Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Cesarean delivery on maternal request

Errol R Norwitz, MD, PhD, MBA
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


Cesarean delivery on maternal request (or "on demand") refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of a standard medical/obstetrical indication for avoiding vaginal birth. While some women are highly critical of the medicalization of childbirth, others strongly seek to avoid a natural childbirth experience and are reassured by safety of contemporary cesarean delivery.

This topic will discuss issues specifically related to cesarean delivery on maternal request. General issues regarding cesarean delivery, such patient preparation, technique, post-operative care, and complications are reviewed separately. (See "Cesarean delivery: Preoperative planning and patient preparation" and "Cesarean delivery: Technique" and "Cesarean delivery: Postoperative issues" and "Anesthesia for cesarean delivery", section on 'Post-cesarean delivery analgesia'.)


The Agency for Healthcare Research and Quality (AHRQ) has published a detailed report on cesarean delivery on maternal request [1]. A synopsis of their findings, as well as subsequently published data, are provided below. These data are limited because no randomized trials on cesarean delivery for nonmedical/nonobstetrical reasons have been performed [2]. Thus, conclusions about the risks and benefits of cesarean delivery on maternal request are not based upon high-quality evidence. Available observational studies have serious methodological issues or provide indirect evidence because the cesareans in randomized trials were performed for breech presentation [3].

As with any medical procedure, the risks and benefits of cesarean delivery on maternal request need to be balanced with the risks and benefits of a planned vaginal delivery. Patient-specific issues that can affect the choice of delivery route include comorbid medical conditions, body mass index, future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the woman's personal philosophy about childbirth.

Providing women with the best available information about pertinent childbirth issues and appropriate support may alleviate some of their concerns about attempted vaginal birth. The motivation for cesarean delivery should be determined and addressed. Every effort should be made to ensure that this is truly the desire of the patient and not a result of undue pressure from family members. Concerns about pain may be addressed by providing detailed information about obstetrical analgesia and anesthesia, as well as consultation with an anesthesiologist. Fear and anxiety stemming from personal trauma, previous childbirth experiences, or the childbirth experiences of friends and family should also be addressed.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: May 2017. | This topic last updated: May 17, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Agency for Healthcare Research and Quality. Evidence report/technology assessment No. 133: Cesarean delivery on maternal request, 2006. www.ahrq.gov/clinic/tp/cesarreqtp.htm#Report (Accessed on December 05, 2007).
  2. Lavender T, Hofmeyr GJ, Neilson JP, et al. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev 2012; :CD004660.
  3. Visco AG, Viswanathan M, Lohr KN, et al. Cesarean delivery on maternal request: maternal and neonatal outcomes. Obstet Gynecol 2006; 108:1517.
  4. Petrou S, Khan K. An overview of the health economic implications of elective caesarean section. Appl Health Econ Health Policy 2013; 11:561.
  5. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013; 309:1930.
  6. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol 2013; 121:904.
  7. Obed J, Bako B, Agida T, Nwobodo E. Caesarean delivery on maternal request: consultants' view and practice in the west african sub region. J West Afr Coll Surg 2013; 3:72.
  8. www.nice.org.uk/guidance/cg132/chapter/1-Guidance#planned-cs (Accessed on March 06, 2017).
  9. Gonen R, Tamir A, Degani S. Obstetricians' opinions regarding patient choice in cesarean delivery. Obstet Gynecol 2002; 99:577.
  10. Kalish RB, McCullough LB, Chervenak FA. Patient choice cesarean delivery: ethical issues. Curr Opin Obstet Gynecol 2008; 20:116.
  11. Demontis R, Pisu S, Pintor M, D'aloja E. Cesarean section without clinical indication versus vaginal delivery as a paradigmatic model in the discourse of medical setting decisions. J Matern Fetal Neonatal Med 2011; 24:1470.
  12. Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical dimensions of elective primary cesarean delivery. Obstet Gynecol 2004; 103:387.
  13. Obstetrics and Gynecology Risk Research Group, Kukla R, Kuppermann M, et al. Finding autonomy in birth. Bioethics 2009; 23:1.
  14. Nilstun T, Habiba M, Lingman G, et al. Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach? BMC Med Ethics 2008; 9:11.
  15. National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol 2006; 107:1386.
  16. Little MO, Lyerly AD, Mitchell LM, et al. Mode of delivery: toward responsible inclusion of patient preferences. Obstet Gynecol 2008; 112:913.
  17. Chervenak FA, McCullough LB. The professional responsibility model of obstetric ethics and caesarean delivery. Best Pract Res Clin Obstet Gynaecol 2013; 27:153.
  18. Burcher P, Gabriel JL, Campo-Engelstein L, Kiley KC. The case against cesarean delivery on maternal request in labor. Obstet Gynecol 2013; 122:684.
  19. Report by HealthGrades, a health care quality company.
  20. Gossman GL, Joesch JM, Tanfer K. Trends in maternal request cesarean delivery from 1991 to 2004. Obstet Gynecol 2006; 108:1506.
  21. MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008; 35:293.
  22. Alves B, Sheikh A. Investigating the relationship between affluence and elective caesarean sections. BJOG 2005; 112:994.
  23. Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ 2002; 324:942.
  24. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: obstetrician-gynecologists' knowledge, perception, and practice patterns. Obstet Gynecol 2007; 109:57.
  25. Turner CE, Young JM, Solomon MJ, et al. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. BJOG 2008; 115:1494.
  26. Amu O, Rajendran S, Bolaji II. Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. BMJ 1998; 317:463.
  27. Hall MH, Bewley S. Maternal mortality and mode of delivery. Lancet 1999; 354:776.
  28. van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74:1.
  29. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust N Z J Psychiatry 1997; 31:728.
  30. www.nice.org.uk/guidance/CG132/chapter/Appendix-C-Planned-CS-compared-with-planned-vaginal-birth (Accessed on March 10, 2017).
  31. Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998; 317:462.
  32. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N Engl J Med 1985; 312:1264.
  33. Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287:2684.
  34. Hovatta O, Lipasti A, Rapola J, Karjalainen O. Causes of stillbirth: a clinicopathological study of 243 patients. Br J Obstet Gynaecol 1983; 90:691.
  35. Hemminki E, Meriläinen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174:1569.
  36. Rosenstein MG, Cheng YW, Snowden JM, et al. Risk of stillbirth and infant death stratified by gestational age. Obstet Gynecol 2012; 120:76.
  37. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341:1709.
  38. Martinez-Biarge M, Madero R, González A, et al. Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events. Am J Obstet Gynecol 2012; 206:148.e1.
  39. McFarland LV, Raskin M, Daling JR, Benedetti TJ. Erb/Duchenne's palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol 1986; 68:784.
  40. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians' personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997; 73:1.
  41. Al-Mufti R, McCarthy A, Fisk NM. Obstetricians' personal choice and mode of delivery. Lancet 1996; 347:544.
  42. Hannah ME, Hannah WJ, Hodnett ED, et al. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. JAMA 2002; 287:1822.
  43. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191:917.
  44. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107:1460.
  45. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011; 118:777.
  46. Miller ES, Hahn K, Grobman WA, Society for Maternal-Fetal Medicine Health Policy Committee. Consequences of a primary elective cesarean delivery across the reproductive life. Obstet Gynecol 2013; 121:789.
  47. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol 2001; 97:765.
  48. Jackson S, Fleege L, Fridman M, et al. Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Am J Obstet Gynecol 2012; 206:139.e1.
  49. Moraitis AA, Oliver-Williams C, Wood AM, et al. Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG 2015; 122:1467.
  50. Bahtiyar MO, Julien S, Robinson JN, et al. Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997. Am J Obstet Gynecol 2006; 195:1373.
  51. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176:455.
  52. Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol 2007; 109:669.
  53. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356:1375.
  54. Liu X, Landon MB, Cheng W, Chen Y. Cesarean delivery on maternal request in China: what are the risks and benefits? Am J Obstet Gynecol 2015; 212:817.e1.
  55. Tulandi T, Agdi M, Zarei A, et al. Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009; 201:56.e1.
  56. Soltan MH, Al Nuaim L, Khashoggi T, et al. Sequelae of repeat cesarean sections. Int J Gynaecol Obstet 1996; 52:127.
  57. Makoha FW, Felimban HM, Fathuddien MA, et al. Multiple cesarean section morbidity. Int J Gynaecol Obstet 2004; 87:227.
  58. Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007; 196:461.e1.
  59. Uygur D, Gun O, Kelekci S, et al. Multiple repeat caesarean section: is it safe? Eur J Obstet Gynecol Reprod Biol 2005; 119:171.
  60. Andolf E, Thorsell M, Källén K. Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. Am J Obstet Gynecol 2010; 203:406.e1.
  61. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
  62. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
  63. Zanardo V, Simbi AK, Franzoi M, et al. Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery. Acta Paediatr 2004; 93:643.
  64. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101.
  65. Zanardo V, Padovani E, Pittini C, et al. The influence of timing of elective cesarean section on risk of neonatal pneumothorax. J Pediatr 2007; 150:252.
  66. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336:85.
  67. Moore HC, de Klerk N, Holt P, et al. Hospitalisation for bronchiolitis in infants is more common after elective caesarean delivery. Arch Dis Child 2012; 97:410.
  68. Black M, Bhattacharya S, Philip S, et al. Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health. JAMA 2015; 314:2271.
  69. Black M, Bhattacharya S, Philip S, et al. Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study. PLoS Med 2016; 13:e1001973.
  70. Le Guennec JC, Bard H, Teasdale F, Doray B. Elective delivery and the neonatal respiratory distress syndrome. Can Med Assoc J 1980; 122:307.
  71. Flaksman RJ, Vollman JH, Benfield DG. Iatrogenic prematurity due to elective termination of the uncomplicated pregnancy: a major perinatal health care problem. Am J Obstet Gynecol 1978; 132:885.
  72. Annibale DJ, Hulsey TC, Wagner CL, Southgate WM. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med 1995; 149:862.
  73. Kolås T, Saugstad OD, Daltveit AK, et al. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol 2006; 195:1538.
  74. Kaplan JL, Shi HN, Walker WA. The role of microbes in developmental immunologic programming. Pediatr Res 2011; 69:465.
  75. MacDorman MF, Declercq E, Menacker F, Malloy MH. Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an "intention-to-treat" model. Birth 2008; 35:3.
  76. De Luca R, Boulvain M, Irion O, et al. Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics 2009; 123:e1064.
  77. Taylor A, Fisk NM, Glover V. Mode of delivery and subsequent stress response. Lancet 2000; 355:120.
  78. Kulas T, Bursac D, Zegarac Z, et al. New Views on Cesarean Section, its Possible Complications and Long-Term Consequences for Children's Health. Med Arch 2013; 67:460.
  79. Almgren M, Schlinzig T, Gomez-Cabrero D, et al. Cesarean delivery and hematopoietic stem cell epigenetics in the newborn infant: implications for future health? Am J Obstet Gynecol 2014; 211:502.e1.
  80. Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A 2010; 107:11971.
  81. Chu DM, Ma J, Prince AL, et al. Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery. Nat Med 2017; 23:314.
  82. Cesarean childbirth: Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development. Department of Health and Human Services, Washington, DC 1980.
  83. Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new classification. J R Soc Med 2000; 93:346.
  84. Yoles, I, Maschiach, S. Increased maternal mortality in cesarean section as compared to vaginal delivery? Time for re-evaluation. Am J Obstet Gynecol 1998; 178:S78.
  85. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 2000; 183:1187.
  86. Groom K, Brown SP. Caesarean section controversy. The rate of caesarean sections is not the issue. BMJ 2000; 320:1072.
  87. Belizán JM, Althabe F, Barros FC, Alexander S. Rates and implications of caesarean sections in Latin America: ecological study. BMJ 1999; 319:1397.
  88. D'Souza R. Caesarean section on maternal request for non-medical reasons: putting the UK National Institute of Health and Clinical Excellence guidelines in perspective. Best Pract Res Clin Obstet Gynaecol 2013; 27:165.
  89. Klein K, Worda C, Leipold H, et al. Does the mode of delivery influence sexual function after childbirth? J Womens Health (Larchmt) 2009; 18:1227.