Cesarean delivery on maternal request: maternal and

neonatal complications
Young Mi Leea and Mary E. D’Altonb
a
Division of Maternal-Fetal Medicine, Department of Purpose of review
Obstetrics and Gynecology, NYPH, Weill Cornell
Medical College and bDepartment of Obstetrics and
A complicated but relevant and timely concept, cesarean delivery on maternal request
Gynecology, NYPH, Columbia University Medical (CDMR) is defined as a cesarean delivery for a singleton pregnancy on maternal request
Center, New York, New York, USA
at term in the absence of medical or obstetrical indications.
Correspondence to Mary E. D’Alton, Department of Recent findings
Obstetrics and Gynecology, NYPH, Columbia
University Medical Center, 620 West 168th Street, Multiple potential risks and benefits exist with both vaginal and cesarean deliveries.
PH 16, New York, New York 10032, USA A CDMR performed prior to the onset of labor for a mother planning on only one
Tel: +1 212 305 2377
or two children may be reasonable after informed consent and counseling. However, the
Current Opinion in Obstetrics and Gynecology most concerning complications from cesareans are the neonatal respiratory
2008, 20:597–601
morbidity and the impact on a mother’s future reproductive health, including the risk of
abnormal placentation such as placenta previa or accreta. The literature on CDMR is
limited and is derived primarily from observational or extrapolated studies. A well
designed prospective study does not currently exist but is needed comparing the
optimal groups of planned vaginal delivery and planned CDMR.
Summary
Discussions regarding CDMR should be individualized. Until there are more data on
CDMR and guidelines implemented, an explicitly executed informed consent should
form the framework of any decision regarding mode of delivery.

Keywords
cesarean, maternal morbidity, maternal request, neonatal morbidity

Curr Opin Obstet Gynecol 20:597–601

ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-872X

(1) More research on CDMR is needed.

Introduction (2) Decision to perform a CDMR should be individua-
Cesarean delivery on maternal request (CDMR) is lized and consistent with ethical principles.
defined as a cesarean delivery for a singleton pregnancy (3) CDMR should not be performed prior to 39 weeks’
on maternal request at term in the absence of medical or gestation unless there is documentation of fetal
obstetrical indications [1]. The most recent national lung maturity.
statistics estimates that in 2006, over 30% or 1.3 million (4) Effective pain management services should be avail-
births were via cesarean, a national record, and an esti- able to all laboring women and their unavailability
mated 2.5% of all births in United States were CDMR should not be the motivator for CDMR.
[1,2]. The controversy and debate surrounding CDMR (5) CDMR is not recommended for women desiring
not only reflects changing medical practice but a shift several children.
in attitude of both healthcare providers and patients. In (6) Potential risks of CDMR include a longer maternal
March 2006, the National Institute of Child Health and hospital stay, hemorrhage, neonatal respiratory
Human Development (NICHD) branch of the National morbidity, and complications in subsequent preg-
Institutes of Health (NIH) sponsored a State-of-the- nancies such as uterine rupture, placenta previa,
Science conference on CDMR to analyze and system- or accreta.
atically review the current evidence, educate the public
of the findings, and identify potential areas of future A variety of maternal and fetal outcomes were examined
research. Conclusions drawn from the 2006 NIH State- in the conference but an extensive literature search
of-the-Science conference and 2007 American College of identified only five areas supported by moderate level
Obstetricians and Gynecologists (ACOG) Committee evidence: maternal length of stay, hemorrhage, neonatal
Opinion on CDMR are as follows [3]: respiratory morbidity, subsequent placenta previa or
1040-872X ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/GCO.0b013e328317a293

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 598 Healthcare management strategies

accreta, and subsequent uterine rupture [1,3]. The data [4]. Unlike premature births, term births lack large data-
on CDMR are sparse but suggest that there are a number of bases from which reliable estimates of specific outcomes
important risks and benefits from both vaginal and cesar- can be determined. Respiratory complications often seen
ean deliveries. Although the safest route of delivery may in term neonates include transient tachypnea of the
be an uncomplicated vaginal delivery, accurately predict- newborn, respiratory distress syndrome resulting from
ing who will achieve this outcome is currently not possible. iatrogenic prematurity, and persistent pulmonary hyper-
The impact on future pregnancies should be carefully tension of the newborn or hypoxic respiratory failure.
considered; however, a CDMR performed prior to the
onset of labor for a mother planning on only one or two At least one study suggests that corticosteroid adminis-
children may be reasonable after informed consent and tration in the term gestation may be beneficial in redu-
counseling on the risks and benefits. Since the 2006 NIH cing respiratory distress. In the antenatal steroids for term
conference, few studies on CDMR have been published caesarean section (ASTECS) trial, 998 patients were
with the majority remaining observational or extrapolated randomized to steroid administration or no medication
research, leaving many questions unanswered. prior to elective cesarean at term (at or greater than
37 weeks) [6]. The incidence of admission with respir-
atory distress was 0.051 in the control group and 0.024 in
Neonatal respiratory morbidity the treatment group [relative risk (RR) 0.46, 95% CI
The most concerning impact on the neonate from CDMR 0.23–0.93] [6]. The findings raise the question on the
appears to be the risk of neonatal respiratory morbidity. role antenatal steroids may play in the growing CDMR
Potential benefits for the neonate from planned vaginal debate. However, the potential long-term consequences
delivery include a lower risk of respiratory problems, less remain a concern and more studies are needed. Until
risk of iatrogenic prematurity, and shorter length of then, current recommendations advise limiting adminis-
hospital stay. Although serious respiratory distress prim- tration of corticosteroids to enhance fetal lung maturation
arily follows iatrogenic prematurity, transient tachypnea to those gestations between 24 and 34 weeks who are at
of newborn and persistent pulmonary hypertension are risk for preterm delivery within 7 days [7].
both increased with elective cesarean regardless of gesta-
tional age [4]. Respiratory distress syndrome requiring
mechanical ventilation is significantly reduced to one in Neonatal morbidity
10 000 newborns if elective cesarean delivery is delayed Rare but serious complications such as intracranial hemor-
until after 39 weeks’ gestation [5]. This stresses the rhage and neonatal asphyxia and encephalopathy are all
importance of accurate dating and adherence to ACOG more frequently found with complicated vaginal deliveries
guidelines disapproving of elective delivery prior to and unplanned cesareans. Using some epidemiological
39 completed weeks without documentation of fetal lung models, adopting a universal approach of cesarean delivery
maturity [1]. on all women at 39 weeks has the potential of reducing our
nation’s numbers of both transient and permanent brachial
Morrison et al. [5] prospectively collected data on over plexusinjury,neonatalencephalopathy, intrapartum death,
33 000 deliveries at term (37 weeks’ gestation) over and intrauterine fetal death beyond 39 weeks [8]. Not
9 years and found that the respiratory morbidity was surprisingly, the potential for brachial plexus injury is high-
significantly higher for neonates delivered by cesarean est for assisted vaginal delivery and higher for infants born
before the onset of labor (35.5/1000) compared with via the vaginal route as compared with cesarean. The risk of
cesarean during labor [12.2/1000; odds ratio (OR) 2.9; fetal trauma is increased with a difficult delivery, whether
95% confidence interval (CI) 1.9–4.4; P < 0.001] or vaginal or cesarean, such as sequential instrumentation like
vaginal delivery (5.3/1000; OR 6.8; 95% CI 5.2–8.9; vacuum followed by forceps or vice versa or an emergent
P < 0.0001). These findings are consistent with the situation such as stat cesarean for cord prolapse. Although
widely held belief that neonatal passage through the elective cesarean would reduce these risks, the magnitude
birth canal accompanied by exposure to endogenous of reduction would be minimal as these risks with planned
steroids and catecholamines released in normal labor vaginal delivery remain low.
and delivery improve the neonatal pulmonary transition
from amniotic fluid to breathing air [4]. In 1998, Badawi et al. [9,10] published a case–control study
of 164 term infants with moderate or severe newborn
The general impression about respiratory morbidity in encephalopathy and observed a decreased risk of neonatal
term infants is that of benign self-limited disease requir- encephalopathy with elective cesarean compared with
ing limited intervention; however, some of these neo- spontaneous vaginal delivery (adjusted OR 0.17, 95% CI
nates become seriously ill and may require prolonged 0.05–0.56). In patients who underwent elective cesarean
oxygen therapy, mechanical ventilation, extracorporeal without labor, there was an 83% reduction in risk of
membrane oxygenation (ECMO), or rarely end in death moderate or severe neonatal encephalopathy but this

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 Cesarean delivery on maternal request Lee and D’Alton 599

hypothetically amounts to approximately 5000 cesareans women for planned cesarean, 90.4% delivered by cesar-
to prevent one case of hypoxic ischemic encephalopathy ean; of which 50% were in labor. Of 1042 women for
[8]. One must also acknowledge that reduction in long- planned vaginal delivery, 56.7% delivered vaginally and
term outcome is less clear as this does not eliminate the 22% with forceps. The two study groups had no signifi-
possibility of permanent neurologic injury such as cerebral cant differences in overall composite morbidity (planned
palsy. Despite the rising cesarean rates over the last cesarean versus planned vaginal delivery, RR 1.13, 95%
decade, the number of neonates with cerebral palsy and CI 0.92–1.39) or specific outcomes of hemorrhage,
other long-term neurologic conditions has remained rela- transfusion, genital tract injury, wound complications,
tively stable over the same time period. systemic infection, or depression [18,19]. There were
no hysterectomies or cases of thromboembolism and
Unexplained stillbirth remains a devastating and com- no significant differences in rates of pain or depression
mon obstetrical problem occurring in nearly 1% (6.4 per were appreciated at 3-month follow-up.
1000) of all births in the United States [11]. Particularly
frustrating is the fact that unexplained intrauterine fetal Benefits of a vaginal delivery include shorter length
death comprises a substantial number of cases. If one of hospital stay and lower rates of infection such as
weighs the prospective risk of fetal death in ongoing endometritis and urinary tract infections [3]. Anesthesia
pregnancies, or the risk of fetal death beyond a given complications are lowest in vaginal deliveries and high-
gestational age, against the risks of neonatal morbidity at est during emergency induction of anesthesia such as
birth, there may be an argument for delivery at 39 weeks, those performed for unplanned, emergent cesareans.
thus obviating the risk of stillbirth [12,13]. Delivery at a Although a meta-analysis suggests that neonates deliv-
given gestational age averts the risk of stillbirth, but there ered by cesarean are less likely to initiate breastfeed-
has been some concern that this thought has contributed ing, there does not appear to be any difference at 3 or
to a rise in the number of births between 34 and 37 weeks’ 24 months [19,20]. On the other hand, postpartum
gestation, exposing a large number of neonates to com- hemorrhage occurs less frequently in planned cesareans
plications of late preterm birth [14]. The experience in than planned vaginal or unplanned cesareans. However,
Brazil, a country where cesarean rates exceed that of the much of the higher hemorrhage incidence in planned
United States, warns that acknowledging maternal vaginal delivery group reflects the contribution of
request as an indication for cesarean may open the operative vaginal deliveries and cesarean in labor [3].
door for iatrogenic late preterm births. Barros et al. [15] Maternal mortality, hysterectomy, and thromboembo-
analyzed a prospective cohort study of all urban births lism are rare outcomes and therefore the data on their
in Brazil in 1982, 1993, and 2004 and found that the impact are limited. Data are lacking for other important
prevalence of preterm births increased from 6.3 to 16.2% variables such as depression, bonding, and postpartum
and rate of cesareans increased from 28 to 43% with pain. Overall, however, the current literature suggests
cesareans performed for 82% of all private deliveries that composite short-term maternal morbidity is similar
in 2004. in women undergoing planned vaginal and planned
cesarean deliveries.

Maternal morbidity and mortality Regarding pelvic floor dysfunction, the data are unclear.
The current literature suggests that term planned cesar- There may be a potential benefit of planned cesareans on
ean and planned vaginal deliveries have similar low short-term stress urinary incontinence; however, any
absolute and relative rates of maternal morbidity [16]. benefit may be decreased or eliminated in older, parous,
A Cochrane Database Systematic Review studying short-term and obese patients [21]. Only one randomized trial has
maternal outcomes of three randomized trials compared studied the difference in pelvic floor symptoms after
planned cesarean with planned vaginal delivery for planned vaginal or cesarean birth and the investigators
breech [17]. The review noted a somewhat increased found an initial lower rate after planned cesarean at
overall maternal morbidity in the planned cesarean 3-month postpartum (4.5 versus 7.3%; RR 0.62, 95%
group (9.1 versus 8.6%, RR 1.29, 95% CI 1.03–1.61). CI 0.41–0.93) but no difference at 2 years [20]. In a
Two of the three studies were conducted several decades recent large population-based publication, investigators
ago and randomized participants in labor, thus potentially of the Norwegian Epidemiology of Incontinence in the
increasing the operative morbidity among cesareans and County of Nord-Trøndelag (EPINCONT) study [22]
questioning their applicability to CDMRs today [16]. found no difference at 5 years regardless of delivery type.
The literature on anorectal dysfunction, sexual function,
The largest and most recent randomized trial with proxy and pelvic organ prolapse is weak and favors neither route.
comparison groups is the Term Breech Trial evaluating Anal incontinence following vaginal delivery is strongly
2088 women from 121 centers in 26 countries with term associated with overt and occult sphincter lacerations and
(37 weeks), singleton breech fetuses [18]. Of 1041 operative vaginal delivery [23]. More research is needed in

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 600 Healthcare management strategies

this area, especially as pregnancy itself appears to have a gestation was 1.1 per 1000 for women who had a previous
role in pelvic organ dysfunction and cesarean does not cesarean and 0.5 per 1000 for those who had not [35].
eliminate the risks for urinary or anorectal incontinence,
pelvic organ prolapse, or sexual dysfunction. Other potential reproductive consequences from cesarean
delivery on request that have been raised are increased risk
Fortunately, death associated with pregnancy rarely occurs of spontaneous abortion and ectopic pregnancy, infertility,
today but has become a greater concern with an increasing uterine scar dehiscence, uterine rupture, and placental
number of complications such as placenta previa and abruption. In addition, an entity rarely seen in the past,
accreta, uterine rupture, or cesarean scar ectopic preg- cesarean scar ectopic pregnancies have recently demon-
nancy. Current studies often lack adequate power to strated a considerable increase [36]. Awareness of these
clearly discern a relationship between mortality and complications is critical as the rates of these potentially
method of delivery. However, studies from the United lethal sequelae rise.
Kingdom emphasize the difference between cesareans
performed electively and those unplanned or performed
after the onset of labor [24,25]. Although one might Conclusion
anticipate a slight increase in maternal deaths with Well designed, systematic data on CDMR are lacking and
cesareans as compared with vaginal delivery, one must many questions remain unanswered. Potential medical
also acknowledge a potential concomitant decrease risks that should be emphasized include neonatal respira-
in mortality associated with intrapartum, unplanned tory morbidity and risks to future pregnancies such as
cesareans. Therefore, the current data are inadequate to abnormalplacentation.Theprimaryadvantageofcesareans
accurately estimate the absolute risk of maternal mortality on maternal request is avoiding emergent or unplanned
with CDMR but suggests there may not be a significant net cesareans, which carry higher risks for morbidity and
increased risk of maternal death with CDMR. potential psychological trauma than scheduled or planned
cesareans [3]. Other potential benefits include scheduling
convenience, lower risk of hemorrhage, and decreased
Subsequent pregnancies neonatal neurologic injury. Most obstetrician–gynecolo-
One of the most serious complications of cesarean deliv- gists recognize an increased demand for CDMR within
ery is the impact on a woman’s future reproductive their practices and agree that studies regarding risks and
health. Cesareans are a well established risk factor for benefits are crucial to guiding decision-making with regard
subsequent development of abnormal placentations such to CDMR. Because of the complexity of this question, the
as placenta previa and/or accreta [3,26]. Placenta accreta decision-making process will vary for each individual
occurs most frequently in women with a prior history of [37,38]. Mothers should be counseled that the most
cesarean and current placenta previa with studies esti- concerning risks involve her future obstetrical health. In
mating the risk for placenta previa-accreta to be 11–24% addition to the medical impact, discussions should also
in women with one prior cesarean [27,28,29]. The inci- include psychological, economic, and sociologic consider-
dence of placenta accreta appears to be rising coincident ations and may focus on mental and behavioral character-
with higher cesarean rates as a recent study reported that istics, probabilities and finances, or societal implications
one of 533 deliveries was complicated by accreta at their [39]. There are no current studies comparing the optimal
institution over a two-decade period from 1982 to 2002 groups of planned vaginal delivery with CDMR. The most
[30]. A potentially life-threatening condition, placenta feasible, optimal study on CDMR may be a large multi-
accreta has become the leading indication for cesarean center, multidisciplinary prospective cohort trial following
hysterectomy in many centers and can lead to massive short and long-term outcomes. Such a study would ideally
obstetrical hemorrhage with subsequent disseminated include analysis on strategies to predict and influence like-
intravascular coagulopathy, surgical visceral injury, renal lihood of successful vaginal birth and modifiable factors in
failure, acute respiratory failure, or death [31]. labor management that can affect outcomes. Although
literature on CDMR has been published since the 2006
Four major studies [32,33–35] have focused on the NIH conference, it comprises primarily commentaries,
potential relationship between prior cesarean and still- editorials, and review articles but few original studies. A
birth and found no consistent direction of effect with two concerted, rigorous effort is needed to gather more infor-
showing an increased risk and no difference in another mation on CDMR. Until then, an explicitly executed
two. In a study of 120 633 births in Scotland, Smith et al. informed consent should form the framework of any
[35] analyzed linked datasets from 1980 to 1998 and decision regarding CDMR and mode of delivery.
found that a risk of unexplained stillbirth in women
with a history of cesarean was apparent from 34 weeks
Acknowledgement
(adjusted hazard ratio 2.23, 95% CI 1.48–3.36). The Financial disclosures for Mary E. D’Alton include as a consultant for
absolute risk of unexplained stillbirth at or after 39 weeks’ Artemis Health, Inc. (Menlo Park, California, USA).

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Cesarean delivery on maternal request Lee and D’Alton 601

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