Decision Making for Primary Cesarean Delivery: The Role of Patient and Provider Preferences
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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2023, Seminars in Arthritis and RheumatismA prediction tool for mode of delivery in twin pregnancies—a secondary analysis of the Twin Birth Study
2023, American Journal of Obstetrics and GynecologyA qualitative study of nulliparous women's decision making on mode of delivery under China's two-child policy
2018, MidwiferyCitation Excerpt :Currently, the implementation of China's two-child policy has made numerous families reshape their birth intentions and decision making on mode of delivery (Zhu et al., 2016). A decision-making process regarding mode of delivery has a dynamic nature during the course of pregnancy and labour (Kaimal and Kuppermann, 2012; Deng et al., 2014). Women's preferences for delivery mode differ widely within diverse cultural backgrounds.
Women's attitudes towards the medicalization of childbirth and their associations with planned and actual modes of birth
2017, Women and BirthCitation Excerpt :In the 20th century, women actively contributed to this process and sought medical ways to reduce pain in labour. This process continues nowadays and therefore medical choices, such as a caesarean, are often related not only to provider decisions but also to women's attitudes and preferences.24 Our study has several limitations.