How do good candidates for trial of labor after cesarean (TOLAC) who undergo elective repeat cesarean differ from those who choose TOLAC?

Abstract

OBJECTIVE Our aim was to compare good candidates for trial of labor after cesarean (TOLAC) who underwent repeat cesarean to those who chose TOLAC. STUDY DESIGN Data for all deliveries at 14 regional hospitals over an 8-year period were reviewed. Women with a primary cesarean and 1 subsequent delivery in the dataset were included. The choice of elective repeat cesarean vs TOLAC was assessed in the first delivery following the primary cesarean. Women with ≥70% chance of successful vaginal birth after cesarean as calculated by a published nomogram were considered good candidates for TOLAC. Good candidates who chose an elective repeat cesarean were compared to those who chose TOLAC. Women who were delivered at 2 preselected tertiary centers by a general obstetrician-gynecologist practice were subanalyzed to determine whether there was an effect of physician group. RESULTS In all, 5445 women had a primary cesarean and a subsequent delivery. A total of 3120 women were calculated to be good TOLAC candidates. Of this group, 925 (29.7%) chose TOLAC. Women managed by a family practitioner or who were obese were less likely to choose TOLAC while women who were managed by a midwife or had a prior vaginal delivery were more likely to choose TOLAC. At the 2 tertiary centers, 1 general obstetrician-gynecologist group had significantly more patients who chose TOLAC compared to the other obstetrician-gynecologist physician groups (P < .001), with 63% of their patients choosing TOLAC. CONCLUSION Less than one-third of the good candidates for TOLAC chose TOLAC. Managing provider influences this decision.

Outcomes of trial of labor after cesarean birth by provider type in low‐risk women

“…We found no national data on the number of TOLAC deliveries managed by CNMs, but our findings suggest that increasing opportunities for midwives to manage low‐risk TOLAC patients could be a safe and effective means to improve vaginal birth rates. A cultural and ideological shift toward offering TOLACs may be a notable obstacle; however, as fewer providers and hospitals are allowing TOLACs, some women may be unaware of the opportunity, and some reports suggest that fewer women overall are requesting VBAC . Our data were collected prior to the publication of specific guidelines to reduce primary cesarean birth .…”

Mode of delivery preferences in a diverse population of pregnant women

“…3 Metz et al, for example, have suggested provider factors are a potentially significant reason for disparities in rates of trial of labor after cesarean among women who are good candidates. 27 Similarly, Bernstein et al found when women with a prior cesarean perceived their provider to have a preference, they were more likely to choose their perceived provider-preferred delivery mode. 28 Patient preferences should be considered along with safety and medical capacity, and providers have a role in offering balanced counseling incorporating realistic framing of risks and benefits.…”

Predicting the chance of vaginal delivery after one cesarean section: validation and elaboration of a published prediction model

“…Personal wishes of the pregnant woman and her partner would influence the decision to a great extent, as would the experiences of the counseling obstetrician and the traditions of the specific delivery ward. Metz et al [33] found that less than one third of women regarded as good candidates for TOL, (with a VBAC chance !70% using the Grobman model [8]), finally chose TOL. Bernstein et al [22] showed that candidates for TOL were poorly educated about risks and benefits associated with different delivery modes, and that the majority chose the delivery mode preferred by their care-provider.…”