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The First World Congress On:
Controversies in Obstetrics, Gynecology & Infertility |
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Woman’s Right – CS Following Patient’s Request: Yes or No?
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Summary Most people would agree that caesarean sections (CS) are appropriate in situations where the risks of labour or vaginal delivery are considered too high. The question is who should decide what risks are too high and to whom? Obstetricians cannot define optimum CS rates and while the evidence comparing elective CS to anticipated labour is inadequate neither are without risk and the interests of the mother and her baby are often conflicting. Dialogue between obstetrician and patient needs to be full and open in the explanation of these issues but the mothers judgement may differ from that of her obstetrician: in those societies where patient autonomy is respected how should we be responding to such differences and on what grounds can the opinion of a woman who prefers to accept the risks of elective CS over those of labour be rejected? Ethics of Choice Any woman challenging a firm medical opinion must have a very good reason for doing so as the patient is in a relatively weak position when faced with an experienced, informed and confident professional. In the rare situations where such differences of opinion are apparent they should be explored further and not seen as a direct threat to professional judgement. The right of a patient to refuse treatment is universally acknowledged as is the opposite right to request many interventions; why then are caesarean section requests so controversial?1-5 In the UK a recommendation from Changing Childbirth6 that women should have a pivotal role in their obstetric care was made expecting more women to choose natural childbirth and home deliveries. The fact that some womens choices reflect more rather than less medicalisation should not challenge the initial premise. More recently the General Medical Council in the UK has published a leaflet on good medical practice7 and this also guides us to patient choice quite deliberately. If we are to go against these recommendations and conclude that women should not be allowed to choose an elective CS then we must be satisfied that the risks of the CS are so much worse than those of labour that we must exclude patient preference from the equation. Balance of the Risks The relevant risks to compare are those to infant and mother of elective CS versus labour (vaginal delivery or normal delivery are inappropriate comparators as no woman entering labour can be guaranteed a particular type of delivery). The balance of these risks is far from clear, with significant pros and cons to both processes (covered by Professor Fisk’s lecture) and on their own merits cannot be used as a reason to ignore womens opinions. Other Grounds for Refusal? 1. “Unnatural” As a surgical procedure CS is unnatural, like medicine – or is it? Evolution, includes the development of the brain and intelligence, and the conflict between think vs run can be overcome by CS.8 2. Financial Although CS cost approx £ 780 more than vaginal delivery in the UK9 this is a meaningless comparison, and a more relevant analysis by MacKenzie has costed CS as £ 24 more than IOL in nulliparous women and £ 174 more in multiparae.10 In addition to this, many other costs should be taken into the equation when considering elective CS against labour: such as the longterm health costs of future deliveries, future pelvic floor dysfunction, future corrective surgery and many of the costs associated with brain damaged babies. 3. Logistics The demand for CS is likely to be very small, and the logistics of staffing an acute unit with a variable workload is much more complex and inefficient than staffing a theatre list. 4. Technicians |
