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Better Counseling Needed to Boost Number of Women Who Choose a Trial of Labor After Cesarean

Key findings

  • Among 299 women eligible for a trial of labor after cesarean (TOLAC), most indicated a preference for an uncomplicated vaginal delivery if that could be guaranteed, but only a minority later opted for TOLAC
  • Strength-of-preference scores explained the discordance: women indicated strong preferences for both uncomplicated TOLAC and uncomplicated elective repeat cesarean delivery, but any alteration in either the process or outcome decreased their preferences
  • Race/ethnicity, insurance status and order of presentation also affected women's preferences, indicating that these factors should influence a clinician's approach to counseling about delivery after cesarean

The rate of vaginal birth after cesarean decreased from a high of 28% in 1996 to 12% in 2015, as reported by the Centers for Disease Control's National Vital Statistics Report. A substantial portion of this decline was shown to be related to women foregoing a trial of labor after cesarean (TOLAC), even when that option is available.

Guidelines of the American College of Obstetricians and Gynecologists emphasize that a woman's preferences should play a key role in choosing the delivery approach after cesarean. In the Journal of Women's Health, researchers led by Anjali J. Kaimal, MD, MAS, director of the Deborah Kelly Center for Outcomes Research in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, report findings from a study that provides guidance on how to counsel patients.

Study Participants and Design


Between December 2014 and April 2016, the researchers recruited 299 pregnant women at Mass General in Boston, Northwestern University Medical Center in Chicago, University of California San Francisco and California Pacific Medical Center, St. Luke’s Campus in San Francisco and Marin Community Clinic in San Rafael in the San Francisco Bay Area.

Eligibility criteria included:

  • Singleton gestation at 26–34 weeks
  • One prior cesarean delivery
  • No prior vaginal delivery after cesarean
  • No contraindications to vaginal delivery

The cohort was racially and ethnically diverse (47% white, 23% Latina, 13% Asian/Asian American and 11% black). Most women (74%) had labored in the past, and 8% had a vaginal delivery before their cesarean.

The women were interviewed face-to-face in English or Spanish and completed a sociodemographic and attitudinal questionnaire. They also participated in a series of exercises using ELICIT, a computerized tool developed to elicit patient preferences.

Preference for Delivery Approach

The researchers asked each participant, ''If you could be guaranteed an uncomplicated delivery of either type, which delivery would you prefer?'' with response options of ''vaginal delivery'' or ''cesarean delivery.'' A clear majority of participants (84%) stated a preference for vaginal delivery, but only 38% later underwent TOLAC.

Utility Scores

For each of the multiple possible scenarios, the researchers calculated the utility score, which indicated the strength of the participants' preference. The team used the time tradeoff metric, which generates scores ranging from 0 (worst outcome) to 1 (ideal outcome). Results included:

  • TOLAC without any interventions or complications received the highest average score: 0.984
  • Scenarios that deviated from that ideal resulted in lower scores even if they resulted in a healthy mother and baby:
    • Elective repeat cesarean delivery (ERCD) without complications: 0.931
    • TOLAC with uterine rupture, no maternal or infant sequelae: 0.930
    • TOLAC augmented by oxytocin resulting in vaginal delivery: 0.927
    • TOLAC ending in an uncomplicated cesarean: 0.917
  • Scenarios involving neonatal adverse outcomes, whether minor or more severe, generally were assigned lower scores:
    • TOLAC complicated by chorioamnionitis, requiring antibiotic administration and ending with vaginal delivery: 0.918
    • ERCD with transient neonatal complications: 0.880
    • ERCD resulting in future complications (accreta and preterm birth): 0.83
  • Unsurprisingly, the lowest score, 0.448, was for TOLAC with uterine rupture resulting in fetal hypoxic-ischemic encephalopathy or infant death

Results for Patient Subgroups

Asian and Latina race/ethnicity were associated with lower scores for the use of oxytocin to assist with vaginal birth and for complications related to future cesarean. Asian and black race/ethnicity were associated with lower scores for severe perineal laceration.

Having public insurance was associated with lower scores for complications of both TOLAC and ERCD, and women who planned to have additional pregnancies assigned a lower score to TOLAC resulting in a hysterectomy.

Ordering Effects

The order in which the various scenarios were presented to study participants also affected the results. When the risk of severe neonatal injury with TOLAC was presented before consideration of other outcomes, women gave less weight to potential short- and long-term complications of ERCD, which are more common.

Tips for Counseling Patients About the Approach to Delivery

  • In order to incorporate informed patient preferences in decisions about approach to delivery after cesarean, women need to understand the processes and potential outcomes of TOLAC and ERCD
  • Put the potential for labor interventions (e.g., oxytocin) and complications in context, so that women understand the potential benefits as well as risks
  • Include information about maternal outcomes as well as neonatal outcomes
  • Consider the order in which complications are discussed—even if the absolute risk is low, rare complications that are presented first will change the way that more common complications are perceived and weighted
  • Depending on an individual's personal characteristics and plans, decision support may need to be individualized to ensure that all patients have the support to express their informed preferences.

84%
of participants stated a preference for vaginal delivery

38%
Only 38% of participants followed through and later underwent TOLAC

Learn more about the Deborah Kelly Center for Outcomes Research

Learn more about OB/GYN research

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