Making sense of rising caesarean section rates

Editor—Anderson's editorial on rising caesarean section rates highlights an important medical and ethical dilemma in current obstetric practice—the relevance of patients' choice in deciding the mode of delivery.¹ Anderson points out the lack of clear evidence supporting caesarean section as a safer option in terms of immediate and long term pregnancy outcomes.

Clarification of this issue can help resolve the ethical and moral conflict of doctors who agree to perform a caesarean section at the mother's request in the absence of a medical indication. In addition, it would make the informed consent for a vaginal delivery more complete, with information on the short and long term complications, including risk of pelvic floor dysfunction.

Fetal distress, labour dystocia, and previous caesarean section are the commonest indications for caesarean section. However, at least for the first two indications it is not possible to carry out randomised controlled trials to study the safer route of delivery. By the time the fetal distress or labour dystocia is diagnosed, a continued trial of vaginal delivery is not feasible in many cases. For example, a baby cannot be delivered vaginally when cephalopelvic disproportion is diagnosed in active labour or when fetal acidaemia worsens far from delivery. Therefore such cases cannot be randomised to vaginal delivery or caesarean section.

Instead, a feasible and informative trial may be to randomise women during early pregnancy into two groups—a trial of vaginal delivery versus elective caesarean section, with analysis on an intention to treat basis rather than actual mode of delivery. Comparison of outcomes for mothers and babies from such a trial will go a long way in guiding evidence based obstetric practice.