L’élévation du taux de césariennes : un progrès nécessaire de l’obstétrique moderne

Abstract

During the last 10 Years, the cesarean section (CS) rate was increased despite of the recommendations of the World Health Organization to keep it below 10-15%. The purpose of this review of the literature was to demonstrate how the concept of CS rate limitation has become obsolete. The increase in the CS rate is mainly justified by the decrease in maternal mortality and morbidity following elective CS: surgery-related risks have decreased and the confusion that was made between the risks of vaginal delivery and those of trial of labor has to be clarified to show that maternal mortality and morbidity are not increased by elective CS. However, instrumental delivery and CS during labor remain two situations at high risks both for the mother and her fetus. There is also an association between the increase in the CS rate and the decrease in perinatal mortality and morbidity, but this effect would only become clinically significant after a dramatic increase in the CS rate: this is the preventile principle of "marginal death". Numerous articles have been published reporting on the effects of vaginal delivery for the pelvic floor: urinary incontinence, pelvic organ prolapse, and especially fecal incontinence. All these publications concluded that CS has a protective effect. The rising duty to provide information to patients in high risk obstetrical situations such as a history of CS also contributes to the overall increase in CS rate mainly through the elective CS rate. Indeed, when faced with the alternative choices of potentially severe complications either for themselves or their child, women are likely to choose what appears to be the safest mode of delivery for their child and thus to opt for a CS. Finally, widespread delivery of information to the patients about trial of labor itself and the risks of vaginal delivery is the first step towards a "principle of preference", which consists in giving an important place to the patient's choice in the decision-making process, and thus to recognize her right to ask for an elective CS.