Roundtable discussion: "no one can condemn you to a C-section!".

The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician.

Hippocratic ideal, Faustian bargain and Damocles' sword: erosion of patient autonomy in obstetrics.

Respect for patient autonomy remains a foundational principle guiding the ethical practice of medicine-a mission first articulated by Hippocrates. Damocles, another figure from ancient Greece, provides a useful parable for describing performance under distress: Damocles loses his desire for opulence and power when he notices a sword dangling precariously above his head. Contemporary obstetricians deciding whether to forestall or impose major abdominal surgery on parturients entrusted to their care struggle valiantly in the chasm dividing Hippocratic idealism from the economic realism driven by the medicolegal sword of Damocles. Given the inherent risk of unforeseeable and unsalvageable fetal catastrophe during labor and vaginal delivery, and the often unsubstantiated, yet automatic, allegation of negligence that follows a labor-associated adversity, obstetricians-and their liability insurance carriers-have recalibrated obstetric practice in alignment with the increasingly risk-averse preferences of most patients. Indeed, less intrapartum risk for patients and less corresponding medicolegal exposure for obstetricians help explain the rising cesarean delivery rate and, more importantly, the steady disappearance of higher-risk interventions such as vaginal birth after cesarean (VBAC). Is this increasing reluctance to offer VBAC supervision ethically defensible? This paper argues that it is. Fiduciary professionalism mandates physician self-sacrifice, not self-destruction; a VBAC gone awry without negligence or substandard care may, nevertheless, render future affordable liability coverage unattainable. Yet, the unavailability of VBAC infringes on the autonomy of women who want to assume the intrapartum risks of a VBAC in lieu of a repeat cesarean delivery. The proposed solution is the regionalization of VBAC care provision in designated medical centers and/or the implementation of binding arbitration in an ethical trade-off to enhance patient autonomy regarding the preferred mode of delivery despite parallel constraint on legal options.

Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery.

This article presents the findings of qualitative research which explored, from the mothers' perspective, the process of decision-making about mode of delivery for a subsequent birth after a previous Caesarean Section. In contradiction to the clinical literature, the majority of mothers in this study were strongly of the opinion that a vaginal birth after caesarean (VBAC) posed a higher risk than an elective caesarean (EC). From the mothers' perspective, risk discussions were primarily valuable for gaining support for their pre-determined choice, rather than obtaining information. The findings posit ethical concerns with regards to informed consent and professional obstetric practice at a time when there is a documented and worrying trend towards an increase in births by caesarean section (CS).