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Mode of Delivery: Toward Responsible Inclusion of Patient Preferences

Little, Margaret Olivia PhD1; Lyerly, Anne Drapkin MD, MA2; Mitchell, Lisa M. PhD3; Armstrong, Elizabeth M. PhD, MPA4; Harris, Lisa H. MD, PhD5; Kukla, Rebecca PhD6; Kuppermann, Miriam PhD, MPH7

doi: 10.1097/AOG.0b013e3181888fd8
Current Commentary

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference–driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.

Guidelines around mode of delivery should more explicitly incorporate patient preferences in several clinical scenarios.

From 1Georgetown University, Washington, DC; 2Duke University, Durham, North Carolina; 3University of Victoria, Victoria, British Columbia, Canada; 4Princeton University, Princeton, New Jersey; 5University of Michigan, Ann Arbor, Michigan; 6University of South Florida, Tampa, Florida; and 7University of California, San Francisco, San Francisco, California.

Supported in part by the Josiah Charles Trent Foundation at Duke University; the Greenwall Foundation; the Robert Wood Johnson Foundation; Georgetown University; the University of California, San Francisco, Department of Obstetrics, Gynecology, & Reproductive Sciences and Center for Excellence in Women's Health; Carleton University; the Center for Health and Wellbeing at Princeton University; the Social Science and Humanities Research Council of Canada; and the University of Michigan Institute for Research on Women and Gender. Dr. Lyerly is supported by a Career Development Award from the National Heart, Lung, and Blood Institute, the National Institutes of Health (1 K01 HL79517-01).

The views expressed in this article are solely those of the authors.

Corresponding author: Margaret Olivia Little, 420 Healy Hall, Georgetown University, Washington DC 20057; e-mail:

Financial Disclosure The authors have no potential conflicts of interest to disclose.

© 2008 The American College of Obstetricians and Gynecologists