Elsevier

Seminars in Perinatology

Volume 36, Issue 5, October 2012, Pages 384-389
Seminars in Perinatology

Decision Making for Primary Cesarean Delivery: The Role of Patient and Provider Preferences

https://doi.org/10.1053/j.semperi.2012.04.024Get rights and content

Primary cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the range of contexts in which decision making takes place and the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate that are safe and acceptable to both patients and providers. We conducted a review of the literature on patient and provider preferences and obstetrical decision making in the context of primary cesarean delivery, and offer recommendations for future research directions, including potential interventions that may impact the patient and provider factors affecting the primary cesarean rate.

Section snippets

Decision Making Regarding Cesarean Delivery in Context

As with any medical procedure, cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. However, the dynamic nature of decision making for cesarean delivery during the course of pregnancy, and particularly during labor, is unique, and the relative importance of patient and provider factors affecting this decision may vary depending on the specific circumstances. Part of the context for decision making arises

Shared Decision Making in Obstetrics

Shared decision making has been defined as a process in which decisions are shared by patients and health care providers, informed by the best evidence available and weighted according to the specific characteristics and values of the patient.2, 3 Although the shared decision-making model has been endorsed for some clinical contexts in obstetrics and gynecology,4 mode of delivery decisions, particularly in a first pregnancy, are more frequently viewed as opportunities for education and

CDMR and Beyond: The Impact of Patient Preference

CDMR is defined as a planned primary cesarean delivery in the absence of any medical or obstetrical indication. Significant media attention has been devoted to this entity, and in the context of the rising cesarean rate, attempts have been made to quantify the impact of CDMR on the cesarean rate as a whole. Unfortunately, it is difficult to accurately assess the rate of CDMR based on research studies, coding, or reimbursement information.5 Surveys of obstetrical providers indicate that although

Primary Cesarean Delivery Performed During Labor: Decision Making Under Uncertainty

In contrast to cesarean deliveries performed before labor, where clinical indications such as breech presentation, placenta previa, or multiple gestation are clear to both the patient and the provider, cesarean deliveries performed during labor for the indications of active phase arrest or nonreassuring fetal heart tracing depend more on provider judgment of the clinical situation and assessment/inclusion of patient preference as they see fit. A recent study by Barber et al21 found that the

The Impact of the Provider on Decision Making for Primary Cesarean Delivery

Given the priority that patients give to provider assessment of benefits and risks of a particular mode of delivery, as well as the inescapable fact that providers make the recommendation for cesarean delivery during labor, it is intuitive to think that provider attitudes and differences in management style may explain some of the increase in cesarean rate. Analysis of the strength of indication for a primary cesarean delivery showed that in one sample, patients who were older, white, privately

Management of Uncertainty in Obstetrics

Evidence regarding the subjectivity of decision making in the case of primary cesarean delivery highlights the uncertainty that is inherent in the labor and delivery process, particularly for women experiencing their first labor. Uncertainty has been defined as a form of metacognition or a “knowing about not knowing”; in health care decision making, the patient, the provider, or both may be uncertain. In the era of evidence-based medicine, shared decision making, and patient-centered care, the

Interventions to Reduce the Primary Cesarean Rate

Given that the interaction between the patient and the provider remains central in decision making regarding primary cesarean deliveries, interventions to reduce the cesarean rate must target both patients and providers. All preferences are not informed preferences, and both patients and providers bring their biases to decision making. Educational tools may be helpful to allow both patients and providers define their priorities and cope with the uncertainty that is inherent in a first labor.

Future Research Directions

In sum, despite evidence suggesting that patient and provider preferences play key roles in how decisions for primary cesarean delivery are made, data from large prospective studies among sociodemographically diverse pregnant women outside the context of CDMR are lacking. Ideally, future studies should assess the strength of patient preference for a particular delivery mode, including the dynamic nature of preferences through both the course of antenatal care and labor, and also should measure

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