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Kara Dent, West Midlands
Perinatal Institute,
21/06/2001
Review on Caesarean
Sections
Introduction:
There has been much concern in the rising caesarian
section rate seen over the last 2 decades. This rise
has been attributed to several different factors: surgical
delivery of breeches, "daylight" or "defensive" obstetrics
or simply for patient request. Financially, the audit
commission in England and Wales estimated that a 1%
rise in the LSCS rate costs the National Health Service £5
million ( 1)
This needs to be offset by the cost of litigation -
although it is interesting to note that there has been
no decline in the rate of litigation seen in line with
the rise of caesarian section rates.
In this era of evidence-based medicine, the issue
of informed consent, and thorough counselling, is an
important one. Many papers concentrate on the maternal
issues, forgetting the fetal viewpoint. Using data
from the UK Confidential Enquiries into Maternal Deaths
(1998), it was calculated that an elective section
carries a 2.84 fold greater chance of maternal mortality
over a vaginal birth, if there is no emergency present
(2).
The fetus also carries a risk: 1.9% chance of a knife
laceration (which goes up to 6% if not a cephalic presentation),
RDS and iatrogenic prematurity (2)These
are factors that need to be presented to the mother
in order that she can make a considered decision. Many
Obstetricians feel helpless in light of a woman's right
to choose. The fact that a patient has the right to
refuse medical intervention is unquestioned, but do
they have the right to choose a surgical intervention
when there is no medical cause? Interestingly, the
FIGO ruling in 1999 considered the ethical issue raised
here and stated " Perfoming caesarean section
for non-medical reasons is ethically not justified." (3)
References
1. Editorial. What is the right number
of caesarean sections? The Lancet 1997;349(9055):815, Abstract
2. Hall MH. Maternal mortality and mode of delivery. Lancet 1999;354:776, Abstract
3. FIGO committee for the Ethical Aspects of Human Reproduction and Women's
Health. Ethical aspects regarding caesarean delivery for non-medical reasons.
Int J Obst Gynecol 1999;64:317-22
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