CDMR Counseling Tool

AI-assisted clinical and ethical decision support for cesarean delivery on maternal request

What is CDMR?

A cesarean delivery on maternal request (CDMR) is a primary cesarean delivery performed at the patient's request, in the absence of maternal or fetal medical indications, undertaken solely based on maternal preference. It may be scheduled before labor or requested after labor has begun.

The first clinical question is always whether a true indication exists. This tool works through that question before any CDMR counseling begins.

Clinical flow

1 Contraindications to Vaginal Delivery — if present, cesarean is medically indicated. This is not CDMR. Stop here.

2 Conditions That Increase Risk and May Favor Cesarean — if a clear clinical indication is present, this is a medically influenced decision, not pure CDMR. Stop here.

3 Patient Profile — age, gestational age, obstetric history, fetal presentation, and timing of request.

4 The "Why" — future reproductive plans, patient's stated reasons, contextual factors, cognitive biases, and additional notes.

5 Counseling + Documentation — AI-generated individualized counseling framework, risk reference, physician assessment, and documentation checklist.

Contraindications to Vaginal Delivery

Step 1 of 5 — Are any absolute indications for cesarean delivery present?

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Absolute Indication Present — This is Not CDMR

One or more absolute indications for cesarean delivery are present. Cesarean is medically indicated regardless of patient preference. The CDMR framework does not apply.

Proceed with standard cesarean informed consent: the specific indication, risks and benefits of cesarean for this indication, alternatives where applicable, and implications for future pregnancies.

Conditions That Increase Risk and May Favor Cesarean

Step 2 of 5 — Are any relative indications present that favor cesarean?

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Conditions That Increase Risk and May Favor Cesarean — Not a Pure CDMR Scenario

A clinical indication is present that shifts the risk-benefit balance toward cesarean. This is a medically influenced shared decision, not a pure CDMR. The patient's preference aligns with clinical reasoning. Proceed with indication-specific counseling.

Counseling should address: the specific indication and its clinical significance, vaginal delivery as an alternative where still feasible, risks of both modes for this indication, and the patient's individual values. Document the indication — this is not counted as CDMR for quality metrics purposes.

Use "Proceed Anyway" if the relative indication is borderline or you wish to document patient preference alongside the clinical indication.

Patient Profile

Step 3 of 6 — Demographics and timing of request

Demographics

Maternal Age

Gestational Age (weeks)

Gravida / Para / Abortus

Fetal Presentation

Timing of Request

Antepartum — before labor onset

Counseling can occur without time pressure; allows scheduling at 39 weeks if agreed.

Intrapartum — patient is in active labor

Higher-complexity scenario. Pain, exhaustion, and anxiety may influence judgment. Neither immediately dismiss nor immediately accede. Assess decision-making capacity.

The Patient's Request

Step 4 of 6 — Reproductive plans, reasons for request, and contextual factors

Future Reproductive Plans

This directly shapes the counseling priorities. A patient planning two or more future pregnancies faces compounding cesarean risks that must anchor the conversation.

No future pregnancies planned

1 more pregnancy planned

2 or more pregnancies planned

Unsure / not discussed

In the patient's own words — why is she requesting a cesarean?

Summarize what the patient told you. This will be used to generate individualized counseling language.

Contextual factors — select all that apply

These do not constitute medical indications but are essential to counseling. Some (tocophobia, sexual trauma, prior birth trauma) may warrant clinical consideration in their own right.

Tocophobia — severe, disabling fear of childbirth

Affects 7-25% of primiparous women; 7-18.6% of those affected request cesarean without medical indication

History of sexual assault or sexual trauma

1 in 3 US women have experienced sexual violence; pelvic exams and labor are recognized triggers

Prior traumatic birth experience

Witnessed serious birth complication in family member or close contact

Availability heuristic — vivid recalled events inflate perceived risk beyond statistical base rates (Kahneman)

Strong concern about pelvic floor damage or incontinence

A legitimate clinical consideration — data show real protective effect of cesarean on pelvic floor disorders

Scheduling preference — work, family, or travel logistics

Active anxiety disorder or perinatal depression

Cultural or personal belief system favoring cesarean

Significant misinformation about vaginal delivery risks

Denominator neglect — focuses on vivid poor outcomes rather than statistical base rates

Additional clinical notes

Psychiatric history, prior obstetric complications, support system, partner involvement, specific concerns not captured above.

Counseling Framework

Step 5 of 6 — Individualized counseling, risk reference, and documentation support

AI COUNSELING Individualized Clinical Counseling Framework

Click the button above to generate tailored counseling language for this patient.

Physician Assessment & Outcome

Complete after reviewing the evidence, generating the counseling framework, and discussing with the patient. This is the documented outcome of the counseling encounter.

Physician recommendation following counseling

Recommend vaginal delivery

No indication for cesarean; vaginal delivery recommended per beneficence-based obligations. Patient's autonomous decision respected after full informed consent.

Willing to perform CDMR after completed counseling

Counseling completed; patient's autonomous choice for cesarean is respected; scheduling not before 39 weeks.

Declining to perform CDMR — referring to willing provider

Ethically permissible. Referral to a qualified provider is required (ACOG CO 761). Document referral in the medical record.

Patient's decision following counseling

Accepts recommendation for vaginal delivery

Requests to proceed with CDMR

Requests additional time to decide

Seeking second opinion

Document outcome note (for medical record)

Comparative Risk Reference

Sources: Alperin & Artsen, JAMA 2026; Chervenak et al., AJOG 2026; Adewale et al., AJOG MFM 2023 (meta-analysis, 15 RCTs, n=6,618)

Outcome	Planned Cesarean	Planned Vaginal	Direction
Maternal mortality (approximate)	1 in 4,200	1 in 25,000	Higher with CD
Postpartum infection	2.87%	0.94%	Higher with CD
Thromboembolism	0.19%	0.08%	Higher with CD
Median days to pain-free recovery	27 days	19 days	Longer with CD
Pelvic organ prolapse (lifetime)	4%	8%	Lower with CD
Stress urinary incontinence (lifetime)	11%	18%	Lower with CD
Overactive bladder (lifetime)	9%	15%	Lower with CD
Urinary incontinence at 1-2 yr (RCT meta-analysis, n=6,618)	16.9%	22% — RR 0.77	Lower with CD
Neonatal birth trauma — nerve injury, skull or long-bone fracture (RCT)	0.3%	0.7% — RR 0.45	Lower with CD
Neonatal hypotonia (RCT)	0.4%	3.5% — RR 0.11	Lower with CD
Neonatal respiratory morbidity	Higher (especially before 39 wk)	Lower	Higher with CD
Childhood obesity (meta-analysis)	RR 1.10 (95% CI 1.01-1.18)	Reference	Higher with CD
Perinatal mortality (RCT meta-analysis)	1.3%	1.3%	Similar
Uterine rupture in subsequent pregnancy	0.21%	0.0038% (no prior CD)	Higher after prior CD
Placenta accreta — after 1st cesarean	0.31%	0.20% (no prior CD)	Higher after prior CD
Placenta accreta — after 3rd cesarean	0.6%	—	Cumulative risk
Hysterectomy at time of 3rd cesarean	~1% overall	—	Cumulative risk

Documentation Checklist — Professional Responsibility Model

Click each item as completed.

Explored patient's reasons for requesting CDMR through open-ended questions and reflective listening

Confirmed absence of absolute and relative indications — documented in the medical record

Provided balanced, evidence-based information on risks and benefits of vaginal vs. cesarean delivery

Discussed short-term maternal risks of cesarean (infection, thromboembolism, longer recovery, anesthesia)

Discussed long-term maternal risks (placenta accreta spectrum, uterine rupture, reduced IVF implantation rates)

Discussed pelvic floor protection — quantitative data on prolapse, stress incontinence, overactive bladder

Discussed neonatal considerations (respiratory morbidity, microbiome alterations, birth trauma data)

Discussed future reproductive plans and compounding risks with repeat cesarean deliveries

Identified and addressed cognitive biases if present (availability heuristic, denominator neglect, framing effect)

Screened for and addressed trauma history — tocophobia, sexual assault, prior birth trauma

Confirmed gestational age 39 weeks or beyond before scheduling (if proceeding with CDMR)

Teach-back completed — patient demonstrated understanding of key risks and benefits

Physician recommendation documented; patient's autonomous decision documented

Referral to willing provider discussed if physician declines CDMR (ACOG CO 761)

Consent form completed at 6th-8th grade reading level (CDC/NIH standard)

Evidence Base

Publications underlying this tool — every data point displayed traces to these sources

PUBLICATIONS USED IN THIS TOOL

1

Chervenak FA, Mcleod-Sordjan R, Pollet SL, Bachman G, Warman A, Grünebaum A. Cesarean delivery on maternal request: the essential role of professional obligations. Am J Obstet Gynecol. 2026;(Suppl):S216-S225.

Professional Responsibility Model

Primary framework paper. Source for: the professional responsibility model, autonomy-based vs. beneficence-based obligations, 12-step informed consent framework, cognitive biases (Kahneman/Tversky — availability heuristic, denominator neglect, affect heuristic, framing effect), trauma-informed care, tocophobia prevalence (7-25%), physician conscientious objection, and referral duty.

2

Alperin M, Artsen A. Cesarean delivery on maternal request. JAMA. 2026;335(10):903.

Clinical Outcomes Data

Current JAMA Insights summary (2.5% of US births). Source for: pelvic floor disorder data (prolapse 4% vs 8%, stress incontinence 11% vs 18%, overactive bladder 9% vs 15%), infection rates (2.87% vs 0.94%), thromboembolism (0.19% vs 0.08%), recovery time (27 vs 19 days), and placenta accreta spectrum risk by number of prior cesareans (0.31% after 1st, 0.6% after 3rd, ~1% hysterectomy at 3rd).

3

Minkoff H, Pearl A. Elective cesarean section for maternal preference. N Engl J Med. 2026;394(6):603-607.

Ethics — Autonomy Perspective

NEJM Clinical Decisions feature. Source for: the autonomy argument for honoring CDMR, denominator neglect as a form of health illiteracy, the role of patient values in risk acceptance, and the 39-week elective induction context as a comparator.

4

Ecker J. Elective cesarean delivery on maternal request. JAMA. 2013;309(18):1930-1936.

Clinical Review

Comprehensive JAMA Clinical Crossroads review. Source for: CDMR prevalence (less than 3% of all deliveries), structured risks and benefits framework, the requirement to evaluate all outcomes of planned vaginal delivery rather than simply comparing cesarean to vaginal, and the counseling structure used in this tool.

5

Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med. 2003;348(10):946-950.

Foundational Ethics Paper

Seminal NEJM Sounding Board. Source for: the foundational ethical framework for CDMR counseling, early maternal benefit analysis (pelvic floor, avoidance of emergency cesarean), and fetal benefit analysis (antepartum/intrapartum death rate ~2 in 1,000 after 39 weeks, meconium aspiration risk). Foundation for all subsequent frameworks.

6

ACOG Committee Opinion No. 761. Cesarean delivery on maternal request. Obstet Gynecol. 2019;133:e73-77.

ACOG Guideline

Defines CDMR. States vaginal delivery is recommended in the absence of indication. Endorses CDMR after appropriate counseling. Source for: the 39-week minimum threshold, discussion of placental abnormalities and hysterectomy risk in counseling, physician conscientious objection as ethically permissible, and the referral obligation when declining CDMR.

7

Sitoe Muhandule CJL, Benetti CMS, Fogulin LB, Bento SF, Amaral E. Cesarean delivery on maternal request: the perspective of birth companions. [Article in press].

Patient and Social Perspective

Qualitative study of birth companions' perspectives on CDMR decisions. Source for: the role of fear of pain and prior negative birth experiences in requesting cesarean, partner and family influence on CDMR decisions, and the perception of cesarean as protection.