Caesarean delivery on maternal request
Encyclopedia
Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section
, where the conduct of a childbirth
via a caesarean section
(CS, or c-section) is requested by the pregnant
patient. While it is a form of an elective caesarean section
, the absence of a medical indication is its distinguishing mark.
was done on the basis of some medical grounds; the CDMR situation, however, makes the mother's preference the determining factor for the delivery mode.
An elective caesarean will be agreed in advance. An elective caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any caesarian section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it.
The popular media suggest that many women are opting for cesareans in the belief that it is a practical solution. The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth. Furthermore, with women living longer, concern about damage to the pelvic floor organs by vaginal delivery adds an additional dimension to the issue. Such damage could lead to a relaxation in the ligaments that hold the pelvic organs in place; urinary incontinence can become a consequence.
. It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by. The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery.
Proponents for CDMR will point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby. Furthermore, there is some evidence that urinary stress incontinence
as a long-term result of damage to the pelvic floor
is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher, infection
rates are higher, hospitalization longer, and rates for breastfeeding
decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk.
Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section. This study was harshly criticized for excluding cases where unforeseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with "no indicated risk", and thereby inappropriately including emergent cesarean sections in their "elective cesarean" cohort. In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate. A study published in the February 13, 2007 issue of the Canadian Medical Association Journal found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries.
Caesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
, where the conduct of a childbirth
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
via a caesarean section
Caesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
(CS, or c-section) is requested by the pregnant
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
patient. While it is a form of an elective caesarean section
Elective caesarean section
Elective caesarean section refers to a caesarean section that is performed on a pregnant woman on the basis of an obstetrical or medical indication or at the request of the pregnant patient.[1] The elective CS is usually also a "planned CS" and executed prior to labor...
, the absence of a medical indication is its distinguishing mark.
Background
Over the last century, delivery by CS has become increasingly safer. The indications for delivery by CS therefore could become "softer", and the move to perform CS on request can be viewed as an extension of this development. Until recently an elective caesarean sectionElective caesarean section
Elective caesarean section refers to a caesarean section that is performed on a pregnant woman on the basis of an obstetrical or medical indication or at the request of the pregnant patient.[1] The elective CS is usually also a "planned CS" and executed prior to labor...
was done on the basis of some medical grounds; the CDMR situation, however, makes the mother's preference the determining factor for the delivery mode.
An elective caesarean will be agreed in advance. An elective caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any caesarian section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it.
The popular media suggest that many women are opting for cesareans in the belief that it is a practical solution. The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth. Furthermore, with women living longer, concern about damage to the pelvic floor organs by vaginal delivery adds an additional dimension to the issue. Such damage could lead to a relaxation in the ligaments that hold the pelvic organs in place; urinary incontinence can become a consequence.
Prevalence
The movement for CDMR may have started in BrazilBrazil
Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...
. It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by. The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery.
Controversy
A meeting of experts sponsored by the NIH in March, 2006 attempted to address the medical issues and found "insuffient evidence to evaluate fully the benefits and risks" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand. The available evidence suggests certain differences as follows:Proponents for CDMR will point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby. Furthermore, there is some evidence that urinary stress incontinence
Stress incontinence
Stress incontinence is a form of urinary incontinence.Stress urinary incontinence , also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.-Pathophysiology:...
as a long-term result of damage to the pelvic floor
Pelvic floor
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the levatores ani and coccygei, with which may be included the...
is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
rates are higher, hospitalization longer, and rates for breastfeeding
Breastfeeding
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers breastfeed for six months or...
decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk.
Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section. This study was harshly criticized for excluding cases where unforeseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with "no indicated risk", and thereby inappropriately including emergent cesarean sections in their "elective cesarean" cohort. In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate. A study published in the February 13, 2007 issue of the Canadian Medical Association Journal found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries.