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.

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