Cesarean delivery on maternal request: maternal and neonatal outcomes.
OBJECTIVE
To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery.


METHODS
We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria.


METHODS
We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery.


RESULTS
We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency.


CONCLUSIONS
The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.
Visco
Anthony G
AG
Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina 27599, USA. anthony_visco@med.unc.edu
Viswanathan
Meera
M
Lohr
Kathleen N
KN
Wechter
Mary Ellen
ME
Gartlehner
Gerald
G
Wu
Jennifer M
JM
Palmieri
Rachel
R
Funk
Michele Jonsson
MJ
Lux
Linda
L
Swinson
Tammeka
T
Hartmann
Katherine
K
D002585:Cesarean Section; D017604:Cesarean Section, Repeat; D036861:Delivery, Obstetric; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D017060:Patient Satisfaction; D016896:Treatment Outcome