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Elective Cesarean Delivery
Elective Cesarean Delivery (Belly Birth)
Elective cesarean delivery is delivery of the baby by cesarean without a medical indication at the request of the mother. It has many names in the literature and the American College of Obstetricians and Gynecologists (ACOG) refers to it as Cesarean Delivery on Maternal Request. They even have a Committee Opinion about this matter. ACOG states that, “There is no randomized clinical trial that has compared cesarean delivery with trial of labor for singleton term gestations with vertex presentation.”
In general, elective cesarean delivery is NOT a choice that is presented to women. It is almost always requested by the woman. It is assumed that all women want a vaginal delivery if not medically contraindicated. I am guilty of never presenting this birth option to my patients, but I will perform it for them after informed consent- to include discussing their reasons for wanting an elective cesarean delivery. Both vaginal delivery and cesarean delivery have risks. There is no risk-free mode of delivery.
There are people who try to make women feel guilty about avoiding a vaginal delivery, saying they are, “Too posh to push.” A derogatory term for an elective cesarean delivery is, “Unnecesarean.” Some women have logical reasons for wanting an elective cesarean delivery while others might have tokophobia- fear of childbirth. This tokophobia might arise from a fear of genital damage, death, injury to the baby, and so on. Both logic and emotion drive the desire to avoid damage to the genital tract. Some women will refuse to get pregnant until they find an obstetrician who will guarantee to deliver by cesarean. Therapy for tokophobia is recommended.
Some famous women have chosen to have an elective cesarean delivery: Catherine Zeta-Jones, Victoria Beckham, Madonna, Celine Dion, etc. Other women who fear childbirth pay a surrogate.
Cesarean delivery occurs in about 1 in 3 births nationally. Let’s talk about the matter in general terms first and then provide a little more detail.
What is a cesarean delivery?
It is a surgical procedure to deliver your baby through an incision on your lower abdomen. Cesareans are one of the most common surgeries performed in the U.S. If done correctly by an experienced and dedicated obstetrician, it can be safe.
First an incision is made transversely, sideways, in your lower abdomen just above the pubic bone. The incision goes through the skin, fat, and then muscle fascia. The rectus muscle is separated and the peritoneum (lining of the abdominal cavity) is entered. After separating the top of the bladder from the lower part of the uterus, the uterus is entered and the baby is delivered. Then everything is closed up.
There are two types of obstetricians when it comes to cesarean deliveries. Sloppy, impatient, and arrogant ones who pride themselves on how fast they can finish a cesarean delivery who often do substandard work during the closing of the uterus and abdomen, sometimes resulting in complications such as bleeding, bowel perforation, need to re-operate, and so on. Then there are obstetricians who put the patient first and take the little extra time to avoid complications and close the surgical site layer by layer. I do not believe in leaving a mess for the next obstetrician to deal with or the patient to suffer from.
Skin closure can be a subcuticular (under the skin) stitch and glue or staples. I prefer stables because they give a thin, beautiful scar. Staples also allow blood and fluid to drain during the first 24 hours to prevent complications. And in the rare instance that a wound infection occurs, the surgeon only has to open a couple of staples instead of the whole wound.
What happens on the day you arrive for surgery?
You don’t eat for 8 hours before surgery and you have already washed with Hibiclens the night before and the day of surgery. Then you change into a gown, have an IV started and blood drawn, are asked many questions by the nurse, and consented by the anesthesiologist and the obstetrician. Any hair in the surgical field will be removed by a clipper. Do not let them use a razor, as the infection rate is higher when a razor is used.
You will then walk into the OR, sit on the edge of the table, get a spinal anesthetic (which I think hurts less than getting an IV started), lie down, have a vaginal prep, Foley catheter placed, and abdominal prep. You will then be draped and your partner will be brought in. There will be some pushing and pulling during the surgery but there should not be any pain. Rarely you will have to be put to sleep if the spinal is not providing adequate pain relief. It takes about an hour in and out of the OR. You will be walking in your room that night and eating regular food. The Foley comes out after about 12 hours. The nice thing about the spinal is that they also inject a long-acting morphine derivative that lasts 24 hours or longer to provide you with very good pain relief. Most patients want to go home two days after the surgery.
Depending on the hospital, the nurse and / or hospitalist (hospital employed obstetrician on call for the unit) might try to talk you out of or even try to prevent you from having an elective cesarean delivery- especially if this is your first pregnancy. This is because there is a national campaign to lower the cesarean rate in women having their first delivery. It is referred to as NTSV cesarean delivery rate. Nulliparous (first baby), Term (37 weeks and above), Singleton (one baby), Vertex (head down).
In a perfect world every woman could and would have a vaginal delivery. There are different reasons, most medical but some not, for having an elective cesarean delivery. Large babies, twins or triplets, placenta previa (placenta is over the cervix), previous uterine surgery (like a myomectomy), and so on are some reasons women have a cesarean delivery. But some women do not want to go through the experience of a vaginal delivery for several reasons. Fear of pain, fear of the birth process, desire to keep their reproductive pathway in pristine condition, horror stories from family or friends, desire to be in control of the birth process, wish to deliver exactly on a certain date, and so on.
However, even in this age of elective major surgery on demand, there are hospitals and obstetricians who want to deny women their right to have a cesarean delivery. The fact is, when you deny a woman her right to an elective cesarean delivery, you are FORCING her to have a vaginal delivery. This might be somewhat tenable if it was being done for completely altruistic or beneficent reasons, but as you will see, it is not.
What every woman needs to know is that their insurance company likely offers a financial incentive to get hospitals to lower their NTSV cesarean rate. Since cesareans cost a few thousand dollars more, the insurance company sees this as an easy way to make more money by bribing the hospital, who in turn economically credentials physicians. If a physician honors the patient’s request for an elective cesarean delivery, the hospital can get rid of that physician. With American medicine being for profit, hospitals have been given the power over physicians and patients by your Federal government. In reality, you and your physician have very limited rights when either one of you get in the way of profits. There are reports that the cost of an elective cesarean delivery is equivalent to a vaginal delivery with oxytocin.
Bottom line: If your obstetrician does not talk you out of an elective cesarean delivery, or agrees to perform an elective cesarean delivery, the hospital can revoke or not renew their privileges.
You can read, Case Study: Maternity Payment and Care Redesign Pilot, by Pacific Business Group on Health. It details how they used ‘payment reform’ to take away the economic incentive to perform cesarean deliveries to physicians and hospitals. I have no problem with being paid the same regardless of the mode of delivery, but the hospitals are put in the position of punishing physicians for performing cesarean deliveries in order to increase profits- economic credentialling.
Aligning Birth Payment to Reduce Unnecessary C-Section: A Menu of Options. By SmartCare California. This article advocates paying less for an elective cesarean delivery AND for scheduled repeat cesarean deliveries.
Now to be fair, an article in JAMA 2021 noted that the cesarean rate was higher in hospitals that made more money from the procedure. So, it would be ethical for insurance companies to come to an economic understanding with the hospitals and obstetricians that would not endanger the baby or violate the rights of the very few women who want an elective cesarean delivery. Instead of imposing an artificial target for the NTSV cesarean rate, it would make more sense to review all NTSV cesarean deliveries to see if they were medically indicated, excluding the elective cesarean deliveries.
Since only 2.5 % of deliveries are elective cesarean deliveries, then is appears that denying women this right with the goal of lowering the NTSV Cesarean Delivery Rate in order to make the insurance company and hospital more money is not ethical and would have little impact on the overall NTSV rate. Remember, about a third of those women denied an elective cesarean delivery will end up getting a cesarean delivery anyway for medical indications during labor. It is illegal for hospitals to bribe physicians to refer patients to them, but it appears to be legal for insurance companies to bribe hospitals to deny women their right to choose the mode of delivery.
Ethically, if your hospital suggests other medical interventions to you regarding your pregnancy, such as induction of labor, they should also talk to you about your option to have a cesarean birth. This would be part of informed consent. Consent and refusal are constitutional rights. A woman’s right to decide what happens with her body remains even when she is pregnant. Put another way, her right to refuse to have a vaginal delivery is just as germane as her (settled) right to refuse to have a cesarean delivery.
Personal and professional statement: I would prefer that all pregnant women have a vaginal delivery if possible. However, I did not spend 12 years of my adult life to become an obstetrician so I could bully women into submitting to my wishes or the demands of others. I fully counsel my patients and my advice is always provided with my patient’s welfare in mind. Greed, inconvenience, and personal bias do not factor into the advice I give to my patients.
My only goal in obstetrics is providing the best outcome for both the mother and the baby.
More information if you are interested:
The Term Breech Trial (randomized) demonstrated no significant increase in the risk of MATERNAL death or serious MATERNAL morbidity with respect to whether the woman had a vaginal or cesarean delivery. This would be expected to apply to women with a vertex (head down) pregnancy.
Potential risks for subsequent pregnancies after a cesarean:
Placental abruption 1%, placental previa 0.5%
Neonatal respiratory distress: 3.5% pre-labor cesarean, 1.2% cesarean after labor, 0.5% vaginal
Cesarean delivery is ridiculed as not being natural. It is also hard to characterize a long hospital labor, continuous fetal monitoring, induction or augmentation of labor, epidural analgesia, forceps or vacuum delivery, episiotomy, and multiple providers as normal or natural childbirth.
Planning for a vaginal delivery and then undergoing an emergency cesarean delivery is riskier for the mother than an elective cesarean delivery.
Women may choose elective cesarean delivery for a diversity of reasons. Desire to protect the sexual function and performance of the pelvic organs, fear of fetal death, desire for a quick delivery with minimal pain, fear of pain due to inadequate analgesia.
For true informed consent the woman must be mentally and legally competent, aware of alternative choices, and has the knowledge and understanding about the procedure.
The ethical goal is to maximize beneficence and minimize non-maleficence.
Woman must make her decision early enough before labor so as to ascertain that she can deliver at a hospital that will provide an elective cesarean delivery.
If fear of pain, appropriate counseling must occur, yet one cannot guarantee that epidural will provide a pain-free delivery.
Unlike in developing countries the elective cesarean delivery is not unnecessarily taking away scarce resources from another who might need them. Unless it leads to higher insurance premiums that affect all insured. Yet, your insurance premiums pay for sexual reassignment surgery, gastric bypass, breast reduction, and Viagra. It would be fair to say that if you deny a woman her elective cesarean delivery then you should deny others procedures that could be argued to be elective
Defining whether elective cesarean delivery is essential is a value judgement and who gets to make that determination is debatable. The insurance company, the hospital who is paid by the insurer to lower NTSV rates, the physician who should be the patient's advocate, or the patient?
If it is unethical to prescribe medications that are not medically indicated, then it can be construed to be unethical to provide an elective cesarean delivery. However, elective cesarean delivery can be considered a 'perineum-saving procedure'. Therefore, it would be medically indicated. Circumcision is not indicated and has no unbiased significant medical benefit but it is covered by insurance and allowed by hospitals without question.
In the US courts have ruled that 'neither fetal rights nor state interests on behalf of the fetus supersede women's rights as ultimate decision maker. If a woman is forced to have a vaginal delivery against her decision to have an electivecesarean delivery, this could be interpreted as assault.
You can ask for an elective cesarean delivery even if your provider does not think that you have a medical need for one. If a provider objects based on own conscience, they should refer the patient and not deny. The same applies to the hospital. Your hospital must listen to your reasons for wanting an elective cesarean birth and have good reasons for saying no.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that if you ask for an electivecesarean delivery, the hospital should support this if they are satisfied you are making an informed choice. That the hospital should discuss with you why you want a cesarean birth and the risks and benefits of cesarean and vaginal birth. If your request is due to anxiety about childbirth the hospital should refer you to a provider who is an expert in perinatal health. You do not have to accept this offer. NICE says that is you still want a cesarean birth after this discussion, the hospital should offer you an elective cesarean delivery. An individual obstetrician can refuse to perform a cs but should refer you to another obstetrician who is willing, if even if it means transferring you to another hospital. Nowhere does it state that the hospital can refuse the patient request.
In the European Convention on Human Rights, Article 8, it states that a woman has the right to make decisions about the circumstances of her birth, to include the manner in which she gives birth.
Some people raise the question of whether women who are consenting to elective cesarean delivery are TRULY informed about the short-term and long-term risks associated with cesarean birth versus a vaginal birth. Yet, obstetricians do not do the same for a vaginal birth. The myriad and severe complications such as postpartum hemorrhage, postpartum depression, PTSD, urinary incontinence, rectocele, cystocele, pelvic prolapse, need for perineoplasty, A-P repair, urethral sling, hysterectomy, decreased sexual satisfaction for woman and male partner, shoulder dystocia, fetal injury or death, need for emergency Cesarean and so on are never spelled out to a woman when admitted in labor with the expectation of a vaginal delivery.
In 2000 a former president of the ACOG wrote that perhaps the time had come when the risks, benefits, and costs between vaginal and elective cesarean birth as so balanced that women can choose both how and when to have their babies.
It has been argued that since a net benefit does not exist, then performing an elective cesarean delivery is not ethical. Yet, preservation of the female genitourinary tract is a significant medical benefit for some women. Dr. Jennifer Berman, a urologist who completed a reconstructive surgery fellowship, decided to have an elective cesarean birth for this reason. The ethics (justice, beneficence, autonomy, and non-maleficence) of elective cesarean delivery are left to the reader to investigate.
In the UK 31% of female obstetricians would choose elective cesarean delivery for themselves, compared to 8% of male obstetricians for their wives. In the US, female obstetricians perform elective cesarean deliveries less often than males. One article predicted that women will have to sign a consent for vaginal delivery that lists all of the risks of normal labor.
ACOG Committee Opinion 761
“It is estimated that 2.5% of all births in the United States are cesarean delivery on maternal request. Cesarean delivery on maternal request is not a well-recognized clinical entity. 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, 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.
A systematic literature review of 1,406 articles was conducted to evaluate the relevance of exist- ing studies on cesarean delivery on maternal request and the quality of the evidence. The panel concluded that 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.
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.
Although the risk of peripartum hysterectomy in a woman’s first delivery is similar for planned cesarean delivery and planned vaginal delivery, there is a significant increased risk of placenta previa, placenta accreta spectrum, placenta previa with accreta, and the need for gravid hysterectomy after a woman’s second cesarean delivery
Cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.
There are limited studies on cesarean delivery on maternal request and neonatal outcomes. There is insufficient evidence to recommend cesarean delivery on maternal request over planned vaginal delivery for neonatal outcomes.”
End ACOG CO 761
BIRTH RISKS- The problem with obstetrics is that birth is unpredictable.
There is not much difference in risk between a successful vaginal delivery and an elective cesarean delivery (without labor). The stillbirth rate is actually lower with a cesarean delivery at 39 weeks. The risks to the baby and mother are significantly higher when a cesarean occurs after a failed labor.
A fact is that the most dangerous way to deliver a baby is by emergency cesarean delivery. One study showed a three times greater chance of maternal death when emergency cesarean delivery is compared to elective cesarean delivery.
There is no difference in the maternal death rate between an elective cesarean delivery and a vaginal delivery.
The public debate over whether a baby is better off being born by a vaginal or cesarean delivery is decades old. When I was in college I read a woman’s magazine article about this. In this article, the obstetrician said that he told his patients that a baby born vaginally will have the potential to get into Harvard but that a baby born by cesarean will have the potential to be the Dean of Harvard. No one would dare say that today. There is no concrete data to cause an ethical obstetrician to counsel a patient that there is a fetal benefit to a cesarean delivery in a low-risk pregnancy without a medical indication- an elective cesarean delivery.
RISKS OF VAGINAL DELIVERY
Postpartum hemorrhage, postpartum depression, PTSD, urinary incontinence, rectal incontinence, rectocele, cystocele, pelvic prolapse, need for perineoplasty, A-P repair, urethral sling, hysterectomy, decreased sexual satisfaction for woman and male partner, shoulder dystocia, need for emergency Cesarean and so on.
Obstetrical lacerations, infection of the uterus or obstetrical lacerations, inadequate pain relief provided by the epidural. Need for transfusion. Damage to the baby: brachial plexus injury, cerebral palsy, spinal cord injuries, broken arm or collar bone, facial paralysis. Need for Forceps or Vacuum delivery.
Failed vaginal delivery that requires a cesarean delivery. Because the head of the baby is stuck in the pelvis, a cesarean delivery at this point is much more difficult and dangerous to the baby and mother. This is discussed below.
BENEFITS OF VAGINAL DELIVERY
This is by far the best way to have a baby, provided everything goes as planned. It is quite an accomplishment that you have a right to be proud of.
You are able to do skin-to-skin and breastfeed right after birth, walking around with minimal discomfort after the epidural wears off, and ready to go home the next day in most cases.
You can have more than one person with you during the birth. There is no fasting.
Any obstetrical lacerations, if repaired correctly, will almost always heal without any problems.
There are less respiratory complications. You will not be compelled to limit your family size.
RISKS OF ELECTIVE CESAREAN DELIVERY
Will likely need cesarean delivery for the next pregnancy. 90% of women do.
Longer hospital stay (by a day usually) and a longer recovery period.
Surgical site infection: Rare.
Bleeding requiring a blood transfusion: Rare
Injury to organs around the uterus: bowel, bladder, etc. Rare.
Risk of uterine rupture with next pregnancy: Rare
Risk of placenta acreta (abnormal attachment) or previa (location over the cervix): Rare
Need for cesarean hysterectomy with next pregnancy: Rare
Increased maternal morbidity, long-term health risks- placenta accreta
Slight risk of needing to convert from a spinal anesthetic to a general anesthetic.
Slight, transient increase in initial breathing problems.
BENEFITS OF CESAREAN DELIVERY
Lower risk of genital trauma, urinary incontinence, and sexual dysfunction.
Less risk of oxygen deprivation at birth and neonatal encephalopathy.
Lower risk of birth trauma to the baby. Avoids shoulder dystocia with the risks of hypoxia, brachial plexus injury, fractures, brain damage, and death.
Less risk of urinary incontinence. 5% after cesarean v 22% after vaginal delivery v 33% after forceps delivery. Fecal incontinence may be reduced by elective cesarean delivery. Risk of unexplained or unexpected stillbirth may be reduced. Elective cesarean delivery avoids labor pain, fear and anxiety related to labor or birth, and reduced worry about the health of the baby. Elective cesarean delivery allows precise timing of the delivery as well as reduced risk of chorioamnionitis, fetal hart rate abnormalities and cord prolapse.
Social convenience, avoiding maternal -fetal risk,
AVOIDS Forceps or Vacuum delivery.
Avoids rare risk of fetal death in labor. One report was this occurred 1 in 5000 deliveries.
Less stress and risk of unplanned or emergency cesarean delivery. About of third of planned vaginal deliveries end up converting to a cesarean delivery.
If an elective cesarean delivery is performed at 39 weeks, it prevents stillbirth compared to expectant management after 39 weeks.
In women with herpes, it prevents the slight chance of transmitting the virus to the baby. Women can still shed the virus even if they are asymptomatic.
COMPARISON OF ELECTIVE CESAREAN TO VAGINAL DELIVERY
Although the risk of peripartum hysterectomy in a woman’s first delivery is similar for planned cesarean delivery and planned vaginal delivery, there is an increased risk of placenta previa, placenta accreta spectrum, placenta previa with accreta, and the need for gravid hysterectomy after a woman’s second cesarean delivery.
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.
COMPARISON OF ELECTIVE CESAREAN TO CESAREAN AFTER LABOR
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.
The risk to the mother and baby is greatly increased when a cesarean if performed after a failed labor. There is increased risk of damage to the baby when trying to get the head that is wedged into the pelvis. The risk of extending the uterine incision into the bladder and blood vessels is also increased, which increases the risk of blood loss and cesarean hysterectomy. Cesarean hysterectomy has an increased risk of blood transfusion and damage to the ureter/bladder, and maternal mortality.
Summary:
If you made it this far, I propose that the matter of elective cesarean delivery should be left to the woman and her obstetrician with appropriate oversight to guarantee that full informed consent occurred, that the woman is not being forced to undergo the procedure, and that counseling (if desired) is available. It is appropriate and desirable for the insurance company to participate in this oversight. But financial coercion by the insurance company or hospital to force a woman to attempt a vaginal delivery she does not want should not be allowed.
An attempt to lower NTSV cesarean delivery rates in laboring patients by standardizing obstetrical practice and eliminating financial gain is also appropriate. However, the small number of elective cesarean deliveries (2.5%) is a different and distinct matter that needs to be addressed by patient education, reassurance, and communication.
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