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Preventive ethics for cesarean delivery: the time has comeFrank A. Chervenak, MD; Laurence B. McCullough, PhD

rs Salmeen and Brincat make a valuable contribution

D to descriptive obstetric ethics by documenting theimportance of time constraints for informed consent for ce-sarean delivery. In their very well-executed retrospective studyof the range of consent time for cesarean delivery duringlabor, they show that the median time from consent toincision was 48 minutes. For women who underwent cesar-ean delivery for fetal heart rate indications, the odds ofdelivering in <30 minutes after consent were 4.7 higher. DrsSalmeen and Brincat reasonably conclude that the consenttime for cesarean delivery during labor is brief.1 Given thedistractions of labor and the momentum for surgical in-tervention that can build as maternal or fetal indicationsjustifiably come to dominate clinical judgment, obtaininginformed consent during labor for cesarean delivery is, by itsvery nature, ethically challenging.

The best way to address this ethical challenge is with pre-ventive ethics, which is a concept that we introduced in theJournal in 1990.2 Preventive ethics uses the informed consentprocess to anticipate, prevent, and responsibly manage thepotential for ethical conflict between the pregnant womanand her obstetrician. The absence of a preventive ethicsapproach to decision-making with patients about cesareandelivery unwittingly fosters the misperception of the “perfectbaby”3 and misses important opportunities to prepare thepregnant woman for the rush of decision-making about ce-sarean delivery so that it does not overwhelm her autonomyor birth experience.

The goal of a preventive ethics approach to informedconsent for cesarean delivery is to empower the pregnantwoman with information about cesarean delivery that shemay need later. Given time and adequate support, pregnantwomen demonstrate the capacity to make informed, scien-tifically sophisticated decisions about their medical care (eg,the use of invasive prenatal diagnosis on the basis of theresults of noninvasive risk assessment to make decisions

From the Department of Obstetrics and Gynecology, Weill MedicalCollege of Cornell University, New York, NY (Dr Chervenak), and theCenter for Medical Ethics and Health Policy, Baylor College of Medicine,Houston, TX (Dr McCullough).

The authors report no conflict of interest.

Reprints: Frank A. Chervenak, MD, New York Presbyterian Hospital,525 East 68th St., M-724, Box 122, New York, NY 10065.fac2001@med.cornell.edu.

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about invasive diagnosis in advance of the potential needfor it).4

An adequate informed consent process for cesarean de-livery takes time. This process by its very nature requires thepregnant woman to give her attention to her obstetrician, tolisten carefully, to think through and carefully assess thebenefits and risks of cesarean delivery, and to appreciatethat, for maternal or fetal indications, cesarean delivery canbecome the only medically reasonable alternative for delivery.All of this takes time and a minimum of distraction, whichare difficult to achieve under the time constraints that DrsSalmeen and Brincat have well documented. Obstetricianscan and should take advantage of the fact that most pregnantwomen are seen prenatally, some even before conception,which creates multiple opportunities for a preventive ethicsapproach to informed consent for cesarean delivery.

As part of routine prenatal care, every pregnant womanshould be informed that cesarean delivery occurs in aboutone-third of pregnancies.5 Every pregnant woman should alsoappreciate that a low-risk pregnancy can change rapidly into ahigh-risk pregnancy during the intrapartum period and thatcesarean delivery may become necessary for either maternalor fetal indications. The obstetrician should elicit the patient’sattitudes about cesarean delivery and tailor subsequent in-formation accordingly. The obstetrician should emphasizethat cesarean delivery cannot guarantee a normal child.3

For some women, depending on their medical conditionand informational needs, decisions about cesarean deliveryrequire more than this general information that every preg-nant women should receive. For these women, the obstetri-cian should explain that cesarean delivery is not alwaysdichotomous.6 The obstetrician may need to identify for thepregnant woman the medically reasonable alternatives for theintrapartum management of her pregnancy (ie, those reliablyexpected to result in net clinical benefit to the pregnantwoman or her future child). In the language of professionalmedical ethics, deliberative clinical judgments of medicalreasonableness are beneficence-based.7 Vaginal delivery is thedefault delivery mode in beneficence-based deliberative clin-ical judgment. The medical reasonableness of vaginal delivery,however, decreases as the evidence base in support of cesareandelivery increases. The choice between vaginal and cesareandelivery, however, is not always dichotomous and thereforecan range along a continuum that is a function of the qualityand strength of the evidence base for the relative clinicalbenefits of cesarean delivery.6

The obstetrician should explain to these pregnant womenhow 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

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of cesarean delivery. In such clinical circumstances, vaginaldelivery becomes no longer medically reasonable. It followsthat the obstetrician has the professional responsibility torecommend cesarean delivery and will do so. The strength ofsuch recommendations should be directly proportional to thestrength of the evidence base for relative clinical benefit ofcesarean delivery.

The obstetrician should explain that sometimes cesareandelivery is recommended justifiably in advance of the intra-partum period (eg, when there is a history of a classic ce-sarean delivery). The obstetrician should also explain thatcesarean delivery is sometimes justifiably recommendedduring the intrapartum period (eg, for newly diagnosed fetaldistress). Such discussion prepares the woman for theimmediacy and urgency of both expected and unexpectedintrapartum complications and lays the foundation for therapid decision-making that might become necessary.

When the evidence base for cesarean delivery is not clearcut (eg, previous low transverse cesarean delivery in a womanin her second pregnancy), both cesarean delivery and trial oflabor after cesarean delivery are medically reasonable.8,9 Insuch clinical circumstances, the obstetrician has the profes-sional responsibility to offer both but refrain temporarilyfrom making a recommendation until the pregnant womanhas had the opportunity to think through both alternatives.This approach allows the pregnant woman to exercise hercapacity for autonomous decision-making without beingunduly influenced by her obstetrician’s views. If deliberativeclinical judgment supports one alternative relative to theother, the obstetrician may then recommend it for thepregnant woman’s consideration.

A preventive ethics approach to the informed consentprocess for cesarean delivery should at long last become anaccepted component of routine obstetric care. Taking apreventive ethics approach to the informed consent processfor cesarean delivery should be expected to enhance theautonomy of pregnant women by preparing them to cope

more effectively with the complexity and urgency ofdecision-making about cesarean delivery. A preventive ethicsapproach creates the opportunity to identify and resolvepotential conflicts about cesarean delivery.2 Sometimes, it isnot possible to engage in a preventive ethics approach toinformed consent for cesarean delivery. Nonetheless, takingaccount of the time constraints during labor that havebeen documented by Drs Salmeen and Brincat,1 obstetriciansstill have the professional responsibility to obtain informedconsent for cesarean delivery. -

REFERENCES

1. Salmeen K, Brincat C. Time from consent to cesarean delivery duringlabor. Am J Obstet Gynecol 2013;209:212.e1-6.2. Chervenak FA, McCullough LB. Clinical guides to preventing ethicalconflicts between pregnant women and their physicians. Am J ObstetGynecol 1990;162:303-7.3. Chervenak, McCullough, Brent RL. The perils of the imperfectexpectation of the perfect baby. Am J Obstet Gynecol 2010;203:101.e1-5.4. Nicolaides KH, Chervenak FA, McCullough LB, et al. Evidence-basedobstetric ethics and informed decision-making about invasive diagnosisafter first-trimester assessment for risk of trisomy 21. Am J ObstetGynecol 2005;193:322-6.5. Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Wilson EC,Mathews TJ. Births: final data for 2010. US Department of Health andHuman Services; Centers for Disease Control and Prevention; NationalVital Statistics Report. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf. Accessed: May 10, 2013.6. Kalish RB, McCullough LB, Chervenak FA. Decision-making aboutcaesarean delivery. Lancet 2006;367:883-5.7. Chervenak FA, Brent RL, McCullough LB. The professional re-sponsibility model of obstetric ethics: avoiding the perils of clashing rights.Am J Obstet Gynecol 2011;205:315.e1-5.8. National Institutes of Health Consensus Development ConferencePanel. National Institutes of Health consensus development conferencestatement: vaginal birth after cesarean: new insights, March 8-10, 2010.Obstet Gynecol 2010;115:1279-95.9. Chervenak FA, McCullough LB. An ethical framework for the informedconsent process for trial of labor after cesarean delivery. Clin Perinatol2011;38:227-31.

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