The Case Against Cesarean Delivery on Maternal Request in Labor

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The ethical obligations of an obstetrician to a patient who requests a cesarean delivery without maternal or fetal indication differ depending on whether the ...
Current Commentary

The Case Against Cesarean Delivery on Maternal Request in Labor Paul Burcher,

MD, PhD,

Jazmine L. Gabriel,

PhD,

Lisa Campo-Engelstein,

The ethical obligations of an obstetrician to a patient who requests a cesarean delivery without maternal or fetal indication differ depending on whether the request is made before or during labor. Informed consent is an essential dimension of respecting patient autonomy, and the process of informed consent should be extensive for a cesarean delivery in the absence of maternal or fetal indications during active labor. For this reason, physicians should rarely grant a request for cesarean delivery made during active labor. Although physicians may think that declining a request for cesarean delivery is a violation of patient autonomy, they should also be concerned about the violation of patient autonomy that results if they are unable to adequately complete the process of informed consent during labor. (Obstet Gynecol 2013;122:684–7) DOI: 10.1097/AOG.0b013e31829d83c2

A

few months ago, I (P.B.) attended a 27-year-old woman in labor with her first child. She had submitted a birth plan before labor expressing a strong desire to avoid any interventions, including epidural and cesarean delivery. She had attended natural birthing classes and seemed committed to this approach to labor. She was laboring well without any analgesia when, at 6cm dilatation, the external fetal monitor recorded a single significant variable deceleration. The fetal heart rate dropped from a baseline of 140 down to 60 for approximately 1 minute before returning to normal. Her nurse See related editorial on page 513.

From the Department of Obstetrics and Gynecology, Alden March Bioethics Institute, Albany Medical College, Albany, and the Philosophy Department, Siena College, Loudonville, New York. Corresponding author: Paul Burcher, MD, PhD, Assistant Professor, Department of Obstetrics and Gynecology, Alden March Bioethics Institute, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2013 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/13

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PhD,

and Kevin C. Kiley,

MD

notified me of the deceleration and I reviewed the tracing in the room with the patient. I reassured her that a single deceleration was not worrisome and that the tracing remained favorable. In fact, after several minutes, there had been no recurrences and all the positive aspects of a fetal tracing associated with fetal well-being (good variability and the presence of accelerations) were present. Despite my reassurance and the normal fetal heart rate tracing, the patient insisted that I perform a cesarean delivery as soon as possible. She said that she felt that her fetus could still be in danger and that she “didn’t want to take any chances.” I again attempted to convince her that her fetus was in no danger and that we were perfectly capable of performing a timely cesarean delivery should her fetus show any real signs of fetal compromise. She was unmoved and continued to request that a cesarean delivery be performed immediately. This was surprising given her prior devotion to a noninterventionist approach to labor. One measure of whether a patient choice is truly autonomous is the degree to which it reflects a patient’s values and life plan, and I was worried that this choice did not seem to meet that standard because it was based on unfounded fears.1 My attempts to dissuade the patient were unsuccessful, and I performed a cesarean delivery of a healthy neonate with Apgar scores of 9 and 9. The patient’s postoperative recovery was uneventful. At the time, I believed that I was respecting her autonomy by performing the cesarean delivery she requested during labor, especially given the 2008 Committee Opinion by the American College of Obstetricians and Gynecologists (the College) on the ethical permissibility of cesarean delivery on maternal request.2 A more recent committee opinion in 2013, however, although still allowing cesarean delivery on maternal request, takes the position that vaginal birth is preferable and should be recommended by physicians when women request elective cesarean delivery before labor.3 Even before the College’s statement recommending vaginal birth over cesarean delivery on maternal request, I have

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questioned whether I had in fact respected her autonomy by performing a cesarean delivery during labor without a medical indication. Beauchamp and Childress, the two ethicists responsible for the principlist theory of bioethics, insist that complete respect for patient autonomy includes action that goes beyond noninterference to include “building up or maintaining others’ capacities for autonomous choice while helping to allay fear and other conditions that destroy or disrupt autonomous action.”1 As ethicists (P.B., L.C.E., J.G.), we are ambivalently supportive of a woman’s choice to have a cesarean delivery on maternal request before labor. However, a strong case can be made for denying cesarean delivery on maternal request during labor. There are three reasons for this conclusion: once labor starts, the risks and benefits of vaginal birth and cesarean delivery are no longer commensurate, informed consent for cesarean delivery on maternal request cannot in many cases be adequately completed during labor, and cesarean delivery on maternal request during labor can blur the distinction between elective and indicated cesarean delivery. Much of the logic behind the ethical permissibility of cesarean delivery on maternal request is underpinned by the relative lack of consensus regarding the superiority of one route of delivery over another.2–5 However, this parity of risks and benefits is lost once a woman is laboring, particularly if she has ruptured membranes. A vaginal birth has a lower rate of morbidity and mortality than a cesarean delivery after laboring, and an elective cesarean delivery before labor has a lower maternal mortality rate than a cesarean delivery performed on a laboring woman.6 The rate of postpartum infection is 10-fold higher in intrapartum patients undergoing cesarean delivery than in patients who deliver vaginally.7 When choices are no longer equal in medical terms, it is neither required nor recommended that physicians offer the less beneficial or riskier procedures. If a patient requests a less than optimal option, the physician is not expected to act on the patient’s wishes.8 There is no reason this standard should not apply to cesarean delivery on maternal request during labor. In this case, the patient was progressing well, and there was every indication that she would have had a successful vaginal birth. Although her postoperative recovery was uneventful, her surgery exposed her to unnecessary risks. The justification for performing this procedure is that the patient requested it and the patient’s choices must be respected. However, although patients have a nearly inviolable right to refuse treatment, the right

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to a requested treatment, and the physician’s duty to provide the requested treatment, is much more circumscribed.8 For example, our patients can refuse a hysterectomy even in the face of life-threatening cancer, but they cannot expect physicians to provide hysterectomies without medical indication. Patient requests for treatment cannot always be respected without coming into conflict with the professional integrity of the physician. The physician’s duties of beneficence and nonmaleficence require the physician to help the patient and minimize the risk of harm to the patient.1 Respecting patient autonomy cannot mean that the physician has an obligation to knowingly and without medical benefit put a patient at risk, even if this is what the patient desires. Although physicians may initially feel that respecting patient autonomy requires them to agree to a cesarean delivery on maternal request during labor, further consideration reveals that the opposite may be the case: physicians may be violating the patient’s autonomy when they agree to a cesarean delivery on maternal request during labor. For a patient’s decision to be autonomous, the physician needs to initiate a process of informed consent consistent with the National Institutes of Health conference statement addressing cesarean delivery on maternal request.4 The panel emphasizes that the informed consent process for cesarean delivery on maternal request is an extensive one that involves the weighing of multiple factors, including individualized risks and benefits as well as patient values. Informed consent is obtained when a patient receives “accurate and relevant information,”9 yet what is considered relevant is context-dependent. The relevant information for informed consent for a cesarean delivery when the fetus appears to be intolerant of labor can be brief: the physician’s assessment of the fetal risk compared with the maternal risks of cesarean delivery. Given the time constraints, if the pregnant woman responds as most do when faced with a risk to fetal well-being, the conversation can be short although still adequate to the task at hand. In contrast, cesarean delivery on maternal request during labor is by definition nonindicated, elective surgery; hence, the informed consent process needs to be more careful and deliberate in these circumstances than it would be in an emergency or clearly indicated surgical recommendation. What is relevant to a decision about a cesarean delivery on maternal request is a wide-ranging discussion of short-term and long-term risks and benefits. A discussion that fully addresses the individualized risks and benefits of the elective procedure and that enables the patient to make a decision consistent with her values requires time. Time is needed not only for

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the physician to convey the information, but also for the patient to weigh and consider the information before making a decision. The physician not only has a duty to offer context-dependent information, but also to ensure that the information is conveyed in a way that supports and empowers the patient to make her own decision. The success of the informed consent process is further complicated by laboring patients’ difficulty recalling and repeating the information conveyed.10 There is little to remember or assess when the choice has clear benefits for the mother or the fetus or both. However, the informed consent process for cesarean delivery on maternal request during labor includes more information, and the patient must remember this information to weigh both short-term and long-term risk factors. There is empirical evidence that suggests that women in labor may not be able to recall the information relevant to their decisions; eg, a study by Swan examining recall of informed consent information for laboring women requesting epidural analgesia found that patients had little ability to repeat information communicated during labor regarding the risks of an epidural. Given that the physicians communication and the patients retention of information is central to informed medical decision-making, Swan concludes that informed consent for epidural analgesia should occur before the onset of labor.11 It may be preferable to consent women for epidural analgesia before labor or in early labor, and the anesthesiologists at our institution seek to obtain consent for epidurals before active labor with our patients based on this reasoning. It does not necessarily follow from this that laboring women cannot consent to indicated procedures, but decisions about elective surgery, particularly cesarean delivery with its lifelong implications, should be made by women in a low-stress environment, deliberately, preferably over several prenatal visits. Few if any obstetricians would perform a postpartum tubal ligation on a woman if her first request and discussion of this occurred in labor. Requests for cesarean delivery during labor should be seen in the same light. The highest standards for informed consent should be held for procedures without a medical indication. This standard cannot be realistically upheld during labor. There is no reason to assume that it is a return to paternalistic thinking to argue that elective decisions with far-reaching consequences should not be initiated during labor with its attendant stressors of fatigue, hunger, anxiety, and pain. The apparent conflict between patient autonomy and the physician’s duty to nonmaleficence dissolves once we acknowledge that respecting autonomy requires respecting the process of informed consent. Decisions made without adequate

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information diminish rather than enhance autonomy. Autonomy means more than simply having more choices.12 It is unclear whether the statements by the College and the National Institutes of Health have affected behavior on labor and delivery or whether cesarean delivery on maternal request during labor was a pre-existing phenomenon before these organizations gave their qualified support to it.2–4 Kalish et al showed that cesarean delivery on maternal request during labor occurs in numbers greater than was previously known or described.13 In this study of intrapartum cesarean delivery, 8.8% of the cesarean deliveries were precipitated by maternal request. An additional 5% of elective cesarean deliveries were initiated by the physician making the suggestion in the absence of obstetric indications being met for cesarean delivery. If these numbers are valid nationwide, elective cesarean deliveries may be an underappreciated driver of cesarean delivery rates today. There is another aspect of the Kalish data that is disturbing to those of us who wish to see a safe reduction in cesarean delivery rates nationally, namely, the suggestion that both physicians and patients were “throwing in the towel” early when any problem on labor and delivery arose rather than following accepted standards for cesarean delivery indications during labor. This practice blurs the distinction between an obstetrically indicated cesarean delivery and an elective cesarean delivery because these cesarean deliveries are strictly speaking neither entirely elective (because the request for cesarean delivery sometimes occurs when something in labor appears awry) nor obstetrically indicated (because it fails to meet accepted criteria). Furthermore, physicians may fear that to refuse a request for an elective cesarean delivery places them at increased risk of liability should anything go wrong in labor after a request for cesarean delivery has been denied. Our response to this concern is twofold: obviously obstetricians are always at risk, and only at risk, when there is a bad outcome, so following standard obstetric practices and indications for cesarean delivery does not in itself either protect or place the physician at risk. Second, to do a procedure that places the patient at increased risk of complications to avoid the possibility of liability is to abdicate professional integrity in favor of personal safety. This is precisely what we must not do as physicians. Perhaps, using the thinking of Frank Chervenak and Laurence McCullough, we should adopt a “preventive” strategy with our prenatal patients and inform them that we believe it to be our ethical duty, based on the reasons previously discussed, to decline requests for nonindicated cesarean delivery in an intrapartum setting.14

Cesarean Delivery on Maternal Request in Labor

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Consistent with the principles of preventive ethics, during the antepartum informed consent process for cesarean delivery on maternal request, the physician and patient should make plans for different possible scenarios. One possibility that should be discussed during prenatal care is the appropriate response if the patient arrives in labor with an elective cesarean delivery already planned and scheduled. Such cases require case-by-case consideration based on her original reasons for the cesarean request, her risks now that labor has started, and the degree to which the prior informed consent discussion remains valid. For example, if her original reason for wanting the cesarean delivery was to plan around her busy work schedule, and she arrives in advanced labor, our recommendation should shift toward expectant management over cesarean delivery. A cesarean delivery in this case would not be at odds with the woman’s original wishes, and her risks and recovery now favor an attempted vaginal birth. However, denying a cesarean delivery to a woman who insists on a cesarean delivery out of concerns over sexual function or prolapse, and who arrives in early labor, would both violate the woman’s wishes and not substantially reduce her risks of other complications.1 The College now defines cesarean delivery on maternal request as a request for a primary prelabor cesarean delivery without maternal or fetal indication.3 Physicians are encouraged to recommend vaginal birth over cesarean delivery before labor. If physicians should recommend vaginal over cesarean delivery when the request is made before labor, there is an implicit and ethically relevant distinction between requests made before and during labor. We agree with this distinction between prelabor requests and requests during labor and believe there are solid ethical grounds to not only recommend vaginal birth, but to reject requests for elective cesarean delivery during labor. Informed consent is difficult during labor, and an elective procedure requires a more extensive informed consent process than a medically indicated procedure. The risks of cesarean delivery once labor has started are higher than the risks of vaginal birth. Finally, if

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cesarean deliveries are performed during labor when the physician or patient thinks there may be a problem, but an obstetric indication for cesarean delivery has not been met, the effect is to blur the distinction between indicated and elective procedures with the potential of increasing our already elevated cesarean delivery rates nationally. REFERENCES 1. Beauchamp T, Childress J. Principles of biomedical ethics. 6th ed. New York (NY): Oxford University Press; 2009. 2. Surgery and patient choice. ACOG Committee Opinion No. 395. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:243–7. 3. Cesarean delivery on maternal request. Committee Opinion No. 559. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:904–7. 4. National Institutes of Health state-of-the-science conference statement: cesarean delivery on maternal request March 27– 29, 2006. Obstet Gynecol 2006;107:1386–97. 5. Minkoff H, Chervenak F. Elective primary cesarean delivery. N Engl J Med 2003;348:946–50. 6. Lilford RJ, van Coerverden de Groot HA, Moore PJ, Bingham P. The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances. Br J Obstet Gynaecol 1990;97: 883–92. 7. Hadar E, Melamed N, Tzadikevitch-Geffen K, Yogev Y. Timing and risk factors of maternal complications of cesarean section. Arch Gynecol Obstet 2011;283:735–41. 8. Whitney SN, McCullough LB. Physicians’ silent decisions: because patient autonomy does not always come first. Am J Bioeth 2007;7:33–8. 9. O’Neill O. Some limits of informed consent. J Med Ethics 2003; 29:4–7. 10. Burcher P. The Ulysses contract in obstetrics: a woman’s choices before and during labor. J Med Ethics 2013;39:27–30. 11. Swan HB, Borshoff DC. Informed consent—recall of risk information following epidural analgesia in labour. Anaesth Intensive Care 1994;22:139–41. 12. Burrow S. On the cutting edge: ethical responsiveness to cesarean rates. Am J Bioeth 2012;12:44–52. 13. Kalish R, McCullough L, Gupta M, Thaler H, Chervenak F. Intrapartum elective cesarean delivery: a previously unrecognized clinical entity. Am J Obstet Gynecol 2004;103:1137–41. 14. McCullough L, Chervenak F. Ethics in obstetrics and gynecology. New York (NY): Oxford University Press; 1994.

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