WOMEN GIVEN FINAL CHOICE FOR C-SECTIONS

Doctors must perform upon patient’s request

Pregnant women have a right to choose a caesarean section even if there is no valid medical reason to warrant one, Canada’s obstetricians say.

In a significant softening of its long-held stance that C-sections should be reserved for pregnancies in which the health of the mother and/or fetus is at risk, the Society of Obstetricians and Gynaecologists of Canada now says the choice, ultimately, should be the woman’s.

If, after being “fully briefed” about the pros and cons, a woman still insists on a pre-planned C-section, the doctor must either agree to perform the surgery or refer the woman to another doctor, the SOGC said in a statement released Tuesday.

“Some physicians may not agree with the request because of ethical or medical reasons,” Dr. Jennifer Blake, the group’s chief executive officer, said. “But if a patient decides they want to go ahead with the procedure, contrary to the wishes of their doctor, that doctor has a responsibility to refer the patient for a second opinion or transfer care.”

In Canada, 28 per cent of births were via C-section last year, with a high of 35 per cent in B.C., and a low of 18 per cent in the Northwest Territories, the Canadian Institute for Health Information reported. More than 103,000 C-sections were performed in Canada last year, making them the most common “in-patient” surgical procedure in Canadian hospitals.

For years, the SOGC has said C-sections shouldn’t be offered when there’s no medical reason for opting for abdominal surgery over vaginal delivery.

“The Society is concerned that a natural process would be transformed into a surgical process,” reads its 2004 position statement on C-sections on demand.

So why the change, and why now? The SOGC said it still holds to the principle that there should be a medical need for doing a C-section.

“We shouldn’t as practitioners offer them, or do them generally, unless there is a medical reason,” said Dr. Jon Barrett, chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre and one of the authors of the new opinion statement. “However, there is no doubt that there is a group of patients who, for whatever their own reason, come forward and request a caesarean section without indication. So, what is a practitioner to do with that?” Barrett said.

“There’s the perception that this category is increasing. Therefore, we felt we had to have a position on this.”

Rising rates of C-sections have been blamed on everything from almost phobic fears of vaginal delivery, to older first-time mothers and a phenomenon obstetricians have dubbed “precious baby” syndrome — the idea that this might be the only pregnancy the woman will likely ever have, and nothing should be done to risk it.

C-sections have been tied to slight decreases in stillbirths; and fewer babies are running into trouble due to lack of oxygen at birth.

However, a C-section is surgery, with all the inherent risks of surgery. The risk of severe hemorrhage, cardiac arrest and deep vein thrombosis is increased in women who have a planned C-section compared to those who try a vaginal birth.

Doctors are also seeing a significant increase in placenta accrete, where the placenta in the next pregnancy invades through the scar of the previous C-section, resulting in a serious risk of bleeding and hysterectomy.

Risks to babies include potential fluid overload in the lungs. When babies are born via vaginal birth, their lungs are squeezed as they pass through the birth canal, releasing fluid from the lungs. That doesn’t happen with a C-section.

“There’s a higher risk of the baby not being able to breathe properly,” which sometimes requires intensive care, Barrett said.

Still, the vast majority of C-sections happen without complications, Barrett said. And the trouble with birth is that it’s unpredictable.

“It’s all very well to say, ‘I’m going to have a planned vaginal birth,’ but we know that there is a significant risk of having to have a caesarean section in labour, or an emergency caesarean section.”

Vaginal deliveries also come with a higher risk of damage to the pelvic floor muscles.

Barrett said that if a woman requests a planned Csection, her reasons for doing so should be fully explored, but that ultimately patient autonomy should prevail.

“A physician has to either perform it and if they really cannot because it’s against their principle or they believe it’s not safe for the patient then they have to refer to somebody who will,” he said.