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The U.S. cesarean delivery rate continues to rise, accounting for nearly one third of all births in 2009. Although elective cesarean deliveries (i.e., those without specified indications) represent <3% of all U.S. births, maternal requests for this delivery mode have become more common. In 2006, an NIH consensus panel concluded that available data were insufficient to allow recommendations for or against planned vaginal delivery or cesarean delivery on maternal request (CDMR) as optimal modes. Now, the American College of Obstetricians and Gynecologists (ACOG) has issued an updated Committee Opinion on this issue. Key points are as follows:
Planned vaginal delivery is associated with short-term maternal benefits such as shorter hospital stays and lower rates of infection and anesthesia-related complications.
Risks for postpartum hemorrhage and short-term surgical complications are lower with CDMR, but the likelihood of complications such as uterine rupture, placenta previa, and placenta accreta, as well as the need for hysterectomy, increases with subsequent pregnancies. For example, the cumulative likelihood of obstetric morbidity by a fourth pregnancy has been estimated at 10% among women who chose CDMR for the first birth, compared with 4% among those who attempted vaginal delivery.
CDMR before 39 weeks' gestation carries increased risk for neonatal respiratory morbidity and complications of prematurity, although the risk for brachial plexus injury is lower with CDMR than with vaginal delivery.
Evidence for differences in rates of postpartum depression, pelvic organ prolapse, subsequent stillbirth, and maternal death is inconclusive.
Based on this evidence, ACOG recommends vaginal delivery as a safe option in the absence of maternal or fetal indications for cesarean delivery. CDMR should not be performed before 39 weeks' gestation, and fear of pain during labor should not be the sole motivation for cesarean delivery; in such instances, counseling, increased support, and effective analgesia should be offered.
Committee on Obstetric Practice. ACOG Committee Opinion 559: Cesarean delivery on maternal request. Obstet Gynecol 2013 Apr; 121:904. (http://dx.doi.org/10.1097/01.AOG.0000428647.67925.d3)
Comment
Curbing the rapid rise in cesarean rates will require incremental approaches to the problem. Although cesarean delivery on maternal request accounts for a small proportion of all U.S. deliveries, a data-driven campaign guiding the recommendations of clinicians and the decisions of women and their families is critical. Whereas this Committee Opinion leaves room for CDMR in well-counseled women, its firm recommendations in favor of planned vaginal delivery (particularly for women who wish to have several children) and against CDMR prior to 39 weeks' gestation should curtail morbidity and mortality in women and children across their lifespans.