Request For Cesarean Delivery Research Articles

Impact of cesarean delivery due to maternal choice on perinatal outcome in term nulliparous patients with a singleton fetus in a vertex presentation

Objective The objectives of our study were to: (1) evaluate the prevalence of cesarean delivery due to maternal request among nulliparous, term, singleton, vertex (NTSV) patients; (2) identify the clinical profile, if any, of these patients; and (3) compare the perinatal outcomes between NTSV patients who requested a cesarean delivery versus patients who did not request cesarean delivery. Study design This was a retrospective case control study performed at a single institution between November 2018 and July 2019. All NTSV patients who had a cesarean delivery due to maternal choice were identified and compared to the next two NTSV patients in labor who delivered vaginally or by medically indicated cesarean delivery following a cesarean delivery by maternal choice. The primary outcome was composite neonatal morbidity. Secondary outcomes were individual components of composite neonatal and maternal morbidity. Results Of 1138 NTSV patients, 61 (5.4%) patients opted for cesarean delivery by maternal choice. There were significant differences in the demographic/clinical profile between cases and controls including BMI (35.3 kg/m2 vs. 32.7 kg/m2, p < .01), birthweight (3552 gr vs. 3333 gr, p < .001) and documented mental illness (41.0% vs. 22.1% respectively, p < .01). There was no significant difference in composite neonatal morbidity between cases and controls (6.6% vs. 5.7%, adjusted odds ratio [aOR] 0.96, 95% CI 0.25–3.61). The risk for postpartum hemorrhage requiring blood transfusion was higher (but not statistically significant) in the study group (5.0% vs. 0.0%, aOR 6.43, 95% CI: 0.65–63.24). Patients who chose cesarean delivery during the intrapartum period had a higher (but not statistically significant) composite neonatal morbidity (14.3% vs. 5.7%, aOR 2.24, 95% CI 0.52–9.78) and composite maternal morbidity (28.6% vs.11.8%, aOR 2.90, 95% CI 0.92–9.16) and significantly higher transfusion rate (aOR 16.93, 95% CI 1.53–187.74). Conclusion Cesarean delivery by maternal choice in NTSV patients is not associated with improved neonatal outcomes; in contrast, it is associated with increased composite maternal morbidity and increased transfusion rate.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study

BackgroundNo Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA).MethodsNA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016.ResultsThe rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = − 0.782 (95%CI [− 0.948, − 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = − 0.914 (95%CI [− 0.989, − 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05).ConclusionsOur study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Cesarean delivery and infant cortisol regulation

BackgroundCesarean delivery reduces the risk of infant and maternal morbidity and mortality when medically indicated, however, the cesarean delivery rate is estimated to be two to three times higher than medically necessary. The World Health Organization and American College of Obstetricians and Gynecologists have expressed concern over the high rates of cesarean delivery, citing evidence that cesarean delivery has negative short- and long-term consequences for the health of the infant, mother, and for future pregnancies. Infants delivered by cesarean are at an increased risk of metabolic disease and immune dysfunction throughout the lifespan. Preliminary research suggests that the hypothalamic pituitary adrenal (HPA) axis is a plausible pathway linking cesarean delivery to poor health later in life. The present study examines the relation between mode of delivery and HPA axis function in six-month-old infants. We also examine whether the cesarean delivery was elective or indicated altered to the relation between mode of delivery and infant cortisol profiles. MethodsThe sample included 136 mother/infant pairs. Thirty-nine women delivered by cesarean and 97 delivered vaginally. Maternal and infant medical records were reviewed for prenatal medical history and birth outcomes. Infant saliva was collected for cortisol analysis at a 6-month well-baby checkup. Samples were collected upon arrival to the appointment (baseline) and 20 min after exposure to a painful stressor, the inoculation procedure (response). A mixed model ANCOVA was conducted to determine whether salivary cortisol concentrations differed between the two delivery groups. To examine whether complications related to having an indicated cesarean delivery contributed to any association between mode of delivery and cortisol production, cortisol concentrations were compared between the subgroup of infants whose cesarean deliveries were elective (e.g. maternal request or previous cesarean delivery) to infants delivered vaginally. ResultsInfants delivered by cesarean had lower cortisol concentrations at baseline and after the inoculation procedure compared to those delivered vaginally. Further, the relation between mode of delivery and cortisol levels persisted even when the analyses were restricted to compare only the elective cesarean deliveries (e.g. maternal request or previous cesarean delivery) to those delivered vaginally. DiscussionThis study provides evidence for an association between cesarean delivery and infant HPA axis function in infancy. Findings are consistent with the hypothesis that the HPA axis is a plausible pathway that links cesarean delivery with long-term health outcomes.

The Validity and Reliability of the Wijma Delivery Expectancy/Experience Questionnaire (Version A) in Primiparous Women in Mashhad, Iran.

Background: Although pregnancy and childbirth are physiological processes, fear of childbirth is a common problem that is often associated with requests for cesarean delivery. This study was undertaken to determine the validity and reliability of the Wijma Delivery Expectancy/Experience Questionnaire A (W-DEQ [A]) primiparous women in Mashhad, Iran.Methods: This study was conducted on 220 primiparous women with a gestational age of 28-30 weeks referred to health centers in Mashhad. Using demographic questionnaire, Beck’s Anxiety Inventory, Beck’s Depression Inventory, and the W-DEQ (A), for determining the validity and reliability of the W-DEQ (A), first two linguists translated the questionnaire into Persian; then, two other linguists translated the Persian version back into English. The content validity of this version was then assessed by expert faculty members. The final version was sent to the questionnaire’s original developers (Klass Wijma and Barbro Wijma) and then used after their approval. Factor analysis was used to analyze the data.Results: The result of actor analysis revealed six factors, forming 58.8% of the total variance. The reliability of this questionnaire was confirmed with a Cronbach’s alpha coefficient of 0.84, and the fear of childbirth was found to be correlated with Beck’s anxiety (r=0.414) and depression (r=0.287) scores.Conclusion: The W-DEQ (A) is a valid and reliable tool for measuring the fear of childbirth and is recommended to be used for measuring the fear of childbirth among Iranian women.

An ethical framework for counseling about mode of delivery for desired psychosocial benefit in pregnancies complicated by severe fetal anomalies

Abstract Background A fetal diagnosis poses ethical challenges when a woman requests elective cesarean delivery for psychosocial reasons. We address the ethical challenges of counseling such patients. Case presentation A 36-year-old G4P2012 has chosen to continue a pregnancy despite a high likelihood of trisomy 18. At 36.5 weeks she was admitted for preeclampsia with severe features and requested to be delivered by primary cesarean section. Due to the poor prognosis associated with trisomy 18, the patient’s request for cesarean delivery was declined even when her baby changed to breech presentation with Category 2 fetal heart rate (FHT). The patient subsequently experienced a traumatic stillbirth and post-traumatic shock disorder (PTSD). Conclusion The obstetrician’s goal should be to transform the patient’s request into an informed decision. The obstetrician should explain that, while a cesarean could increase the likelihood of a live birth, it will not alter long-term neonatal outcomes and entails net biomedical risk for the current and future pregnancies. The obstetrician should ensure that the patient understands these clinical realities. The obstetrician should support the patient’s decision-making about whether to accept the risks of cesarean delivery for psychosocial benefit. The obstetrician should initiate counseling during prenatal visits to empower the patient with information to meaningfully exercise her autonomy. If the patient makes an informed decision for cesarean delivery, it becomes ethically permissible. Plans regarding intrapartum management and mode of delivery should be documented in case the patient is delivered by a physician who was not involved in prenatal counseling.

Placenta response of inflammation and oxidative stress in low-risk term childbirth: the implication of delivery mode

BackgroundCaesarean delivery rate is increasing gradually in China and there is no doubt that delivery mode is closely associated with the maternal health and infant development.This study examined the independent effect of delivery mode on placenta inflammation response and oxidative stress response.MethodsA total of 3474 pregnant women recruited in Ma’anshan Birth Cohort Study were the initial study population. Data on maternal socio-demographic characteristics and pre-pregnancy BMI were collected at their 1st antenatal checkups. Pregnancy-specific anxiety was assessed during the three trimesters of pregnancy. Common pregnant complications were monitored in the whole pregnancy period. Delivery modes, as well as newborn characteristics were abstracted from medical records. Delivery modes included vaginal deliveries (VD), caesarean delivery with medical indications (CDMI), caesarean delivery on maternal request (CDMR) and urgent cesarean delivery (UCD). Placentas were collected during childbirth. The mRNA expression of IL-1β, TNF-a, IL-6, IFN-γ, IL-4, IL-10, IL-8, and HO-1 were assessed in the final sample of 1978 low-risk women with singleton term-births.ResultsThe overall rate of caesarean delivery (CD) was 50.5% (1650/3265) in singleton term childbirths in this study. Among women who reported definite CD reasons, 56.8%of them chose the surgery without any medical indications.It shows a non-linear relationship between cytokines related with placenta inflammatory response, oxidative stress response and different delivery modes. At high percentiles of IL-1β, IFN-γ and IL-8, women with CDMR had higher expression levels compared to women with VD. Women with CDMI had higher levels at median percentiles of IL-1β, IFN-γ and IL-8. Women with CDMR had higher expression compared with VD at high percentiles of IL-6 and HO-1, and women with CDMI had higher levels of these two cytokines at their low percentiles. It is worth noting that at high percentiles, compared with normal delivery, the expression of IL-1β, IFN-γ, IL-8 and HO-1 have significantly altered in women with CDMR.ConclusionA high overall CD rate was found in this study, and caesarean delivery on maternal request was the major contributor to the high prevalence. Maternal placental oxidative stress and inflammatory response were closely associated with delivery mode. The effect is much amplified at high levels of expression in women who chose CD on maternal request.Such difference needs to be noticed and may have important implications for obstetricians, midwives and other perinatal health care workers.

When Patients Request the Knife – Cesarean Delivery on Maternal Request

When Patients Request the Knife – Cesarean Delivery on Maternal Request Cesarean delivery on maternal request is defined as a prelabor cesarean delivery on maternal request in the absence of any maternal or fetal indications. There are many reasons underlying why women may desire this type of delivery versus planned vaginal delivery: anxiety over the birthing process, concern for perineal trauma during vaginal delivery, potential for urinary incontinence or pelvic organ prolapse, or the desire of selecting the date of delivery..

The Case Against Cesarean Delivery on Maternal Request in Labor

The ethical obligations of an obstetrician to a patient who requests a cesarean delivery without maternal or fetal indication differ depending on whether the request is made before or during labor. Informed consent is an essential dimension of respecting patient autonomy, and the process of informed consent should be extensive for a cesarean delivery in the absence of maternal or fetal indications during active labor. For this reason, physicians should rarely grant a request for cesarean delivery made during active labor. Although physicians may think that declining a request for cesarean delivery is a violation of patient autonomy, they should also be concerned about the violation of patient autonomy that results if they are unable to adequately complete the process of informed consent during labor.

Cesarean delivery on maternal request: survey among obstetricians/gynecologists in south-east Hungary

increased frequency of maternal request for cesarean delivery may be a contributing factor to the rising cesarean section rate in Hungary, although there is no formal indication that would allow Hungarian obstetricians to perform this procedure legally. Thus, it is difficult to estimate the role of maternal request in the rising cesarean rate. The aim of the authors was to assess the attitudes of obstetricians toward this procedure. In early 2010 anonymous questionnaires were distributed to each of the 137 obstetricians working in the maternity wards of counties Bács-Kiskun, Békés and Csongrád, with a response rate of 74.5% (n = 102). More than half of the respondents refused the possibility of a legalized indication for this procedure in Hungary; however, in case it was legalized, 81 (79.4%) obstetricians would feel ready to perform it. The resistance of more than half of the obstetricians to an explicit indication for the procedure is in conflict with the theoretical willingness of the majority of them to perform it.

Cesarean by Choice? Empirical Study of Public Attitudes

Objective. This study examines public attitudes towards maternal requests for cesarean delivery and its association with health care and birth experiences. In addition, this study attempts to ascertain whether gender, age and residence influence these attitudes. Design. Cross-sectional population survey with a postal questionnaire. Setting. The counties of Stockholm and Vasterbotten in Sweden. Population. Equal numbers of women and men between 20 and 80 years of age (n = 2,000) by population size and gender distribution. Methods. Descriptive statistics and content analysis. Results. Of the 1,066 women (53%) who responded, two-thirds stated that a cesarean should be decided on for medical reasons and by a doctor. One-third considered that a woman, without persuasion, should decide herself about mode of delivery and should be free to choose a cesarean. These respondents used arguments such as women's rights, bodily integrity and childbirth fear. The results were associated with low trust in health care, women being young or middle aged, urban living and having no children. Low trust in health care was associated with experiences of insecurity, vulnerability and perceived maltreatment. Conclusion. Public norms towards women's own decision making on mode of delivery are associated with younger age, lower trust in health care and urban living. Antenatal care will encounter more parents asking for a cesarean and demanding that health professionals provide an ethically appropriate informed consent process. Considering the risk of violating young women's trust if not respecting her wish, it seems reasonable that making decisions whether or not to perform a cesarean is part of shared decision making.

Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia

The rate of cesarean section in Australia now exceeds 30 percent, and evidence from population studies indicates that maternal requests for elective cesarean delivery might make an important contribution. The objective of this study was to explore the rate of such deliveries in Australia, in the absence of a formal investigation. An anonymous survey was sent to all 1,239 specialist obstetricians and 317 obstetric specialty trainees in Australia. Specialists were asked the number of elective cesarean deliveries they performed in 2006 that satisfied the National Institutes of Health definition of maternal request cesarean delivery. Trainees were asked whether they intended to agree to maternal requests for cesarean section in their future specialist practice. The response rate from specialists was 98.6 percent, and from trainees was 81 percent. To account for possibility of multiple submissions, we performed two analyses: one using all responses, the other after removing 297 surveys in the second mail-out that were identical to surveys received from the first mail-out (n = 735). Proportions were similar in both groups. We estimated that between 8,553 and 12,434 maternal request cesarean sections were performed in Australia in 2006, representing at least 17 percent of all elective cesarean sections, and slightly more than 3 percent of all births. Maternal request is an important contributor to cesarean section rates in Australia.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Trends in Maternal Request Cesarean Delivery from 1991 to 2004

Trends in Maternal Request Cesarean Delivery from 1991 to 2004

Trends in Maternal Request Cesarean Delivery From 1991 to 2004

Trends in Maternal Request Cesarean Delivery From 1991 to 2004

Trends in Maternal Request Cesarean Delivery From 1991 to 2004

Trends in Maternal Request Cesarean Delivery From 1991 to 2004

Trends in Maternal Request Cesarean Delivery From 1991 to 2004

To review definitions and terminology for and to estimate percentages of maternal request cesarean deliveries in the United States between 1991 and 2004. National Hospital Discharge Survey data 1991-2004 (N=458,767) were used to identify maternal request cesarean deliveries. After excluding women with a history of cesarean delivery, women who labored, and women with indicated risks against labor, 2,394 potential maternal request cesarean deliveries remained. Indicated risks were identified with a recognized protocol. Maternal request cesarean deliveries have two properties: 1) cesarean delivery before labor and 2) cesarean delivery in the absence of medical conditions presenting a risk for labor. Risk is either absolutely absent or it is relatively absent. In 1991-2004, 0.20% of women who delivered live infants and 1.34% of women who delivered by primary cesarean delivery did so without any medical conditions listed on their hospital discharge record. Estimates for maternal request cesarean deliveries without certain indicated risks were 0.75% for women who delivered live infants and 5.03% for women who delivered by primary cesarean delivery. Maternal request cesarean deliveries without any indicated risk peaked in 1999 for women who delivered live infants. Maternal request cesarean deliveries without certain indicated risks crested in 2004. Our estimates were affected by three factors: 1) lack of agreement on a definition of maternal request cesarean deliveries, 2) changes in medical coding practices, and 3) changes in physician response to medical conditions. To validly and reliably estimate maternal request cesarean deliveries requires an empirically tractable, standard definition. III.

Caesarean Section on Request: A Comparison of Obstetricians??? Attitudes in Eight European Countries

In this cross-sectional survey, conducted in 8 European countries (Italy, Spain, France, Germany, Netherlands, Luxembourg, United Kingdom, Sweden), obstetricians who had at least 6 months of experience were surveyed regarding their attitude about performing cesarean section at the mother's request absent of any medical indication for the procedure. Of the 149 maternity centers with neonatal intensive care units asked to participate, 105 (70%) agreed, and 1530 practitioners (77%) answered an anonymous self-administered questionnaire. The highest rate of compliance with the woman's request because this was her (79%) was in the United Kingdom, and the lowest rate (15%) was in Spain. Being a colleague did not significantly influence a physician's willingness to perform a cesarean, nor did fear of vaginal delivery-except in Sweden, where 49% of obstetricians would perform a cesarean because it was the patient's choice, but 79% would perform a cesarean because of patient fear. In all countries, practitioners were more likely to accede to the woman's request for cesarean delivery if she had a previous cesarean, traumatic vaginal delivery, intrapartum death, or a disabled first child. The reason cited most for doing a cesarean exclusively because it was the woman's choice was respect for the woman's autonomy. In addition, more than half the respondents in most countries cited a wish to avoid possible legal consequences should vaginal birth be complicated. More than half of the respondents in all countries cited fear of litigation as often influencing their decision. Physicians from university-affiliated units were twice as likely to do a cesarean on demand. Female physicians honored the request less than male physicians, but this was the case only for physicians who themselves had children. Factors that were not influential included the physician's age, involvement in private practice or research, the unit's annual delivery and cesarean rates, and whether the unit was a referral center for high-risk pregnancies. Obstetricians who are asked to perform cesarean deliveries electively must balance their respect for the woman's autonomy and their understanding of the woman's underlying motivations and fears against what they believe will best promote the health and well-being of both the mother and fetus.

Physicians??? Responses to Patient-requested Cesarean Delivery

Argument continues about whether women should be empowered to choose cesarean delivery even if there is no medical indication. This survey, distributed in the year 2000 to all obstetrician-gynecologists in the Portland, Oregon, area, was designed to ascertain what determines physicians' responses to 17 scenarios involving a term patient with a singleton pregnancy who requested primary cesarean delivery. Two thirds of the physicians, numbering 170, responded; 140 of them, whose mean age was 47 years, were currently in practice and had been for 15 years on average. More than 90% of physicians agreed to cesarean delivery in 4 of the 5 cases with clear medical indications. In contrast, most practitioners did not agree to surgery when there were no medical indications. When medical indications were not clear, responses were divided. Male respondents were significantly likelier than females to agree to perform a cesarean delivery when a woman was concerned about future urinary incontinence or had a history of stillbirth. With no medical indications, female physicians were less likely than men to agree to cesarean delivery. After adjusting for physician-related factors, respondents were more likely to agree with a request from a high-socioeconomic-status woman. The physicians' responses were not significantly associated with their age, years in practice, or type of practice. Physicians do not readily agree to a patient's request for cesarean delivery unless there is a clear medical indication for the procedure. This is especially the case for female physicians.

Maternal age and the likelihood of a maternal request for cesarean delivery: A 5-year population-based study

The purpose of this study was to examine associations between maternal age and maternal request cesarean deliveries. Five-year population-based data from Taiwan (1997-2001) that covered 904,657 singleton deliveries without a clinical indication for cesarean delivery that were judged by the attending physician were subjected to multiple logistic regression, year-wise, to examine the association of maternal age with request cesarean delivery, adjusted for health care institutional characteristics. Request cesarean delivery rates steadily increased over the study period within each age group, disproportionately so among the 34+ age group. Women aged < 25 years were less likely than women aged 25 to 34 years (reference group) to request a cesarean delivery (odds ratio range, 0.67-0.88) and women aged 34+ were more likely than the reference group to have a request cesarean delivery (odds ratio range, 1.96-2.01), adjusted for health care institutional characteristics. Population-based data confirms the expectancy that request cesarean delivery propensity increases with maternal age.

Physicians’ Responses to Patient‐Requested Cesarean Delivery

The issue about whether a woman's autonomy in childbirth should include the choice of cesarean delivery in the absence of medical indications has become a major source of debate. Our objective was to examine factors that determined physicians' responses to patient-requested cesarean delivery. Surveys were distributed to all obstetrician-gynecologists in the greater Portland, Oregon, metropolitan area in Spring, 2000. Physicians were asked to respond to scenarios involving a term patient with a singleton pregnancy requesting primary cesarean delivery. One hundred and seventy of 255 physicians (67%) responded, of whom 68 to 98 percent agreed to cesarean delivery in cases with clear medical indications. Without a clear medical indication, most practitioners would not perform a cesarean delivery. In cases where medical indications were unclear, responses were divided. Physician male gender and patient high socioeconomic status were associated with increased likelihood of physician agreement to patient-requested cesarean delivery. Age, years in practice, and practice type were not associated with agreement. Physicians are reluctant to agree to patient request for primary cesarean delivery without a clear medical indication. Male physicians were more likely to agree to a patient's request for cesarean delivery than female physicians.