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reduction in the absolute risk of infection between the two
groups (95CI: -0.00 to -0.00; p=0.02; I
2
=74%; Figure 3.4).
Effect of cesarean section on maternal request or without indi-
cation on the rate of admission to neonatal ICU
The average hospital stay in neonatal ICU obtained from
studies (
B
)
2,4,6,8,10
evaluating this outcome is 1.2% in the ce-
sarean group,
versus
1.8% in the group of planned vaginal
delivery (Table 6). Despite the fact that the group of cesar-
ean delivery on maternal request has a lower rate of neo-
natal ICU hospitalization compared to the group of planned
vaginal delivery, based on the simple average of all studies,
the meta-analysis shows that the reduction is not signifi-
cant (95CI: -0.01 to -0.00; p=0.84; I
2
=0%, Figure 3.5).
F
inal
recommendations
The authors conclude that cesarean delivery on maternal
request or without indication increases the risk of bleed-
ing, infectious, breastfeeding and respiratory complica-
tions for the newborn. There was a reduction in the risk
of emergency cesarean section and Apgar score ≤ 7 com-
pared to planned vaginal delivery. Cesarean delivery on
maternal request does not present significant increases
or reductions in maternal mortality, post surgical wound
complications, neonatal asphyxia, neonatal infection, and
admission to neonatal ICU.
Based on this information and in the absence of ma-
ternal and/or fetal indications for resolution by cesarean
delivery, a vaginal birth should be safe and suitable for rec-
ommendation to a pregnant woman. If, after the explana-
tion of the risks and benefits of each obstetric resolution,
showing every detail of the risks in each mode of delivery,
the patient still rejects vaginal delivery, cesarean section
should not be performed before 39 weeks of gestation. The
cesarean delivery should be discouraged for patients who
want more offspring, because of the risk of placenta
accre-
ta
, low insertion of placenta and hysterectomies in subse-
quent births; C-section should not be recommended as a
painless option of delivery over vaginal delivery, either.
In this context, based onmaternal request for cesarean
section, the authors propose that the physician should try
to know more deeply the personal values and preferences
of the pregnant patient, addressing them in a process of
shared decision-making (
A
)
11
(
D
).
12,13
Thus, the declared and
underlying motivations of the patient can be investigated,
including the intense fear of childbirth, also known as to-
kophobia, and other factors associated with cesarean sec-
tion onmaternal request: previous complicated pregnancy;
adverse experience in labor or delivery; anxious or avoidant
personality traits; or history of sexual abuse (
D
)
14,15
(
B
).
16,17
Studies indicate that women undergoing cesarean at
their own request have a higher frequency of psychopatho-
logical manifestations and psychiatric diseases. Specifical-
ly, a recent meta-analysis identified prevalence in the com-
munity of three percent for postpartum post-traumatic
stress disorder (
A
).
18
Cesarean section may be regarded by
some patients as a resource to alleviate the suffering derived
from anxious or depressive symptoms. Therefore, it is rec-
ommended that the doctor is also aware of the need for eval-
uation and treatment by a psychiatrist and/or psychologist
with expertise in perinatal mental health.
R
eferences
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Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole
B, Ruyan P; WHO Global Survey on Maternal and Perinatal Health Research
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Global Survey on Maternal and Perinatal Health. BMC Med. 2010; 8:71.
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maternal request: a review of facts, figures and guidelines. J Perinat Med.
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Rouhe H, Salmela-Aro K, Gissler M, Halmesmäki E, Saisto T. Mental health
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118(9):1104-11. PubMed PMID: 21489127.
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Sydsjö G, Möller L, Lilliecreutz C, Bladh M, Andolf E, Josefsson A. Psychiatric
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