Indications for cesarean section on maternal request – Guidelines for counseling and treatment

Sexual & Reproductive Healthcare 3 (2012) 99–106

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Review

Indications for cesarean section on maternal request – Guidelines for counseling and treatment Ingela Wiklund a,⇑, Ellika Andolf a, Håkan Lilja b, Ingegerd Hildingsson c a

Division of Obstetrics and Gynaecology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden Institute of Clinical Sciences, Department of Obstetrics and Gynaecology, Sahlgrenska Academy, University of Gothenburg, Sweden c Mid Sweden University, Department of Health Science, Sundsvall, Sweden b

a r t i c l e

i n f o

Article history: Received 17 April 2012 Revised 7 June 2012 Accepted 8 June 2012

Keywords: Cesarean section Maternal request Guidelines

a b s t r a c t Aim: The aim was to find scientific evidence and, based on this, to develop national medical guidelines in Sweden for cesarean section on mother’s request. Background: More than 17% of all births in Sweden in 2008 were cesarean sections, compared to 5% at the beginning of the 1970s. About 8% of the cesarean sections were performed at mother’s request. The predominant reason for this preference is fear of childbirth. When deciding whether to perform an elective cesarean section, the obstetrician must emphasize the long- and short-term health consequences for the mother and her baby, as well as weigh the risks associated with the procedure itself against not performing the procedure. Clarification is needed to determine for which conditions it is appropriate to comply with the mother’s request. Materials and method: A literature review was conducted to identify factors that were relevant as an argument to meet the request for cesarean section on maternal request. The authors analyzed these factors individually to determine. Findings: The guidelines suggest that it is appropriate to comply with a woman’s request for cesarean section if the reason for her request is deemed sufficiently serious and if, after participating in a counseling program, the woman persists in her request for cesarean section. Conclusion: A request for cesarean section where no medical indication is present should not be met without considerations concerning the safety of the mother and her baby, while also weighing the risk of adverse outcomes for mother and baby. Ó 2012 Elsevier B.V. All rights reserved.

Background To date, there are no randomized studies of planned cesarean sections in which the baby is in cephalic presentation. However, there are three studies in which healthy women with babies in breech position were randomized at full-term for a planned cesarean section or vaginal birth [1–3]. The largest and most recent study of more than 2000 patients showed no difference in maternal morbidity [3]. This study was done under other circumstances than those prevailing in Sweden; it included developing countries with varying degrees of health among women and the care during pregnancy. The number of emergency cesarean sections was high in the study. Other studies of planned cesarean sections were mostly retrospective cohort studies [4,5]. In recent years, there have been no large studies that have tried to correct the data for

⇑ Corresponding author. Address: Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88 Stockholm, Sweden. Tel.: +46 8 655 79 98. E-mail address: [email protected] (I. Wiklund). 1877-5756/$ - see front matter Ó 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.srhc.2012.06.003

different variables [6,7]. In one study, the data were analyzed based on intention to treat [7]. A birth can affect a woman’s future health, and a negative birth experience may affect future childbearing. Approximately 20% of all pregnant women experience fear of childbirth to some degree [8,9]. Approximately 2% of women who have given birth suffer from post-traumatic stress disorder [10,11], which can create fear of future childbirths. In Sweden, the frequency of cesarean sections increased from 5% of all births in the beginning of the 1970s to 17.5% in 2009 [12]. The prevalence of cesarean sections based on mother’s request is difficult to study. The diagnosis code that is usually used for cesarean section when there is no medical indication is O828, also labeled ‘psychosocial indication’. According to a register study of 6796 birth records from 1997 to 2006, this diagnosis was sometimes combined with a secondary diagnosis, such as breech position or previous cesarean section [13]. The percentage of cesarean sections in Sweden with a psychosocial indication diagnosis increased by 80% during the period 1990–2001 [13]. There is a small group who undergo cesarean sections based on this

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indication. However, this number is underestimated because women who undergo cesarean section, having previously had a cesarean based on psychosocial indication, are recorded as a previous cesarean delivery, and not in the group with psychosocial indication [14]. In certain cases when a cesarean section is performed because of breech presentation, fear of childbirth can be one component in decision-making, leading the woman to not want to attempt to turn the breech. It is important that this group of women is properly diagnosed and that pregnancy and birth information are tracked and monitored. One of the most common reasons for women who choose a cesarean section is a previous negative birth experience. Other reasons are complications such as tearing, uterine prolapse or urinary and fecal incontinence, and the fear that their sexual life will be adversely affected. Finally, for many women, there is a great fear that their babies will be harmed during a vaginal birth. The desire for a cesarean section is common after sexual abuse and also in women with anxiety and depression [15,16]. According to Swedish healthcare laws, a woman cannot request a cesarean section, but can decline to have it performed. An important question here is how much consideration should be given to the woman’s wishes in relation to short- and long-term medical risks? This report is intended to serve as an aid in decision-making.

Method A literature review was conducted to identify factors that were relevant as an argument to allow or decline cesarean section on maternal request. The authors analyzed these factors individually to determine how they should be included.

Findings Short-term maternal consequences associated with cesarean section Postpartum Hemorrhage >1000 ml It is difficult to compare the amount of postpartum bleeding after a vaginal birth with that from a cesarean section because hemorrhage is measured in various ways and, as a result, with different precision. In a Danish study women undergoing cesarean section were compared to women with an intended vaginal birth and analyzed according to intention-to-treat. Bleeding requiring a transfusion was recorded in 0.47% in the planned vaginal birth group compared to 0.46% of the planned cesarean section group [17]. Similar conclusions have been reported in other reviews [4,5,18]. The studies where it was not always possible to control for all confounding factors and for indication, or which did not account for emergency cesarean sections separately, all point to major bleeding in the cesarean section group [6,7]. In a retrospective review of the Swedish Medical Birth Register, bleeding more than 1000 ml was observed in 13% of all cesarean sections, compared with 3.5% of non-instrumental vaginal births [14].

Damage to other abdominal organs Damage to other abdominal organs is rare, but is most common in cases of emergency and repeated cesarean sections. Injury of the urinary bladder occurs in 0.1–1% [18,19], ureter injury in 0.02– 0.05% and intestinal damage in less than 0.1% of all cesarean sections. Most studies do not report evidence regarding damage to other abdominal organs, and they often report various types of cesarean sections as intermixed. In a study from the Danish Birth Register, where only planned cesarean sections were examined, the risk of bladder or intestinal damage was 0.08% [17].

Infection The risk of infection is greater after a cesarean section than after a vaginal birth. Large wounds, anemic bleeding and emergency surgery increase the risk of infection. The most common infections after a cesarean section are endometritis, wound infection and urinary tract infection. A retrospective database study of 33,000 fullterm uncomplicated pregnancies in which a cesarean section was performed before the onset of labor compared to a spontaneous vaginal birth reported a ninefold increased risk of endometritis. Performing cesarean sections after labor began increased the risk 20-fold [20]. Data from the Swedish Medical Birth Register and the Hospital Discharge Register showed 14.3% of women had endometritis/sepsis after cesarean section compared to 4.2% after uncomplicated vaginal birth [14]. In a study with high evidence, wound infections and endometritis occurred in 6.4% of women with planned cesarean sections and in 4.9% of women with planned vaginal birth [3]. A Danish registry study that followed up women up to 30 days after birth showed an infection rate of 1.6% in the vaginal birth group and 7.6% in the cesarean section group [21]. The study was not analyzed according to planned mode of delivery. Thromboembolism Deep vein thrombosis and the associated risks of pulmonary embolism are one of the most common reasons for maternal death in conjunction with pregnancy and childbirth [22]. The relative risk of deep vein thrombosis increased by 10 times during early pregnancy to 1 in 1000 women [23], and a further eight times with cesarean sections, in particular, in cases of acute and complicated surgery [24]. A survey of 32,834 uncomplicated pregnancies with gestational age 37 weeks or more during the period 1995–2000 found the incidence of deep vein thrombosis was 0.1% after spontaneous vaginal birth and 0.2% for planned and emergency cesarean section. The difference was only statistically significant for emergency cesarean sections, but this could be due to the lack of study power [20]. Breastfeeding Onset of breast-feeding might be affected by post-surgical pain [25]. A Swedish study found that women who had undergone cesarean sections at their own request described more lactation problems than women who had a planned vaginal birth [26]. Another study showed that the physiological concentration peaks of oxytocin seen in maternal plasma after vaginal birth were less frequent after an emergency cesarean section [27]. Conclusion: Short-term maternal consequences In conclusion, two major database studies [6,7] showed overall short-term complications after cesarean section. Liu et al. [7] compared 46,000 planned cesarean sections performed due to breech position with 2.3 million planned vaginal births in a study analyzed according to intention-to-treat. The results showed a higher maternal morbidity, which included hysterectomy, thrombosis, infection, wound complication, anesthesia complication, or cardiac arrest, of 27/1000 for the cesarean section group compared to 9/ 1000 for the vaginal birth group. In another study that analyzed according to intention-to-treat, Villar et al. [6] examined 13,000 planned cesarean sections, 18,000 emergency cesarean sections and 60,000 spontaneous vaginal deliveries. The results were adjusted for marital status, parity, previous cesarean section and pregnancy complications and showed an odds ratio for the combined complications of 2.0 for emergency cesarean section and 2.3 for planned cesarean section compared with vaginal births. The risk of any of these complications was double in planned or emergency cesarean section.

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Long-term maternal consequences associated with cesarean section Assessing the risk of long-term complications after cesarean section is even more difficult than assessing the short-term complications. There are no studies published with high evidence and assessment of non-randomized studies must take into account several confounding factors such as age and high BMI. Repeated cesarean sections also increase the risk of complications. There are considerable practical difficulties in studying the correlation between cesarean section and complications that occur much later. Uterine rupture and hysterectomy Previous surgery on uterine musculature or on the uterine wall increases the risk of uterine rupture during the subsequent birth. Uterine rupture increases the risk that the uterus must be removed and also the risk that the baby will die during an attempted vaginal birth. Studies with moderate degree of evidence show a risk of uterine rupture of 4–6/1000 women during a vaginal birth in women who had previously undergone a cesarean section [4,14,28]. After two cesarean sections, the risk is 0.9–3.0% (i.e. 9–30/1000 women) [29,30]. Placental complications The frequency of placental complications after a first-time cesarean section has gradually increased in correlation with the increasing rate of cesarean sections [31]. All placental complications result in increased mortality and morbidity for both mother and infant. Risk of ablatio placentae because of an earlier cesarean section has been estimated at about 1%, increasing the risk 1.3–2.4 times [32]. The risk of placenta previa is 0.2–0.5% for women who have given birth vaginally, but increases to 0.4–0.8% after a cesarean section [28]. The risk of placenta previa increases with the number of previous cesarean sections and is seven times higher, or 3–5%, after 2–3 previous cesarean sections and up to 45 times higher (equivalent to 20–30% risk) after four previous cesarean sections. Placenta previa, in turn, increases the risk of placenta accreta, which carries a high risk of blood loss during childbirth where the placenta does not detach, and therefore often causes the uterus to be removed during delivery. The risk of placenta accreta with placenta previa was 3%, 11%, 40%, 61% and 67%, respectively, after one, two, three, four or five or more previous cesarean sections [33]. Post-surgical complications The risk of long-term bowel complications after cesarean section has not been sufficiently studied. However, the risk of adhesions is lower after cesarean section than after other abdominal surgery procedures. In a retrospective study, risk of adhesions was reported at 1:2000 [34]. In a study based on data from the Swedish Medical Birth Register, the risk of being treated for adhesions or ileus within 15 years after a cesarean section (emergency and planned combined) was 0.64% and after a vaginal birth 0.32% [35]. Pelvic floor disorders Some studies show that women giving birth vaginally suffer from urinary incontinence to a greater extent compared to women who delivered by cesarean section. In a prospective study, 541 primiparous women undergoing elective cesarean section or vaginal birth were investigated. The authors found that at 9 months after birth, the prevalence of stress incontinence after vaginal birth was significantly higher than in women who had cesarean sections [36]. In one population-based study of approximately 16,000 women, 2.5–3.9% of women who underwent an elective or emergency cesarean section reported that they had complications

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after 3–6 months compared with 8.8% of those who delivered vaginally. In women who delivered via forceps, the risk was 18–60% [37]. A study from the Swedish Medical Birth Register showed that the risk of surgery for stress urinary incontinence was 136/30,000 for women who had only cesarean section and 723/60,000 for women who only gave birth vaginally. The resulting ‘‘number needed to harm’’ was 357 for how many women having to undergo a cesarean section would be affected by incontinence [38]. In Hannah’s randomized study, 36/798 (4.5%) of women in the cesarean section group reported urinary incontinence compared with 58/ 797 (7.3%) in the group delivering vaginally [3]. It has been suggested that the risk of incontinence symptoms can be halved if all of a woman’s babies are born via elective cesarean section [39]. However, several studies with long-term follow-up have shown that the protective effect of cesarean sections is temporary. Fecal incontinence may be caused by tears in the anal muscle or damage to the pudendal nerve during delivery. The frequency of sphincter rupture was specified in international studies as 3–4%, according to some reports, and up to 7% of primiparae. However, cesarean sections do not always protect against anal incontinence. In the randomized breech study, there was no difference in symptoms after 3 months [3]. A Cochrane report showed that there are some benefits of elective cesarean section to reduce the risk of anal incontinence; however, no randomized studies are available [41]. Studies using magnetic resonance imaging on levator musculature have shown damage after birth with prolonged labor. Damage to tissues and the pudendal nerve has also been documented. Some studies showed that cesarean sections were protective [39,40] while other studies did not detect any such effect [42,43]. Large register studies of Scottish and Swedish patients showed that the risk of surgery for prolapse was much greater if a woman had only undergone vaginal births [43]. In a study from the Swedish Medical Birth Register, the risk of having prolapse surgery was 0.0019 for women who delivered only via cesarean section and 0.021 for women who gave birth only vaginally. The number of women needing to give birth vaginally who would suffer from prolapse requiring surgery was 135 (‘‘number needed to harm’’) [38]. Postpartum depression Postpartum depression, defined as high scores on the Edinburgh Postnatal Depression Scale, occurs in about 10% of all women who have had a pregnancy, regardless of method of delivery [44]. Observational studies, which compared elective cesarean section with elective vaginal birth, showed no difference in terms of postpartum depression [4,18]. A randomized study showed no differences in rates of postpartum depression between elective cesarean section and vaginal deliveries 2 years after giving birth [45]. Length of breastfeeding Research has shown that the total lactation period does not differ between women who give birth vaginally or via cesarean section [46]. Other studies have shown significant differences in breastfeeding duration, where women who delivered via cesarean section had a shorter duration of lactation [45]. Reproductive consequences A systematic overview of eight cohort studies [47] shows that women who have had cesarean sections gave birth to fewer children than those giving birth vaginally. The relative risk of infertility after cesarean section is 1.5 (95% confidence interval 1.1–2.0) [48]. The interval between births was also longer. It is difficult to assess the extent to which cesarean sections are an important factor for this interval [49]. A lower fertility may reflect conditions that existed prior to the cesarean section, therefore cesarean section

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might not be the reason for the lower fertility reported after cesarean section [48,49]. In a register study, a relationship was found between cesarean section and subsequent miscarriage, ectopic pregnancy and growth retardation [50]. Pregnancies implanted into the uterine scar have also been described [51] and can lead to miscarriages with significant bleeding. Another register study showed a higher risk of intrauterine fetal death after a cesarean section: 1.1/1000 compared to 0.5/1000 for women who have undergone a cesarean section [52]. Other studies, however, have not been able to confirm this [53]. Conclusion: Long-term maternal complications after cesarean section A birth by cesarean section may result in long-term negative consequences for the mother, primarily increased risk of uterine rupture and placental complications during subsequent pregnancies. The risk of these complications increases for each cesarean section. In the long-term, the risk of urinary and anal incontinence is roughly comparable between women who gave birth vaginally and by cesarean section. The risk of uterine prolapse, however, is higher for women who have given birth vaginally than for women who have only given birth by cesarean section. Neonatal short-term consequences associated with cesarean section Consequences for the baby Cesarean section can, when done with a medical indication, minimize the medical risk for both the baby and the mother. When a cesarean section is performed against the mother’s wishes, without medical reason, or despite the preference for vaginal birth according to medical assessment, the increased medical risks to the baby may be of relatively great importance. Neonatal respiratory distress The most common complication after an elective cesarean section is neonatal respiratory disorder [54–58]. The reduced resorption of fluid after cesarean section can result in an increased risk of respiratory distress and inefficient gas exchange in the lungs [59]. The risk of any kind of respiratory disturbance decreases the closer the procedure occurs to the time of expected delivery. In a large British study from 1995, the incidence at 37 weeks’ gestation was 7.4% after elective cesarean section compared with 1.3% after vaginal birth [60]. Later research reports from several other countries showed similar results. Several studies showed that elective cesarean section before 39 weeks’ gestation, compared with delayed surgery, considerably increased the risk of respiratory disorders of different severity and the need for mechanical ventilation. Elective cesarean sections should, therefore, be carried out after 39 completed gestational weeks [60–62]. Other negative consequences for the infant delivered via elective cesarean section are increased risks of hypoglycemia [63] and hypothermia [64]. Several studies have shown that when a cesarean section was performed before 39 completed weeks, there was a multi-fold increased risk of neonatal hypoglycemia, sepsis, admission to neonatal intensive care unit and length of hospital stay of more than 5 days [60,62,63]. Data concerning breastfeeding related to mode of delivery are not conclusive. Certain studies show a slightly shorter period of breastfeeding after cesarean section, while others have not been able to show this pattern [65,66,67]. Cesarean section seems not to effect mother–baby interaction [26,66,67]. Conclusion: Short-term risks for the baby The timing of a cesarean section is very important for how much risk the baby is exposed to. The most common immediate

complication with a cesarean section is neonatal respiratory impairment of varying degrees. With an elective cesarean section prior to full-term, the risk of respiratory impairment is greater than with an emergency cesarean section or vaginal birth at full-term due to the different degrees of lung maturation. Other complications more common with cesarean section than with vaginal birth are sepsis, hypothermia and hypoglycemia. Neonatal long-term consequences associated with cesarean section Affected bacterial flora In infants delivered by cesarean section, the intestinal bacterial flora is established later than after a vaginal birth, and this could lead to permanent differences in the bacterial flora [68]. This difference could result in an imbalance between the bacterial products that, in turn, could have an effect on intestinal mucosal structure and function. Some studies also described that the bacterial flora in the gut was important for the development of the immunological system [69–72]. Asthma and gastroenteritis A Swedish register study showed that infants delivered by cesarean section had about a 30% higher risk of hospitalization for asthma and/or gastroenteritis compared with infants born vaginally. The risk was somewhat higher in elective than in emergency cesarean sections. The frequency of asthma was 2.6% of infants born via cesarean section compared with 2.0% of those born vaginally. Also, the risk of food allergies and atopy was shown to be elevated. The frequency of gastroenteritis was 4.0% of those delivered by cesarean section and 3.1% of those delivered vaginally. For each of these conditions, the differences were significant, but no cause was established [73]. There are other studies in which there was no relationship between elective cesarean sections and later development of asthma [74]. A meta-analysis that included 20 trials of mostly cohort studies, however, found the risk of being diagnosed with asthma during childhood was 20% higher for those born via cesarean section than for those delivered vaginally [75]. In this analysis there was no difference between elective and emergency cesarean sections. The prevalence of physician-diagnosed asthma in Swedish school children 7–8 years of age increased from 5.7% in 1996 to 7.4% in 2006 [76]. Celiac disease The incidence of celiac disease in Sweden has increased sharply, from 19/100,000 in 1998 to 44/100,000 in 2003. Preliminary results from an ongoing study in Sweden suggest that prevalence among children in grade 6 can be as high as 3/100 [77]. The etiology is considered to be multifactorial because there are significant regional differences in Sweden. Diabetes Type 1 The risk of developing Type 1 diabetes before the age of 15 has doubled in the last 20 years in Sweden, which has reported the world’s second highest incidence, about 45/100,000 [78,79]. The etiology is probably multi-factorial. In addition to genetic factors, the influence of environmental factors and viral infection has been discussed. There are also reports of increased incidence of Type 1 diabetes in infants delivered via cesarean section compared to vaginal births. A risk increase of 23% for diabetes after cesarean section was reported in a meta-analysis of 20 observational studies [80]. A weakness in the analysis is that the authors were unable to assess the possible discrepancy between elective and emergency cesarean sections. In a study from Northern Ireland and Scotland, however, the increased risk was more marked after an elective cesarean section [81].

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Tumor diseases Some uncommon tumors have been reported to occur more often in babies delivered via cesarean section than vaginally [82,83], however no distinction was made between elective and emergency cesarean sections. Other studies have not been able to confirm any such correlation [84]. There is still no evidence for the causal relationship between birth by cesarean section and later neoplasia, but the significance of the method of delivery to the development of later disease is receiving increased attention. A recent Swedish study showed changes in the expression of the genetic material of infants born by cesarean section compared with infants born by vaginal birth [85]. Perinatal death Studies showed that there was an increased risk of perinatal death following childbirth if the first birth was a cesarean section [86]. Are there any positive consequences for the baby? In the discussion of risks to the baby, the protective effects of the cesarean section against certain conditions are also highlighted. Meconium aspiration Meconium in amniotic fluid is present in various degrees at 10– 15% of full-term pregnancies [87]. In a cohort study from Australia and New Zealand covering nearly 2.5 million vaginal births, the need for intubation and mechanical ventilation due to meconium aspiration was 0.43/1000 births [88]. Severe asphyxia An association between neonatal asphyxia and intrauterine meconium release, emergency cesarean section, vacuum extraction, breech delivery, oxytocin augmentation, cord complication, external compression to assist delivery and asphyxia has been described [89]. Plexus brachialis injury A plexus brachialis injury could be prevented by cesarean section. The risk was evaluated in a Swedish study that included 1,213,987 deliveries and was reported at 0.2% for vaginal deliveries without forceps, at 0.9% for vaginal deliveries with forceps, and 0.04% for cesarean sections [90]. Intracranial hemorrhage Intracranial hemorrhage in neonates was investigated in a U.S. study of 583,340 births with singleton pregnancies and infants weighing 2500–4000 g. Such bleeding occurred in 0.05% with spontaneous vaginal birth, in 0.12% of neonates delivered with vacuum extraction, 0.15% of neonates with forceps delivery, 0.11% of neonates with emergency cesarean sections and 0.04% of neonates with elective cesarean sections. The authors’ conclusion was that a common risk factor was abnormal labor [91]. Neonatal sepsis and meningitis The incidence of neonatal sepsis and/or meningitis at full-term is very low. A Swedish study reported 2.2/1000 neonates with a mortality rate of 0.1/1000. Of those affected, 59% had the early form which is considered to be related to vaginal birth, with the incidence of 1.3/1000 [92]. Conclusion: Long-term complications associated with cesarean section There is evidence that cesarean sections pose increased risks to children, in terms of asthma, gastroenteritis and diabetes, compared with vaginal deliveries. Cesarean sections can also reduce

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the risk of rare but serious complications associated with vaginal birth, such as serious consequences of meconium aspiration and severe hypoxia. Cesarean sections can lead to negative health effects, even for future children, such as increased risk of perinatal death, although some risks associated with vaginal birth can be avoided. Factors associated with a wish for cesarean section on maternal request Fear of childbirth Studies indicate a prevalence of fear of childbirth in 5–40% of pregnant women [9,93–98]. A woman’s fear of childbirth may be based upon the concern for the baby’s or her own health or upon the concern of losing control or not being able to give birth as expected. Fear of childbirth could be associated with a previous negative birth experience, personality traits with easily aroused anxiety and fears, lack of social support, anxiety disorder and actual depression [98]. First-time mothers with fear of childbirth form a separate group because they have no personal experience with giving birth. It is important to take care of these women because the first birth is crucial to the woman’s reproductive health. For women who want a cesarean section because of fear of childbirth, both the nature and the degree of fear are factors for how the individual care should be formulated and constitutes an important basis for deciding whether the woman’s request should be met. The degree of fear of childbirth can be measured with the aid of different psychometric instruments. Age Age itself cannot be used as the basis for whether an action should be adopted or not. It is more a matter of the factors associated with age. The woman’s age is strongly related to both the ability to become pregnant, as well as to how the birth outcome will be [12]. A young woman undergoing a cesarean section and the babies she will possibly expect are exposed to a future risk. The risk of cesarean section is not about age in itself but rather about the possibility of becoming pregnant once again. Persuading a young woman who has expressed a desire for a cesarean section to plan for a vaginal birth instead, may therefore be important, especially if she is a first-time mother. Previous cesarean section In Sweden, a previous cesarean section does not constitute an obstacle for a future vaginal birth. A previous cesarean section indeed increases the risk of an emergency cesarean section at the next vaginal birth, but the risk is considered not to be so high that it outweighs the other risks that a cesarean section involves. However, it is common for women who sustained a previous emergency cesarean section to express a wish for an elective cesarean section for the next delivery [98–100]. Previous birth injury Previous birth injuries, such as large tears and incontinence, are not a medical reason for a cesarean section unless there are persistent complaints. However, a previous injury can generate fear of childbirth in the woman and contribute to her wanting to have a cesarean section. These women need time to discuss why the damage occurred and need to obtain information about preventing its recurrence. Sexual abuse Women who have been victims of sexual violence, other types of violence or torture are a special group. They may be afraid that they will feel exposed during a vaginal birth, lose control or that the pain during delivery will arouse strong memories of the things

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to which they have been subjected. It can be difficult to clearly determine what lies behind the woman’s wishes. This factor may constitute an indication for elective cesarean section, but requires an individual assessment. Previous stillborn or injured infant related to pregnancy or delivery An injured or dead baby in connection to a previous vaginal birth is usually not an indication for a cesarean section. It takes special effort to give these couples the necessary information and the opportunity to discuss the previous event. If it proves difficult to establish security for a new vaginal birth, this reason may be an indication for a planned cesarean section, but requires an individual assessment. Psychiatric illness Mental illness in individual cases may constitute a medical reason for an elective cesarean section. In these cases, it concerns an acute psychiatric profile. A woman experiencing such circumstances can have difficulty coping with the situation during a vaginal birth. A woman with a history of psychosis or other serious mental illness that is stabilized with pharmacological treatment and in a stable phase may well be able to undergo a vaginal birth after psycho-educational intervention with information and psychological preparation. Decisions about the method of delivery should be made in consultation with a psychiatrist and obstetrician. Other reasons for requesting a cesarean section A small group of women may not give reasons for their desire or may indicate that they want a cesarean section for practical reasons. Practical reasons include when the woman or couple cannot give reasons other than the purely practical, for example, the partner is out-of-town, the couple live far from the hospital or that it fits in their life-plan. These reasons are not considered to be indications for a cesarean section. Sometimes there is a misuse of the counseling provided as studies have shown that women were referred to and participated in counseling for fear of childbirth, although the fear could not be verified by means of a screening instrument [101,102]. Conditions that should be met to grant the wish Patient-related conditions The woman has reported the reason for her request for cesarean section, and the reason is assessed to be a sufficiently important serious factor. A prerequisite for a woman to be provided with a cesarean section without medical reasons should be that she clearly states the reason for her request. There is no right to demand a surgical procedure. For the indication to be available, the reason must be presumed to be sufficiently serious. The woman adheres to her wish. If the woman adheres to her request after she has received and understood information about the short- and long-term consequences of the different modes of delivery (for both herself and the baby as well as for any future pregnancies) and has been offered and received counseling or other type of support, there may be grounds to meet her desire for a cesarean section. It is fundamental that there is sufficient time for her to receive and process the implications of various means of giving birth, as well as time for supportive discussion and other possible actions. It is therefore important that midwives involved in antenatal care early in the pregnancy, ask any woman how she feels about giving birth, so that those who need special assistance can be referred to counseling consultation for childbirth fear. Healthcare-related conditions A structured medical history has been taken and the woman’s reasons

are evaluated. A structured medical history is a prerequisite for evaluating a woman’s desire for an elective cesarean section. On the basis of this history, the woman’s reasons and their strength can be assessed. Fear should be graded using a psychometric tool for that purpose. Women who wish to have a cesarean section for practical reasons or who fail to state any reason for their request are deemed not to have compelling reasons for undergoing a cesarean section. In some cases, women can have serious reasons not to consider a vaginal birth. A probability and risk assessment has been performed. An assessment should be performed in which the probability of additional pregnancies and increased risk related to the delivery method has been weighed. The assessment considers both the probability of additional pregnancies and the likelihood that a vaginal birth would result in an emergency cesarean section, as well as the risk of any elective cesarean section. Information about the short- and long-term consequences of a cesarean section. It is of great importance that women who desire a cesarean section receive accurate and detailed information about the consequences of a cesarean section for both mother and child. The information should be given both verbally and in writing. The healthcare provider should be certain that the woman understands the information. Appropriate strategies for support to the woman have been designed. Support is designed and based upon an aggregate evaluation of the strength of the reasons women have stated and risk assessment for a possible cesarean section. Supportive discussion and actions should have been provided and implemented. Actions should be adjusted to the reasons the woman has for her request, partly after the strength of her concern/fear. A local plan should be available at all clinics to help determine how women with different reasons and level of risk should be managed. Conclusions When there are no medical reasons to perform a cesarean section, the procedure usually involves a higher risk for mother and baby/infant in both the short- and long-term compared to a vaginal birth. Therefore, it is important to initially make a structured and thorough case history when a woman’s reason for desiring a cesarean section is clear. Thereupon, the reasons will be evaluated. With weakly valid reasons, such as planning reasons, there is no indication for a cesarean section. For those women who are considered to have overriding reasons, a risk assessment should be made based on the answers to the following questions: How likely is it that the woman will undergo more pregnancies and births? How high is the risk of complications that require an emergency cesarean? What risks does an elective cesarean section involve? A very important part of the process is to inform the woman about the short- and long-term consequences of a cesarean section, both for herself and for her baby. The risks in future pregnancies and births will increase to some extent after a cesarean section. If the woman is planning to give birth to more babies or is so young that it is likely that she will, it is important that she is aware of the consequences of each option and can judge what is best for herself, the baby she is expecting and any future children. The woman should be offered assistance in the form of counseling or other treatment. The intensity of the interventions vary based on how strong a reason she has and the results of the risk assessment. The differentiation is made with a view to invest the most resources on those patients who have most to gain from re-evaluating their desire for a cesarean section. If a patient who is deemed to have suffi-

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