Women's Preferences Regarding the Processes and Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery

Effectiveness of shared decision-making for mode of delivery after caesarean section: A systematic review and meta-analysis of randomized controlled trials

AIM

To review the content, format and effectiveness of shared decision-making interventions for mode of delivery after caesarean section for pregnant women.

DESIGN

Systematic review and meta-analysis.

METHODS

Six databases (PubMed, Web of science Core Collection, Cochrance Network, Embase, CINAHL, PsycINFO) were searched starting at the time of establishment of the database to May 2023. Following the PRISMAs and use Review Manager 5.3 software for meta-analysis. Two review authors independently assessed the quality of the studies using the risk of bias 2 tool. The protocol was registered in PROSPERO (CRD42023410536).

RESULTS

The search strategy obtained 1675 references. After abstract and full text screening, a total of seven studies were included. Shared decision-making interventions include decision aids and counselling that can help pregnant women analyse the pros and cons of various options and help them make decisions that are consistent with their values. The pooled results showed that shared decision-making intervention alleviated decisional conflicts regarding mode of delivery after caesarean section, but had no effect on knowledge and informed choice.

CONCLUSION

The results of our review suggest that shared decision-making is an effective intervention to improve the quality of decision-making about the mode of delivery of pregnant women after caesarean section. However, due to the low quality of the evidence, it is recommended that more studies be conducted in the future to improve the quality of the evidence.

CORRELATION WITH CLINICAL PRACTICE

This systematic review and meta-analysis provides evidence for the effectiveness of shared decision-making for mode of delivery after cesarean section and may provide a basis for the development of intervention to promote the participation of pregnant women in the decision-making process.

Social disparities in delivery choice among patients with history of cesarean

OBJECTIVE

Given the call to reduce rates of non-medically indicated cesarean deliveries (CDs) by encouraging trials of labor after cesarean (TOLAC), this study looks at social characteristics of patients choosing a TOLAC versus a scheduled repeat cesarean delivery (SRCD) to determine disparities regarding delivery method choice.

METHODS

This was a retrospective cohort study of patients with a history of one CD between April 29, 2015-April 29, 2020. Patients were divided based on type of delivery chosen at admission. Chi-squared tests examined proportional differences between groups and logistic regression models examined odd ratios of choosing TOLAC versus SRCD according to socially dependent categories including race/ethnicity, health insurance, pre-pregnancy body mass index, and Social Vulnerability Index (SVI).

RESULTS

1,983 patients were included. Multivariable logistic regression models revealed that patients with a high SVI (reference: low/medium SVI) (AOR 2.0, CI: 1.5, 2.5), self-identified as Black/ African American (AOR: 2.4, CI: 1.6, 3.6) or Hispanic/Latina (AOR: 2.0, CI: 1.4, 2.8) (reference: White), had public insurance (reference: private insurance) (AOR: 3.7, CI: 2.8, 5.0), and who had an obese BMI (reference: non-obese BMI) were more likely to opt for a TOLAC rather than SRCD.

CONCLUSION

These findings demonstrate differences in delivery method preferences. Specifically, more disadvantaged patients are more likely to choose TOLAC, suggesting that social and economic factors may play a role in delivery preferences. These findings have implications for improving individualized counselling and engaging in shared decision-making around mode of delivery.

Preferences of pregnant individuals to undergo labor after one cesarean in southern China

BACKGROUND

Labor after cesarean (LAC) remains an optional delivery method among healthy pregnant individuals. Exploring women's attitudes, preferences, reasons for previous cesarean delivery, and the incentives underlying pregnant individuals' preferences could help us understand their choice of delivery mode. In this study we evaluated the preferences and attitudes of eligible pregnant women regarding participation in a LAC in Foshan, China.

METHODS

A cross-sectional survey was conducted among 438 pregnant individuals with one prior cesarean delivery (CD) who attended their antenatal examination at a tertiary hospital in southern China, between November 1, 2018, and October 31, 2019. Information on demographic characteristics, obstetric data, preferences for LAC, and incentives for LAC were analyzed.

RESULTS

Overall, 85.4% (374/438) of women preferred LAC if they did not have contraindications before delivery, whereas 12.3% (54/438) refused and 2.3% (10/438) were unsure. Participants reported that the most important factors affecting their willingness to undergo LAC were safety indicators (i.e., "ability of hospitals to perform emergency cesarean delivery" [score of 9.28 ± 1.86]), followed by accessibility indicators (i.e., "priority bed arrangements" [score of 9.17 ± 1.84]). Logistic regression analysis indicated that neonatal wellbeing with the prior CD was an independent influencing factor (OR = 2.235 [95%CI: 1.115-4.845], p = 0.024) affecting willingness to access LAC in the subsequent pregnancy.

CONCLUSIONS

We found a high preference for LAC among pregnant individuals without contraindications before delivery in southern China. Healthcare providers need to ensure access to LAC and increase pregnant individuals' LAC willingness through high-quality shared decsision-making in alignment with patient preferences.

Preferred mode of delivery and its associated factors in pregnant women with a previous cesarean scar at a tertiary care hospital in Ethiopia: institutional-based cross-sectional study

BACKGROUND

Vaginal births after cesarean or elective repeat cesarean sections (CS) are the options for delivery after one cesarean scar. However, there is a lack of data regarding the preferred next mode of delivery in Ethiopia after a previous cesarean section. Thus, this study assessed the preferred mode of delivery and determinants after one previous CS in the antenatal clinic at the University of Gondar Comprehensive Specialized Hospital (UoGCSH).

METHODS

An institutional-based cross-sectional study was conducted among pregnant mothers with one previous CS at UoGCSH from March to August 2022. Structured questionnaires were used to collect the data. The collected data were entered, cleaned, and edited using Epi-data 4.6 and exported to SPSS version 26 for analysis. A binary logistic regression was performed to assess the determinants of the preferred mode of delivery. A p-value of < 0.05 at the 95% confidence level (CI) was considered statistically significant.

RESULTS

The majority, 71.5% (95% CI: 64.7, 77.1), of participants preferred the trial of labor after cesarean (TOLAC) as their mode of delivery. Mothers who were married (AOR = 4.47, 95% CI: 1.19-16.85), had a diploma educational level (AOR = 3.77, 95% CI: 1.84-12.36), had previous post-cesarean complications (AOR = 3.25, 95% CI: 1.08-9.74), and knew about the success of the trial of labor after cesarean (AOR = 13.56, 95% CI: 4.52-37.19) were found to prefer the trial of labor compared with their counterparts.

CONCLUSION

This study concluded that most pregnant mothers preferred labor trials after one CS, which is a bit lower but comparable with recommended practice guidelines. Providing adequate information and counseling mothers to make informed decisions about their preferred mode of delivery could be substantial.

To Try or Not to Try: A Questionnaire Study among Women with Previous Lower Segment Cesarean Section

Background

The recent increase in the cesarean section (CS) rate worldwide has led to global concerns and vaginal birth after CS (VBAC) as an effective way to reduce the CS rate. In this study, our main aim was to know about various factors that help women make their preferred mode of delivery following a previous CS.

Material and Method

This was a questionnaire-based study conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Jodhpur, among 200 women with previous one lower segment CS (LSCS).

Results

Elective repeat cesarean delivery (ERCD) was found to be more among uneducated women and those who had complications in their previous babies. The most common reason for opting for ERCD was fear of labor pains. Women who were counseled by senior doctors were more likely to opt for a trial of labor after cesarean section (TOLAC).

Conclusion

Improving the education levels of mothers, counseling about advantages associated with vaginal birth, counseling by senior obstetrician, and information regarding labor analgesia can decrease CS rates.

VBAC calculator 2.0: Recent evidence

Following criticism for the use of race as a biological predictor of vaginal birth after cesarean (VBAC), an updated version of the Society for Maternal-Fetal Medicine (SMFM) VBAC calculator has been published. The variable "African American" or "Hispanic" (yes/no), which produced systematically lower chances of VBAC for nonwhites has been replaced with "chronic hypertension requiring treatment" (yes/no). Although there are no published external validation studies to date, developers report accuracy (area under the curve and calibration) nearly identical to the original calculator and it is published online for immediate use. This review examines the history of the calculator, measures of its validity, and recent studies measuring its performance among Hispanics, Blacks, Asians, and others with lower range scores. Underprediction of successful VBAC is evident in the original calculator, especially as predicted VBAC decreases. These studies raise a concern about the use of calculator scores in clinical management, that is, discouraging or restricting access to labor after cesarean (LAC) for parents with lower calculator scores. This raises special concern for minority populations who experience increased cesarean-related morbidity, face obstacles accessing LAC care, and who may benefit disproportionately from increased LAC uptake. Although calculator developers have discouraged using calculator scores to restrict access to LAC, such uses are documented. It is not clear what effect the removal of race will have on calculator performance, and further study is required before calculator scores are used in counseling. This includes studies that include large numbers of low scoring and minority patients.

Factors associated with labor after cesarean in a prospective cohort

BACKGROUND

The goals of this study were (a) to determine how experiences in the first perinatal period shape birth mode preference among individuals with a first birth by cesarean; and (b) to examine the relationship between birth mode preference and other factors and subsequent labor after cesarean (LAC).

METHODS

Data are from the First Baby Study, a prospective cohort of 3006 primiparous individuals. The analytic sample includes individuals with a first cesarean birth and a second birth during the 5-year follow-up period (n = 394). We used multivariable logistic regression to examine the relationship between experiences in the first perinatal period and subsequent preference for vaginal birth, and between preference for vaginal birth and LAC in the second birth.

RESULTS

About a third of the sample preferred vaginal birth in a future birth, and 20% had LAC. Factors associated with higher odds of future vaginal birth preference were favorable prenatal attitude toward vaginal birth, lower perceived maternal-infant bonding at 1 month after the first birth, post-traumatic stress symptoms after the first birth, and desiring more than 1 additional child after the first birth. Odds of LAC were nearly 8 times higher among those who preferred vaginal birth (AOR = 7.69, P < .001). Fatigue after the first birth, post-traumatic stress symptoms after the first birth, and having higher predicted chances of vaginal birth after cesarean were also associated with higher odds of LAC.

CONCLUSIONS

Our findings suggest that the formation of preferences around vaginal birth may present a modifiable target for future counseling and shared decision-making interventions.

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas

OBJECTIVE

This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI.

STUDY DESIGN

This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations.

RESULTS

Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81).

CONCLUSION

Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI.

KEY POINTS

· Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

Patient decision aid for trial of labor after cesarean (TOLAC) versus planned repeat cesarean delivery: a quasi-experimental pre-post study

OBJECTIVE

To assess the impact of a web-based decision aid on patient-centered decision making outcomes among women considering a trial of labor after cesarean (TOLAC) versus planned repeat cesarean delivery.

METHODS

The Birth Decision Aid Study (B-READY) was a quasi-experimental pre-post study of two sequential cohorts. From June 18, 2018 to July 31, 2019, 50 women were enrolled in routine care, followed by 50 women who were enrolled in the decision aid group. Inclusion criteria were singleton pregnancies between 19/0 to 36/6 weeks, ≤2 prior cesareans, and no contraindications to TOLAC. The decision aid group viewed the online Healthwise® "Pregnancy: Birth Options After Cesarean" program. Both groups received the same birth options counseling and completed the same online assessment. Primary patient-centered outcomes were knowledge about birth options and shared decision making at online assessment, and informed, patient-centered decision making about her preferred mode of delivery at delivery admission.

RESULTS

Among 100 women participated in this study (50 per group), the mean gestational age at enrollment was 31 weeks, and 71% or 63/89 women who consented to delivery data abstraction had a cesarean delivery. Women in the patient decision aid group gained more knowledge (defined as score ≥ 75%) about birth options compared to those in the routine care group (72% vs. 32%; adjusted odds ratio, AOR: 6.15 [95% CI: 2.34 to 16.14]), and were more likely to make an informed, patient-centered decision (60% vs. 26%; AOR: 3.30 [95% CI: 1.20 to 9.04]. Women in both groups reported similar involvement in shared decision making, as well as satisfaction and values. More than 90% of decision aid users reported it was a useful tool and would recommend it to other TOLAC-eligible women.

CONCLUSIONS

A web-based birth options patient-centered decision aid for TOLAC eligible women can be integrated into prenatal Telehealth and may improve the quality of decision making about mode of delivery.

TRIAL REGISTRATION

The study was registered with ClinincalTrials.gov and the ID# was NCT04053413 . Registered 12 August 2019 - Retrospectively registered.

Women's preferences for mode of second birth-A prospective study of two Israeli birth cohorts

INTRODUCTION

Various biopsychosocial factors affect women's preferences with respect to mode of birth, but they are usually not examined simultaneously and prospectively. In the current study, we assessed the contribution of personal characteristics of first-time mothers, their prior prenatal perceptions, events during birth, and subjective birth experiences, on their preference about mode of second birth.

METHODS

This was a secondary analysis of two prospective birth cohort studies. Participants included 832 primiparous women recruited mostly from women's health centers in Israel, and through natural birth communities and cesarean birth websites. Women completed questionnaires prenatally and were followed up at 6-8 weeks postpartum to understand their preferences for a second birth.

RESULTS

Regression models indicated that after vaginal first birth, being less religious, believing that birth is a medical process, and having a negative experience increased the odds of preferring primary cesarean for the second birth. After cesarean birth, being more religious, having higher education, conceiving spontaneously, having a more negative birth experience, and perceiving better treatment from the staff during birth contributed to preferring vaginal birth for the second birth.

CONCLUSIONS

Religiosity is central to women's preferences, probably because of its association with the desire to have many children. Modifiable factors, such as women's beliefs about the nature of birth, their overall birth experience, and their perceived treatment from the staff, could influence the uptake of having vaginal births. Intrapartum care that is empathic and encouraging, along with education about modes of birth, could help decrease cesarean birth rates.