as placenta previa and accreta, and consequent gravid hysterectomy.

Conclusions and Relevance There is no immediate expectation for CDMR to reduce the health risks of mothers or infants. Accordingly, counseling and decisions regarding CDMR should be made after considering a woman's full reproductive plans.

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Figure. Schematic Comparison of Normal Placentation and Placenta Accreta
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A, With normal placentation, chorionic villi invade to the decidual layer and do not invade the myometrium, allowing placental separation after delivery. B, Abnormalities of trophoblast invasion and placental attachment, generally referred to as placenta accreta, include 3 levels of placental invasion into the uterine wall: accreta—attachment to the myometrium; increta (shown)—attachment within the myometrium; and percreta—invasion through the myometrium and serosa. Areas of placenta where villi are embedded in the myometrial layer are adherent to the uterine wall and fail to separate after delivery. Risk for placenta accreta is increased in areas of uterine scarring, such as from a prior cesarean delivery, and in association with placenta previa because implantation occurs over the cervix and lower uterine segment where the decidual layer is thin.

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Better identification of specific CDMR risks is needed - and possible
Posted on May 10, 2013
Pauline M Hull
Editor, electivecesarean.com
Conflict of Interest: Co-author of Choosing Cesarean, A Natural Birth Plan
I agree that maternal request should involve an individualized consultation of risks and benefits; however, it's very important that these risks and benefits are discussed in the appropriate context, and relevant to current recommendations for CDMR.For example, this article states, "CDMR is associated with a higher risk of neonatal respiratory morbidity", but research suggests that this higher risk is only for surgeries performed earlier than the recommended 39+ gestational weeks. If recommendations are appropriately followed, respiratory risk is not necessarily higher for CDMR compared with a trial of labor.Health professionals need to be very careful not to attribute risks to CDMR that are not directly relevant, and unfortunately in many hospitals this is not always the case. Emergency cesarean risks are often mixed with planned risks, and the short- and long-term risks of surgeries at different gestational ages are frequently mixed together too. In terms of ensuring greater clarification of specific CDMR risks and benefits in the future, and in the knowledge that there is strong opposition to a randomized clinical trial, a very simple method of gathering information would be to ensure that hospitals capture CDMR births in their collection of birth data and corresponding health outcomes. The outcomes of women and babies in healthy pregnancies who chose CDMR with those who chose a trial of labor can then be compared.
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