Counselling Women about the Caesarean Delivery in Future Pregnancies – PART 1

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.}