Physician Support for Maternal Request

Book Cover
The quotes below are taken from our book, Choosing Cesarean, A Natural Birth Plan (published in 2012):

Dr. Philip J. Steer, FRCOG 
Editor in Chief of BJOG: An International Journal of Obstetrics and Gynaecology
People make many choices about their lives, some of which are safe (e.g., going on holiday by scheduled airline) and some of which are less safe (e.g., going on holiday by microlight), but we recognize their autonomy to make individual choices over a wide  range of risks. Elective cesarean section is very safe compared with many other things we do in life, for both mother and baby. Cosmetic surgery carries risks, but no one suggests it should not be allowed. We need to know more about the long-term effects of elective cesarean at maternal request, but it seems to me very unlikely that we will find anything that will make them so risky as to be inadvisable.

Dr. Felicity Plaat
Consultant anesthetist at Queen Charlotte’s Hospital, London, England
It seems to me that proponents of choice are not actually advocates of real freedom to choose—they want women to “choose” a mode of delivery that they think is best/cheapest/most natural. Women’s choice is fine if they chose normal deliveries or home birth but not if they want a cesarean. Whatever one thinks, one should be consistent!

Dr. Bryan Beattie, FRCOG
Consultant obstetrician at a tertiary teaching hospital in the United Kingdom
From an ethical perspective, women should be provided with accurate unbiased information about the limitations of assessing risk, and the risks of various interventions available, to allow them to make informed choices about their pregnancy and place and type of delivery. However, whilst they should be supported in their choices by obstetricians and midwives, they and their partners must also be prepared to accept the
consequences of their decisions, bearing in mind their unborn baby had no choice in the matter. This applies equally to those who choose to have a homebirth or delivery in a standalone midwifery-led unit where access to medical care may be too late if things go wrong, or those who have complications from a maternal choice cesarean section in hospital. That said, obstetricians and midwives who are opposed to the concept of maternal choice cesarean section in uncomplicated pregnancies at term should ask themselves when the last time a baby had to be admitted to a special care baby unit (SCBU) and compare it to the last admission for a “low risk” woman who was planning a vaginal delivery.

Dr. Harry Gee (retired in 2009)
Former consultant obstetrician at Birmingham Women’s Hospital, England, and former Director of West Midlands Postgraduate School of Obstetrics and Gynaecology
An individual who has had a very successful natural birth does not have the right to assert that everyone else can have the same experience. It’s a very unscientific and authoritarian way of thinking because you can’t generalize like that. My standpoint is that women should be given as much information as they require. We as professionals should facilitate whatever is their decision. This may include elective cesarean… If I’ve
felt that the patient has understood the important points and she still believes a cesarean is right, then I have gone along with the request, and some of my colleagues do likewise too.

Professor James Drife (retired in 2009)
Former obstetrician at Leeds General Infirmary, England
It is ironic that a woman’s right to refuse a cesarean should be upheld while her right to refuse vaginal delivery is not. She is allowed to refuse a cesarean even though doing so may kill her or her baby. I think women are perfectly able to make up their own minds provided they are given all the facts, and I think they have the right to do so… the problem I have with trying to dissuade them is knowing that they too might end up with a difficult vaginal birth. It’s not that obstetricians want to encourage more cesareans at all. They rather like doing clever vaginal births; they get to use their skills if it’s an instrumental birth and have a sense of achievement at the end. But that may not necessarily be the best thing for the woman.

Dr. Linda Brubaker, MD, MS
Senior Associate Dean for Clinical and Translational Research; Professor, Department of Obstetrics & Gynecology and Urology, Loyola University Medical Center, Chicago; and Director, Division of Female Pelvic Medicine and Reconstructive Surgery

Patients, midwives, and doctors all agree that the perfect birth outcome includes both a healthy infant and a healthy mother. Yet birth, trends and traditional, are being questioned like never before. Women have become assertive in obtaining their healthcare. Most mothers would willingly transfer risk to themselves if it helped their child in any way. However, if the baby is equally safe, and there are differing risks for the mother, it seems most reasonable that she be given this information.

Dr. W. Benson Harer Jr., FACOG
Retired obstetrician and a former president of the American College of Obstetricians and Gynecologists
A paradox: Why is it that we celebrate every medical advance that enhances or prolongs life except cesarean delivery? The facts to support elective prophylactic cesarean delivery as a rational choice continue to mount in contradiction to the politically correct
“truth” that trial of labor has to be better. Cesarean delivery is major surgery and should not be taken lightly, but we tend to forget that cesarean births are the major factor in preventing vaginal births from being fatal events for 1 percent of women and many more babies. Vaginal birth may be nature’s way, but nature’s way has always been hazardous and still is in nations where cesarean delivery is not a readily available option.

Some critics of elective prophylactic cesarean delivery claim that it is a waste of resources and is more expensive. Such arguments do not take into account costs of later pelvic reconstructive surgery or the massive expense of providing care for a child with cerebral palsy. Latin American physicians claim that a high volume of elective procedures actually allows more efficient use of surgical suits and reduces need for extra
staffing and overtime to meet erratic demand…

Because most damage occurs with the first vaginal delivery, I would recommend elective prophylactic cesarean delivery be reserved for nulliparous (borne no children) or multiparous (borne two or more children) women who have had major pelvic surgery. I would further restrict it to women who intend to have no more than two children. This means most women in developed nations are good candidates for elective prophylactic cesarean delivery.

Dr. Ralph W. Hale, FACOG
Executive Vice President of the American College of Obstetricians and Gynecologists
Elective cesarean delivery has become a reality in the practice of obstetrics today as more and more of the women who approach delivery have strong feelings that the option of the mode of delivery should be their decision to make unless there are compelling medical indications for a specific delivery method. Their reasons will vary from woman to woman, but whatever decision she may make, the patient needs to know all of the available risks and benefits.

Historically, for many years, elective cesarean was thought to only be for Hollywood women. It was called the “vaginal preservation operation”; that was the name of it back years ago… My own personal opinion—and I stand by what I’ve done—is if you’re my patient and you come in to see me and say, “I want a cesarean delivery,” and I am sure of
your dates and everything, I would offer it to you. I would discuss with you all the rationale, I would explain the risks to you, including the fact that repeat cesareans can have an increased incidence of previa and abruption, and if you still felt you wanted to have an elective cesarean delivery, we’d have an elective cesarean delivery picked on the date that you wanted. I believe a patient should be informed of all aspects, but then it is her choice.

Dr. Duncan Turner
Medical Director of Santa Barbara Obstetrics and Gynecology Associates, California
If a woman wants a cesarean she should get it, and I feel very strongly about this. Obviously I would talk through the pros and cons of surgery and the risks involved, but there are many more elective surgeries today that are much more dangerous—and far less as important as childbirth— and women are able to elect for these. So in my opinion, any reason should be OK—if the woman doesn’t want to go through labor, she doesn’t want labor pain, she wants to plan around a certain day or she feels that cesarean delivery is safer for her baby…

One reason some doctors have been reluctant to give women a cesarean is because historically, they weren’t the gold standard and also, they were criticized for doing too many of them. So some doctors think: “If a woman asks for a cesarean and I end up doing more cesareans as a result, then I will have more criticism.” But for me, as long as the patient knows what they are getting into, then they should be allowed to have one. I’m a strong advocate of patients doing things their way with the appropriate knowledge. There isn’t one treatment that’s right for everyone, so informed choices are what are most important. Doing something that a patient does not want is, in my opinion, malpractice.

Dr. Samantha Collier
Former Executive Vice President and Chief Medical Officer, HealthGrades
Surgery is not without risk, and my own personal decision would not be to go through surgery because I don’t like the idea of anesthetic. Anecdotally as a physician and study researcher, I would personally probably prefer a vaginal birth because I think recovering from surgery and looking after a newborn isn’t pleasant. But that’s a personal decision. I don’t see why cesareans should be treated as a negative procedure, when there have been technological advances in every other area of medicine which we accept, and where invasive, laparoscopic, and cosmetic surgery is a multimillion-dollar business. I’ve seen patients die having a nose job or bleed to death having liposuction.

“With cesareans, yes, there is an absolute risk because it’s surgery but it’s about 0.000 percent. If I fly in a plane once a year and my risk is x and then because I fly three times in a year my risk triples, this doesn’t stop me flying. If the cesarean debate is all about a
death risk then women just shouldn’t get pregnant… I think that there is maybe too much emphasis on the negative. It’s more important that women become more empowered and that they get exactly what they want in healthcare. Who is it for us to decide what a
woman should do when both risks are comparable and the cesarean risk possibly even lower? [Vaginal or cesarean] are just two alternatives, and it’s not for us to decide, but rather to support a woman and help inform them to make the best decision for them. A woman should be fully informed, and that is our obligation in the medical community.

“It’s about choice and preserving autonomy. Objectively, we can provide you with data, the risks, long-term implications, and possible outcomes for you and your baby. Even taking an aspirin has risks and benefits which we can tell you about but it’s up to you to decide.

Dr. Peyman Banooni
Obstetrician at Cedar Sinai Hospital, Beverly Hills, California
I’m not a proponent of it, and I’m not against it. I think you should have the option of being able to do this, an elective cesarean section, and if you’re aware of the information, the pros and cons of both, and you make your own decision, then we’ll do whatever it is that you decide is right for you.

Dr. Elmar Joura
Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria
The main end points are healthy children and mothers; the route of delivery is merely a detail. We give so much medical support in birth today that you can’t call it “natural” anymore. A very big system protects women and prevents negative effects where possible throughout her pregnancy, and the delivery is just at the end. I tell my patients very early in their pregnancy that they have free choice of their mode of delivery. I give them all the information and then they take a few weeks to go away and think about it. At the end, most of them know what is best for their personality.

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