- December 9, 2015
- Posted by: emobile
- Category: Trending Issues
Counselling Women about the Caesarean Delivery in Future Pregnancies – PART 1
This article in bullets points is to enable women to know more about CD and to provide accurate counselling for the following important clinical situations:
●Caesarean delivery on maternal request;
●Women with a history of one or two caesarean deliveries;
●Women with history of three or more caesarean deliveries.
WHAT YOU SHOULD KNOW ABOUT CAESAREAN DELIVERY
- Caesarean delivery (CD) is the most common surgery performed in the world.1,2
- Over 32% and over 25% of all deliveries annually in the USA and UK, respectively.1,2
- Previous uterine scar was the primary indication for >50% of all CDs.
- 83% of women with a uterine scar are delivered by CD.3,4
- Maternal morbidity and mortality among women delivered by CD remains substantially higher.
- The risks increase with each subsequent CD (haemorrhage, endometritis, operative injury, hysterectomy and maternal death).Counselling women desiring elective CDMR
- Caesarean delivery on maternal request (CDMR) refers to a primary pre-labour CD performed in the absence of maternal or foetal medical indications.
- Exact prevalence of women seeking CDMR remains difficult; estimates ranging from 2% – 8% of all deliveries in the USA.3,5,7
- Counselling recommendation based largely on expert opinion (ACOG, RANZCOG & NICE).Important concepts in counselling women for CDMR
- Understand the reason(s) for the request.
- Enquire into the woman’s desired family size.
- Woman’s understanding of the risks and benefits of and alternatives to CD vs planned vaginal delivery in the current and future pregnancy.
- Respect of patient autonomy and, when appropriate, determination of optimal timing of CD.
- Respect of provider autonomyWhen CDMR is planned it should not be performed before 39w.
- It should not be motivated by unavailability of effective pain management.
- It is particularly not recommended for women desiring several children given that each CD increases the risk of:□Placenta previa□Placenta accreta□HysterectomyOUTCOME OF RANZCOG(2013)9
- Agree to perform CD if patient understands risks and benefits of this course of action.
- Decline to perform CD if obstetrician believes there are significant health concerns for mother or baby; or patient appears to not have sufficient understanding to enable informed consent. Advise patient to seek second opinion.OUTCOME OF NICE (2011)2If a woman requests a CD:
- Discuss and record reasons for request.
- Discuss and record overall risks and benefits of CD compared with vaginal birth.
- Discuss request with other members of obstetric team to ensure woman has accurate information. Outcomes that favoured planned vaginal delivery:
- It reduces maternal hospital length of stay.
- It reduces neonatal respiratory morbidity.
- It reduces risk of subsequent placenta previa or accreta.
- It reduces risk of subsequent uterine ruptureOutcome favouring planned CD:
- It decreased risk of maternal haemorrhage.10 Outcomes for which there was insufficient evidence:
- Foetal mortality.
- Newborn infection.
- Intracranial haemorrhage.
- Neonatal asphyxia or encephalopathy.
- Birth injuries.