Trial of Labor Versus Repeat Cesarean

Abstract

Although the use of vaginal birth after cesarean (VBAC) has been advocated, and patients have been counseled as to its benefits and risks, published literature suggests that patient education is lacking and that lack of discussion with the clinician is often associated with choosing a cesarean delivery. This prospective, observational study was undertaken to assess the hypothesis that the national low rate of VBAC is due in part to insufficient informed consent about the risks and benefits of trial of labor (TOL). Patients eligible for a TOL after cesarean (TOLAC) received prenatal care and counseling in a private physician’s office or in a hospital-based clinic. A questionnaire was administered to women after admission to the obstetric unit either just before the scheduled elective repeat cesarean section (ERCS) or after admission for TOL. The questionnaire covered demographics, prior cesarean experience, family planning goals, perceived provider preference, factors affecting patient’s choice, and risks and benefits of ERCS and TOLAC. Data were analyzed using χ2 and Fisher exact tests. Eighty-seven women presented for TOLAC, and 68 presented for ERCS; they did not differ statistically in age, level of education, ethnicity, and provider type. Patients demonstrated an overall lack of knowledge about the risks and benefits of TOLAC and ERCS. Only 13% of TOLAC patients and 4% of ERCS patients knew that the chances for a successful TOLAC are 60% to 80%, whereas 54% in the TOLAC group and 73% in the ERCS group indicated they did not know. Forty-nine percent of TOLAC patients and 26% of ERCS patients knew that the risk of uterine rupture is 0.5% to 1%, whereas 64% of ERCS patients stated that they did not know what the risk is during TOLAC. Moreover, 52% of patients in the ERCS group did not know that the recovery period after a cesarean is longer than after a vaginal delivery, and 46% did not know that the complication rates increase with each successive cesarean. Twenty percent of ERCS patients believed that the indication for the previous cesarean had no role in their chances of a subsequent successful vaginal delivery. When asked about the risks of ERCS versus TOLAC, 50% of women or greater in both groups were aware of the greater risk of damage to organs, excessive bleeding, and infection, but 30% or less knew that an ERCS carries an increased risk of maternal death, neonatal respiratory compromise, and admission to the neonatal intensive care unit. When patients thought their providers preferred ERCS, 19 (86%) of 22 chose ERCS, whereas when they thought their doctor preferred a TOLAC, 36 (78%) of 46 chose TOLAC. If patients thought their doctor had no preference or they did not know the preference, 50% chose TOLAC and 50% chose ERCS. Women in both groups were not adequately informed about the risks and benefits of TOLAC and ERCS. Opportunities for patient counseling are readily available during prenatal visits, especially at the end of the pregnancy. Respondents showed deficiencies in the area of comprehension, a major tenet of informed consent. They lacked awareness and understanding of their situation and possibilities despite the fact they were an older and more highly educated population than the average across the United States, which suggests that wider knowledge gaps could exist throughout the country. Future studies should evaluate counseling styles and decision aids and their influence on delivery preference and the patient knowledge base.