Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. F1000: "Changes Clinical Practice"

John Svigos


Faculty of 1000 

Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG
Am J Perinatol 2010 Mar 16

Commentary from Faculty Member John Svigos

Changes Clinical Practice: There is insufficient evidence to refuse a woman her legitimate right both ethically and now scientifically to request an elective primary caesarean section at 39 weeks gestation.

At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section.

The National Institutes of Health (NIH) statement re caesarean delivery on maternal request in 2006 that there was insufficient evidence to evaluate fully the benefits and risks of elective caesarean delivery[1] stimulated many workers to try to find this elusive evidence. Most studies before and after this statement and until the publication of this article were fundamentally flawed by including outcomes from emergency and elective surgeries in women (and babies) with pre-existing medical conditions and not including in the vaginal delivery group those that did not deliver vaginally and their respective morbidity and mortality. Additionally, there was a tendency to place more emphasis on caesarean morbidities such as haemorrhage and infection and less emphasis on the more commonly occurring post-delivery pelvic floor dysfunction and pain. The continued use of morbidity/mortality statistics from primary caesarean for breech presentation as the surrogate for caesarean section on maternal request can no longer be justified and is positively misleading if one analyses the paper by Liu et al.[2] Furthermore, the most recent paper by Lumbiganon et al.[3] after detailed analysis demonstrates the bias directed against the proposal of primary elective caesarean on maternal request. Whilst there has been considerable emphasis placed on examining maternal morbidity and mortality in this context, it would seem that the study by Hankins et al.[4] has reassured most practitioners that perinatal morbidity and mortality is not compromised and indeed may be improved in women requesting elective caesarean section at 39 weeks gestation. I believe that there is now a legitimate case for women to request elective caesarean section at 39 weeks gestation and that, as responsible obstetricians, we should be striving to reduce the number of caesarean sections in women who do not wish to have a caesarean section, particularly increasing our resolve against the flawed Term Breech Trial and the impaired retrospective studies favouring elective caesarean section for twin pregnancies and giving these women a choice to deliver vaginally!



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