Caesarean birth on maternal request — structured SAQ (15 marks)

(a) Structuring the first consultation and screening (5 marks)

One mark per point, maximum five. The opening question is itself worth a mark. ^[1][8]

• Open with the reason, then stop talking. "Before I answer that, can you tell me what's behind it?" Six in ten requests change once the real reason is heard; do not answer the surface question first.^[8][9]
• Screen deliberately for fear of childbirth — tokophobia may be primary (dating from before any pregnancy), secondary (after a traumatic birth), or a symptom of antenatal depression. Hofberg and Brockington described all three in the original case series.^[8]
• Screen for previous birth trauma, sexual violence and family violence — an apparently casual request may hide any of these, and they change the consultation.^[1][8]
• Ask how many children she hopes to have. It is the single most decision-relevant question: the accreta gradient is steep with each successive caesarean, and the first scar starts the climb.^[3]
• Defer the decision to a second visit, and offer what may make the request unnecessary in the meantime: continuity of carer, a named midwife, a written birth plan, epidural on request, a debrief of any previous birth, and perinatal mental health referral where indicated.^[1][9]

Examiner rewards the order: reason before information, and screening before decision.^[1]

(b) Benefits and harms in absolute terms, with certainty (4 marks)

Half a mark per correctly stated outcome with its direction; full marks require stating that the certainty behind the whole table is very low. ^[5][1]

Harms that appear to rise with planned caesarean (give absolutes, not relatives):^[5]

• Placenta accreta in a future pregnancy — odds ratio about 10.9, and with praevia the risk climbs from about 3% at a first caesarean to 40% at the third and 61% at the fourth.^[3][5]
• Future uterine rupture — odds ratio about 24 against an unscarred uterus, and the scar pregnancy and caesarean scar ectopic travel with it.^[5]
• Peripartum hysterectomy — odds ratio about 1.8 against a baseline near 8 per 10 000; maternal death odds ratio about 5.6 against a baseline of 0.4 per 10 000, though the absolute numbers are tiny.^[5]
• Surgical morbidity this pregnancy — wound infection, endometritis, haemorrhage, bladder and bowel injury, venous thromboembolism.^[1][5]

Benefits that appear to favour planned caesarean:^[7]

• Long-term stress urinary incontinence — about 8% absolute less after caesarean, adjusted odds ratio 1.85 for vaginal birth versus caesarean pooled across 15 studies.^[7]
• Pelvic organ prolapse surgery and anal sphincter injury — both reduced, the latter especially relative to assisted vaginal birth.^[5][7]

Must state: RANZCOG grades the certainty behind every one of these outcomes as very low, because source cohorts cannot reliably separate true maternal request from other elective indications. Say the uncertainty out loud — it frames the whole discussion. ^[1]

(c) The options under RANZCOG C-Obs 39 (3 marks)

One mark per point. There are exactly two lawful endings; naming the third (refuse and stop) loses the mark. ^[1]

• After a full discussion over more than one visit of the benefits and harms of both planned caesarean and planned vaginal birth, if the woman still requests caesarean birth, the obstetrician may agree to perform it.^[1]
• Or the obstetrician may refer to a second obstetrician for further discussion with the woman in order to reach a decision.^[1]
• Conscientious objection is permitted; abandonment is not. Declining without a timely, named referral is professionally indefensible — refer promptly enough that she still has choices, and document that you did.^[1]
• The recommendation carries very low GRADE certainty; a local decision aid is recommended as a good practice point.^[1]

(d) Counselling the request for 38 weeks (3 marks)

One mark per point. Hold the 39-week line unless there is a written clinical reason. ^[1][12]

• State the default: a planned caesarean without additional risk is booked at 39+0 weeks or later — cross-referenced in C-Obs 39 to C-Obs 23.^[1]
• Give the respiratory numbers by week. Severe respiratory morbidity is about 2.4 times more likely at 37+0 to 38+6 than at 39 weeks or later, and exceeds 3% at 37+0 to 37+6; the neonatal composite odds against 39 weeks are roughly 2.1 at 37 weeks.^[12]
• Acknowledge her reason without conceding the date. A family event is a real wish but not a clinical indication; offer alternatives (an earlier 39-week date, a planned date she controls) rather than moving below the evidence-based threshold.^[1]
• If a date before 39 weeks is ever agreed, record the reason in the notes — an undated, unexplained early booking is the documentation failure most likely to generate a complaint.^[1][12]