Ethical issues in cesarean delivery.

Cesarean delivery is the most common and important surgical intervention in obstetric practice. Ethics provides essential guidance to obstetricians for offering, recommending, recommending against, and performing cesarean delivery. This chapter provides an ethical framework based on the professional responsibility model of obstetric ethics. This framework is then used to address two especially ethically challenging clinical topics in cesarean delivery: patient-choice cesarean delivery and trial of labor after cesarean delivery. This chapter emphasizes a preventive ethics approach, designed to prevent ethical conflict in clinical practice. To achieve this goal, a preventive ethics approach uses the informed consent process to offer cesarean delivery as a medically reasonable alternative to vaginal delivery, to recommend cesarean delivery, and to recommend against cesarean delivery. The limited role of shared decision making is also described. The professional responsibility model of obstetric ethics guides this multi-faceted preventive ethics approach.

Vaginal Birth After Caesarean Section in Low Resource Settings: The Clinical and Ethical Dilemma.

Vaginal birth after Caesarean section (VBAC) has long been practised in low resource settings using unconventional methods. This not only poses danger to the woman and her baby, but could also have serious legal and ethical implications. The adoption of this practice has been informed by observational studies with many deficiencies; this is so despite other studies from settings in which the standard of care is much better that show that elective repeat Caesarean section (ERCS) may actually be safer than VBAC. This raises questions about whether we should insist on a dangerous practice when there are safer alternatives. We highlight some of the challenges faced in making this decision, and discuss why the fear of ERCS may not be justified after all in low resource settings. Since a reduction in rates of Caesarean section may not be applicable in these regions, because their rates are already low, the emphasis should instead be on adequate birth spacing and safer primary operative delivery.

L'accouchement vaginal après césarienne (AVAC) est pratiqué depuis longtemps au moyen de méthodes non conventionnelles au sein de pays ne disposant que de faibles ressources. Cela entraîne non seulement des risques pour la femme et son enfant, mais peut également donner lieu à de graves conséquences sur les plans juridique et éthique. L'adoption de cette pratique est soutenue par des études observationnelles comptant de nombreuses carences. Cette pratique perdure malgré la publication d'autres études (issues de milieux au sein desquels les normes de diligence sont beaucoup plus élevées) qui indiquent que la tenue d'une césarienne itérative planifiée (CIP) pourrait en fait être plus sûre que l'AVAC, ce qui soulève des questions quant à la nécessité d'insister sur la mise en œuvre d'une pratique dangereuse, compte tenu de l'existence de solutions de rechange plus sûres. Nous soulignons certains des défis à relever pour la prise d'une décision dans de telles situations et traitons des raisons pour lesquelles les craintes quant à la tenue d'une CIP pourraient ne pas être justifiées après tout au sein des milieux ne disposant que de faibles ressources. Puisqu'une réduction des taux de césarienne pourrait ne pas être possible dans ces régions (car ces taux y sont déjà faibles), l'accent devrait plutôt être placé sur l'espacement adéquat des grossesses et sur la tenue d'un accouchement opératoire plus sûr dans le cadre de la première grossesse.

The Ulysses contract in obstetrics: a woman's choices before and during labour.

Women recognise that labour represents a mind-altering event that may affect their ability to make and communicate decisions and choices. For this reason, birth plans and other pre-labour directives can represent a form of Ulysses contract: an attempt to make binding choices before the sometimes overwhelming circumstances of labour. These choices need to be respected during labour, but despite the reduced decisional and communicative capacity of a labouring woman, her choices, when clear, should supersede decisions made before labour.

The effect of malpractice claims on the use of caesarean section.

Malpractice fears are believed to influence various aspects of obstetrical practice. They seem to have contributed in small part to the rising primary caesarean section rate, but have also played a considerable role in the downtrend in vaginal birth after caesarean statistics. The rising vaginal birth after caesarean section rate between 1981 and 1995 was interrupted by a spate of lawsuits associated with broadened indications for vaginal birth after caesarean section in conjunction with requirements for immediate clinician availability. These factors dramatically reduced the availability of hospitals and clinicians willing to offer vaginal birth after caesarean section. This reversal, however, has not diminished the demand for vaginal birth after caesarean section from various stakeholders in the name of patient autonomy, clinician beneficence and optimal care. Nevertheless, as long as stringent requirements remain for clinician attendance during vaginal birth after caesarean section, and as long as the spectre of preventable error and the lingering dread of lawsuits retain their hold on obstetrical practice, caesarean section trends are unlikely to change.

VBAC in the trenches: a community perspective.

Is vaginal birth after cesarean in the community a disappearing practice? Since 1996 the rate of trial of labor after cesarean for low-risk women has dropped precipitously. This paper reviews the current literature and summarizes opinions of community obstetricians and midwives. Descriptive data are presented to document the scope of the problem and identify barriers: liability concerns, provider biases, and institutional restrictions. Our perspective draws on experience in our community hospital with a previously high vaginal birth after cesarean rate and a subsequent ban. Strategies to reduce the skyrocketing cesarean rate and encourage trial of labor after cesarean for low-risk women are outlined.

An ethical framework for the informed consent process for trial of labor after cesarean delivery.

In 2010, a National Institutes of Health Consensus Panel and the American College of Obstetricians and Gynecologists issued updated statements on trial of labor after cesarean delivery (TOLAC). This article presents an ethical framework for the informed consent process for TOLAC. Three conclusions are reached. For women with one previous low transverse incision, TOLAC and elective repeat cesarean delivery should be offered. Obstetricians should recommend against TOLAC when a pregnant woman has had a previous classical incision. TOLAC after two previous low transverse incisions may be offered provided that the informed consent process presents the uncertainties of the evidence.

Roundtable discussion: "no one can condemn you to a C-section!".

The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician.

Toward an ethically responsible approach to vaginal birth after cesarean.

Determining approach to delivery after a previous cesarean is among the most contentious areas of obstetrics. We present a framework for ethically responsible guidelines and practice regarding vaginal birth after cesarean. We describe ethical complexities of 3 key issues that mark the debate: the cesarean delivery rate, safety, and patient autonomy. We then describe a taxonomy of considerations that should inform a responsible framework for guideline development and highlight critical distinctions between types of guidelines that have been blurred in the past. We then forward 2 central claims. First, in otherwise uncomplicated birth after a single previous cesarean, both vaginal birth after cesarean and repeat cesarean should be regarded as reasonable options; women, rather than policymakers, providers, insurance carriers, or hospitals, should determine delivery approach. Second, in complicated cases, providers and policymakers should carefully calibrate the strength of evidence to ensure differential risk and cost are adequate to justify directive guidelines given important variations in values women bring to childbirth.

Hippocratic ideal, Faustian bargain and Damocles' sword: erosion of patient autonomy in obstetrics.

Respect for patient autonomy remains a foundational principle guiding the ethical practice of medicine-a mission first articulated by Hippocrates. Damocles, another figure from ancient Greece, provides a useful parable for describing performance under distress: Damocles loses his desire for opulence and power when he notices a sword dangling precariously above his head. Contemporary obstetricians deciding whether to forestall or impose major abdominal surgery on parturients entrusted to their care struggle valiantly in the chasm dividing Hippocratic idealism from the economic realism driven by the medicolegal sword of Damocles. Given the inherent risk of unforeseeable and unsalvageable fetal catastrophe during labor and vaginal delivery, and the often unsubstantiated, yet automatic, allegation of negligence that follows a labor-associated adversity, obstetricians-and their liability insurance carriers-have recalibrated obstetric practice in alignment with the increasingly risk-averse preferences of most patients. Indeed, less intrapartum risk for patients and less corresponding medicolegal exposure for obstetricians help explain the rising cesarean delivery rate and, more importantly, the steady disappearance of higher-risk interventions such as vaginal birth after cesarean (VBAC). Is this increasing reluctance to offer VBAC supervision ethically defensible? This paper argues that it is. Fiduciary professionalism mandates physician self-sacrifice, not self-destruction; a VBAC gone awry without negligence or substandard care may, nevertheless, render future affordable liability coverage unattainable. Yet, the unavailability of VBAC infringes on the autonomy of women who want to assume the intrapartum risks of a VBAC in lieu of a repeat cesarean delivery. The proposed solution is the regionalization of VBAC care provision in designated medical centers and/or the implementation of binding arbitration in an ethical trade-off to enhance patient autonomy regarding the preferred mode of delivery despite parallel constraint on legal options.

Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery.

This article presents the findings of qualitative research which explored, from the mothers' perspective, the process of decision-making about mode of delivery for a subsequent birth after a previous Caesarean Section. In contradiction to the clinical literature, the majority of mothers in this study were strongly of the opinion that a vaginal birth after caesarean (VBAC) posed a higher risk than an elective caesarean (EC). From the mothers' perspective, risk discussions were primarily valuable for gaining support for their pre-determined choice, rather than obtaining information. The findings posit ethical concerns with regards to informed consent and professional obstetric practice at a time when there is a documented and worrying trend towards an increase in births by caesarean section (CS).

Vaginal birth after caesarean section: clinical and legal perspectives.

Vaginal birth after Caesarean section (VBAC) is currently the preferred method of delivery for pregnant women who have undergone 1 previous low transverse Caesarean section. This common practice warrants some reconsideration in light of recent clinical data on the risks associated with VBAC, and it is incumbent upon clinicians to ensure that women under their care are fully aware of these risks. Indeed, in some circumstances, an attempt at VBAC may be perceived by the courts to represent a negligent standard of care.