Question: What's the best course to take if 22 year old Primigravida requests to have elective LSCS, when there is no obstetric indication to do LSCS. After appropriate counselling by senior personnel, patient still insists on LSCS
Help us improve clinical query answers - just fill in a survey after reading this page
Please note: the search for this response was carried out over 1 year ago.
Eligible users may request an update of the evidence by submitting a new Clinical Query here.
Answer: A National Institute for Health and Clinical Excellence (NICE) guideline on caesarean section [CS] was published in 2004, which says:
"When a woman requests a CS because she has a fear of childbirth, she should be offered counselling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, because this results in reduced fear of pain in labour and shorter labour.
(Evidence level 1)
An individual clinician has the right to decline a request for CS in the absence of an identifiable reason. However the woman’s decision should be respected and she should be offered referral for a second opinion." (Good practice point)
An update of this guideline is due for publication in November 2011.
A Royal Australian and New Zealand College of Obstetricians and Gynaecologists statement says:
"If after full discussion the patient persists with a request for delivery by Caesarean section, the obstetrician may:
1. Agree to perform the caesarean section, providing the patient is able to demonstrate an understanding the risks and benefits of the course of action she has chosen
OR
2. Decline to perform the caesarean section in circumstances where:
- the obstetrician believes there are significant health concerns for mother or baby if this course of action is pursued , or
- the patient appears to not have an understanding sufficient to enable informed consent to the procedure
OR
3. Advise the patient to seek the advice of another obstetrician for a second opinion."
(Evidence level IV)
A Cochrane review (Lavender) found no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. The latest search for evidence was in April 2009.
A 2006 report (Viswanathan) found "Virtually no studies exist on cesarean delivery on maternal request (CDMR), so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent."
The issue of patient autonomy in a case of caesarean section on maternal request is discussed by Reilly.
References:
- Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GML. Caesarean section for non-medical reasons at term. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004660. DOI: 10.1002/14651858.CD004660.pub2. Abstract (and full text in some countries). Full text for Fellows, Members and Trainees.
- National Institute for Health and Clinical Excellence. Caesarean section. Clinical guideline. 2004.
- Reilly DR. Caesarean section on maternal request: how clear medical evidence fails to produce ethical consensus. J Obstet Gynaecol Can. 2009 Dec;31(12):1176-9.
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Caesarean Delivery on Maternal Request (CDMR). College statement C-Obs 39. July 2010.
- Viswanathan M, Visco A G, Hartmann K, Wechter M E, Gartlehner G, Wu J M, Palmieri R, Jonsson Funk M, Lux L, Swinson T, Lohr K N. Cesarean delivery on maternal request. Agency for Healthcare Research and Quality, 2006:138.
Search date: March 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
This clinical query answer was produced following the clinical query protocol as described here.
The RCOG will not be liable for any special or consequential damages arising from the use or reliance on information contained within the Query Bank.
