Case 67: Elective caesarean section request

 

Case 67: Elective caesarean section request

CASE 67: ELECTIVE CAESAREAN SECTION REQUEST

History

A 39-year-old woman has an appointment with you in the antenatal clinic to discuss the

mode of delivery of her baby. She requests a caesarean section.

This is her first ongoing pregnancy, having had two first-trimester miscarriages in the last

3 years. She and her partner then tried for 12 months to conceive this pregnancy. The pregnancy however has been uncomplicated, with normal first trimester and anomaly scans and

no medical concerns. She is now 34 weeks’ gestation.

When asked why she wanted a caesarean section she says that she does not want to take any

risks with this baby as she had been through the two miscarriages following which it has been

so difficult to conceive this time. Her sister needed an emergency caesarean section a few

months ago without complication.

The blood pressure is normal, there is no proteinuria and the symphysiofundal height is

appropriate for the gestational age.

Questions

• How might you proceed in this consultation?

• What advantages and disadvantages will you put to this woman regarding her

request for elective caesarean section for maternal request?

• Is it appropriate to agree to the woman’s request for caesarean section without medical grounds?100 Cases in Obstetrics and Gynaecology

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ANSWER 67

In this consultation it is important to understand what factors have brought this woman to

make a request for caesarean section. For example she may have a fear of labour (‘tocophobia’), she may have feelings of not wanting to be out of control, she may be afraid of pain. All

of these situations should be explored because the correct solution if there is, for example,

a fear of labour, may be to address any underlying problem rather than bypassing it by performing caesarean. It is then important to ascertain what she already knows about caesarean

section in terms of the nature of the operation, the recovery time, the possible complications

and the effect on future modes of delivery or any future surgery she may need. The woman

needs evidence-based information and support. This information should include indications

for caesarean, what the procedure involves, associated risks and benefits, and implications for

future pregnancies and birth after CS. In counselling her it is important to take into account

her individual circumstances, concerns and priorities.

Potential advantages of caesarean section delivery

• Predictable timing of delivery (unless labour occurs prior to the planned date

of caesarean)

• Avoidance of the need for an emergency caesarean, which has higher complication rates

• Avoidance of the possibility of birth trauma to the baby, although the studies do

not show a difference in incidence of hypoxic ischaemic encephalopathy or intracranial haemorrhage

• Reduction in the chance of pelvic floor weakness (although this occurs in part due to

pregnancy itself and therefore incontinence and prolapse are not completely avoided

by caesarean section)

• Lower rate of immediate postpartum haemorrhage

• Lower rate of injury to the vagina and perineum

Potential disadvantages of caesarean section delivery

• Increased rate of admission of baby to neonatal care unit

• Greater pain following abdominal surgery

• Possibility of intraperitoneal trauma to bowel or bladder at surgery

• Increased risk of wound infection

• Possibility of thrombosis (although this is minimized by the use of heparin prophylaxis)

• Longer hospital admission

• Increased likelihood of needing caesarean section in a subsequent pregnancy

• Very small increase in chance of hysterectomy for postpartum haemorrhage or of

cardiac arrest

Are there medical grounds to agree with the request

for caesarean section in this case?

Recent national guidance suggests that women with possible mental health concerns or significant anxiety about natural birth should be referred to an appropriate mental health professional for psychological counselling. If however they request caesarean section despite this

offer of support and after informed consent, then the guideline suggests that delivery by elective caesarean section should be agreed.Case 67: Elective caesarean section request

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KEY POINTS

• UK National Guidance suggests that women requesting elective caesarean section

may have this request agreed to after appropriate psychological counseling.

• Both immediate and long term consequences of caesarean section should be

explained when considering non-medically indicated caesarean section.