Caesarean section on request - the challenge of informed choice

Abstract

The worldwide caesarean rate has risen dramatically over the past 20 years. Among various contributing factors, the increasing patient expectations have led to an increased rate of delivery by the route perceived to be the safest. This is particularly the case in those paying for the services. This conflict between patients' autonomy and criticism of rising caesarean section rates prompted us to assess the impact of patients' choice on our caesarean section rate in the public sector.

The study was a retrospective review over one year from Dec 97 to Nov 98. Out of 4148 deliveries, 708 (17.1%) were delivered by caesarean section, 195 (4.7%) performed electively and 513 (12.4%) as an emergency operation. As a whole, maternal requests constituted 4.7% (33/708) of all the caesarean sections, 15.4% (30/195) of the elective procedures, 0.6% (3/513) of the emergency operations and 0.8% (33/4148) of the total deliveries.

48.5% (16/33) of the group had their fetuses presenting by the breech and it accounted for 9.6% (16/166) of the total breech presentations during the same period. Of these, 13 women were in their first pregnancy and 3 had previously had a successful vaginal delivery. The reasons mostly cited was the concern over the safety of vaginal breech delivery, in particular the difficulties with delivery of the aftercoming head. During the same period, there were 58.4% (97/166) breech presenting babies considered suitable for vaginal delivery with a success of 43.3% (42/97). 42.4% (14/33) of the requesting group had had one previous caesarean section and it constituted 4.0% (14/346) of all the women having one previous caesarean section. Among these 14 women, only two of them had a successful vaginal delivery before. The reasons against for trial of scar included reluctance to go through the pain of labour if there was a risk of ending up with an emergency caesarean section, previous bad experience of labour, and risk of scar rupture. Concurrently, 227/346 (65.6%) patients were considered suitable for trial of scar with a success rate of 78.0% (177/227). The remaining three patients 9.1% (3/33) included one elderly primigravida, one primigravida with 4.4kg baby and one postterm twin pregnancy.