Cesarean birth on patient request

INTRODUCTION — Cesarean birth on patient request (or "on demand") refers to a cesarean birth performed because the pregnant person requests this method of delivery in the absence of a standard medical or obstetrical indication. It is not synonymous with "elective cesarean delivery" and "planned cesarean prior to labor," terms often used historically in circumstances when there is an indication (even if relative) for a cesarean. Cesarean birth on patient request is specific to a small percentage of cesarean births (approximately 2.5 to 3.5 percent in the United States) in which the pregnant person requests this mode of delivery even though there is no standard medical indication.

This topic will discuss issues specifically related to cesarean birth on patient request. General issues regarding cesarean birth, such as patient preparation, technique, anesthesia, postoperative care, and complications, are reviewed separately.

●(See "Cesarean birth: Preoperative planning and patient preparation".)

●(See "Cesarean birth: Surgical technique".)

●(See "Cesarean birth: Postoperative care, complications, and long-term sequelae".)

●(See "Anesthesia for cesarean delivery".)

OVERVIEW — Professional standards do not mandate discussing the option of cesarean birth on request with every patient. In this topic, our aim is to assist the obstetric care provider if and when the issue of cesarean on request is raised by the pregnant patient or their family. We agree with the most recent American College of Obstetricians and Gynecologists' committee opinion that "in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended" [1].

The Agency for Healthcare Research and Quality (AHRQ) has published a detailed report on cesarean birth on patient request [2]. A synopsis of their findings, as well as subsequently published data, are provided in the sections below. These data are limited because no randomized trials on cesarean birth for nonmedical/nonobstetrical reasons have been performed [3]. Thus, conclusions about the risks and benefits of cesarean birth on patient request are not based upon high-quality evidence. Available retrospective observational studies have serious methodological issues and/or provide indirect evidence because the cesareans in randomized trials were performed for such indications as breech presentation [1,4]. Data extrapolated from studies that do not specifically address cesarean on patient request should be interpreted cautiously.

As with any surgical procedure, the risks and benefits of planned cesarean on patient request need to be balanced with the risks and benefits of a planned vaginal birth (which may end in a successful vaginal birth or an unscheduled/emergency cesarean with or without labor). Patient-specific issues that can affect the choice of delivery route include comorbid medical conditions, body mass index, future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the individual’s personal philosophy about childbirth.

Providing patients with the best available information about pertinent childbirth issues and appropriate support may alleviate some of their concerns about attempting vaginal birth. Their motivation for avoiding a vaginal birth should be determined and addressed. Every effort should be made to ensure that the request is truly the desire of the patient and not a result of undue pressure (coercion) from family members or others. Concerns about pain may be addressed by providing detailed by providing detailed information about prenatal childbirth education, emotional support in labor, and obstetric analgesia and anesthesia [1]. If concerns regarding pain are the primary driver to request cesarean, antepartum consultation with a member of the obstetric anesthesia team should be offered.

Fear and anxiety stemming from personal trauma, previous childbirth experiences, or the childbirth experiences of friends and family should be addressed. Fear can also stem from pain catastrophizing and intolerance of uncertainty [5]. Tocophobia, defined as severe anxiety or fear of pregnancy and childbirth, may be more common than previously appreciated, affecting more than 1 in 10 pregnant persons worldwide [6]. It may be alleviated by interventions such as education and short-term individual psychotherapy/cognitive behavioral therapy and possibly group discussion, peer education, and art therapy [7-9]. In a meta-analysis, non‐pharmacological interventions in pregnant patients with high to severe fear of childbirth reduced the cesarean delivery rate compared with usual care (28 versus 40 percent; RR 0.70, 95% CI 0.55-0.89; 5 trials, 557 participants) [8].

Cost is not addressed in this topic as this depends on multiple factors and varies widely. Available evidence is conflicting regarding the cost-effectiveness of patient-request cesareans when compared with trial of labor [10].

REASONS INDIVIDUALS OPT FOR CESAREAN BIRTH ON REQUEST — Reasons for choosing cesarean birth on request include [11-13]:

●Convenience of scheduled birth

●Fear of the pain, process, length, and/or complications of labor and attempted vaginal birth

●Prior poor labor experiences

●Concerns about fetal harm from labor and attempted vaginal birth

●Concerns about trauma to the pelvic floor from labor and vaginal birth, and subsequent development of symptoms associated with pelvic organ prolapse

●Concerns about the need for and risks of emergency cesarean or operative vaginal delivery

●Need for control

A patient's statement during a case conference published in a journal aptly summarizes the opinion of many pregnant people who choose cesarean birth: "I feel like there's a lot more that can go wrong in a natural birth for the baby than can go wrong in the C-section for the mom, and I feel like I'm more willing to take something happening to me than something happening to my baby" [14].

ETHICAL ISSUES — Although there is a paucity of evidence on the value that pregnant patients, clinicians, and society place on the option of elective cesarean delivery [10], a pregnant person's right to be actively involved in choosing the route of their delivery is widely accepted by clinicians and patients in contemporary society. Performing a cesarean birth on patient request in a well-informed patient is considered medically and ethically acceptable [15,16]. In-depth reviews of the ethical issues are available elsewhere [1,17-25].

Professional standards do not mandate discussing the option of cesarean birth on request with every patient, given the high degree of uncertainty about its clinical benefits and risks compared with vaginal birth [18,26,27]. Moreover, obstetricians are not obliged ethically or professionally to perform these procedures. Early referral to another health care practitioner is appropriate in such cases [16,28].

When asked about cesarean birth on patient request, the clinician should find out the reasons for the patient's request; explore their values and emotional and social needs; address their concerns about labor and vaginal birth and any misinformation leading to those concerns (eg, unavailability or danger of effective pain management); and engage them and possibly their support persons in a balanced discussion about the risks and benefits (relative and absolute) of the procedure over a series of visits [14].

Some clinicians have opined that obstetric care providers should not grant a request for cesarean birth that is first made during active labor unless they can thoroughly discuss all of the issues necessary for informed consent of this request, which cannot easily be done intrapartum [29]. Such requests in active labor can be very challenging to care providers, since every effort should be made to respect patient autonomy.

PREVALENCE — Studies of the prevalence of cesarean birth on patient request vary widely across countries, ranging from 0.2 to 42 percent of all deliveries, but most studies report a prevalence of <5 percent [30]. In the United States, these deliveries accounted for <1 percent of all births and between 2.5 to 3.5 percent of cesarean births [1,23,31,32]. Limitations of available data are that birth certificates and discharge codes usually do not indicate whether a cesarean was performed at patient request and prevalence is affected by the year of the study and multiple characteristics of the study population.

Some surveys of obstetricians, urogynecologists, and colorectal surgeons have reported a preference for cesarean by request for themselves and their family members [33-35]. In contrast, nearly all midwives report a preference for vaginal birth [35].

Of note, given its low prevalence, the American College of Obstetricians and Gynecologists did not include recommendations addressing patient request cesarean births in their consensus opinion on the prevention of primary cesarean delivery [36].

POTENTIAL BENEFITS OF PLANNED CESAREAN BIRTH

Known date for delivery — A planned cesarean birth is usually scheduled. A known date for delivery facilitates issues related to work, child care, and help at home for the pregnant person and partner. It also provides an opportunity to schedule surgery with a particular provider.

On the other hand, if a known date for delivery is the goal, induction of labor and attempted vaginal delivery is a reasonable alternative.

Avoidance of postterm pregnancy — Planned cesarean births are typically scheduled at or shortly after 39+0 weeks of gestation. Thus, postterm pregnancy, which is associated with higher rates of perinatal morbidity and mortality than pregnancies delivering at term, can be avoided. (See "Postterm pregnancy".)

As discussed above, if avoidance of postterm pregnancy is the goal, then induction of labor and attempted vaginal delivery is a reasonable alternative.

Reduction in risks associated with unplanned surgery — An attempted vaginal delivery may result in any one of the following outcomes: uncomplicated vaginal birth, operative vaginal birth, or intrapartum cesarean birth. Some patients want to reduce their chances of having an operative vaginal birth or intrapartum cesarean birth because of potential risks associated with these procedures, which may be increased over that associated with scheduled cesarean birth [2]. A report on cesarean birth commissioned by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom reported that rates of injury to the bladder or ureter, iatrogenic surgical injury, and pulmonary embolism appeared to be lower with planned cesarean than with planned vaginal birth, but data were of low quality [37].

In addition to the physical issues, an emergency cesarean birth is often an emotionally traumatic experience for patients and has been associated with postnatal depression and posttraumatic stress disorder [38]. (See "Assisted (operative) vaginal birth", section on 'Complications' and "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Complications'.)

Prevention of late stillbirth — Once the fetus is delivered, it is no longer at risk of intrauterine demise. The medical literature suggests that 1 in 500 to 1 in 1750 fetuses reach maturity in utero and are subsequently involved in a catastrophe resulting in death or severe disability [39-43]. The frequency of intrapartum fetal death is lower and estimated to be 1 in 5000 births [39]. It is clear that scheduled cesarean birth at term would save some fetuses destined for disaster: One stillbirth would be prevented per approximately 1200 cesareans performed at 39 weeks of gestation [44].

On the other hand, if delivery at 39 weeks is the goal, induction of labor is a reasonable alternative.

Reduction in nonrespiratory neonatal disorders — Planned cesarean birth prior to the onset of labor reduces or eliminates fetal/neonatal morbidity and mortality related to the process of labor and vaginal birth [45,46]. Intrapartum complications that are potentially reduced or avoided include brachial plexus injury related to shoulder dystocia, bone trauma (fracture of clavicle, skull, humerus), and asphyxia related to intrapartum events (eg, umbilical cord prolapse, abruption, uterine rupture, difficult fetal extraction because of shoulder dystocia) [2,45,47].

The risk of intrapartum transmission of some infections (eg, herpes simplex virus [HSV], human immunodeficiency virus [HIV]) is also reduced by avoiding vaginal birth. The best means of protecting the neonate from maternal infection varies according to the specific infection and the absolute risk and consequences of intrapartum transmission. As an example, cesarean birth is recommended to reduce intrapartum transmission of active HSV or HIV infection (in patients without a low HIV viral load), whereas passive and active neonatal immunization is adequate protection against intrapartum hepatitis B transmission during vaginal birth.

Reduction in risk of pelvic floor injury — Fear of perineal injury and urinary and fecal incontinence from labor and vaginal delivery is a common reason for patient request for cesarean birth [48,49]; however, these concerns are not based on high-quality evidence.

In the Term Breech Trial, fewer participants had urinary incontinence in the months after a planned cesarean birth versus planned vaginal birth [50], but urinary incontinence rates two and five years after delivery were not significantly different between the two groups [51]. In addition, planned cesarean birth did not appear to confer protection against fecal incontinence compared with planned vaginal delivery [51,52]. However, data are discordant. Another study of individuals 5 to 10 years after delivery compared outcomes between those who had had cesarean births without labor (n = 200), those who had cesarean births in labor (n = 400), and the remainder who had a spontaneous or operative vaginal delivery (n = 400) [53]. Compared with individuals who had cesarean births only before labor, the risk of pelvic organ prolapse was increased in individuals who had a spontaneous vaginal birth or an operative vaginal birth (adjusted odds ratio [aOR] 5.64, 95% CI 2.16-14.70 and aOR 7.50, 95% CI 2.70-20.87, respectively).

Although there is some evidence from observational studies that cesarean birth on patient request may reduce the long-term risk of pelvic organ prolapse, the relationships between pelvic organ prolapse/urinary incontinence/anal incontinence and pregnancy/labor/vaginal delivery/cesarean birth are not well-defined. These data are discussed in detail separately. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse" and "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

Desire to avoid episiotomy is also reported as a reason that some patients request elective cesarean [54]. However, the rate of episiotomy has decreased substantially in recent years and data suggest that mediolateral procedures do not increase the risk of obstetric anal sphincter injury. (See "Obstetric anal sphincter injury (OASIS)".)

Reduction in early postpartum hemorrhage — A report on cesarean birth commissioned by the National Institute for Health and Care Excellence (NICE) in the UK noted that the risk of early postpartum hemorrhage was lower with planned cesarean versus planned vaginal delivery in patients with uncomplicated pregnancies and no previous cesarean (4 to 56 fewer hemorrhages per 1000) [37]. However, this was based on low-quality data and was not associated with a significant reduction in transfusion or hysterectomy for control of bleeding.

POTENTIAL DISADVANTAGES AND RISKS OF PLANNED CESAREAN BIRTH

Risks in future pregnancies — Pregnant people considering planned cesarean birth should consider the consequences of this decision on future pregnancies. The relative risks and benefits change as the number of cesarean births increases [1,37,55]. The increased risk of abnormal placental attachment is a major concern because of the frequency of this complication and the potential for life-threatening hemorrhage.

Increased risk of placental attachment disorders — Placenta previa and placenta accreta spectrum are significantly increased in pregnancies following cesarean births, and the risk increases with the number of prior cesarean births (table 1). Moreover, these complications may necessitate cesarean hysterectomy. For this reason, pregnant persons requesting cesarean delivery who also desire additional children, particularly more than three additional children, should be counseled thoroughly about the risks in subsequent pregnancies, given that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each cesarean birth. (See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality" and "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences" and "Repeat cesarean birth".)

A first delivery by cesarean may also be associated with a higher risk of abruption in future pregnancies [56,57]. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences" and "Acute placental abruption: Management and long-term prognosis".)

Increased risk of uterine rupture — Most uterine ruptures are related to a trial of labor after a previous cesarean birth (TOLAC), but rupture can occur before labor, during preterm labor, or very early in labor. Uterine rupture may require hysterectomy to control bleeding and is associated with an increased risk of fetal and maternal morbidity and mortality. (See "Uterine rupture: After previous cesarean birth".)

Stillbirth in a subsequent pregnancy — The effect of cesarean birth on future stillbirth is controversial. We believe that the association between unexplained stillbirth and a prior cesarean birth observed in some studies is likely due to residual confounding factors.

Although a 2015 meta-analysis reported a significant positive association between cesarean birth and antepartum stillbirth in a second pregnancy (pooled hazard ratio 1.40; 95% CI 1.10-1.77) [58], the analysis excluded the largest published study.

This study, which included almost 1.8 million singleton second births in patients with no underlying medical conditions and fetuses with no structural or chromosomal abnormalities, found no association between previous cesarean and future term fetal demise [59]. The study was excluded from the analysis because it included intrapartum stillbirths, which may have a different etiology. In this study, the fetal death rates at term in those with and without a previous cesarean birth were 0.7 and 0.8 per 1000 births, respectively. In the entire cohort of over 11 million singleton births (second and subsequent births), the fetal death rates at term for patients with and without a previous cesarean were 0.4 and 0.6 per 1000 births, respectively. (See "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Unexplained stillbirth'.)

Anesthetic complications — Given the need for surgical level anesthesia, planned cesarean is associated with a slightly higher rate of failed regional anesthesia than regional anesthesia for planned vaginal delivery. Management of inadequate block depends on patient factors. In urgent situations, general anesthesia should be induced rather than making further attempts at neuraxial anesthesia. Maternal mortality may be higher with general anesthesia, but the absolute risk is very low. (See "Anesthesia for cesarean delivery".)

Longer recovery period — Both the duration of hospitalization and the postpartum recovery period are longer after cesarean compared with vaginal delivery. By three months postpartum, however, pain scores after planned cesarean and planned vaginal delivery are similar [50].

Increased maternal morbidity — Maternal morbidity may be higher with planned cesarean birth than with planned vaginal delivery [60,61]. In one of the largest series, composite severe maternal morbidity after planned primary cesarean for breech presentation (n >46,000 pregnant people) and planned vaginal delivery (n >two million pregnant people) was 27.3 and 9per 1000 deliveries, respectively (odds ratio [OR] 3.1, 95% CI 3.0-3.3) [60]. Compared with the planned vaginal delivery group, the planned cesarean group had a significantly higher postpartum risk of cardiac arrest (OR 5.1), wound hematoma (OR 5.1), hysterectomy (OR 3.2), major puerperal infection (OR 3.0), anesthetic complications (OR 2.3), venous thromboembolism (OR 2.2), and hemorrhage requiring hysterectomy (OR 2.1), but the absolute rate of these events was low for both groups.

On the other hand, in the Term Breech Trial (n = 2083 pregnant people), the difference in serious maternal morbidity between those who planned cesarean birth and those who planned vaginal birth was not statistically significant (3.9 versus 3.1 percent; relative risk 1.28, 95% CI 0.81-2.02) [62]. Similarly, a retrospective cohort study including over 16,000 nulliparous pregnant people who underwent cesarean birth on patient request observed no difference in serious maternal morbidity between this group and the group that underwent planned vaginal delivery [63].

Contemporary standards for infection and thromboembolism prophylaxis in patients undergoing cesarean should result in a reduction in these morbidities and further narrow any difference in morbidity between cesarean and vaginal birth; however, contemporary data from randomized trials are not available.

Long-term complications of abdominal surgery and hysterotomy

●Complications related to adhesions – Formation of adhesions is common after cesarean birth, and the extent and density increase with increasing numbers of repeat cesarean births. The reported prevalence of adhesions is 12 to 46 percent of patients at their second cesarean and 26 to 75 percent of patients at their third cesarean [64-68]. The rate of bowel obstruction after cesarean birth is much lower, with the highest risk in patients who have undergone multiple cesarean births. (See "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Adhesions and bowel obstruction'.)

Adhesions also increase the difficulty of future intra-abdominal surgical procedures and may increase the risk of bladder or bowel injury during such surgery. Although adhesive disease can impair fertility, a causal relationship between cesarean birth and subfertility has not been proven.

●Complications related to incisions – Transabdominal incisions are at risk for incisional hernia formation or localized numbness. (See "Management of ventral hernias".)

In addition to rupture (see 'Increased risk of uterine rupture' above), the hysterotomy incision can be the site of a future ectopic pregnancy (cesarean scar pregnancy). (See "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Scar complications'.)

Increased risk of respiratory problems in offspring — Neonatal respiratory problems (eg, transient tachypnea of the newborn) are more common after cesarean than after vaginal delivery, and may lengthen the neonate's hospital stay [69-72]. In addition, a meta-analysis reported that children delivered by cesarean were at increased risk of asthma up to the age of 12 years (3.8 versus 3.1 percent; OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) [73].

Respiratory problems are more frequent after cesarean birth without labor because mechanisms for reabsorbing lung fluid are not fully activated [74-77]. Respiratory distress related to iatrogenic early term or preterm birth is virtually eliminated if delivery occurs after 39 weeks of gestation [69,70,72] (see "Overview of neonatal respiratory distress and disorders of transition"). For this reason, the American College of Obstetricians and Gynecologists (ACOG) recommends not performing cesarean birth on patient request before 39+0 weeks of gestation [1].

Increased neonatal mortality — A population-based study that used birth certificate data and an intention-to-treat methodology to examine the risk of neonatal mortality for low-risk births by method of delivery found higher mortality after planned cesarean [78]. All United States live births and infant deaths from 1999 to 2002 (8,026,415 births and 17,412 infant deaths) were examined. Low-risk births were defined as singleton, term, vertex births with no medical risk factors, placenta previa, or prior cesarean birth noted on the birth certificate. The "planned vaginal delivery" group consisted of vaginal births and those cesareans performed in the setting of labor complications or procedures (n = 7,755,236), while the "planned cesarean birth" group comprised patients who underwent cesareans with no documented labor complications or procedures (n = 271,179). After adjustment for maternal age, race/ethnicity, education, parity, smoking, infant birth weight, gestational age, and exclusion of infants with congenital anomalies, the odds of neonatal death with "planned cesarean birth" were significantly higher than with "planned vaginal delivery" (OR 1.93, 95% CI 1.67-2.24). The accuracy of these findings is limited by (1) reliance on birth certificate data, which can be inaccurate and incomplete, (2) the absence of data on the indication for cesarean, and (3) the absence of information on the causes of neonatal death.

A subsequent retrospective cohort study of 56,549 late-preterm and term deliveries from Geneva, Switzerland also reported an increase in neonatal mortality and clinically relevant morbidities (neonatal intensive care unit admission, respiratory problems) in late-preterm and term births by planned cesarean birth compared with planned vaginal delivery [79]. The authors speculated that a policy of restricted indications for planned cesarean birth possibly selected pregnancies with higher neonatal risk and thus may have led to an overestimation of unfavorable outcomes.

Other possibly increased adverse neonatal effects — Theoretic concerns of planned cesarean birth include risks to offspring from not experiencing labor-related stress and immune activation, lack of exposure to maternal vulvovaginal/bowel flora, and potential epigenetic changes related to mode of delivery [80-83]. While delivery mode appears to impact the newborn microbiome at a number of sites within 24 hours of birth [84], this difference seems to disappear by six weeks of age [85]. The clinical significance of the short-term difference in bacterial colonization is not known.

In an attempt to restore normal neonatal colonization of cesarean-born neonates, vaginal seeding has been suggested; however, both the safety and effectiveness of this practice are unproven and it is not recommended other than in research trials. (See "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Adverse effect on gut microbiota in the newborn' and "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Role of vaginal seeding'.)

OUTCOMES THAT ARE SIMILAR FOR BOTH PLANNED VAGINAL AND PLANNED CESAREAN BIRTH

Maternal mortality — Although not of high quality, the available evidence suggests there is no significant difference in maternal mortality for planned cesarean versus planned vaginal delivery [2]. There are few data specifically addressing the maternal death rate for cesarean birth on patient request. The lack of data is due, in large part, to the absence of well-designed clinical trials, failure to analyze existing data by intent (eg, classifying patients in the vaginal delivery group if they undergo emergency cesarean in the course of planned vaginal delivery), and the rarity of maternal death in resource-abundant countries.

It is likely that the risk of maternal death from patient request cesarean birth is similar to that with scheduled repeat cesarean birth prior to the onset of labor. This risk ranges from 1 in 5000 cesarean births to fewer than 1 in 70,000 cesarean births [86-89].

If cesarean is more dangerous than vaginal delivery, then one would expect a higher maternal mortality rate among populations with high cesarean birth rates, but this association has not been demonstrated [86,90]. In fact, using national estimates of cesarean birth rates after 1990 in 19 Latin American countries [91], one study found that the highest maternal mortality was in populations in which the cesarean birth rate was lowest. Although this does not prove cause and effect, it does cast doubt on the assumption that cesarean is more dangerous for the mother than vaginal delivery.

Some authors have interpreted available data as showing that planned cesarean birth is safer than planned vaginal delivery [92]. The safety of cesarean has been attributed to safer surgical and anesthetic techniques and widespread use of prophylactic antibiotics and thromboprophylaxis.

Postpartum sexual function — Postpartum sexual function does not appear to be affected by method of delivery [2]. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Pregnancy and childbirth'.)

Pain remote from delivery — In the immediate postoperative period, vaginal delivery is associated with more perineal pain while cesarean birth is associated with more abdominal pain. However, by four months postpartum, there appears to be no difference in pain between pregnant people who planned cesarean birth and those who planned vaginal birth [37].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cesarean birth".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Vaginal birth after a cesarean (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Cesarean birth on patient request refers to a cesarean birth performed because the pregnant person requests this method of delivery in the absence of conventional medical or obstetrical indications. It may be a primary or repeat cesarean performed before or after the onset of labor. (See 'Introduction' above.)

●Factors considered in choosing a delivery route – Patient-specific issues that can affect the choice of delivery route include comorbid medical conditions, body mass index, future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the individual's personal philosophy about childbirth. (See 'Overview' above.)

●Benefits and risks of cesarean birth on patient request – As with any surgical procedure, the risks and benefits of cesarean birth on patient request need to be balanced with the risks and benefits of a planned vaginal delivery. The best available evidence suggests that planned cesarean birth is associated with a lower risk of fetal injury than planned vaginal delivery, but longer hospital stay/recovery and increased risks of short-term neonatal respiratory problems, abnormal placentation in future pregnancies, and uterine rupture in future pregnancies. Planned cesarean birth minimizes the risk of surgical complications associated with unplanned or emergency cesarean birth, which may become necessary during attempted vaginal delivery. (See 'Potential benefits of planned cesarean birth' above and 'Potential disadvantages and risks of planned cesarean birth' above.)

●Clinical approach

•Ethical issues and provider responsibility – Performing a cesarean birth on patient request in a well-informed patient is considered medically and ethically acceptable. Professional standards do not mandate discussing the option of cesarean birth on request with every patient, given the high degree of uncertainty about its clinical benefits and risks compared with planned vaginal birth. (See 'Ethical issues' above.)

Obstetricians are not obliged ethically or professionally to perform cesarean birth on request; early referral to another health care practitioner willing to act in accordance with the patient's request is appropriate in such cases. (See 'Ethical issues' above.)

•Patient evaluation and counseling – When a patient requests a cesarean birth, the clinician should find out the reasons for the request, address their concerns about labor and vaginal birth and any misinformation leading to those concerns, and engage them and possibly their support persons in a balanced discussion about the risks and benefits of the procedure over a series of visits. In particular, work and family pressures, personal fears and anxieties about childbirth, and concerns about pain should be addressed. (See 'Ethical issues' above.)

•Provider recommendations

-In the absence of maternal or fetal indications for cesarean birth, vaginal birth is safe and appropriate and should be recommended. For pregnant people planning several pregnancies, we suggest trying to avoid cesarean birth on request (Grade 2C). Patients should be informed that the risks of placenta previa and placenta accreta spectrum increase with each subsequent cesarean birth (table 1). If the patient undergoes a trial of labor in the future, they will be at increased risk of uterine rupture and puerperal hysterectomy. (See 'Risks in future pregnancies' above.)

-If a planned vaginal birth is still not an acceptable option after discussion of the benefits and risks in both current and subsequent pregnancies, a planned caesarean birth should be offered to pregnant persons requesting such a delivery. If cesarean birth on patient request is planned, it should be scheduled at or shortly after 39+0 weeks of gestation to minimize the risk of neonatal respiratory problems. (See 'Increased risk of respiratory problems in offspring' above.)