Elective C-sections may not be optional
Oblgyns in Canada still advocating or vaginal deliveries where possible
Medical Post / March 2004
OTTAWA- For patients inquiring about C-sections, ob/gyns may need to reinforce the message that for most women vaginal delivery poses a lower risk, said Dr. Jan Christilaw, a past-president of the Society of Obstetricians and Gynecologists of Canada (SOGC).
Some confusion was created by the ”Elective C-sections gaining acceptance” commentary in the March 2 Canadian Medical Association Journal (CMAJ).
It said Canadian experts will be releasing guidelines similar to those of the American College of Obstetricians and Gynecologists, which support the permissibility of elective cesarean delivery in a normal pregnancy, after adequate informed consent. But the ethics committee of the SOGC has, to date, made no decision to support elective C-sections, according to a recent media advisory from the society. It will release its position statement in late spring.
Nevertheless, the CMAJ commentary attracted an outpouring of media headlines that C-sections will be available ”on demand” for Canadians without the presence of a medical indication.
Dr. Mary Hannah, principal investigator of the Term Breech Trial published in 2000 that found C-section best for breech, authored a different article in the March 2 CMAJ about elective cesarean section. She is director of the Maternal, Infant and Reproductive Health Research Unit at the University of Toronto.
In addressing the quandary now faced by Canadian physicians if a woman without an accepted medical indication requests delivery by C-section, the article by Dr. Hannah suggests the request should be supported if, after a thorough discussion about the risks and benefits, a woman continues to perceive the benefits outweigh the risks.
In her article, Dr. Hannah acknowledged there is higher maternal mortality associated with C-section birth, as well as a longer recovery time and operative complications with C-section.
”But the highest mortality is associated with emergency ce-sarean, which is not something done electively, but happens because planned vaginal birth failed,” said Dr. Hannah in an interview with the Medical Post.
”It is reasonable in some situations to respond positively to a woman’s request (for a C-section), if the woman understands the pros and cons.” she said.
But it is speculative to draw conclusions about the risks and benefits of C-sections from the CMAJ commentary, which referred to the women in the Term Breech Trial who were at higher risk for C-sections than the general population, said Dr. Christilaw, a clinical professor of obstetrics and gynecology at the University of British Columbia in Vancouver, and an obstetriciangynecologist in White Rock, B.C. Canadian ob/gyns will want to carefully consider a patient’s request for a cesarean section with· out medical indication, she added.
”Often the primary motivator is fear of pain and labour… However, they may not be aware of postoperative pain that can occur up to six weeks after surgery, as well as the risks associated with surgery itself, such as a higher risk of thromboembolic complications and complications with future pregnancies.”
While the society is deliberating on this topic, Dr. Hannah said the delay of a committee opinion from the society could be an opportunity for physicians in Canada to influence the development of the society’s recommendations.
KAREN RICHARDSON
