Little Margaret Olivia, Lyerly Anne Drapkin, Mitchell Lisa M, Armstrong Elizabeth M, Harris Lisa H, Kukla Rebecca, Kuppermann Miriam
Georgetown University, Washington DC 20057, USA.
Obstet Gynecol. 2008 Oct;112(4):913-8. doi: 10.1097/AOG.0b013e3181888fd8.
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.
对于产科医护人员和政策制定者而言，决定何时以及如何纳入患者对分娩方式的偏好是一项具有挑战性的任务。对四种临床情况（既往剖宫产史、双胎分娩、臀位分娩以及产妇要求剖宫产）的现行指南进行分析后发现，一些指南规定性很强，而另一些则更具灵活性，取决于医生的判断或（较少见）患者的偏好，对于何时允许、建议或必须采用这种灵活性，既没有一致性，也没有明确的理由。尽管患者选择的倡导者呼吁制定更能响应患者需求的指南，但也有人提出了担忧，尤其是在讨论产妇要求剖宫产的背景下，担心不受约束的患者偏好驱动的临床决策存在风险。在本文中，我们概述了一个将患者偏好负责任地纳入分娩方式决策的框架。我们使用这个框架得出结论，在前三种情况下需要更明确地纳入患者偏好，并指出为何扩大产妇要求剖宫产的可及性更为复杂，需要更多数据并作进一步考量。
