This was a reply to Jill from the Unnecesarean’s thoughtful comment on my already-a-reply-turned-post about requests for cesareans for moms who were tired of pushing. (See why I called it “three way mirror style”? It is a post of replies reflecting upon replies…)
That is a really good point. I have discussed this with my faculty adviser at school. He thinks elective cesarean section is a valid choice in the patient choice spectrum, and is an integral part of reproductive rights and patient autonomy. I sometimes wonder if I am rigid in my ignorance of what the “real world” is like in practice, and if I would consider doing some elective cesareans in the future.
Even when I was writing this post, I paused at the last paragraph and thought a lot about my language. I will tell people that I don’t think cesareans are medically justified in many situations, and that I would advise against them in situations that are medically normal (like a not-even-prolonged 2nd stage) when the risks outweigh the benefits.
The only person I know well who opted for a true maternal request elective cesarean had a family history of complications in labor and delivery. From what I have heard, none of these would indicate that she would have similar issues (I think one was a severe shoulder dystocia with a poor outcome), but I can clearly see her fear of vaginal delivery. I have strong faith in genetic issues with labor and delivery. Women deliver like their mothers and sisters, and I take do not take these concerns lightly.
I think this is a fine line that needs a lot of cooperation between patient and doctor, and an acknowledgment that this is a gray area. (OK, I have a feeling this is turning into a reply-turned-post). I know many people want a strong balance of maternal rights with practitioner or government legislation. Limiting women’s choices for elective cesarean might also limit her access to homebirth. Or VBAC. Or selective reduction. Or abortion.
I think this is a topic that needs to be discussed with a lot of nuance (der) and there is room for a balance between evidence based medicine, patient autonomy, informed consent, and yes, sigh, provider conscience. I am strongly in favor of all of these thing with a passion that sometimes makes ethical hypotheticals (as of now, who knows what I will be facing in the next few years?) very challenging.
I strongly support the right of refusal of care. I am not as fervent about the right to interventions that are not evidence based. That is one of the ways I base my ethical decision making. I am much more willing to listen to an argument against intervening rather than for intervening, for the most part. This consideration seems more likely to prevent an overzealous practitioner from pressuring someone into an unwarranted procedure or medication. Or, an uneducated or emotional patient or guardian insisting on an invasive procedure that is either elective or not indicated, that has inherent risks over any potential health benefits. Or, less likely to favor patients who insist on the latest advertised medication for PMDD or the latest compounded hormone recommended on Oprah. Most favorable health outcomes based on available literature is also a large factor for me. Luckily, for obstetrics, these two things tend to go hand in hand.
As of right now, this is how I think I will handle maternal request for elective cesarean. I will inform them of the risks versus the benefits of all of their options. If they seem to understand that cesarean section on a healthy mother and fetus with no medical indications for surgery has more risk than benefit to the mother and fetus (according to current literature), and still want a cesarean, I think I will politely refer them to one of my peers who I think is an excellent surgeon and wish them the best.