1. What are the perinatal risks of vaginal birth compared with cesarean delivery?
The current literature says not enough evidence to evaluate the benefits and risks of the road on maternal request cesarean compared with vaginal delivery via elective. Each has its own advantages and disadvantages, however, most of these, according to studies, have a low quality of evidence.
Risks associated with vaginal delivery
maternal : birth canal laceration, uterine inversion, uterine rupture.
newborn: newborn trauma born, asphyxiation (by holding his shoulders, etc), complications of dystocia.
Both may have complications of forceps delivery.
Risks associated with cesarean maternal
: Infection antestésicas complications, injury to vessels and bruising (due to extension of the incision), lesions of the bladder and bowel complications lung (amniotic fluid embolism), paralytic ileus, bladder distention from atony and wound dehiscence.
neonatales: taquipnea transitoria del recién nacido, 0,4% de los RN tendrán laceraciones accidentales.
Los únicos con Evidencia moderada
HEMORRAGIA: la frecuencia de hemorragia postparto en cesárea electiva es menor que la reportada en comparación con la combinación de parto vaginal electivo y cesárea no electiva.
ESTADÍA EN EL HOSPITAL: La cesárea, sea planeada o no, requiere una hospitalización prolongada que el parto vaginal. Sin embargo, estos analisis son alterados al comparar cesáreas (tanto electivas como no electivas) versus all vaginal deliveries.
RESPIRATORY DISEASE: Staff at caesarean section, which is directly related to the gestational age of fetus, so that current evidence says that caesarean section for maternal request, should not be performed before 39 weeks gestation or without verification of lung maturity, because of the significant risk of neonatal respiratory complications.
2. What are the future risks of a cesarean v / s vaginal delivery? Can the cesarean limit future fertility?
ESTADÍA EN EL HOSPITAL: La cesárea, sea planeada o no, requiere una hospitalización prolongada que el parto vaginal. Sin embargo, estos analisis son alterados al comparar cesáreas (tanto electivas como no electivas) versus all vaginal deliveries.
RESPIRATORY DISEASE: Staff at caesarean section, which is directly related to the gestational age of fetus, so that current evidence says that caesarean section for maternal request, should not be performed before 39 weeks gestation or without verification of lung maturity, because of the significant risk of neonatal respiratory complications.
2. What are the future risks of a cesarean v / s vaginal delivery? Can the cesarean limit future fertility?
2.1 Future Risks of a cesarean
The risks depend on the type of cesarean section and their number. Are uterine rupture, placenta previa , accreta, uterine synechiae if some type of complication with the birth and curettage is necessary.
The risk of placenta previa is 2.6 times higher in women with previous cesarean. This risk increases with each subsequent cesarean. (Cv. 1997). Therefore is not recommended for route cesarean in women who wish to have many children, except they have a medical condition (maternal-fetal) to make a risky vaginal delivery.
4.5% of placenta previa accreta in patients are no uterine scar. In contrast to 8% of placenta previa are accreta in patients with uterine scar. (Lam. 1993)
Vaginal birth after cesarean delivery: the risk of uterine rupture in women with prior cesarean cross is 0.2 to 1.5%. Published evidence suggests that the benefits of vaginal birth after cesarean outweigh the risks in most muejeres with cesarean. (ACOG 1999).
2.2 future risks of vaginal birth
One of the better-known risks in the long term and one of the most feared by women is prolapse of the intrapelvic structures through the urogenital meatus, especially if labor is instrumented (forceps .) They are also risk factors for fetal macrosmía, prolonged labor and dystocia position. It is very important number of vaginal deliveries to a woman.
As a major consequence of prolapse may be mentioned the Urinary stress incontinence, which considerably reduces the quality of life of women.
However we can not identify a vaginal delivery as the only risk factor, as it has shown a level of not less than women with prolapse who have never given birth this way.
2.3 Caesarea as limiting the future fertility
Cohort studies have shown a reduction in subsequent pregnancies in women undergoing caesarean section, compared with those who had vaginal deliveries. However, this effect may be due to a voluntary limitation of the number of children by them.
Caesarean section is a surgical procedure is not without complications, although the frequency of these is low, we expect to produce in extreme cases limitations on fertility.
Caesarean section is a surgical procedure is not without complications, although the frequency of these is low, we expect to produce in extreme cases limitations on fertility.
Some of these complications include:
- synechiae post cesarean section that could affect the passage of sperm through the oviducts, preventing fertilization.
- Uterine rupture
- Hysterectomy
One aspect that must undoubtedly take into account the number of caesarean sections. It would be advisable to have more than 3 cesarean section, that due to fibrosis and degeneration of the segment and multiple abdominal adhesions between structures that may occur.
Finally, we mention that the rate of caesarean section may also limit the possibility of pregnancy with vaginal delivery, because if there is a history of cesarean body is an absolute indication for cesarean delivery.
3. Are there any clinical ethical problem here?
Yes, there is an ethical-clinical.
a) From there you can identify?
The problem is in the decision to be taken on the route of delivery of this pregnancy of 36 weeks that has evolved physiological and the treating physician considered by the maternal-fetal conditions that pregnancy should be resolved by the vaginal route, which is opposed the decision of the patient requiring Caesarean section because of the fear felt when faced with a vaginal delivery and the experiences of other women he has known and who have had complications due to the resolution of the pregnancy vaginally. In short there is a mismatch between what they think both actors on the route of delivery, each is motivated and believes that his solution is the most appropriate and safe.
b) What is the opinion of obstetricians with you talked about this case ? Does it has happened before? How have they solved?
Cree
you that we are in a case that can be invoked this principle in bioethics?
Is it a decision that no conflict of values \u200b\u200bor principles?
Before answering this question, let's review some aspects of medical decision. The medical decision in this case involves certain ends and means, which are:
- The good of their patients, health of mother and son
- The medium is the way of delivery to choose, given that it must lead them better to get a mother and a healthy newborn
- A second purpose is good for one's own doctor, who can be more or less noble.
also participates in all medical decision the patient's desire, explicit or implied by this attitude, for or against the decision under consideration. This represents the self, in this case the mother and is not nothing but the expression of the good that she sees for himself and / or your child in a particular way of delivery. Taking
clear what aspects are implicit in a medical decision can analyze this case in particular.
First, the positions of both parties (doctor and patient) are divided as to the choice of route of delivery. The doctor argues that idea of \u200b\u200bcesarean delivery in a woman whose pregnancy progresses with normal is like "twisting the hand of nature", which denotes an initial motivation to reject the request of the patient. This can certainly be a conflict of principles, can generate conflict as well as the perception of the doctor of being "threatened" by the patient. However, after reflection, the doctor admits that the fear that generates the mother-vaginal childbirth is a factor to consider in a future decision regarding the good of his patient is both physical and mental well-being .
How do you proceed in this situation?
As a first step back to discuss the risks and benefits of both routes of delivery through a non-executive board that incorporates the values \u200b\u200band cultural context of women with sensitivity to the interests of the patient, which can be in this case , fear of pain or fear of complications.
What possible courses of action may recommend treating doctor?
b) What is the opinion of obstetricians with you talked about this case ? Does it has happened before? How have they solved?
The two teachers with whom we spoke told us that in his practice have been many times with similar cases, especially in private practice, in which the pregnant woman wishes, requests and sometimes requires the completion of delivery through caesarian, usually based on a great fear of normal childbirth, the pain involved and the likely future complications ( prolapse and urinary incontinence) however tell us that in most cases adequate counseling is done, showing both the risks and benefits of normal childbirth and cesarean section, and what is the best option according to the medical point of view for themselves and for the newborn and therefore the woman changes her mind and opted for natural childbirth, but there are other women who still insist on a caesarean section to which they have decided to make, as they believe that the opinion of the patient is quite relevant and whether she is very afraid to face a vaginal birth can be risky. But also consider an option to derive the patient if the doctor does not feel or by performing a cesarean section on a woman who for medical reasons does not.
Cree
you that we are in a case that can be invoked this principle in bioethics?
If we believe that the patient may invoke their right to autonomy, since it is a principle inherent in the human condition and patient to decide or accept the medical treatment offered. There are some situations where this principle can be ignored, such as when the patient is unable to exercise as very young children, patients with mental illness, unconsciousness, life-threatening, etc. In this case, however, the patient presents with a normal pregnancy, not diseases or conditions that indicate added exclusively one or another mode of delivery, this combined with the evidence that would indicate that cesarean section is riskier for the binomial mother-son vaginal delivery is insufficient for a doctor to achieve desired always a vaginal delivery, so you should evaluate each case in context. For
So when the doctor fails, based on clinical citerios, making judgments about the best way of delivery, it seems legitimate to participate in the choice of preference or her choice, ie, leading to autonomy.
This is a competent patient?
Yes, this can be inferred about the description of this case, when we say the patient is a lawyer and his practice, which is necessary for a competent person, which means (according to RAE ): "It has the qualities or knowledge to do work or perform a function", led the context we can deduce that the patient is competent to make a decision about his future.
Before answering this question, let's review some aspects of medical decision. The medical decision in this case involves certain ends and means, which are:
- The good of their patients, health of mother and son
- The medium is the way of delivery to choose, given that it must lead them better to get a mother and a healthy newborn
- A second purpose is good for one's own doctor, who can be more or less noble.
also participates in all medical decision the patient's desire, explicit or implied by this attitude, for or against the decision under consideration. This represents the self, in this case the mother and is not nothing but the expression of the good that she sees for himself and / or your child in a particular way of delivery. Taking
clear what aspects are implicit in a medical decision can analyze this case in particular.
First, the positions of both parties (doctor and patient) are divided as to the choice of route of delivery. The doctor argues that idea of \u200b\u200bcesarean delivery in a woman whose pregnancy progresses with normal is like "twisting the hand of nature", which denotes an initial motivation to reject the request of the patient. This can certainly be a conflict of principles, can generate conflict as well as the perception of the doctor of being "threatened" by the patient. However, after reflection, the doctor admits that the fear that generates the mother-vaginal childbirth is a factor to consider in a future decision regarding the good of his patient is both physical and mental well-being .
How do you proceed in this situation?
As a first step back to discuss the risks and benefits of both routes of delivery through a non-executive board that incorporates the values \u200b\u200band cultural context of women with sensitivity to the interests of the patient, which can be in this case , fear of pain or fear of complications.
Then if the patient persists with the idea of \u200b\u200ba caesarean section despite hearing my opinion as a doctor, which I know she will study a physiological pregnancy, has high chances of having a normal birth without complications to her and baby, you practice a caesarean section anyway because there is still insufficient evidence to assess the benefits and risks road by Caesarean section for maternal request compared with planned vaginal birth canal .* addition to the above, to reiterate the validity of the exercise of autonomy of the patient.
* NIH State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request
What possible courses of action may recommend treating doctor?
Possible courses of action:
1. Of gestation via cesarean section.
2. Refer to another physician if unable to support this request.
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