FIGO Ethics and Professionalism Guideline: Decision Making about Vaginal and Caesarean Delivery

Background

Professionally responsible decision making with patients is based primarily on the ethical principles of beneficence and respect for autonomy. The physician has the beneficence-based obligation to identify and present the medically reasonable alternatives for the clinical management of the patient’s condition.

In obstetrics ‘medically reasonable’ means that a form of clinical management is technically feasible, and in evidence-based clinical judgment it is reliably expected to benefit the pregnant woman, foetus, and neonate. In presenting the medically reasonable alternatives there are distinct roles for directive counselling (defined as making evidence-based recommendations) and non-directive counselling (defined as presenting but not recommending medically reasonable alternatives).

Both forms of counselling implement the ethical principle of ‘respect for autonomy’ by empowering the pregnant woman with the clinical information that she needs to make an informed decision.

Counselling should be directive when it is certain there is only one medically reasonable option. Counselling should be non-directive when the clinical indications for caesarean delivery are uncertain. 

In most cases there are no evidence-based clinical indications for caesarean delivery. This means that a clinical judgment that is in favour of caesarean delivery as a medically reasonable alternative has little evidence.

A patient’s request for a form of clinical management does not, by itself, mean that the request is medically reasonable. The judgment of medical reasonableness requires a level of clinical expertise that very few patients have. The goal in responding to a patient’s request should be to transform it into an informed decision about the alternatives.

The individual or group self-interests of physicians in such matters as payment orconvenience, have no place in counselling the pregnant woman. This is becausethey can bias both the physician’s clinical judgment and the woman’s decisionmaking. (See FIGO Ethics and Professionalism Guideline: Responsiblymanaging conflicts of interest in clinical practice and research.)

Recommendations

• Recommending Vaginal Delivery

When there are no evidence-based clinical indications for caesarean delivery,vaginal delivery should be recommended. The absence of an evidence base for caesarean delivery and its’ clinical significance should be explained to the pregnant woman. The obstetrician-gynecologist should explain that, when there is no evidence base supporting caesarean delivery, vaginal delivery is safer than caesarean delivery for both mother and baby.

• Recommending Caesarean Delivery

Caesarean delivery should be recommended as the only medically reasonable alternative if, and only if, there is certainty of an evidence-base for the clinical judgment that caesarean delivery is clinically superior to vaginal delivery.

• Offering both Vaginal and Caesarean Delivery

Vaginal delivery and caesarean delivery should both be offered as medically reasonable alternatives if there is clinical uncertainty about the benefits and risks of each.

• Management of Self-Interest

It is impermissible in the professional ethics of obstetrics and gynecology to knowingly bias decision making on the basis of individual or group self-interest incompensation, convenience, or any other form of self-interest.

To prevent this bias, the obstetrician-gynecologist should identify and constantly remain aware of such self-interests and never include them as a basis for clinical judgment about the medical reasonableness of vaginal or caesarean delivery. The way to accomplish this goal is to adhere strictly to the intellectual discipline of evidence based clinical reasoning.

• Responding to Patient’s Requests

Sometimes a patient may request a mode of delivery that the obstetrician-gynecologist does not recommend.  The obstetrician-gynecologist should never take personally a patient’s request of a mode of delivery that lacks an evidence base, because this response can bias subsequent counselling.  The obstetrician-gynecologist should ask the patient for her reasons and listen for incomplete or mistaken beliefs, and respectfully correct them.

The obstetrician-gynecologist should then explain the evidence base for the recommendation that was made and repeat the recommendation. The patient should be asked to reconsider, especially if her stated reasons support the obstetrician-gynecologist’s recommendation.  

If, after these efforts to inform the patient’s request have been completed and she is therefore able to make an informed and voluntary request, it is ethically permissible to implement her request.

• Preventive Ethics

The obstetrician-gynecologist should take advantage of prenatal visits to initiate decision-making with the pregnant woman about the clinical management of her pregnancy, including intrapartum management. This is known as a preventive ethics approach to decision making with pregnant patients.

The reality that a low-risk pregnancy can suddenly and without warning become a high-risk pregnancy should be explained. The potential of this change to make caesarean delivery something that must be considered for either maternal or fetal indications should also be explained. The goal should be a mutually acceptable birth plan to manage such an eventuality, or other concerns that the pregnant woman may have.

About FIGO

FIGO is a professional organisation that brings together obstetrical and gynecological associations from all over the world.

FIGO’s vision is that women of the world achieve the highest possible standards of physical, mental, reproductive and sexual health and wellbeing throughout their lives. We lead on global programme activities, with a particular focus on sub-Saharan Africa and South East Asia.

FIGO advocates on a global stage, especially in relation to the Sustainable Development Goals (SDGs) pertaining to reproductive, maternal, newborn, child and adolescent health and non-communicable diseases (SDG3). We also work to raise the status of women and enable their active participation to achieve their reproductive and sexual rights, including addressing FGM and gender based violence (SDG5).

We also provide education and training for our Member Societies and build capacities of those from low-resource countries through strengthening leadership, good practice and promotion of policy dialogues.

FIGO is in official relations with the World Health Organization (WHO) and a consultative status with the United Nations (UN).