Neonatal Morbidity

Cesarean delivery is associated with less risk of fetal trauma.

And this in many instances influences the choice of cesarean
delivery despite the associated maternal risks. Alexander and
colleagues (2006) found that fetal injury complicated 1 percent
of cesarean deliveries. Skin laceration was most common, but
others included cephalohematoma, clavicular fracture, brachial
plexopathy, skull fracture, and facial nerve palsy. Cesarean
deliveries following a failed operative vaginal delivery attempt
had the highest injury rate, whereas the lowest rate 0.5 percent
occurred in the elective cesarean delivery group. That
said, Worley and colleagues (2009) found that approximately
a third of pregnant women who were delivered at Parkland
Hospital entered spontaneous labor at term, and 96 percent of
these delivered vaginally without adverse neonatal outcomes.
Although physical injury risks are lower, cesarean delivery
per se may have no bearing on the neurodevelopmental
prognosis of the infant. Scheller and Nelson (1994) in a report
from the National Institutes of Health and Lien and associates
(1995) presented data specifically refuting any association
between cesarean delivery and lower rates of either cerebral
palsy or seizures. Moreover, as discussed in Chapter 33 (p. 638),
the incidences of neonatal seizures or cerebral palsy have not
diminished as the rate of cesarean delivery has increased (Miller,
2008; Miller, 2013).
Patient Choice in Cesarean Delivery
As women have taken a more active role in their obstetrical
care, some request elective cesarean delivery. Data regarding the
true incidence of cesarean delivery on maternal request (CDMR)
are limited, however, estimates are a 1- to 7-percent rate in the
United States in 2003 (Gossman, 2006; Menacker, 2006).
Reasons for requested cesarean delivery include reduced risk
of fetal injury, avoidance of the uncertainty and pain of labor,
protection of pelvic floor support, and convenience. Thus, the
debate surrounding CDMR includes its medical rationale from
both a maternal and fetal-neonatal standpoint, the concept of
informed free choice by the woman, and the autonomy of the
physician in offering this choice.
To address this, the National Institutes of Health (2006)
held a State-of-the-Science Conference on Cesarean Delivery
on Maternal Request. A panel of experts critically reviewed
available literature to form recommendations based on identified
risks and benefits. It is noteworthy that most of the maternal
and neonatal outcomes examined had insufficient data to
permit such recommendations. Indeed, one of the main conclusions
of the conference was that more high-quality research
is needed to fully evaluate the issues. The American College
of Obstetricians and Gynecologists (2013) concluded that data
comparing planned cesarean and planned vaginal delivery were
minimal and thus should be interpreted cautiously.
The panel was able to draw a few conclusions from existing
information. Cesarean delivery on maternal request should not
be performed before 39 weeks gestation unless there is evidence
of fetal lung maturity. It should be avoided in women desiring
several children because of the risk of placental implantation
abnormalities and cesarean hysterectomy. Finally, it should not
be motivated by the unavailability of effective pain management.