Substantial Advantages for Older Primiparae

The recent review in Deutsches Ärzteblatt International by Mylonas and Friese is strongly influenced by guidelines from English-speaking countries (1).

German obstetricians are often not aware of the extent to which colleagues in the UK find their professional autonomy curtailed. With the surging influence of midwives, obstetric guidelines have less and less to do with medicine. In 2003, a cesarean section guideline was passed by a committee of 16 members, of which only two were obstetricians—and both of them voted against the final version of that guideline (2). In my place of residence, New South Wales, Australia, a governmental guideline issued in 2010 was largely compiled by a professor of midwifery. To those who would like to ascertain the consequences of such practices I recommend the “Morecambe Bay Report“ (3).

I can only call on my German colleagues to ignore such dubious political “guidelines”. Elective cesarean section offers substantial advantages for older primiparae. The risk of stillbirth alone is reason enough—not to mention the high probability of pelvic floor injury (4). Recently, we have demonstrated that in Sydney only about one quarter of primiparae at term can expect a normal vaginal delivery without permanent damage to the anal sphincter or levator ani.

Obstetricians and midwives need to treat their patients as adults. Dismissing the wishes of (often well-informed) women asking for an elective cesarean section ignores both recent scientific evidence and the ethical and legal principle of patient autonomy.