An ethical framework for counseling about mode of delivery for desired psychosocial benefit in pregnancies complicated by severe fetal anomalies

2019 ◽  
Vol 8 (2) ◽  
Author(s):  
Michelle T. Nguyen ◽  
Laurence B. McCullough ◽  
Frank A. Chervenak ◽  
Kathryn J. Shaw ◽  
Dominique Luckey
Keyword(s):  
Cesarean Delivery ◽  
Mode Of Delivery ◽  
Breech Presentation ◽  
Traumatic Shock ◽  
Informed Decision ◽  
Trisomy 18 ◽  
Ethical Framework ◽  
Ethical Challenges ◽  
Fetal Diagnosis ◽  
Elective Cesarean

Abstract Background A fetal diagnosis poses ethical challenges when a woman requests elective cesarean delivery for psychosocial reasons. We address the ethical challenges of counseling such patients. Case presentation A 36-year-old G4P2012 has chosen to continue a pregnancy despite a high likelihood of trisomy 18. At 36.5 weeks she was admitted for preeclampsia with severe features and requested to be delivered by primary cesarean section. Due to the poor prognosis associated with trisomy 18, the patient’s request for cesarean delivery was declined even when her baby changed to breech presentation with Category 2 fetal heart rate (FHT). The patient subsequently experienced a traumatic stillbirth and post-traumatic shock disorder (PTSD). Conclusion The obstetrician’s goal should be to transform the patient’s request into an informed decision. The obstetrician should explain that, while a cesarean could increase the likelihood of a live birth, it will not alter long-term neonatal outcomes and entails net biomedical risk for the current and future pregnancies. The obstetrician should ensure that the patient understands these clinical realities. The obstetrician should support the patient’s decision-making about whether to accept the risks of cesarean delivery for psychosocial benefit. The obstetrician should initiate counseling during prenatal visits to empower the patient with information to meaningfully exercise her autonomy. If the patient makes an informed decision for cesarean delivery, it becomes ethically permissible. Plans regarding intrapartum management and mode of delivery should be documented in case the patient is delivered by a physician who was not involved in prenatal counseling.

The importance of clinically and ethically fine-tuning decision-making about cesarean delivery

2017 ◽  
Vol 45 (5) ◽  
Author(s):  
Michelle T. Nguyen ◽  
Laurence B. McCullough ◽  
Frank A. Chervenak
Keyword(s):  
Decision Making ◽  
Cesarean Delivery ◽  
Clinical Judgment ◽  
Fetal Heart ◽  
Breech Presentation ◽  
Organizational Factors ◽  
Fine Tuning ◽  
Ethical Framework ◽  
Training Experience ◽  
Significant Harm

AbstractIn obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital’s availability of resources and the obstetrician’s training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.

Comparison of Melatonin Levels in the Colostrum between Vaginal Delivery and Cesarean Delivery

2017 ◽  
Vol 35 (05) ◽  
pp. 481-485 ◽  
Author(s):  
Ziya Kalem ◽  
Tuncay Yuce ◽  
Batuhan Bakırarar ◽  
Feride Söylemez ◽  
Müberra Namlı Kalem
Keyword(s):  
Cesarean Section ◽  
Cesarean Delivery ◽  
Vaginal Delivery ◽  
Mode Of Delivery ◽  
Elective Cesarean Section ◽  
Enzyme Linked Immunosorbent Assay ◽  
Cross Sectional ◽  
Emergency Cesarean ◽  
Study Results ◽  
Elective Cesarean

Objective This study aims to compare melatonin levels in colostrum between vaginal and cesarean delivery. Study Design This cross-sectional study was conducted with 139 mothers who gave live births between February 2016 and December 2016. The mothers were divided into three groups according to the mode of delivery: 60 mothers (43.2%) in the vaginal delivery group, 47 mothers (33.8%) in the elective cesarean delivery, and 32 mothers (23.0%) in the emergency cesarean delivery group. Colostrum of the mothers was taken between 01:00 and 03:00 a.m. within 48 to 72 hours following the delivery, and the melatonin levels were measured using the enzyme-linked immunosorbent assay (ELISA) and compared between the groups. Results The melatonin levels in the colostrum were the highest in the vaginal delivery group, lower in the elective cesarean section group, and the lowest in the emergency cesarean group (265.7 ± 74.3, 204.9 ± 55.6, and 167.1 ± 48.1, respectively; p < 0.001). The melatonin levels in the colostrum did not differ according to the demographic characteristics of the mothers, gestational age, birth weight, newborn sex, the Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores, and for the requirement for neonatal intensive care. Conclusion Our study results showed that melatonin levels in the colostrum of the mothers who delivered vaginally were higher than those who delivered by cesarean section. Considering the known benefits of melatonin for the newborns, we believe that vaginal delivery poses an advantage.

scholarly journals A Survey on Causes of Cesarean Sections Performed on Women and Their Knowledge towards the Mode of Delivery

2020 ◽  
Vol 5 (1) ◽  
Keyword(s):  
Cesarean Delivery ◽  
Mode Of Delivery ◽  
Previous History ◽  
Breech Presentation ◽  
Cesarean Sections ◽  
College Hospital ◽  
Cross Sectional ◽  
Emergency Cesarean ◽  
Special Cases ◽  
History Of

Recently elective cesarean delivery rates have increased alongside with emergency cesarean delivery where less information has been conveyed to the women who have been subjected to C-sections. The main objective of C-section is reducing the incidence of maternal and neonatal mortality during childbirth in dangerous situations. It is recommended when there is a risk to mother or child during vaginal delivery. A descriptive type of cross-sectional study design was used. All the data were collected through structured format in questionnaires. The present study was carried out in the department of Obstetrics and Gynecology in the Chittagong Medical College Hospital. The data was collected from 29th September 2019 to 10th October 2019. Most of the patients who were subjected to c section were within the age range of 15-25 (57%). 41% of the cesarean sections were planned whereas 59% were on the basis of emergency and mostly the decision was doctor’s (66%). 58% of the population had enough information before undergoing C-sections and 42% wasn’t fully aware. Among pain medication intake, only 2% of the patients had taken a combination of three pain medications which include paracetamol, metronidazole and suppository. 80% of the patients consumed a combination of paracetamol and suppository whereas only 10% of population consumed paracetamol and metronidazole. 8% of the patients were managed only with paracetamol. 23% of the cesarean patients had a previous history of ceaser and among them some rare special cases had a previous history of 4 ceasers (2%). 43% of the patients suffered pregnancy induced hypertension and 8% suffered pregnancy induced diabetes. 20% of the c section were due to breech presentation and 80% were due to other reasons which included seventeen factors. Patients are not given enough information about C-section and mostly the decisions are taken by the doctors without the consent of the patients.

Elective cesarean delivery at term and the long-term risk for endocrine and metabolic morbidity of the offspring

2018 ◽  
Vol 10 (4) ◽  
pp. 429-435 ◽  
Author(s):  
R. Moshkovsky ◽  
T. Wainstock ◽  
E. Sheiner ◽  
D. Landau ◽  
A. Walfisch
Keyword(s):  
Cesarean Delivery ◽  
Regression Models ◽  
Maternal Obesity ◽  
Survival Curve ◽  
Strong Predictor ◽  
Cohort Analysis ◽  
Mode Of Delivery ◽  
Elective Cesarean Delivery ◽  
Elective Cesarean

AbstractOther than obesity, no definitive insights have been gained regarding the apparent association between mode of delivery and long-term endocrine and metabolic outcomes in the offspring. We aimed to determine whether elective cesarean delivery (CD) impacts on long-term endocrine and metabolic morbidity of the offspring. A population-based cohort analysis was performed including all singleton-term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via a non-emergent CD and those delivered vaginally (VD). Hospitalizations of the offspring up to the age of 18 years involving endocrine morbidity were evaluated. A Kaplan–Meier survival curve was used to compare cumulative morbidity incidence. Cox and a Weibull regression models were used to control for confounders. During the study period 131,880 term deliveries met the inclusion criteria; 8.9% were elective non-urgent CDs (n=11,768) and 91.1% (n=120,112) were VDs. The survival curve demonstrated a significantly higher cumulative incidence of endo-metabolic morbidity in offspring born via CD (P=0.010). In the regression models, adjusted for maternal obesity, CD was not noted as an independent risk factor for long-term pediatric endocrine and metabolic morbidity of the offspring while maternal obesity emerged as a strong predictor. We therefore conclude that CD per-se does not appear to increase the risk for long-term pediatric endo-metabolic morbidity of the offspring.

scholarly journals Ethical challenges in management of critically ill pregnant patients with coronavirus disease 2019 (COVID-19)

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Moti Gulersen ◽  
Burton Rochelson ◽  
Eran Bornstein ◽  
Laurence B. McCullough ◽  
Frank A. Chervenak
Keyword(s):  
Clinical Judgment ◽  
Mode Of Delivery ◽  
Fetal Monitoring ◽  
Ethical Framework ◽  
Decision Making Process ◽  
Ethical Challenges ◽  
Moral Management ◽  
Surrogate Decision ◽  
Preventive Ethics ◽  
Critical Care Team

Abstract Despite the overwhelming number of coronavirus disease 2019 (COVID-19) cases worldwide, data regarding the optimal clinical guidance in pregnant patients is not uniform or well established. As a result, clinical decisions to optimize maternal and fetal benefit, particularly in patients with critical COVID-19 in the early preterm period, continue to be a challenge for obstetricians. There is often uncertainty in clinical judgment about fetal monitoring, timing of delivery, and mode of delivery because of the challenge in balancing maternal and fetal interests in reducing morbidity and mortality. The obstetrician and critical care team should empower pregnant patients or their surrogate decision maker to make informed decisions in response to the team’s clinical evaluation. A clinically grounded ethical framework, based on the concepts of the moral management of medical uncertainty, beneficence-based obligations, and preventive ethics, should guide the decision-making process.

Delivery modes in case of fetal malformations

2017 ◽  
Vol 45 (3) ◽  
Author(s):  
Tuangsit Wataganara ◽  
Amos Grunebaum ◽  
Frank Chervenak ◽  
Miroslaw Wielgos
Keyword(s):  
Cesarean Delivery ◽  
Mode Of Delivery ◽  
Fetal Outcome ◽  
Ultrasound Screening ◽  
Her Family ◽  
Born Infant ◽  
The Family ◽  
Elective Cesarean ◽  
Fetal Malformations ◽  
Maternal Concern

AbstractAn estimated 276,000 babies die within 4 weeks of birth every year, worldwide, from congenital anomalies. Better quality ultrasound screening can increase the detection of these fetal malformations in the prenatal period. Prenatal counseling for the pregnant woman and her family, regarding the nature of the disease and prognosis is necessary. Options for management in prenatal, perinatal, intrapartum, neonatal, and childhood periods need to be thoroughly discussed, so that the family can make an informed decision. A multidisciplinary approach is usually needed once a decision has been made to optimize fetal outcome, to plan for the timing and location as well as the mode of delivery. In most of the cases, vaginal delivery can be attempted. An elective cesarean delivery should be reserved for maternal concern of dystocia, certain fetal conditions that cesarean delivery will optimize perinatal outcome, or if the parents have a psychosocial determination to have a live-born infant.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation

2017 ◽  
Vol 127 (4) ◽  
pp. 625-632 ◽  
Author(s):  
Laurie A. Chalifoux ◽  
Jeanette R. Bauchat ◽  
Nicole Higgins ◽  
Paloma Toledo ◽  
Feyce M. Peralta ◽  
...  
Keyword(s):  
Success Rate ◽  
Cesarean Delivery ◽  
Meta Analysis ◽  
Randomized Study ◽  
Mode Of Delivery ◽  
Breech Presentation ◽  
External Cephalic Version ◽  
Double Blind ◽  
Additional Increase ◽  
Dose Response Effect

Abstract Background Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose–response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. Methods We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. Results A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004). Conclusions A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.

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