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Preventive ethics for cesarean delivery: the time has come

      See related article, page 212
      Drs Salmeen and Brincat make a valuable contribution to descriptive obstetric ethics by documenting the importance of time constraints for informed consent for cesarean delivery. In their very well-executed retrospective study of the range of consent time for cesarean delivery during labor, they show that the median time from consent to incision was 48 minutes. For women who underwent cesarean delivery for fetal heart rate indications, the odds of delivering in <30 minutes after consent were 4.7 higher. Drs Salmeen and Brincat reasonably conclude that the consent time for cesarean delivery during labor is brief.
      • Salmeen K.
      • Brincat C.
      Time from consent to cesarean delivery during labor.
      Given the distractions of labor and the momentum for surgical intervention that can build as maternal or fetal indications justifiably come to dominate clinical judgment, obtaining informed consent during labor for cesarean delivery is, by its very nature, ethically challenging.
      The best way to address this ethical challenge is with preventive ethics, which is a concept that we introduced in the Journal in 1990.
      • Chervenak F.A.
      • McCullough L.B.
      Clinical guides to preventing ethical conflicts between pregnant women and their physicians.
      Preventive ethics uses the informed consent process to anticipate, prevent, and responsibly manage the potential for ethical conflict between the pregnant woman and her obstetrician. The absence of a preventive ethics approach to decision-making with patients about cesarean delivery unwittingly fosters the misperception of the “perfect baby”
      • Chervenak
      • McCullough
      • Brent R.L.
      The perils of the imperfect expectation of the perfect baby.
      and misses important opportunities to prepare the pregnant woman for the rush of decision-making about cesarean delivery so that it does not overwhelm her autonomy or birth experience.
      The goal of a preventive ethics approach to informed consent for cesarean delivery is to empower the pregnant woman with information about cesarean delivery that she may need later. Given time and adequate support, pregnant women demonstrate the capacity to make informed, scientifically sophisticated decisions about their medical care (eg, the use of invasive prenatal diagnosis on the basis of the results of noninvasive risk assessment to make decisions about invasive diagnosis in advance of the potential need for it).
      • Nicolaides K.H.
      • Chervenak F.A.
      • McCullough L.B.
      • et al.
      Evidence-based obstetric ethics and informed decision-making about invasive diagnosis after first-trimester assessment for risk of trisomy 21.
      An adequate informed consent process for cesarean delivery takes time. This process by its very nature requires the pregnant woman to give her attention to her obstetrician, to listen carefully, to think through and carefully assess the benefits and risks of cesarean delivery, and to appreciate that, for maternal or fetal indications, cesarean delivery can become the only medically reasonable alternative for delivery. All of this takes time and a minimum of distraction, which are difficult to achieve under the time constraints that Drs Salmeen and Brincat have well documented. Obstetricians can and should take advantage of the fact that most pregnant women are seen prenatally, some even before conception, which creates multiple opportunities for a preventive ethics approach to informed consent for cesarean delivery.
      As part of routine prenatal care, every pregnant woman should be informed that cesarean delivery occurs in about one-third of pregnancies.

      Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Wilson EC, Mathews TJ. Births: final data for 2010. US Department of Health and Human Services; Centers for Disease Control and Prevention; National Vital Statistics Report. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf. Accessed: May 10, 2013.

      Every pregnant woman should also appreciate that a low-risk pregnancy can change rapidly into a high-risk pregnancy during the intrapartum period and that cesarean delivery may become necessary for either maternal or fetal indications. The obstetrician should elicit the patient's attitudes about cesarean delivery and tailor subsequent information accordingly. The obstetrician should emphasize that cesarean delivery cannot guarantee a normal child.
      • Chervenak
      • McCullough
      • Brent R.L.
      The perils of the imperfect expectation of the perfect baby.
      For some women, depending on their medical condition and informational needs, decisions about cesarean delivery require more than this general information that every pregnant women should receive. For these women, the obstetrician should explain that cesarean delivery is not always dichotomous.
      • Kalish R.B.
      • McCullough L.B.
      • Chervenak F.A.
      Decision-making about caesarean delivery.
      The obstetrician may need to identify for the pregnant woman the medically reasonable alternatives for the intrapartum management of her pregnancy (ie, those reliably expected to result in net clinical benefit to the pregnant woman or her future child). In the language of professional medical ethics, deliberative clinical judgments of medical reasonableness are beneficence-based.
      • Chervenak F.A.
      • Brent R.L.
      • McCullough L.B.
      The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights.
      Vaginal delivery is the default delivery mode in beneficence-based deliberative clinical judgment. The medical reasonableness of vaginal delivery, however, decreases as the evidence base in support of cesarean delivery increases. The choice between vaginal and cesarean delivery, however, is not always dichotomous and therefore can range along a continuum that is a function of the quality and strength of the evidence base for the relative clinical benefits of cesarean delivery.
      • Kalish R.B.
      • McCullough L.B.
      • Chervenak F.A.
      Decision-making about caesarean delivery.
      The obstetrician should explain to these pregnant women how the alternatives will be assessed in clinical judgment. When the evidence base for cesarean delivery is very strong (eg, well-documented intrapartum complete placenta previa), there is no uncertainty about the relative clinical benefit of cesarean delivery. In such clinical circumstances, vaginal delivery becomes no longer medically reasonable. It follows that the obstetrician has the professional responsibility to recommend cesarean delivery and will do so. The strength of such recommendations should be directly proportional to the strength of the evidence base for relative clinical benefit of cesarean delivery.
      The obstetrician should explain that sometimes cesarean delivery is recommended justifiably in advance of the intrapartum period (eg, when there is a history of a classic cesarean delivery). The obstetrician should also explain that cesarean delivery is sometimes justifiably recommended during the intrapartum period (eg, for newly diagnosed fetal distress). Such discussion prepares the woman for the immediacy and urgency of both expected and unexpected intrapartum complications and lays the foundation for the rapid decision-making that might become necessary.
      When the evidence base for cesarean delivery is not clear cut (eg, previous low transverse cesarean delivery in a woman in her second pregnancy), both cesarean delivery and trial of labor after cesarean delivery are medically reasonable.
      • National Institutes of Health Consensus Development Conference Panel
      National Institutes of Health consensus development conference statement: vaginal birth after cesarean: new insights, March 8-10, 2010.
      • Chervenak F.A.
      • McCullough L.B.
      An ethical framework for the informed consent process for trial of labor after cesarean delivery.
      In such clinical circumstances, the obstetrician has the professional responsibility to offer both but refrain temporarily from making a recommendation until the pregnant woman has had the opportunity to think through both alternatives. This approach allows the pregnant woman to exercise her capacity for autonomous decision-making without being unduly influenced by her obstetrician's views. If deliberative clinical judgment supports one alternative relative to the other, the obstetrician may then recommend it for the pregnant woman's consideration.
      A preventive ethics approach to the informed consent process for cesarean delivery should at long last become an accepted component of routine obstetric care. Taking a preventive ethics approach to the informed consent process for cesarean delivery should be expected to enhance the autonomy of pregnant women by preparing them to cope more effectively with the complexity and urgency of decision-making about cesarean delivery. A preventive ethics approach creates the opportunity to identify and resolve potential conflicts about cesarean delivery.
      • Chervenak F.A.
      • McCullough L.B.
      Clinical guides to preventing ethical conflicts between pregnant women and their physicians.
      Sometimes, it is not possible to engage in a preventive ethics approach to informed consent for cesarean delivery. Nonetheless, taking account of the time constraints during labor that have been documented by Drs Salmeen and Brincat,
      • Salmeen K.
      • Brincat C.
      Time from consent to cesarean delivery during labor.
      obstetricians still have the professional responsibility to obtain informed consent for cesarean delivery.

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