ELECTIVE C-SECTION

Elective cesarean section:
a new dividing line for OBs

By Cindy Starr, MS, RPh

Should women be permitted to request a C/S? Physicians on both sides of the debate offer cogent arguments. What they say can help you shape your own approach.

How might you respond to a pregnant patient who, after two uneventful vaginal deliveries, asks you to deliver her third baby via a scheduled cesarean section? Timing is a concern—she must ask someone to care for her older children during her hospital stay, and she needs to attend some upcoming business meetings. However, she has also heard that vaginal delivery might increase her risk of stress incontinence later in life.

After considering the scenario, ob/gyn Kimberly Biss of St. Petersburg, Fla., says, "Until elective primary C/S becomes the standard of care, I will not honor that patient's request. I would have a hard time justifying the delivery route if the patient died of a complication or postoperative pulmonary embolism. I do have patients with incontinence who were delivered by C/S in their reproductive years. Does not the weight of the pregnant uterus weaken the pelvic floor?"

James H. Bell, an ob/gyn from Long Beach, Calif., would explain to the patient that the procedure carries greater morbidity and mortality and would not help with future continence since she has had two prior vaginal deliveries. "If she persists, I'd have her get a second opinion," he adds. Like Bell, ob/gyn John Luce would suggest another physician, noting, "My one maternal death in 36 years was from disseminated intravascular coagulation after a routine repeat C/S."

Other ob/gyns think elective C/S is a rational idea. Donald L. Block of Atlanta, Ga., for instance, says that it is available in other parts of the world, notably South America. "More and more evidence is emerging that there are serious perineal and vaginal consequences of vaginal delivery," Block says. "I believe that in 5 to 10 years, the standard will be patients' choice. Since insurers will not cover the patient decision, it is fair for the patient to pay the extra costs."