ACOG Committee Opinion, Number 289, November 2003. Surgery and Patient Choice: The Ethics of Decision Making

Responding to refusal of recommended cesarean section: Promoting good parenting

Consideration of what a "good parent" would do in controversial perinatal cases has been largely absent from to ethics literature. This article argues when a cesarean section is required to prevent death or serious disability for a fetus, the pregnant woman has an ethical (although not legal) obligation to undergo that procedure even when she has concerns or conflicting commitments. Further, a clinician may be justified in using persuasive counseling when there is grave harm at stake that the patient has a moral obligation to prevent. This conclusion is tested by exploring its implications in several other analogous controversial contexts.

Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India

As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.

Decision - delivery interval and perinatal outcome of emergency caesarean sections at a tertiary institution

Background and objective: A decision-to-delivery interval (DDI) of 30 minutes for emergency Caesarean sections (CS) has been widely recommended, but there is little evidence to support it. Recent studies however, have questioned not only the practicability of this target but also its anticipated beneficial effect on neonatal outcome and medico-legal implications. Our objective in this study was to find out the time between decision-delivery interval and perinatal outcome of emergency caesarean section at a tertiary care institution in Nigeria

Methods: This was a retrospective study of cases of emergency Caesarean section performed over a 12-month period. Relevant data were collected from the labour ward and theatre records and case files of the University of Benin Teaching Hospital, Benin City, Nigeria between January 1 and December 31, 2012.

Results: A total of 352 emergency Caesarean sections done during the period were reviewed. Only 20 (5.7%) of these were performed within the recommended 30 minutes DDI. The mean DDI was 106.3 + 79.5 minutes and there was no significant correlation between DDI and perinatal outcome. The major causes of delay were anaesthetic delay and busy theatre suits.

Conclusion: This study demonstrated a lack of correlation between DDI and perinatal outcome, which may indicate decision delivery interval of 30 minutes or less may not be applicable to all emergency CS, especially in developing countries with infrastructural challenges. However when faced with acute or catastrophic foetal or maternal conditions, expedited delivery is indicated.

Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies

OBJECTIVE

To assess maternal postpartum and neonatal outcomes associated with previous method of delivery.

STUDY DESIGN

We analyzed prospectively collected maternal and neonatal data from July 2002 to December 2003. Data were collected from dedicated perinatal database and neonatal database from discharge and procedure codes. Groups were: (i) multiparous, prior vaginal delivery (VD), and (ii) multiparous, prior cesarean (CS). This group was subdivided by subsequent pregnancy trial or no trial of labor (No TOL). Results were compared with chi (2)-analysis; significance P<0.05.

RESULTS

There were 17 406 births. Prior CS patients without trial of labor (TOL) required more blood transfusions, intensive care unit admissions and hospital readmissions than women with a prior VD. Prior CS patients with TOL required more aminoglycosides for postpartum infection. Term neonates of (CS) mothers without a TOL were more likely to have prolonged hospitalization and require ventilatory support.

CONCLUSIONS

In their subsequent delivery, women with a prior CS delivery are at significant risks for postpartum maternal and neonatal morbidities compared with parous patients who experienced a prior VD.

Emergent (crash) cesarean delivery: indications and outcomes

OBJECTIVE

The purpose of this study was to define the indications and outcomes of emergent cesarean deliveries.

STUDY DESIGN

We analyzed prospectively collected singleton maternal and neonatal data from January 1, 1998, to December 31, 2004 of all such cesarean deliveries that were performed. A case-control analysis was performed by matching emergent cesarean deliveries with the next 2 acute cesarean deliveries.

RESULTS

There were 126 emergent cesarean deliveries (1:159 deliveries). There were no significant differences in identifiable obstetric or chronic medical risk factors between the 2 groups. Compared with the control subjects, the subjects with emergent cesarean deliveries had an increased risks of cesarean delivery for non-reassuring fetal heart rate (P < .0001; odds ratio, 12.0), cord prolapse (P < .0001), and suspected uterine rupture (P < .0001); in addition, greater risk of a low 1-minute Apgar score (P < .001; odds ratio, 19.5) and low 5-minute Apgar score (P < .001; odds ratio, 10.4), acute respiratory distress of infant (P < .001; odds ratio, 4.21), and infant intubations (P < .0001; odds ratio, 8.1).

CONCLUSION

These data demonstrate that most emergent cesarean deliveries develop during labor in low-risk women and cannot be anticipated by prelabor factors. The outcomes demonstrate that infants are at risk in these clinical situations and suggest that strategies to improve performance in these clinical situations are important.