Pros on Cesarean section

Cons on Cesarean section

Level 1: Values by law

Freedom of autonomous choice for women who want to opt for elective Cesarean section (CS). Right to decide about own body

Given the professional autonomy of the medical professional there is no “freedom” as meant in level 1 as soon as somebody becomes a patient

Full autonomy for patients may encourage commercial clinics that offer only CS on maternal requests, which is not desirable

Allowing full freedom for maternal CS on request may give rise to socially unacceptable higher rates of CS in the population

Contradiction or tension with other ethical principles addressed at level 2

Level 2: Medical ethical principles

Autonomy

Experience autonomy

Women’s birthing experience is important and goes along with women’s satisfaction and experiences of care

Do something, defending one’s own interest, or even “rights”

Desire of women to be able to decide for themselves

The health professional also has an autonomous choice in light of his/her professional standards

Not delivering a baby by oneself but “being delivered by the doctor”

Too strong a dependence on healthcare providers

Once started, there is no way back

Much more burden than expected

Different delivery from most women

Feelings of guilt, because this solution contributes to decreasing acceptance of vaginal delivery (VD)

Feelings of guilt when complications occur

Beneficence

1–4 % chance of third-degree perineal tear as compared to 0 % with CS [2]

Long-term (20 years postpartum) problematic incontinence 11.2 % after VD versus 6.3 % after CS [3]

Lifetime prolapse surgery is more frequent in women after VD (2.2 %) versus CS (0.2 %) [4]

Forceps delivery gives the highest chance on lifetime prolapse surgery (14.3 %) [4]

Levator defects have been found in 15.4 % of women with VD in history [5]

Women with planned CS reported a higher satisfaction score regarding birth experience 2 days after birth compared with women having a planned vaginal birth and this effect remained 3 months postpartum [6]

Potential short-term maternal benefit: less maternal hemorrhage [7]

Risk of fecal incontinence is not more prevalent in women after VD as compared to after CS (6 % in all women), except for women who underwent forceps delivery in which the risk for fecal incontinence doubled [8]

After CS there is a 20 times higher chance of wound infection as compared to vaginal delivery [9]

After CS a ten times higher risk of endometritis (8 % in CS versus 1–3 % for a vaginal delivery) [6]

After CS, 2 times higher risk for deep venous thrombosis and pulmonary embolism (0.03 % in VD versus 0.06 % in CS), but in other study no difference was found [6]

After CS 0.2–1.5 % versus almost 0 % uterine rupture in next pregnancy with 1.2 % chance for perinatal death in case of uterine rupture [10]

After CS 0.65 % versus 0.26 % for subsequent placenta previa with 0.16–0.3 % versus 0.004–0.01 % risk for placenta accreta/increta/percreta in general. This condition increases the risk for postpartum hemorrhage, sometimes necessitating emergency hysterectomy with increased risk for severe maternal morbidity or sometimes mortality [10]

More women who had a planned vaginal birth were breastfeeding at 3 months postpartum compared with women who had a planned CS. This finding was statistically significant [6]

Nonmaleficence

Good monitoring of the process from indication to operation, so the patient feels taken seriously and also feels the possibility to say “no,” even under peer pressure

Prevention of commercial practices in private clinics

Protection of people against themselves when they have insufficient notion of the risks to be expected in this medical or psychological area

NICU admission more prevalent in CS (13.9 % versus 6.3 %) as compared with vaginal delivery [6]

Patronizing, limiting autonomous choice

Possibly going for a vaginal delivery that will cause harm to the mother, due to pelvic organ damage, third- or fourth-degree perineal tears with lifelong consequences

CS inevitably leads to abdominal scarring, which increases the risk for hematomas, wound infections, neurinomas, and unaesthetic scarring that may need plastic surgery later in life

Justice

Insurance fees have been paid, so the insurance has to pay for it

Obstetricians have the professional right to decide what is right for their patient

Costs as calculated by the NHS: the costs of birth and “downstream” costs found that a planned vaginal birth was approximately £ 700 cheaper than a maternal request CS [6]

Level 3: Best medical practice (WHO 2015, NICE guideline 2011, ACOG committee opinion 2013)

When a woman requests a CS, explore, discuss, and record the specific reasons for the request [6]

If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife, and anesthetist) if necessary to explore the reasons for the request and to ensure the woman has accurate information [6]

For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS [6].

An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS [6].

In cases in which CS on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks [7]

CS are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons [11]

CS should ideally only be undertaken when medically necessary [7, 11]

The effects of CS rates on other outcomes, such as maternal and perinatal morbidity, pediatric outcomes, and psychological or social well-being, are still unclear. More research is needed to understand the health effects of CS on immediate and future outcomes [11]

Standard antibiotic treatment during CS is required, which may increase the already evolving threat of antibiotic resistance of bacteria

If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife, and anesthetist) if necessary to explore the reasons for the request and to ensure the woman has accurate information [6]

When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner [6]

Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care [6]

Level 4: Doctor’s own norms and values and norms

In general, there is more lifetime risk of prolapse and incontinence

Third-degree perineal tears will not occur in CS

Absolute lifetime risks for prolapse surgery and incontinence are low and CS is not completely protective against prolapse and incontinence

CS is more expensive and weighs more on scarce healthcare funds

NICU admission more prevalent in CS