Caesarean Section on Maternal Request and the Anaesthetist

Abstract

Caesarean section carried out at the request of the pregnant woman in the absence of ‘medical’ maternal or fetal indication has been extensively debated in medical literature and has acquired a prominent place in public discourse. While the proportion of caesarean sections carried out purely based on maternal request is unclear, both sides of the debate advance prevalence estimates that help generate an impression favorable to their viewpoint. Still, most indications for caesarean section are relative and evolving and the appreciation of what is medically indicated has radically changed over time. Cost based arguments, an appeal to nature or to women’s appreciation of self are insufficient towards resolving the essence of the debate. The issue can not be resolved through an appeal to the duty of non-maleficence if understood with reference to population-based comparisons of risks and benefits or through the provisions within the notion of consent. The perception of an intervention as being ‘indicated’ or ‘not indicated’ is necessarily agent relative. It is the case that the attitudes of patients and clinicians are contingent and can differ. I draw a distinction between the roles of clinicians depending on whether they have a lead, an essential or a supporting role in relation to the intervention. Caesarean section on maternal request provides a distinctive scenario for examining the ethical concerns of anesthetists as clinicians who will necessarily have an essential role. It should not be assumed that a clinician who has an essential role ought simply to concord with the lead clinician’s view of the merits of the proposed intervention. This becomes particularly relevant in those situations that primarily concern best interest valuations where the lead clinician cannot claim crucial or unique expertise. It is also important to consider that the appropriate discharge of ethical duties should take account of the burden this can impose on patients.

Caesarean section (or delivery) on maternal request (CSMR), patient choice caesarean or caesarean on demand all refer to elective caesarean section (ELCS) for singleton term pregnancy carried out at the request of the pregnant woman in the absence of medical maternal or fetal indications [1]. This may have parallels to ‘prophylactic caesarean’ which was proposed in 1985 as an alternative to what was termed ‘passive anticipation of vaginal delivery’ [2]. Renewed interest in the topic followed the report by Al-Mufti et al. that 31% of female obstetricians in London would choose a caesarean section for themselves in case of uncomplicated pregnancy [3]. The relevance of these expressed preferences is unclear as there is no evidence that they have translated into real actions at the relevant time. CSMR has been extensively discussed in medical literature and also in public discourse, where it is often referred to using somewhat derogatory phrases such as ‘too posh to push’ [4–8]. In the UK, recent guidelines to obstetricians issued by the National Institute of Clinical Excellence (NICE) state that: ‘for women requesting a caesarean section (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 caesarean section’. The guidelines go on to advise that any obstetrician unwilling to perform a caesarean section under such circumstances should refer the woman to an obstetrician who will carry out the CSMR [9].