Presentation on theme: "Ethical and Medical Considerations Surrounding the Decision for Elective Cesarean Sections."— Presentation transcript:
Ethical and Medical Considerations Surrounding the Decision for Elective Cesarean Sections
Incidence and Prevalence Elective Cesarean Sections also known as “on demand” or maternal request Without medical/obstetric indication 23% of all births in 2000 were by cesarean section (29% in 2004) Elective Cesarean sections estimated at around 4- 18% of all cesarean deliveries in 2004. Prevalence has risen over the past half a century and no plateau is in sight. Most data obtained from birth certificates in which maternal request versus medically indicated c- sections were not differentiated between.
Basic Ethical Principles Consequential versus principle ethics Consequential focuses primarily on the idea of overall outcome of the alternatives (risks and benefits) Principle Autonomy-respect for individual rights Mother versus Father Mother versus physician: informed consent Child’s rights?? Beneficence-do no harm Hippocratic Oath “Scope of duty” Justice-fairness for individual and society Distribution of scarce resources (time and money)
Elective vs. Emergency C-sections Non-elective Increased maternal mortality Increased post-partum depression and negative feelings towards birthing experience Elective Increased staff on hand Fewer complications during and following birth
Elective vs. Vaginal Delivery Risks to Mother CS Increased maternal death More frequently rehospitalized Increased risk of anemia, abnormal bleeding, UTI, and backaches Increased risk of placenta previa Vaginal Adverse effects on sexuality and daily activities associated with urinary and anal incontinence Benefits to Mother CS Decreased incidence of pelvic floor disorders/injury Vaginal Reduced risk of infection
Elective vs. Vaginal Delivery Risks and Benefits to Child Brachial Plexus Injuries Vaginal delivery increased risk Disease Transmission Fractures and Nerve Injuries Reduced by more than 50% when delivered by cesarean section Respiratory Depression (acidosis) Risk decreases with increased gestational age
Psychosocial Factors Cesarean sections in general are associated with a greater emotional risk for both mother and child More postpartum depression Mood disorders affect child’s development on all levels Vaginal deliveries associated with a more positive bonding experience Breast feeding Shorter hospital stays
Special Considerations Family Planning Fewer people have 3 rd and 4 th elective c-section Elective cesarean delivery appropriate for smaller families, but if planning larger family vaginal delivery prevails Multiple cesarean deliveries associated with increased risk of uterine rupture, placental abruption, hysterectomy, ectopic pregnancy, and stillbirth Weeks of gestation 39 weeks and before onset of labor-elective cesarean section After that increased risk of respiratory depression, stillbirth, death (risk very low)
$$ Healthcare Costs $$ Primary Elective C-section costs 5.9% less than primary vaginal birth Subsequent vaginal birth costs 17.1% less than elective cesarean delivery. Hospital stays are dependent on health of mother/baby, complications, and more importantly insurance. No real imbalance between either mode of delivery; however many factors influence decision
Ethical Considerations: Autonomy Torn between rights of individual patient and paternalistic role of physician Informed consent Regardless of physician’s personal beliefs Offer all information and options If physician chooses not to perform certain procedure, obligated to refer patient Physicians benefit Increased reimbursement, reduced risks, decreased medical-legal liability
Ethical Considerations: Beneficence Hippocratic Oath In 1850, maternal mortality 100% during c-section Invention of anesthesia, antiseptic techniques, PCN, and blood transfusions—decreased rates Clinical benefits outweigh clinical risks Family planning Convenience
Ethical Considerations: Justice Cost Numbers needed to treat in order to prevent one adverse event Thousands of nonelective cesarean deliveries would need to be performed to prevent one mortality form cord compression, etc Availability of resources
Conclusion Ultimately a decision between two goods. Originally research was centered on good of vaginal delivery and the bad of elective cesarean sections. Decision needs to be based on individual patient and situation One type of delivery may very well be both ethically justified and medically beneficial for one family as opposed to another. Until further evidence shows ethical and or medical reasons as to why there should be written guidelines. However, routinely recommending or even offering elective cesarean delivery is not fully maintained by ethical principles used in medicine.
Bailit JL, Love TE, Mercer B. Rising cesarean rates: Are patients sicker? Am J Obstet Gynecol 2004; 191: 800-803. Ben-Meir A, Schenker JG, Ezra Y. Cesarean section upon request: is it appropriate for everybody? J Perinat Med 2005; 33:106-111. Bost BW. Cesarean delivery on demand: What will it cost? Am J Obstet Gynecol 2003; 188: 1418- 1423. Culligan PJ, Myers JA, Goldberg RP, Blackwell L, Gohmann SF, Abell TD. Elective cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia-a decision analysis. Int Urongynecol J 2005; 16:19-28. Ecker JL. Once a pregnancy, always a cesarean? Rationale and feasibility of a randomized controlled trial. Am J Obstet Gynecol. 2004; 190: 314-318. Edge RS, Groves JR, editors. Ethics of Health Care: A guide for Clinical Practice. 3rd ed. New York: Thomson Delmar Learning; 2006. Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs. 2006; 56:121-132. Hershkowitz R, Fraser D, Mazor M, Leiberman JR. One or multiple previous cesarean sections are associated with similar increased frequency of placenta previa. European Journal of Obstetrics & Gynecology and Reproductive Biology 1995; 62:185-188. McFarlin BL. Elective Cesarean Birth: Issues and Ethics of an Informed Decision. J Midwifery Women’s Health 2004; 49: 421-429. Minkoff H, Chervenak FA. Elective Primary Cesarean Delivery. N Eng J Med 2003; 348: 946-950. Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical Dimensions of Elective Primary Cesarean Delivery. American College of Obstetricians and Gynecologists 2004; 103: 387-392. Munson R. Intervention and Reflection: Basic Issues in Medical Ethics. 5th ed. London, England: Wadsworth Publishing Company; 1996. National Institutes of Health State-of-the-Science Conference Statement. Cesarean Delivery on Maternal Request. American College of Obstetrics and Gynecologists 2006; 107:1386-1397. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary Incontinence after Vaginal Delivery or Cesarean Section. N Eng J Med 2003; 348: 900-907. Simpson KR, Thorman KE. Obstetric “Conveniences” Elective Induction of Labor, Cesarean Birth on Demand, and Other Potentially Unnecessary Interventions. J Perinat Neonat Nurs 2003; 19: 134-144. Van Ham M, van Dongen P, Mulder J. Maternal consequences of caesarean section: A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. European Journal of Obstetrics & Gynecology and Reproductive Biology 1997; 74:1-6.