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JME Online First, published on November 18, 2013 as 10.1136/medethics-2013-101558 Clinical ethics
STUDENT ESSAY
Maternal request for caesarean section: an ethical consideration Hannah Selinger University of Southampton, Southampton, UK Correspondence to Hannah Selinger, [email protected] Received 29 April 2013 Revised 4 October 2013 Accepted 25 October 2013
ABSTRACT Caesarean section (CS) is a method of delivering a baby through a surgical incision into the abdominal wall. Until recently in the UK, it was preserved as a procedure which was only carried out in certain circumstances. These included if the fetus lay in a breech position or was showing signs of distress leading to a requirement for rapid delivery. CS is perceived as a safe method of delivery due to the recommendation by the National Institute for Health and Care Excellence (NICE) in these situations. As a result, the opportunity for maternal request for CS arose, whereby the mother requests the operation despite no medical indication. There are risks associated with CS, as with all surgery, however, these risks in current and future pregnancies may not be fully understood by the mother. The ethics of exposing mothers to these risks, as well as performing surgery on what is otherwise a healthy patient, become entangled with the demand for patient choice, as well as the increasing financial strain on our healthcare system. The main question to be examined in this essay is whether it is ethical to allow women to choose a CS in the absence of obstetric indication, taking into account the increased risk to the mother and her future offspring in order to potentially decrease the risk to the current baby. Alongside a case report, this analysis will apply Beauchamp and Childress’ four principles of biomedical ethics and an exploration of the scientific literature.
INTRODUCTION
To cite: Selinger H. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101558
Caesarean section (CS) refers to the surgical procedure undertaken to deliver a baby abdominally. It has been carried out for many centuries with the name believed to stem from the birth of the Roman general Julius Caesar. This link appears to exist in other European languages with the equivalent being literally translated as the ‘emperor’s cut’. As his mother survived to see him into adulthood however, it is highly unlikely that Caesar was delivered this way. The procedure has been refined over centuries and is now a relatively safe procedure performed routinely throughout the developed world. Despite its popularity, CS along with every surgical procedure is not without risk. Consequently in 1985, WHO suggested that no region should have a CS rate over 10–15%.1 Attitudes towards maternal request for CS vary throughout the developed world. The EUROBS study2 in 2006 surveyed obstetricians in eight European countries with focus on their views on maternal requests for CS, and included a case which featured a healthy 25-year-old woman requesting surgical delivery with no medical need for it. The compliance rates
Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558 Copyright Article author (or their employer) 2013.
for obstetricians varied from 79% in the UK to 15% in Spain, with respect for patient autonomy stated as the most common reason to carry out the procedure.2 In November 2011, the National Institute for Health and Care Excellence (NICE) released guidelines stating that pregnant women requesting a CS could receive one, even when there was no medical indication.3 This is known as the ‘maternal request caesarean.’ The CS rate in the UK in 2010–2011 was 24.8%.4 Previous CS is the single greatest risk factor for placenta praevia and placenta accreta5; praevia is where the placenta implants near or over the internal cervical os and accreta being abnormal growth of the placenta into the myometrium. If this occurs, the risk is of catastrophic bleeding at delivery leading to significant maternal morbidity and mortality. The risk of abnormal placentation rises exponentially with the number of caesareans performed, probably as a result of the increasing amount of uterine scar tissue. It has been estimated that if the CS rate continues to rise at the current rate, by 2020 the USA will have a delivery rate of 56.2%.6 This alone will account for an additional 6236 placenta praevias, 4504 placenta accretas and 130 maternal deaths annually.6 CS for an obstetric indication has undoubtedly improved fetal and maternal morbidity and mortality over the last 50 years. It cannot, however, be considered as a completely benign procedure. The increasing worldwide CS rate will be accompanied by an increasing maternal mortality rate from major obstetric haemorrhage in subsequent pregnancies. It is now becoming clear that the potential adverse effects of CS may be far reaching, giving rise to serious complications that impact on current and potential pregnancies, as well as the mother herself. There is literature, such as that of Minkoff,7 that examines the concept of a maternal request for CS from an ethical point of view. This essay will include and expand beyond ethics with the use of a case study and statistics.
CASE REPORT A 38-year-old woman with a history of three prior CSs was diagnosed with placenta percreta, where the placenta implants abnormally into the myometrium and through it into other pelvic structures, 32 weeks into her fourth pregnancy. Her first caesarean had been an emergency in labour. The patient reported that she had been willing to try a vaginal birth for her second child but had been
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1
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Clinical ethics encouraged by the medical team to have a second CS. She had then followed standard UK practice and delivered her third child by CS. At the routine ultrasound scan 20 weeks into her fourth pregnancy, her placenta was noted to be lying under the caesarean scar. Further ultrasound imaging at 32 weeks demonstrated a large area of morbidly adherent placenta (accreta) with placental tissue growing through the uterus and penetrating the bladder wall ( percreta). The recommended management of such cases is not to attempt to separate the placenta from the uterus (after delivering the baby), but to perform a caesarean hysterectomy with the placenta still in situ. This becomes complex when the placenta has grown through the uterus into other structures, in this case the bladder. A multidisciplinary team was assembled to facilitate safe delivery, including obstetricians, anaesthetists, interventional radiologists, haematologists, urologists and neonatologists. The caesarean hysterectomy was performed at 34 weeks to limit the risk of spontaneous labour requiring the surgery to be performed as an emergency. Following steroid injections to mature the fetal lungs, the procedure took 9 h, and despite the assembled expertise, resulted in a major obstetric haemorrhage requiring 14 units of donor blood plus two units of autologous transfusion in addition to fresh frozen plasma, platelets and cryoprecipitate. The main surgical difficulty was separation of the anterior uterine wall from the posterior aspect of the bladder. As a result of the placenta percreta, the ureters and urinary bladder were damaged, and reimplantation and bladder reconstruction was required. The baby required initial resuscitation and was transferred to the neonatal intensive care unit, and the mother to adult intensive care for 24 h. Both went home in the next few weeks, however, considerable urological follow-up was required to manage the significant urological trauma. When interviewed for this paper, one of the most striking issues was the mother felt she had never been warned about the risks of CS to subsequent pregnancies. She had planned to have a large family and believed that had she been told of the risk of placenta accreta, she would have attempted to deliver her second baby vaginally. How much of this can be attributed to the recent traumatic experience combined with her possible recollection bias remains unclear. However, this case raises important issues regarding attitudes towards CS, as well as the current consent procedures. The UK’s Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women are warned about the risk of placenta praevia in future pregnancies but does not recommend discussing the risk of placenta accreta. In order to consider the ethics of maternal request for CS, and the risks it involves to all parties, a balanced and objective review of the literature must be carried out. The discussion of this essay will consider whether it is ethical to allow the mother to choose to increase her risk, and that of her future offspring, in order to potentially decrease the risk to the current baby.
BENEFITS OF CS For the mother Elective CS has several benefits for the mother including reduction of perineal and abdominal pain during birth and 3 days postpartum, when compared with the pain associated with normal vaginal delivery.3 Vaginal delivery can be an unpredictable process and situations such as fetal distress dictate the requirement for an emergency CS. This emergency procedure is accompanied by an increased risk of morbidity and mortality when compared to a planned CS.8 Urinary incontinence and its relationship with pregnancy and delivery is a topic of frequent 2
debate. Gyhagen et al9 state that the prevalence of urinary incontinence at more than 10 years after a single birth is higher for those who had a vaginal delivery (40.3%) compared with women who had a CS (28.8%) after one birth. Overall benefits may also include reduction in anxiety about childbirth and labour and increased psychological satisfaction with childbirth.
For the baby There are benefits of an elective CS for the baby, which include an arguable reduction in antepartum stillbirth. This benefit occurs as a result of the gestation at which most elective caesareans are performed (39 weeks), as the risk of stillbirth increases by a factor of six from 37 to 43 weeks gestation.10 There is also a decrease in the incidence of vaginal delivery-related injuries, most commonly damage to the brachial plexus secondary to difficulty delivering the baby’s shoulders.11 This, however, is only a small reduction of 1 in 5000–10 000 births in the case of elective CS.12 Finally, there is a reduction in the incidence of neonatal encephalopathy; a syndrome defined by central nervous system dysfunction in babies, with one case avoided for every 317 CSs performed.12 However, this does not translate into a decrease in the incidence of cerebral palsy in babies delivered by CS.
RISKS OF CS For the mother When compared with vaginal delivery, CS leads to a longer hospital stay of between 0.6 and 1.4 days3 and an increase in postpartum haemorrhage rate from 3.5% in spontaneous vaginal births to 13% after CS.13 As with all major abdominal surgery, there is a risk of damage to organs such as the bladder in 0.1– 1% of operations.3 Although these risks are small, they are still present and can have a huge effect on quality of life. A study in the Lancet showed that infection of the wound or endometrium occurred in 4.9% of planned vaginal births.14 This figure rose to 6.4% for planned CSs.13 Pregnancy increases the risk of thromboembolism due to alteration of the coagulation system, and surgery further increases this risk. Consequently, CS increases the risk of developing a puerperal deep vein thrombosis eightfold.15 The woman must also take into account the effect of a CS on future pregnancies, as there are two potentially severe consequences. The first is doubling of the risk of stillbirth in the subsequent pregnancy to 1.1% as shown by Smith et al.16 The second arises from the effect of abnormal placentation, such as placenta accreta, or percreta, for which CS is the single greatest risk factor.6 Placenta accreta has a maternal mortality rate of 7%,17 morbidity in the form of emergency hysterectomy and has been shown to be related to the number of previous CSs.17 A pregnant woman who has had one previous CS has a risk of 0.31% for a placenta accreta and a 0.4% risk of hysterectomy. A woman who perhaps only wants two children, may perceive this as a small increase in risk, but it is still present. Increase the number of previous CSs to five and the risk of placenta accreta rises to 6.75% accompanied by an increase in hysterectomy rate of 8.99%.18 In the UK, the incidence of placenta accreta is increasing with the rate of CSs; in the period 1970–1980 the incidence was between 1:4027 and 1:2510 births, whereas during 1982–2002, it had increased to 1:533 births.19 Placenta accreta increases the risk of death, and it also requires specialist antenatal care for safest delivery of the baby. This includes the need for consultant obstetricians, anaesthetists and interventional Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558
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Clinical ethics radiologists, blood products and the availability of intensive care beds for the mother and baby.
For the baby The risks to the baby should also be considered in the balanced view of elective CS. In elective CS, the normal physiological changes that take place during labour do not occur, thus reducing the normal neonatal lung adaptation that takes place. The baby is at increased risk of respiratory and cardiovascular problems; CS is an independent risk factor for respiratory distress syndrome with an increase in risk of 130% when compared with vaginal delivery.20 The risk of the baby requiring transfer to neonatal intensive care unit increases from 5.2% for planned vaginal deliveries to 9.8% in planned caesarean deliveries.21 During delivery, there is a risk of surgical laceration to the fetus, and in the UK currently this stands at around 2%.3 Studies have shown that maternal hypotension during surgery can lead to transient fetal respiratory acidosis and may cause respiratory disorders, such as meconium aspiration.22 Finally, delivery by CS may lead to hypothermia, hypoglycaemia and an increased risk of sepsis for the baby.23 Despite antepartum stillbirth in the unborn baby being reduced by elective CS, the opposite is true for future pregnancies. Evidence shows that the risk of antepartum stillbirth is doubled in women who had a previous CS when compared with those who had not had a CS.3
THE ETHICS OF MATERNAL REQUEST FOR CS The evidence above indicates an overall increased risk of adverse outcomes for the mother and subsequent pregnancies. The principles of Biomedical ethics introduced by Beauchamp and Childress 24 will be used to examine whether it is ethical to allow women to choose a maternal request for CS and increase the risk to themselves and future offspring, to potentially decrease the risk to the current baby. Beauchamp and Childress offer a clear approach to analysis of ethical questions with the use of four basic principles; autonomy, justice, beneficence and non-maleficence.24 ▸ Autonomy is the capacity of a rational individual to make informed uncoerced decisions. ▸ Justice means an equal and fair distribution of resources and treatments. ▸ Beneficence is the act of doing ‘good’, or a state of kindness. ▸ Non-maleficence is defined as the act of doing no harm.
Autonomy Autonomy is translated in medicine as the patient’s right to decide about his or her own care. In the case of maternal request for CS, if the woman’s autonomy is to be respected she must have the right to make the decision about how her baby is to be born. She should have the capacity to make this decision, which must be fully informed and without influence. The EUROBS study discussed above demonstrates clearly that obstetricians stated autonomy of the patient as their main reason for agreeing to a maternal request for CS in the case study of the trial.2 This shows the mother’s decisions about her care are deemed very important within the speciality, and adds weight to the argument that she should be entitled to have some choice in her method of delivery. While much of the concern regarding inappropriate influence is focussed on the agenda of the attending doctor, the influence exerted by media, the woman’s peers, and advisory groups, such as the National Childbirth Trust can also be enormous. Pregnancy is renowned for being a time of hormonal and Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558
emotional liability, with depression and anxiety being common.25 Whether this has an effect on the mother’s decision making is difficult to assess, but should, nonetheless, be considered. The obstetrician also has rights to autonomy. They may feel it is unnecessary or inappropriate to perform major abdominal surgery when vaginal delivery is the default method of delivery. Living in an era of contraception and termination of pregnancy, whether the woman has the right to ask a doctor to do what they may see as wrong is an issue that must be considered. As the professional carrying out the procedure, the obstetrician takes full responsibility including those of any complications, and as a result must feel comfortable in the concept of maternal requests for CSs.
Justice Justice is demonstrated in the above case of placenta percreta where preterm deliveries and CSs in these situations result in a huge use of healthcare resources. If more mothers have CSs without a medical need, the number of placenta praevias and accretas will increase. It might be argued whether the resulting drain on National Health Service (NHS) resources is acceptable in a time of economic downturn with increasing demand on all areas of the NHS budget. Without placental abnormalities, there is still a significant impact on length of stay in hospital and cost in terms of staffing, prophylactic antibiotics and other resources. In an era of an ageing population and increasing technology, there is a constant demand on healthcare resources, and decisions are required on how they should be allocated. Is the question of justice in the distribution of healthcare resources being considered when announcing that mothers have autonomy of decision regarding how their baby is delivered?
Beneficence and non-maleficence Beneficence is something every human should abide by, but when applied to CS there must be a choice between which party benefits. Is it the unborn baby and a reduction in their risk of brachial plexus injury? Is it the mother who had a previous vaginal delivery perceived by her as psychologically traumatic, and by carrying out an elective CS, the doctor removes her abject fear of experiencing the same nightmare? Beneficence must also be considered alongside nonmaleficence. Non-maleficence also includes not acting with malice towards patients, or recommending ineffective treatments. If there is some harm associated with a treatment or procedure then it must be in proportion to the benefit. So, as beneficence and non-maleficence go hand in hand, does the potential small benefit to the baby outweigh the nonmaleficence of denying the procedure to the mother due to her risk of haemorrhage, thromboembolism, placenta accreta and the many other complications associated with surgical delivery? Does the mother receive the beneficence of an elective CS for psychological reasons despite the fact that the current baby may experience transient tachypnoea and any subsequent babies have double the risk of dying in utero as a result of the procedure? Weighing up a maternal request for CS must consider the mother and fetus, and while one may benefit the other may not and, in fact, may become seriously ill or die. Most mothers would choose an increased risk to themselves to decrease a risk to their baby; it is natural instinct. Babies provoke emotional responses as some of the most vulnerable members of society and, consequently, decisions in these situations are often the hardest. 3
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Clinical ethics CONCLUSION The benefits and risks of CS are very important to consider alongside the ethical discussion about maternal request for CS. Despite improvements in surgical and medical care, there remain some serious risks associated with caesarean delivery that must be considered. Ultimately, the question asks whether it is ethical to allow the mother to request a CS when there is no obstetric indication, and in doing so increasing the risk to herself, to decrease the risk to the baby. The autonomy of the mother is of great importance in maternal request for CS, as she is the person consenting to a surgical procedure and, therefore, has the right to an informed decision, and consequently, her choice of method of delivery. Her decision must be respected and understood by healthcare professionals to appreciate her reasoning, and in helping her to achieve the delivery she wishes. Whether a pregnant woman understands the devastating effects of placenta accreta depends upon the consenting procedure, and may also depend on the consenting obstetrician’s own experience of complications resulting from CSs. Beneficence is applied in the situation of maternal request for CS to the mother and the baby, but most importantly to the mother as she is the primary patient. Some obstetricians may argue that carrying out a maternal request for CS is not compliant with non-maleficence due to the risks created by carrying out the procedure, for example, infection. The autonomy of these obstetricians must also be respected, and their wish to refuse maternal request for CS if they feel it may cause undue harm to one or both parties. However, the argument can also be seen from the view that a CS must be carried out to conform to non-maleficence of the baby as the procedure may reduce the risks it is exposed to nonmaleficence must also apply in doing no harm when a mother is anxious and frightened about giving birth vaginally. The obstetrician has the option of maternal request for CS that may solve the fear, and would be doing wrong to withhold this type of delivery. It would be unfair, similarly, to withhold CS for reasons of justice when considering the impact on future pregnancies. If CS is being offered to some women, it must be offered to all, regardless of financial or social status to comply with the principle of justice. The ethical principles appear to steer the argument towards supporting the maternal request for CS due to the significant influence of the autonomy of the mother. Her right to request a CS to decrease the risk to her baby seems to ‘fit in’ in an era when patient-centred treatment is commonplace in the NHS. Alongside this, lies the beneficence to the mother, justice in fair distribution of healthcare and non-maleficence to the unborn baby. However, the science associated with the argument must not be forgotten. A maternal request for CS does increase the risk to the mother, who may be mother to several children. This is why the obstetrician must also play a role in this debate; NICE dictates that they should consider maternal request for CS, but must also care for patients who are at risk of significant morbidity and even mortality from placenta accreta. As the professional who must counsel and take consent, they have a great responsibility to ensure that the woman has had the opportunity to fully explore the significant risks associated with a CS, including those of abnormal placentation in a subsequent pregnancy.
4
Ultimately, as the person who will actually undertake the surgical procedure, the obstetrician must be certain that the risks and benefits have been fully explained, understood and appreciated, and that a CS is the best mode of delivery for that particular woman. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
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World Health Organization. Appropriate technology for birth. Lancet 1985;2:436–7. Habiba M, Gómez MM, da Frè M, et al.; for the EUROBS study group. Cesarean section on request: a comparison of obstetricians’ attitudes in eight European countries. Br J Obstet Gynecol 2006;113:647–56. National Institute for Health and Clinical Excellence. Caesarean Section [CG 132]. London: National Institute for Health and Clinical Excellence, 2011. Hospital Episode Statistics for the NHS Information Centre. NHS Maternity Statistics, England: 2010–11. National Health Service, Report number 13; 2011. Rosenberg T, Pariente G, Sergienko R, et al. Critical analysis of risk factors and outcome of placenta previa. Arch Gynecol Obstet 2011;284(1):47–51. Solheim KN, Esakoff TF, Little SE, et al. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med 2011;24(11):1341–6. Minkoff H. The ethics of cesarean section by choice. Semin Perinatol 2006;30(5): 309–12. Lilford RJ, van Coeverden de Groot HA, Moore PJ, et al. The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances. Br J Obstet Gynecol 1990;97:883–92. Gyhagen M, Bullarbo M, Nielsen T, et al. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. Br J Obstet Gynecol 2013;120:144–51. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. Br J Obstet Gynecol 1998;105:169–73. Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med 2003;348(10):946–50. Hankins GD, Clark SM, Munn MB. Caesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30:276–87. Källén K, Rydström H, Otterblad Olausson P. Cesarean in Sweden 1990–2001 [electronic resource]. National Board of Health and Welfare, 2005. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial, Term Breech Trial Collaborative Group. Lancet 2000;356:1375–83. de Swiet M. Thromboembolism. In: de Swiet M. ed. Medical disorders in obstetric practice. Oxford: Blackwell Scientific Publications, 1995:116–42. Smith GCS, Pell JP, Bobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362(9398):778–84. Garmi G, Salim R. Epidemiology, etiology, diagnosis and management of Placenta Accreta. Obstet Gynaecol Int 2012;2012:873929. Silver RM, Landon MB, Rouse DJ, et al. National Institute of Child Health and Human Development MFM Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192(5):1458–61. Gerten KA, Coonrod DV, Curtis Bay E, et al. Caesarean delivery and respiratory distress syndrome: Does labour make a difference? Am J Obstet Gynecol 2005; 193(3 Suppl):1061–4. Kolas T, Saugstad OD, Daltveit AK, et al. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol 2006;195(6):1538–43. Corke BC, Datta S, Ostheimer GW, et al. Spinal Anaesthesia for caesarean section; the influence of hypotension on neonatal outcome. Anaesthesia 1982;37:658–62. Wiklund I, Andolf E, Lilka H, et al. Indications for cesarean section on maternal request—Guidelines for counselling and treatment. J Sex Reprod Health 2012;3(3): 99–106. Beauchamp T, Childress J. Principles of biomedical ethics. 5th edn. New York: Oxford University Press, 2001. Raynor M. Pregnancy and the puerperium: the social and psychological context. Psychiatry 2006;5(1):1–4.
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JME Online First, published on November 18, 2013 as 10.1136/medethics-2013-101558 Clinical ethics
STUDENT ESSAY
Maternal request for caesarean section: an ethical consideration Hannah Selinger University of Southampton, Southampton, UK Correspondence to Hannah Selinger, [email protected] Received 29 April 2013 Revised 4 October 2013 Accepted 25 October 2013
ABSTRACT Caesarean section (CS) is a method of delivering a baby through a surgical incision into the abdominal wall. Until recently in the UK, it was preserved as a procedure which was only carried out in certain circumstances. These included if the fetus lay in a breech position or was showing signs of distress leading to a requirement for rapid delivery. CS is perceived as a safe method of delivery due to the recommendation by the National Institute for Health and Care Excellence (NICE) in these situations. As a result, the opportunity for maternal request for CS arose, whereby the mother requests the operation despite no medical indication. There are risks associated with CS, as with all surgery, however, these risks in current and future pregnancies may not be fully understood by the mother. The ethics of exposing mothers to these risks, as well as performing surgery on what is otherwise a healthy patient, become entangled with the demand for patient choice, as well as the increasing financial strain on our healthcare system. The main question to be examined in this essay is whether it is ethical to allow women to choose a CS in the absence of obstetric indication, taking into account the increased risk to the mother and her future offspring in order to potentially decrease the risk to the current baby. Alongside a case report, this analysis will apply Beauchamp and Childress’ four principles of biomedical ethics and an exploration of the scientific literature.
INTRODUCTION
To cite: Selinger H. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101558
Caesarean section (CS) refers to the surgical procedure undertaken to deliver a baby abdominally. It has been carried out for many centuries with the name believed to stem from the birth of the Roman general Julius Caesar. This link appears to exist in other European languages with the equivalent being literally translated as the ‘emperor’s cut’. As his mother survived to see him into adulthood however, it is highly unlikely that Caesar was delivered this way. The procedure has been refined over centuries and is now a relatively safe procedure performed routinely throughout the developed world. Despite its popularity, CS along with every surgical procedure is not without risk. Consequently in 1985, WHO suggested that no region should have a CS rate over 10–15%.1 Attitudes towards maternal request for CS vary throughout the developed world. The EUROBS study2 in 2006 surveyed obstetricians in eight European countries with focus on their views on maternal requests for CS, and included a case which featured a healthy 25-year-old woman requesting surgical delivery with no medical need for it. The compliance rates
Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558 Copyright Article author (or their employer) 2013.
for obstetricians varied from 79% in the UK to 15% in Spain, with respect for patient autonomy stated as the most common reason to carry out the procedure.2 In November 2011, the National Institute for Health and Care Excellence (NICE) released guidelines stating that pregnant women requesting a CS could receive one, even when there was no medical indication.3 This is known as the ‘maternal request caesarean.’ The CS rate in the UK in 2010–2011 was 24.8%.4 Previous CS is the single greatest risk factor for placenta praevia and placenta accreta5; praevia is where the placenta implants near or over the internal cervical os and accreta being abnormal growth of the placenta into the myometrium. If this occurs, the risk is of catastrophic bleeding at delivery leading to significant maternal morbidity and mortality. The risk of abnormal placentation rises exponentially with the number of caesareans performed, probably as a result of the increasing amount of uterine scar tissue. It has been estimated that if the CS rate continues to rise at the current rate, by 2020 the USA will have a delivery rate of 56.2%.6 This alone will account for an additional 6236 placenta praevias, 4504 placenta accretas and 130 maternal deaths annually.6 CS for an obstetric indication has undoubtedly improved fetal and maternal morbidity and mortality over the last 50 years. It cannot, however, be considered as a completely benign procedure. The increasing worldwide CS rate will be accompanied by an increasing maternal mortality rate from major obstetric haemorrhage in subsequent pregnancies. It is now becoming clear that the potential adverse effects of CS may be far reaching, giving rise to serious complications that impact on current and potential pregnancies, as well as the mother herself. There is literature, such as that of Minkoff,7 that examines the concept of a maternal request for CS from an ethical point of view. This essay will include and expand beyond ethics with the use of a case study and statistics.
CASE REPORT A 38-year-old woman with a history of three prior CSs was diagnosed with placenta percreta, where the placenta implants abnormally into the myometrium and through it into other pelvic structures, 32 weeks into her fourth pregnancy. Her first caesarean had been an emergency in labour. The patient reported that she had been willing to try a vaginal birth for her second child but had been
Produced by BMJ Publishing Group Ltd under licence.
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Clinical ethics encouraged by the medical team to have a second CS. She had then followed standard UK practice and delivered her third child by CS. At the routine ultrasound scan 20 weeks into her fourth pregnancy, her placenta was noted to be lying under the caesarean scar. Further ultrasound imaging at 32 weeks demonstrated a large area of morbidly adherent placenta (accreta) with placental tissue growing through the uterus and penetrating the bladder wall ( percreta). The recommended management of such cases is not to attempt to separate the placenta from the uterus (after delivering the baby), but to perform a caesarean hysterectomy with the placenta still in situ. This becomes complex when the placenta has grown through the uterus into other structures, in this case the bladder. A multidisciplinary team was assembled to facilitate safe delivery, including obstetricians, anaesthetists, interventional radiologists, haematologists, urologists and neonatologists. The caesarean hysterectomy was performed at 34 weeks to limit the risk of spontaneous labour requiring the surgery to be performed as an emergency. Following steroid injections to mature the fetal lungs, the procedure took 9 h, and despite the assembled expertise, resulted in a major obstetric haemorrhage requiring 14 units of donor blood plus two units of autologous transfusion in addition to fresh frozen plasma, platelets and cryoprecipitate. The main surgical difficulty was separation of the anterior uterine wall from the posterior aspect of the bladder. As a result of the placenta percreta, the ureters and urinary bladder were damaged, and reimplantation and bladder reconstruction was required. The baby required initial resuscitation and was transferred to the neonatal intensive care unit, and the mother to adult intensive care for 24 h. Both went home in the next few weeks, however, considerable urological follow-up was required to manage the significant urological trauma. When interviewed for this paper, one of the most striking issues was the mother felt she had never been warned about the risks of CS to subsequent pregnancies. She had planned to have a large family and believed that had she been told of the risk of placenta accreta, she would have attempted to deliver her second baby vaginally. How much of this can be attributed to the recent traumatic experience combined with her possible recollection bias remains unclear. However, this case raises important issues regarding attitudes towards CS, as well as the current consent procedures. The UK’s Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women are warned about the risk of placenta praevia in future pregnancies but does not recommend discussing the risk of placenta accreta. In order to consider the ethics of maternal request for CS, and the risks it involves to all parties, a balanced and objective review of the literature must be carried out. The discussion of this essay will consider whether it is ethical to allow the mother to choose to increase her risk, and that of her future offspring, in order to potentially decrease the risk to the current baby.
BENEFITS OF CS For the mother Elective CS has several benefits for the mother including reduction of perineal and abdominal pain during birth and 3 days postpartum, when compared with the pain associated with normal vaginal delivery.3 Vaginal delivery can be an unpredictable process and situations such as fetal distress dictate the requirement for an emergency CS. This emergency procedure is accompanied by an increased risk of morbidity and mortality when compared to a planned CS.8 Urinary incontinence and its relationship with pregnancy and delivery is a topic of frequent 2
debate. Gyhagen et al9 state that the prevalence of urinary incontinence at more than 10 years after a single birth is higher for those who had a vaginal delivery (40.3%) compared with women who had a CS (28.8%) after one birth. Overall benefits may also include reduction in anxiety about childbirth and labour and increased psychological satisfaction with childbirth.
For the baby There are benefits of an elective CS for the baby, which include an arguable reduction in antepartum stillbirth. This benefit occurs as a result of the gestation at which most elective caesareans are performed (39 weeks), as the risk of stillbirth increases by a factor of six from 37 to 43 weeks gestation.10 There is also a decrease in the incidence of vaginal delivery-related injuries, most commonly damage to the brachial plexus secondary to difficulty delivering the baby’s shoulders.11 This, however, is only a small reduction of 1 in 5000–10 000 births in the case of elective CS.12 Finally, there is a reduction in the incidence of neonatal encephalopathy; a syndrome defined by central nervous system dysfunction in babies, with one case avoided for every 317 CSs performed.12 However, this does not translate into a decrease in the incidence of cerebral palsy in babies delivered by CS.
RISKS OF CS For the mother When compared with vaginal delivery, CS leads to a longer hospital stay of between 0.6 and 1.4 days3 and an increase in postpartum haemorrhage rate from 3.5% in spontaneous vaginal births to 13% after CS.13 As with all major abdominal surgery, there is a risk of damage to organs such as the bladder in 0.1– 1% of operations.3 Although these risks are small, they are still present and can have a huge effect on quality of life. A study in the Lancet showed that infection of the wound or endometrium occurred in 4.9% of planned vaginal births.14 This figure rose to 6.4% for planned CSs.13 Pregnancy increases the risk of thromboembolism due to alteration of the coagulation system, and surgery further increases this risk. Consequently, CS increases the risk of developing a puerperal deep vein thrombosis eightfold.15 The woman must also take into account the effect of a CS on future pregnancies, as there are two potentially severe consequences. The first is doubling of the risk of stillbirth in the subsequent pregnancy to 1.1% as shown by Smith et al.16 The second arises from the effect of abnormal placentation, such as placenta accreta, or percreta, for which CS is the single greatest risk factor.6 Placenta accreta has a maternal mortality rate of 7%,17 morbidity in the form of emergency hysterectomy and has been shown to be related to the number of previous CSs.17 A pregnant woman who has had one previous CS has a risk of 0.31% for a placenta accreta and a 0.4% risk of hysterectomy. A woman who perhaps only wants two children, may perceive this as a small increase in risk, but it is still present. Increase the number of previous CSs to five and the risk of placenta accreta rises to 6.75% accompanied by an increase in hysterectomy rate of 8.99%.18 In the UK, the incidence of placenta accreta is increasing with the rate of CSs; in the period 1970–1980 the incidence was between 1:4027 and 1:2510 births, whereas during 1982–2002, it had increased to 1:533 births.19 Placenta accreta increases the risk of death, and it also requires specialist antenatal care for safest delivery of the baby. This includes the need for consultant obstetricians, anaesthetists and interventional Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558
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Clinical ethics radiologists, blood products and the availability of intensive care beds for the mother and baby.
For the baby The risks to the baby should also be considered in the balanced view of elective CS. In elective CS, the normal physiological changes that take place during labour do not occur, thus reducing the normal neonatal lung adaptation that takes place. The baby is at increased risk of respiratory and cardiovascular problems; CS is an independent risk factor for respiratory distress syndrome with an increase in risk of 130% when compared with vaginal delivery.20 The risk of the baby requiring transfer to neonatal intensive care unit increases from 5.2% for planned vaginal deliveries to 9.8% in planned caesarean deliveries.21 During delivery, there is a risk of surgical laceration to the fetus, and in the UK currently this stands at around 2%.3 Studies have shown that maternal hypotension during surgery can lead to transient fetal respiratory acidosis and may cause respiratory disorders, such as meconium aspiration.22 Finally, delivery by CS may lead to hypothermia, hypoglycaemia and an increased risk of sepsis for the baby.23 Despite antepartum stillbirth in the unborn baby being reduced by elective CS, the opposite is true for future pregnancies. Evidence shows that the risk of antepartum stillbirth is doubled in women who had a previous CS when compared with those who had not had a CS.3
THE ETHICS OF MATERNAL REQUEST FOR CS The evidence above indicates an overall increased risk of adverse outcomes for the mother and subsequent pregnancies. The principles of Biomedical ethics introduced by Beauchamp and Childress 24 will be used to examine whether it is ethical to allow women to choose a maternal request for CS and increase the risk to themselves and future offspring, to potentially decrease the risk to the current baby. Beauchamp and Childress offer a clear approach to analysis of ethical questions with the use of four basic principles; autonomy, justice, beneficence and non-maleficence.24 ▸ Autonomy is the capacity of a rational individual to make informed uncoerced decisions. ▸ Justice means an equal and fair distribution of resources and treatments. ▸ Beneficence is the act of doing ‘good’, or a state of kindness. ▸ Non-maleficence is defined as the act of doing no harm.
Autonomy Autonomy is translated in medicine as the patient’s right to decide about his or her own care. In the case of maternal request for CS, if the woman’s autonomy is to be respected she must have the right to make the decision about how her baby is to be born. She should have the capacity to make this decision, which must be fully informed and without influence. The EUROBS study discussed above demonstrates clearly that obstetricians stated autonomy of the patient as their main reason for agreeing to a maternal request for CS in the case study of the trial.2 This shows the mother’s decisions about her care are deemed very important within the speciality, and adds weight to the argument that she should be entitled to have some choice in her method of delivery. While much of the concern regarding inappropriate influence is focussed on the agenda of the attending doctor, the influence exerted by media, the woman’s peers, and advisory groups, such as the National Childbirth Trust can also be enormous. Pregnancy is renowned for being a time of hormonal and Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558
emotional liability, with depression and anxiety being common.25 Whether this has an effect on the mother’s decision making is difficult to assess, but should, nonetheless, be considered. The obstetrician also has rights to autonomy. They may feel it is unnecessary or inappropriate to perform major abdominal surgery when vaginal delivery is the default method of delivery. Living in an era of contraception and termination of pregnancy, whether the woman has the right to ask a doctor to do what they may see as wrong is an issue that must be considered. As the professional carrying out the procedure, the obstetrician takes full responsibility including those of any complications, and as a result must feel comfortable in the concept of maternal requests for CSs.
Justice Justice is demonstrated in the above case of placenta percreta where preterm deliveries and CSs in these situations result in a huge use of healthcare resources. If more mothers have CSs without a medical need, the number of placenta praevias and accretas will increase. It might be argued whether the resulting drain on National Health Service (NHS) resources is acceptable in a time of economic downturn with increasing demand on all areas of the NHS budget. Without placental abnormalities, there is still a significant impact on length of stay in hospital and cost in terms of staffing, prophylactic antibiotics and other resources. In an era of an ageing population and increasing technology, there is a constant demand on healthcare resources, and decisions are required on how they should be allocated. Is the question of justice in the distribution of healthcare resources being considered when announcing that mothers have autonomy of decision regarding how their baby is delivered?
Beneficence and non-maleficence Beneficence is something every human should abide by, but when applied to CS there must be a choice between which party benefits. Is it the unborn baby and a reduction in their risk of brachial plexus injury? Is it the mother who had a previous vaginal delivery perceived by her as psychologically traumatic, and by carrying out an elective CS, the doctor removes her abject fear of experiencing the same nightmare? Beneficence must also be considered alongside nonmaleficence. Non-maleficence also includes not acting with malice towards patients, or recommending ineffective treatments. If there is some harm associated with a treatment or procedure then it must be in proportion to the benefit. So, as beneficence and non-maleficence go hand in hand, does the potential small benefit to the baby outweigh the nonmaleficence of denying the procedure to the mother due to her risk of haemorrhage, thromboembolism, placenta accreta and the many other complications associated with surgical delivery? Does the mother receive the beneficence of an elective CS for psychological reasons despite the fact that the current baby may experience transient tachypnoea and any subsequent babies have double the risk of dying in utero as a result of the procedure? Weighing up a maternal request for CS must consider the mother and fetus, and while one may benefit the other may not and, in fact, may become seriously ill or die. Most mothers would choose an increased risk to themselves to decrease a risk to their baby; it is natural instinct. Babies provoke emotional responses as some of the most vulnerable members of society and, consequently, decisions in these situations are often the hardest. 3
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Clinical ethics CONCLUSION The benefits and risks of CS are very important to consider alongside the ethical discussion about maternal request for CS. Despite improvements in surgical and medical care, there remain some serious risks associated with caesarean delivery that must be considered. Ultimately, the question asks whether it is ethical to allow the mother to request a CS when there is no obstetric indication, and in doing so increasing the risk to herself, to decrease the risk to the baby. The autonomy of the mother is of great importance in maternal request for CS, as she is the person consenting to a surgical procedure and, therefore, has the right to an informed decision, and consequently, her choice of method of delivery. Her decision must be respected and understood by healthcare professionals to appreciate her reasoning, and in helping her to achieve the delivery she wishes. Whether a pregnant woman understands the devastating effects of placenta accreta depends upon the consenting procedure, and may also depend on the consenting obstetrician’s own experience of complications resulting from CSs. Beneficence is applied in the situation of maternal request for CS to the mother and the baby, but most importantly to the mother as she is the primary patient. Some obstetricians may argue that carrying out a maternal request for CS is not compliant with non-maleficence due to the risks created by carrying out the procedure, for example, infection. The autonomy of these obstetricians must also be respected, and their wish to refuse maternal request for CS if they feel it may cause undue harm to one or both parties. However, the argument can also be seen from the view that a CS must be carried out to conform to non-maleficence of the baby as the procedure may reduce the risks it is exposed to nonmaleficence must also apply in doing no harm when a mother is anxious and frightened about giving birth vaginally. The obstetrician has the option of maternal request for CS that may solve the fear, and would be doing wrong to withhold this type of delivery. It would be unfair, similarly, to withhold CS for reasons of justice when considering the impact on future pregnancies. If CS is being offered to some women, it must be offered to all, regardless of financial or social status to comply with the principle of justice. The ethical principles appear to steer the argument towards supporting the maternal request for CS due to the significant influence of the autonomy of the mother. Her right to request a CS to decrease the risk to her baby seems to ‘fit in’ in an era when patient-centred treatment is commonplace in the NHS. Alongside this, lies the beneficence to the mother, justice in fair distribution of healthcare and non-maleficence to the unborn baby. However, the science associated with the argument must not be forgotten. A maternal request for CS does increase the risk to the mother, who may be mother to several children. This is why the obstetrician must also play a role in this debate; NICE dictates that they should consider maternal request for CS, but must also care for patients who are at risk of significant morbidity and even mortality from placenta accreta. As the professional who must counsel and take consent, they have a great responsibility to ensure that the woman has had the opportunity to fully explore the significant risks associated with a CS, including those of abnormal placentation in a subsequent pregnancy.
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Ultimately, as the person who will actually undertake the surgical procedure, the obstetrician must be certain that the risks and benefits have been fully explained, understood and appreciated, and that a CS is the best mode of delivery for that particular woman. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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Selinger H. J Med Ethics 2013;0:1–4. doi:10.1136/medethics-2013-101558
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Maternal request for caesarean section: an ethical consideration Hannah Selinger J Med Ethics published online November 18, 2013
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