CESAREAN SECTION ON REQUEST

1
CESAREAN SECTION ON REQUEST

• WHOS CHOICE IS IT?

2

• SHOULD THE WOMAN, OR, SHOULD THE HEALTH CARE
  PROVIDER BE THE FINAL DECISION MAKER? WHY?

3
GOALS

• GOAL OF A DECISION IS FOR A HEALTHY OUTCOME FOR
  THE WOMAN, HER BABY AND THE CLINICIAN.
• A HEALTHY OUTCOME REFERS TO BOTH CLINICAL AND
  PSYCHOLOGICAL HEALTH.

4
ETHICAL CONSIDERATIONS

• WHAT IS THE BEST CHOICE?
• WHO IS IT BEST FOR?
• HAVE ALL, OR AT LEAST MOST OF THE RISKS BEEN
  EXPLORED AND DISCUSSED?
• IS IT FISCALLY RESPONSIBLE?
• DOES THE DECISION SUPPORT THE BEST OUTCOME?

5
INFORMED CHOICE

• IS A FUNDAMENTAL HUMAN RIGHT
• SUPPORTS THE PATIENTS RIGHT TO AUTONOMY
• MEANS ARRIVING AT A DECISION WITHOUT COERCION
• PRIMARY HEALTH CARE PROVIDERS ARE REQUIRED TO
  PROVIDE THE OPPORTUNITY FOR IC DISCUSSIONS

6
THE BEST CHOICE IS DEPENDANT ON EACH SITUATION

• THERE ARE FACTORS WHICH SUPPORT CESAREAN SECTION
  BY REQUEST, AND SOME WHICH DO NOT.

7
SUPPORTIVE FACTORS

• EMOTIONAL WELL BEING LINKED TO PTSD WHICH HAS AN
  INCIDENCE OF 1-2 AFTER CHILDBIRTH
• A HISTORY OF RAPE, SEXUAL ABUSE PREVIOUS BIRTH
  EXPERIENCE, PREVIOUS PPD, FEAR

8
MIXED MESSAGES

• WE OFFER CHOICES WITH PRENATAL SCREENING ALL OF
  WHICH ARE UNNATURAL AND PROMOTE THE CONCEPT OF
  THE DESIGNER BABY.CAN WE THEN REFUSE A WOMANS
  CHOICE IN HOW SHE DELIVERS?

9
RISK FACTORS OF CESAREAN SECTION

• HAEMORRHAGE
• INFECTION
• BLADDER TRAUMA/ INCONTINENCE
• RISKS OF ANAESTHESIA
• PARALYTIC ILEUS
• PULMONARY EMBOLUS
• DVT

10
Risks contd

• INCREASED RISK OF ECTOPIC PREGNANCY
• INCREASED INCIDENCE OF PLACENTA PREVIA
• POST OPERATIVE PHYSICAL LIMITATIONS
• TTN IN THE NEWBORN
• DELAYED BREAST FEEDING

11
WHO IS THE DECISION BEST FOR?

• EXAMPLES.
• PROFESSIONAL WOMEN?
• FAMILY CONVENIENCE WITH SCHEDULING?
• CLINICIAN COMFORT AND SAFETY?..

12
IS THERE ENOUGH RESEARCH?

• CAN A HYPOTHESIS BE FORMED TO ANSWER THE
  QUESTION, ARE THERE OTHER FACTORS IN A WOMANS
  LIFE CYCLE, AS WELL AS THE IMPACT OF NORMAL
  AGING, WHICH CAN BE CONTRIBUTING ELEMENTS TO
  PELVIC FLOOR TRAUMA?

13
WHAT OF THE NULLIPAROUS WOMEN?

• CESAREAN SECTION IS TOUTED AS A GREAT REDUCER OF
  PELVIC FLOOR DAMAGE, BUT, THERE ARE NOT MANY
  STUDIES COMPARING PELVIC FLOOR HEALTH/ PROBLEMS
  IN NULLIPAROUS WOMEN TO WOMEN WHO HAVE HAD
  CHILDREN

14
FACTORS IN PELVIC FLOOR TRAUMA

• TRAUMA FROM A PREVIOUS CESAREAN SECTION
• ADHESIONS FROM PELVIC SURGERY WHICH MAY
  CONTRIBUTE TO TIPPING THE UTERUS BACK
• PELVIC FLOOR DAMAGE FROM A PERSISTENTLY
  RETROVERTED UTERUS

15
Pelvic floor trauma contd

• OBESITY
• CHRONIC COUGHING (SMOKERS)
• FREQUENT STRAINING WITH CONSTIPATION
• HEAVY LIFTING
• SPONTANEOUS ADHESIONS
• ENLARGED UTERUS (E.G. R/T FIBROIDS)

16
Pelvic floor trauma contd

• GENETICS
• AGING
• IMPACT OF INSTRUMENTAL DELIVERY
• PARITY ( MULTIPAROUS WOMEN CARRY LOWER IN
  PREGNANCY).

17
QUESTIONS..

• GIVEN ALL THE INFORMATION DOES THE DECISION
  SUPPORT THE BEST OUTCOME?

18
QUESTIONS..

• IN A PUBLICALLY FUNDED HEALTH CARE SYSTEM IS
  CESAREAN SECTION ON REQUEST FISCALLY RESPONSIBLE?