Scenario: Does an obstetrician always have to follow the patient's wishes?

A healthy, 33-year-old pregnant woman tells her obstetrician that she wants to deliver her baby by cesarean section. The patient explains that she wants to be in control of how long the delivery takes and when it is scheduled. She had one prior vaginal delivery without complications but said her sister-in-law told her C-section is safer for the baby. What professional obligations does the obstetrician have toward her patient in discussing this request?

Reply:

I would like to refer to a statement made by Lois Snyder in Ethical Choices (1996, American College of Physicians) as a framework for my assessment of this case. "Determining what is in the patient's best interest is a matter of professional judgment and medical indication, not a function of patient pressure. The welfare of the patient is paramount in the consultative process. Being a patient advocate does not necessarily mean doing everything the patient wants."

The latest edition of Williams Obstetrics lists accepted indications for cesarean section as: previous cesarean delivery, fetal malpresentation such as breech or transverse lie, fetal distress in labor, active genital herpes simplex and dystocia. Most practitioners would add to the short list of indications a previous surgical repair for pelvic floor defects and a history of sexual abuse/posttraumatic stress disorder with sexual aversion.

Cesarean section is associated with twice the risk of maternal morbidity and mortality as vaginal birth due to thromboembolic disease, double maternal blood loss, a 20% incidence of endomyometritis despite the use of prophylactic antibiotics, and a 1.4% incidence of injury to the mother's bladder or ureters. Like any abdominal procedure, it can create pelvic adhesions that lead to infertility, bowel adhesions and obstruction, or chronic pelvic pain.

There is no evidence to date from the urogynecologic literature that cesarean section can prevent pelvic floor relaxation or neuropathy or urinary incontinence. Rather, the literature shows that the mere state of pregnancy predisposes women to these events regardless of route of delivery. Creasy's Textbook of Maternal Fetal Medicine (1999) states that "reducing maternal and neonatal complications of cesareans begins with a proper respect for the dangers of the procedure and careful selection of patients to be delivered in this manner."

Although cesarean delivery appears to the public as a gentler, more controlled manner of coming into the world, nothing could be further from the truth. As far as our pediatric colleagues are concerned, vaginal birth reduces the incidence of respiratory distress syndrome in premature infants and of transient tachypnea of the newborn in term infants, both of which necessitate newborn ICU admission and invasive interventions. But, a cesarean section performed prior to 39 weeks of gestational age because of uncertain dates or irregular cycles in the mother, or because of scheduling "convenience," can cause respiratory distress syndrome, which might be avoided by awaiting the spontaneous onset of labor. Very likely there is an endocrinologic signal from fetus to mother that initiates the hormonal cascade of events leading to the onset of labor and assuring that the newborn can successfully make the adaptation to breathing air in the extrauterine environment. What is worse, Erb's palsy and skull fractures have occurred in infants during cesarean delivery.

An unnecessary cesarean section will likely commit the woman to repeat cesareans with future pregnancies. Uterine rupture may occur prior to the recognition of labor and can range from benign separations of the incisions to catastrophic rupture with expulsion of the pregnancy into the abdomen. Because of these risks, the only institutions that will permit women to give birth vaginally after a having a cesarean are those equipped to respond to such emergencies.

Each cesarean also adds cumulatively to the risk of placenta previa and accretio, with the potential to involve bowel or bladder by invasion, which frequently result in massive hemorrhage, requiring multiple transfusions and possibly cesarean hysterectomy or uterine artery embolization to prevent death from exsanguination.

Informed consent laws mandate that the physician disclose to the patient the risks and benefits that a reasonable person in the patient's position would want to know in order to make an informed decision. This upholds the concept of patient autonomy. Yet, the complications detailed here are unknown and incomprehensible to most patients unless they are also physicians. It is not paternalistic to apply our education and experience to the way we counsel our patients. Because the performing physician would be held responsible for the subsequent maloccurrences, I believe it would violate professional autonomy to permit lay opinion, hearsay, and fashion to influence practice patterns and to dictate the performance of major surgery.

I would inform the patient that her previous successful vaginal birth makes it extremely likely that this birth would be uncomplicated as well, with a labor duration half as long, and a pushing phase that may last only minutes. It would be a shame to subvert that beautiful option with an unnecessary operation, especially without any data to indicate it is safer for mother or baby, the sister-in-law's opinion notwithstanding. If she insists on her unique choice, I would politely refer her to another obstetric colleague from whom she may solicit her request.

--Susan Richman, MD Assistant professor, obstetrics and gynecology, Yale University School of Medicine, New Haven, Conn.

Reply:

Women are increasingly requesting elective cesarean delivery with the belief that it offers the least risk to their babies and to their own pelvic structures. Currently there is no evidence to refute the statement that "the safest mode of delivery for a baby is by elective cesarean at 39 to 40 weeks gestation." For that reason, many obstetricians are now honoring such requests -- at least for primigravidas or women with prior difficult deliveries.

This patient, however, has a normal pregnancy and had no difficulty with her first pregnancy. The complex and inconclusive data that help guide evidence-based decisions are beyond the scope of this opinion, but suffice it to say justification for her request is much more problematic.

Obstetrics provides unique challenges that confound decision-making because the fetus represents a second patient. The mother's choice for herself may not be perceived by third-party observers as being best for the baby, and the mother may well agree, but still hold her own interest as paramount and refuse treatment that might be primarily of fetal benefit.

In the past, many managed care organizations and hospitals forced women to attempt vaginal birth after a cesarean delivery. Hospitals also have held bedside hearings with judges to obtain a court order forcing the mother to have an unwanted cesarean in what was believed to be the fetal interest. The ethical and legal principles that permitted those practices have virtually disappeared.

This situation requires the same counseling as needed in any informed consent. The patient must be advised of the risks and benefits of the options available -- spontaneous labor, elective induction, and elective cesarean. As well as possible, choice should be tailored to the patient's obstetrical status, as judged by her physician, with full consideration of her desires. In such emotionally charged situations, her husband and/or sister-in-law might well be included.

In this scenario with a normal pregnancy, I believe the preponderance of the evidence favors vaginal delivery. For the doctor's protection, his or her statement of this judgment should be carefully documented.

Chervenak and McCullough presented an elegant, ethically justified algorithm for offering, recommending, and performing cesarean delivery in 1996 in the journal Obstetrics and Gynecology. "When cesarean delivery is requested and well-supported solely in autonomy-based clinical judgment, the physician should repeat the recommendation for vaginal delivery and either perform cesarean delivery or make a referral."

I personally strongly champion the woman's right to determine her mode of delivery. However, physicians have the right to accept or refuse a patient and to refuse to carry out any procedure that they would not feel comfortable performing.

This patient has demonstrated her capability for a safe vaginal delivery for both her and her baby. With no present symptoms or evidence of pelvic floor trauma, the risks of a repeat vaginal delivery are low and probably less than with cesarean -- particularly if she has vaginal delivery without anesthesia. This should be made clear to the patient.

If fear of pain is a factor, she should be advised that second deliveries are typically faster than the first and that epidural anesthesia can relieve pain. However, the common argument that cesarean delivery is more risky because of the anesthesia simply cannot be sustained when labor is accompanied by hours of epidural and the cesarean takes less than an hour. As for scheduling, she could be offered the option of induction of labor when the obstetrical conditions are appropriate as would also be the case in timing an elective cesarean delivery. Currently, one-fifth of women in the United States have induced labor.

If the patient is not persuaded by the evidence favoring vaginal delivery and the obstetrician is uncomfortable with her decision, it would be unwise to accept her as a patient. This discussion should be held at the first visit and resolution achieved. It is equally important to resolve that a patient desiring a vaginal delivery agree to accept the obstetrician's advice to have cesarean delivery when, in her or his opinion, the preponderance of evidence indicates this as the best option for mother or fetus.

In a field as unpredictable as obstetrics, it is a nightmare to be responsible for the welfare of both mother and child and then be in an emergency situation with a mother who adamantly demands that her preconceived scenario be followed.

--W. Benson Harer Jr., MD Past president, American College of Obstetrics and Gynecology; medical director, Riverside County Regional Medical Center, Moreno Valley, Calif.

Opinions expressed in Ethics Forum reflect the views of the authors and do not constitute official policy statements of the American Medical Association. Readers are encouraged to submit questions and comments to the Ethics Standards Group, AMA, 515 N. State St., Chicago, IL 60610; or by fax at (312) 464-4613. Actual names, addresses and affiliations of individuals whose queries are used will not be published.