The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study.

Emy Vankan,Jan Nijhuis,Rosella Hermens,Ellen Schoorel,Sander Van Kuijk,Hubertina Scheepers,Alessandra Solari

doi:10.1371/journal.pone.0222499

Abstract

ObjectiveAfter one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women’s rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers’ fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates.MethodsWe performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion.ResultsThere was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69–1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18–2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40–0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001).ConclusionsImplementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

Highlights

There was no significant difference in vaginal birth after caesarean (VBAC) rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69–1.23))
In the intervention group more women (42%) chose an elective repeat caesarean section (CS) compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18–2.17))
After one previous caesarean section (CS), pregnant women can deliver by elective repeat caesarean section (ERCS) or have a trial of labor (TOL) which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS

Summary

Introduction

After one previous caesarean section (CS), pregnant women can deliver by elective repeat caesarean section (ERCS) or have a trial of labor (TOL) which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women’s rights to make an informed choice and that for most women vaginal birth is safe [1,2,3], TOL and VBAC rates vary greatly worldwide [4]. In The Netherlands, VBAC rates are much higher (54%) [7], but most women are inadequately informed about their choices due to caregivers’ fear of an increase in CS rates [8]. A better inventory of risks, benefits and chance of success might improve shared decision making and reduce unplanned CSs without bringing down the number of VBAC

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Results

Conclusion