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Intrapartum Elective Cesarean Delivery: A Previously Unrecognized Clinical Entity

Kalish, Robin B., MD*; McCullough, Laurence, PhD*†; Gupta, Meruka*; Thaler, Howard T., PhD; Chervenak, Frank A., MD*

doi: 10.1097/01.AOG.0000128118.37737.df
Original Research: Lead Article
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OBJECTIVE: The purpose of the study was to investigate the incidence of intrapartum patient choice cesarean delivery—patients’ requesting cesarean delivery and physicians’ offering it during labor—and factors possibly influencing these requests and offers.

METHODS: For a 6-month period from May 1, 2002, to October 31, 2002, obstetricians were asked to complete a questionnaire after all intrapartum cesarean deliveries regarding whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Patient medical records and physician demographic information were reviewed.

RESULTS: There were 422 cases that met inclusion criteria. Questionnaires were completed in 100% of cases. Cesarean delivery was offered in 13% before a clear medical indication and requested in 8.8%. Older obstetricians, maternal–fetal medicine specialists, and full-time faculty were significantly more likely to offer cesarean delivery (P = .009, P < .001, and P = .015, respectively). Patients who were unmarried or undergoing labor induction were less likely to request cesarean delivery (P = .029 and P = .035, respectively). Maternal age, parity, stage or length of labor, epidural use, gestational age, insurance status, day of week, and time of delivery did not affect whether patients requested or were offered cesarean delivery.

CONCLUSION: This study documents a heretofore unrecognized clinical entity: intrapartum elective cesarean delivery. Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are being offered cesarean delivery.

LEVEL OF EVIDENCE: III

Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are offered cesarean delivery.

From the *Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, New York; †Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; and ‡Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York.

Address reprint requests to: Robin B. Kalish, MD, Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, 525 East 68th Street, Room J-130, New York 10021; e-mail: robinkal@aol.com.

Received January 11, 2004. Received in revised form March 12, 2004. Accepted March 22, 2004.

Controversy concerning elective cesarean delivery is currently an area of growing debate.1,2 Despite advocacy by some,3 elective primary cesarean delivery in an uncomplicated pregnant patient has long been considered unacceptable. Moreover, the International Federation of Gynecologists and Obstetricians maintains that elective cesarean delivery is not ethically justified.4 Recently, this view has been challenged, and patient choice concerning mode of delivery has been supported.5,6 A recent sounding board has declared that for a well-informed patient, elective primary cesarean delivery may be performed.5

Although much debate has focused on the role of patient choice in elective primary cesarean delivery before the onset of labor, it is surprising that the roles of patients’ preferences and physicians’ offering it in the performance of cesarean delivery after labor has been initiated has been neglected. The purpose of the present study was to investigate the incidence of patients’ requests for cesarean delivery and physicians’ offering it during labor and factors possibly influencing these requests and offers.

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MATERIALS AND METHODS

For the 6-month period from May 1, 2002, to October 31, 2002, obstetricians were asked to complete a questionnaire after all cesarean deliveries they performed on patients who had been in labor at New York Weill Cornell Medical Center. The single-page survey queried obstetricians whether they offered a cesarean delivery to the patient before a clear medical indication and whether the patient requested cesarean delivery at any point during labor. The reasons for a physician’s offer or a patient’s request for cesarean delivery were also documented on the questionnaire. An “offer” for a cesarean included cases when the physician asked the patient her wishes during the intrapartum period regarding mode of delivery and, if she declined cesarean, the physician would allow her to continue laboring. A cesarean was considered “medically indicated” when the cesarean was recommended by the obstetrician for any reason and the patient was not given the option to continue laboring. Patients planning elective cesarean delivery before labor or patients prohibited from laboring, for an indication such as placenta previa, were excluded. All questionnaires were distributed and completed by the attending physician as identified on the operative record within 1 week of the delivery. Patients with private health insurance received prenatal care from either full-time faculty or nonfaculty obstetrical group or solo practices. Patients with government-subsidized health insurance (Medicaid) received prenatal care by resident physicians supervised by a full-time faculty obstetrician at the hospital’s clinic.

Patient information, including maternal age, parity, ethnicity, marital status, medical and surgical history, use of assisted reproductive technology, and health insurance status, was documented from medical records. Labor characteristics, such as length of labor, stage of labor, cervical dilation, epidural use, oxytocin use, induction status, and cesarean delivery indication, were recorded as well. Physicians’ demographic data were identified from academic records and included age, gender, years since residency, and subspecialty status (ie, maternal–fetal medicine specialist). This study was approved by the New York Presbyterian Hospital–Weill Medical College of Cornell University Institutional Review Board.

The statistical significance of the relationships of each maternal, intrapartum, and physician characteristic with being offered or requesting cesarean delivery was assessed univariately by the Fisher exact test with odds ratios (ORs) and 95% confidence intervals (CIs) given for statistically significant variables. Factors that were significant at the P < .05 level univariately were considered in a stepwise logistic regression to assess their significance in combination. Logistic regression results are reported as ORs, CIs, and χ2P values. All statistical calculations were performed by using SAS software (SAS Institute, Cary, NC).

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RESULTS

There were 2,650 deliveries, including 936 cesarean deliveries, during the study period. Of the cesarean deliveries, 422 (45.1%) were performed on laboring patients. The indication for surgery was dystocia in 60%, nonreassuring fetal status in 39%, and abruption in 1%. Questionnaires were completed in 100% of the cases.

Of the 422 intrapartum cesarean deliveries, 13% of the patients were offered cesarean delivery before a clear medical indication, and 8.8% requested cesarean delivery at some point while they were in labor. Overall, 18.7% of patients either requested or were offered cesarean delivery (3.1% both requested and were offered cesarean). All singleton pregnancies had a cephalic presentation. Reasons for offering intrapartum cesarean delivery as recorded by the physician on the questionnaire included slow labor progression, fetal or maternal well-being, or suspected macrosomia. Maternal exhaustion, fear of pushing, or concern about fetal status were the main reasons patients requested cesarean delivery. Table 1 shows the comparison of demographic characteristics of patients offered and not offered cesarean delivery. Univariate analysis demonstrated that patients who had undergone assisted reproductive technology were more likely to be offered cesarean delivery compared with patients with spontaneous conceptions (23.4% versus 11.7%; P = .036; OR 2.3; 95% CI 1, 5.1). Also, patients who had a prior cesarean delivery were offered cesarean delivery more often than patients without this history (36.8% versus 11.9%; P < .01; OR 4.3; 95% CI 1.5, 12.5). When patients with a multifetal gestation or history of a prior cesarean delivery were excluded from the analysis, there were no patient characteristics significantly associated with offering cesarean delivery. Marital status was the only maternal characteristic that varied significantly among women who did and did not request a cesarean delivery because 10.1% of married patients requested cesarean delivery compared with only 1.5% of unmarried patients (P = .03; OR 7.2; 95% CI 1, 40.3).

Table 1

Table 1

Table 2 demonstrates that intrapartum factors did not influence the rate of physician offer. However, patients who were admitted for labor induction were significantly less likely to request cesarean delivery. Of 175 patients who underwent labor induction, 9 (5.1%) requested cesarean delivery during labor compared with 28 (11.3%) of 247 of patients who presented in spontaneous labor (P = .03; OR 0.4; 95% CI 0.2, 1.0). Table 3 illustrates the relationship between physician characteristics and behavior. Cesarean delivery was offered more often by obstetricians who are maternal–fetal medicine specialists, full-time faculty, male, aged 40 years or more, or have 10 years of postresidency experience. Physicians aged 40 years or more also were more likely to have their patients request cesarean delivery.

Table 2

Table 2

Table 3

Table 3

Stepwise logistic regression was used to determine the most significant variables associated with offering and requesting cesarean delivery and to control for confounding factors. In this statistical model, maternal–fetal medicine specialists, full-time faculty physicians, physician age, and a history of prior cesarean delivery were the only variables that had significant effects on the rate of physicians offering cesarean delivery (Table 4). Intrapartum factors or other patient characteristics had no significant effect on whether cesarean delivery was offered. In addition, other factors, such as stage or length of labor, time of day, and day of the week were not associated with offering or requesting cesarean delivery.

Table 4

Table 4

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DISCUSSION

Our study addresses the incidence of and factors possibly influencing patients’ requests and physicians’ offers for cesarean delivery once labor has begun when not clearly medically indicated. The results demonstrate that this topic is clinically important because 1 in 8 laboring patients who ultimately had an intrapartum cesarean delivery at our institution had been given an option for the mode of delivery. Moreover, almost 1 in 5 patients (19%) in our study population either requested or were offered an intrapartum cesarean delivery. Because the rate of cesarean delivery has increased from less than 10% in the mid-1960s to more than 24% in 2001,7 there is much interest in understanding the factors possibly influencing the rate of cesarean delivery. The increasing cesarean delivery rate may have major implications for the once again rapidly rising cost of health care in the United States.8,9

This study quantifies 2 previously undocumented potential factors that could be influencing the rate of cesarean delivery during labor: patients’ being offered and patients’ requesting cesarean delivery when not clearly medically indicated in a clinically significant number of cases (13% and 8.8%, respectively). Moreover, the negative findings of this study are of interest. Potentially clinically significant factors, such as stage or length of labor and epidural use, matters of physician convenience such as time of day and day of week, or source of patient payment were not statistically significant. These results support the conclusion that intrapartum elective cesarean delivery is a real clinical entity.

In addition to describing the current practice of physicians, we also sought to understand the various factors that influenced physicians to offer cesarean delivery to their laboring patients. We found that obstetricians who are older, full-time faculty, or maternal–fetal medicine specialists were more likely to offer cesarean delivery. These results suggest that physician characteristics, as opposed to intrapartum factors or patient characteristics except for prior cesarean delivery, are a major determinant of whether laboring patients are being offered cesarean delivery. One possible explanation for these findings is that these physicians may have increased exposure to formal ethics teaching through educational conferences or subspecialty training, which may increase the importance of patient autonomy for these physicians.10 However, we do not discount the idea that perhaps certain patients who are interested in playing a larger role in their care may seek out physicians who would be likely to respond to this demand. Additionally, the finding that patients with a history of a prior cesarean delivery were more likely to be offered repeat cesarean delivery was not surprising as the rate of vaginal births after cesarean has dramatically decreased in the United States during the past decade.7

There were certain limitations of our study. Because the questionnaires were retrospectively completed by the obstetricians and did not include patient input, it is not possible to validate that the responses were completely accurate. In addition, as the questionnaires in our study were only distributed in cases that underwent cesarean delivery, data regarding whether physicians offer cesarean delivery to all patients were not assessed. As our institution is a tertiary care center with a large volume of high-risk patient referrals as reflected in our overall cesarean delivery rate of 35%, our results may not be representative of other populations.

It is possible that intrapartum elective cesarean delivery is of greater frequency and clinical importance than elective cesarean delivery before the onset of labor as currently practiced. Traditional obstetrical thinking concerning intrapartum cesarean delivery has been dichotomous: cesarean delivery is either indicated or it is not. Our study demonstrates that there is an important heretofore-unrecognized discretionary gray zone in which physicians offer or women request cesarean delivery during labor. It is important to define the clinical entity of intrapartum elective cesarean delivery and the factors shaping it more precisely and to explore when intrapartum elective cesarean delivery is justified.

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REFERENCES

1. Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med 2003;348:946–50.
2. Wagner M. Choosing cesarean section [review]. Lancet 2000;356:1677–80.
3. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N Engl J Med 1985;312:1264–7.
4. Schenker JG, Cain JM. FIGO Committee Report: FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. Int J Gynaecol Obstet 1999;64:317–22.
5. Paterson-Brown S, Fisk NM. Cesarean section: every woman’s right to choose [review]? Curr Opin Obstet Gynecol 1997;9:351–5.
6. Harer WB. Quo vadis cesarean delivery? Obstet Gynecol Surv 2002;57:61–4.
7. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM, Sutton PD. Births: final data for 2001. Natl Vital Stat Rep 2002;51:1–102.
8. Levit K, Smith C, Cowan C, Lazenby H, Sensenig A, Catlin A. Trends in U.S. health care spending 2001. Health Aff 2003;22:154–64.
9. Bost BW. Cesarean delivery on demand: what will it cost? Am J Obstet Gynecol 2003;188:1418–21; discussion 1421–3.
10. McCullough LB, Chervenak FA. Ethics in obstetrics and gynecology. New York (NY): Oxford University Press; 1994.

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© 2004 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.