A 30-year-old primigravid woman at 10 weeks gestation comes to the office for an initial prenatal visit. The patient has no chronic medical conditions and no prior surgeries. While discussing what to expect during the pregnancy and delivery, the patient states that she would like a primary cesarean delivery performed. The patient's mother has struggled for years with urinary and fecal incontinence after having 3 vaginal deliveries, and the patient does not want the same complications. The physician discusses the complications associated with cesarean delivery, including the increased risk of complications in future pregnancies. Based on the lack of medical and obstetric indications, the physician is uncomfortable agreeing to perform the procedure. However, the patient states that she understands the risks and still wants a cesarean delivery. Which of the following is the most appropriate management of this patient?

Question

A 30-year-old primigravid woman at 10 weeks gestation comes to the office for an initial prenatal visit.  The patient has no chronic medical conditions and no prior surgeries.  While discussing what to expect during the pregnancy and delivery, the patient states that she would like a primary cesarean delivery performed.  The patient's mother has struggled for years with urinary and fecal incontinence after having 3 vaginal deliveries, and the patient does not want the same complications.  The physician discusses the complications associated with cesarean delivery, including the increased risk of complications in future pregnancies.  Based on the lack of medical and obstetric indications, the physician is uncomfortable agreeing to perform the procedure.  However, the patient states that she understands the risks and still wants a cesarean delivery.  Which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

Although most cesarean deliveries are medically indicated (eg, breech presentation, fetal distress), a small number are performed on maternal request in the absence of maternal or fetal indications. After the risks and benefits of both cesarean and vaginal delivery are discussed, patients can choose their mode of delivery. Physicians uncomfortable with performing a cesarean delivery on maternal request are not professionally or ethically required to perform the procedure (Choice B). However, physicians are responsible for ensuring continuous and comprehensive patient care. Therefore, the most appropriate management for this patient is an early referral to another obstetrician-gynecologist. (Choice A) Early-term (eg, at 37-38 weeks gestation) induction of labor may be performed when the indication for delivery (eg, preeclampsia with severe features) outweighs the increased risk of neonatal morbidity associated with delivery at <39 weeks gestation. In addition, early-term induction does not address the patient's desire to avoid vaginal delivery. (Choice D) Counseling the patient that her insurance will not cover a procedure is an attempt to manipulate and deceive her and is inappropriate. In addition, the patient may develop a medical indication for cesarean delivery as her pregnancy progresses. (Choice E) Because of the variable and sometimes unpredictable intrapartum course (eg, pain, rapid labor), delivery planning should ideally take place prior to the onset of active labor. Educational objective: Patients may desire a cesarean delivery in the absence of maternal or fetal indications. Physicians who are uncomfortable performing cesarean deliveries on maternal request should refer these patients to another obstetrician-gynecologist. References: ACOG committee opinion no. 761: cesarean delivery on maternal request. (http://www.ncbi.nlm.nih.gov/pubmed/30575678)

A 30-Year-Old Primigravid Woman at 10 Weeks Gestation Comes to the Office