Mode of delivery: toward responsible inclusion of patient preferences.
Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.
Little
Margaret Olivia
MO
Georgetown University, Washington DC 20057, USA. littlem@georgetown.edu
Lyerly
Anne Drapkin
AD
Mitchell
Lisa M
LM
Armstrong
Elizabeth M
EM
Harris
Lisa H
LH
Kukla
Rebecca
R
Kuppermann
Miriam
M
D001946:Breech Presentation; D002585:Cesarean Section; D003657:Decision Making; D036861:Delivery, Obstetric; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D010342:Patient Acceptance of Health Care; D010817:Physician-Patient Relations; D011247:Pregnancy; D011272:Pregnancy, Multiple; D040841:Resource Allocation; D016064:Vaginal Birth after Cesarean