Vaginal birth after cesarean or repeat cesarean section: Medical risks or social realities? E. Paul Kirk, MD, Kathleen A. Doyle, MD, Janet Leigh, MD, and Mary L. Garrard, MSN Portland, Oregon Despite the known medical safety and success of vaginal birth after cesarean section, rates of planned repeat cesarean sections remain high. The process involved in women's decisions to choose vaginal birth after cesarean section or repeat cesarean section was investigated by a questionnaire study at a private and a public hospital. Women were questioned regarding timing, influence of others, reasons for their choice, satisfaction with the decision, etc. Results from 160 respondents showed that over half the women identified themselves as the primary decision maker. Physicians exerted more influence on the decisions of patients at the public hospital than on the patients at the private hospital. Overall, social exigencies appeared to playa more important role than an assessment of the medical risks in making these decisions. (AM J OBSTET GVNECOL 1990;162:1398-405.)
Key words: Vaginal birth after cesarean, repeat cesarean section, decision making, informed consent
The obstetric revolution of the last two decades has been characterized by the remarkable results in neonatal intensive care units, particularly with low-birthweight infants, the development of the specialty of perinatology with the focus on the fetus as the patient, and new imaging and monitoring equipment to sharpen that focus, and the dramatically increased use of cesarean section as a method of delivery. Features of the revolution have included the virtual elimination of birth trauma and intrapartum fetal asphyxia death, decreasing maternal and perinatal mortality, decreasing morbidity from cesarean section, rising health care costs and, inevitably, an increasing number of women who enter the second pregnancy with the physical scars and the mental memories of the previous pregnancy, labor, and delivery. As this revolution progressed, another revolution was occurring as pregnant women and their advocates in the late 1960s and early 1970s sought to gain more control over their pregnancies. They were anxious to move away from what was seen as the older paternalistic style, often typified by rigid labor practices, standing orders, spinal anesthetics, and elective outlet forceps. The new style was to include more patient autonomy, more flexibility, more expectant management, fewer physical interventions, more effective childbirth prepFrom the Department of Obstetrics and Gynecology, Oregon Health Sciences University. Presented at the Fifty-sixth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Coronado, California, September 17-21,1989. Reprint requests: E. Paul Kirk, MD, Oregon Health Sciences University, 3181 S.W. Samjackson Park Road, Portland, OR 972013098. 616119912
1398
aration, fewer narcotics, and the encouragement of the delivery as a family event with early mother-infant interaction in the neonatal period. By the late 1970s the trend of the rising cesarean section rate was established and proponents were forecasting a continuing progressive rise.! Skeptics doubted that there was any direct relationship between the increased use of cesarean sections and improved perinatal outcome. Experts were called together to halt this trend and to proffer some sound advice regarding the management of abnormal, and therefore difficult labor and the diagnosis of fetal distress. They cautiously suggested that vaginal delivery after a previous transverse, low-segment cesarean section might be safe under certain rigidly controlled conditions. 2 This cautious opinion was based on the limited information available at that time, which implied that these vaginal deliveries carried a much lower risk to mother and fetus than had been assumed by the practice based on Craigin's original threatening dictum: "Once a section-always a section." The last decade has seen an accumulation of experience and data that fully support the consensus recommendation and studies have shown that the risk of uterine rupture is low. 3-6 Consequently, the risk of fetal injury from uterine rupture is very low and importantly, the probability of vaginal delivery is high: 75% to 80% in those women who attempt vaginal birth after cesarean section. More recent studies have responded to some of the previously unanswered questions regarding the safety of vaginal births after cesarean sections with Pitocin administration, epidural anesthetics,7 low vertical incisions," "unknown" scars,9 multiple pregnancies,I° and breech presentations. l1 As the data have
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Table I. Reasons for women's choice of vaginal birth after cesarean section (percentage) All factors* Hospital A (n = 70)
Danger of cesarean section for mother Danger of cesarean section for infant Longer recovery with cesarean section Wanted experience of vaginal birth "Naturalness" of vaginal birth Financial considerations Other
23
20 61 61
3 20
I
Single most important factort Hospital B (n = 41)
41 29
89 66
7 18
Hospital A (n = 70)
o o
21
19
17
o
43
I
Hospital B (n = 41)
o o
44 27 12 2
15
* Identified from a checklist. t Identified by an open-ended question.
accumulated, public statements have been less cautious. A recent American College of Obstetricians and Gynecologists committee recommended that "The concept of routine repeat cesarean birth should be replaced by a specific indication for a subsequent abdominal delivery, and in the absence of a contraindication, a woman with one previous cesarean delivery with a low transverse incision should be counseled and encouraged to attempt labor in her current pregnancy."12 It would seem that these good results would correspond with the more autonomous style of management of a subsequent pregnancy and that the prospects of a safe delivery, with a good probability of avoiding another abdominal incision, would be enticing. The national experience does not support this assumption. A recent survey published in 1987 showed that 92% of women with a history of previous cesarean sections are delivered by repeat elective surgery and in 50% of the nation's hospitals, a vaginal birth after cesarean section has never been attempted. 13 It is not clear who makes the decision to avoid vaginal births after cesarean section, and why those decisions are made when the clinical data now available would support a much more optimistic approach. In an attempt to understand some of the issues in this clinical management decision, a questionnaire study was undertaken. Material and methods
The study was conducted at two hospitals in the Portland, Oregon metropolitan area: University Hospital (hospital A) and Good Samaritan Hospital (hospital B). Questionnaires were issued to all patients who were delivered of infants between Dec. 1, 1988, and June 30, 1989, who had a history of cesarean section in any of their previous pregnancies. The questionnaires were issued during the postpartum hospital stay; if they were not completed by the time the patient was discharged, one further attempt was made by mail at a later time to have the questionnaire completed. The questionnaires were designed to describe the ethnic and educational characteristics of the different hospital popu-
lations. Separate questionnaires were used for those patients who planned a vaginal birth after cesarean section and for those who chose repeat cesarean section. The questions attempted to identify the patient's perceptions with regard to the management decision and the factors that affected that decision. The answers were collated and comparisons were made between hospital A and hospital B, and between those who chose vaginal birth after cesarean section and those who chose repeat cesarean section. Results
Two hundred fifty-seven questionnaires were distributed; 160 (62%) were returned. Patients planning a vaginal birth after cesarean section at hospital B were more likely to return the questionnaire (73%) than the repeat cesarean section group (47%) (overall return rate from hospital B, 59%). The return rates for vaginal birth after cesarean section and repeat cesarean section groups were virtually identical at hospital A (66% versus 61 %); the overall return rate was 65%. At hospital A there was a total of 1480 births with 265 cesarean sections; the cesarean section rate was 17.8% (14.E,% primary, 3% repeat). At hospital B there were 1245 births; the cesarean section rate was 19%, (13.6% primary, 5.4% repeat). The average age of the patient with a vaginal birth after cesarean section was 27.6 years (range, 17 to ·n years), and for the repeat cesarean section group, 30.6 years (range, 18 to 42 years). Ninety-one percent were married or identified a steady partner. Hospital B respondents tended to have a higher educational level, with 69% of hospital B versus 47% of hospital A patients having some college or a college degree; 19% and 5% of hospital B and hospital A patients, respectively, had a professional degree. Eighty percent of patients from hospital A were white; the remainder came from a variety of minority backgrounds. All but one patient from hospital B were white. Eighty-four percent of patients at hospital A had had their prenatal care at a resident or county clinic, with only half attending for their first prenatal visit in the
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June 1990 Am J Obstet Gynecol
Table II. Time women reported first hearing about vaginal birth after cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A !HosPital B (n = 70) (n = 40)
Never heard about vaginal birth after cesarean section Before current pregnancy First half of current pregnancy Last half of current pregnancy During labor
I(n Both = 110)
Women planning repeat cesarean Hospital A (n = 16)
302 49 65 55 26 30 27 10
3
IHospital B I Both (n = (n = 33)
19 38 12 12
7
3 55 30 3
o
604
49)
8 49 .24 6
0
0
Table III. Timing of decision for vaginal birth after cesarean section or repeat cesarean (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Before current pregnancy First half of current pregnancy Last half of current pregnancy During labor
I
Hospital B (n = 41)
37 54 7 0
23 33 26 9
Table IV. Reasons for choice of repeat cesarean section (percentage) Women planning repeat cesarean Hospital A (n = 15)
Danger of vaginal birth after cesarean section for mother Danger of vaginal birth after cesarean section for infant Avoid pain of labor Convenience of timing birth Low probability of vaginal delivery Knew what to expect
Both (n = 48)
33
21
25
20
33
29
20 13
49 33
40 27
33
61
52
27
42
38
first trimester. At hospital B, 95% of the prenatal care was in a private office, and 90% of the first visits were in the first trimester. The responses to the question regarding reasons women chose vaginal birth after cesarean section are summarized in Table I. Half the patients were aware of vaginal birth after cesarean section as an option before conception (Table II). The patients from hospital A had no clear pattern in the timing of the decision, whereas patients at hospital B tended to make the decision for vaginal birth after cesarean section early in pregnancy and for repeat cesarean section, late in pregnancy (Table III). The patient's reason(s) for choosing an elective re-
I
(n
Both = 110)
28 40 19 5
Women planning repeat cesarean Hospital A (n = 15)
27 27 20 13
I
Hospital B (n = 33)
9 24 58 6
I
(n
Both =
48)
15 25 46 8
peat cesarean section are listed in Table IV. The patient's perceptions of her chances of vaginal delivery are shown in Table V. The majority of patients identified themselves as the decision maker either alone (55%) or in conjunction with the physician (34%), although the physician alone was identified as the decision maker in 11 % of hospital A vaginal births after cesarean sections, and 33% of hospital A repeat cesarean sections (Table VI). The patient's perceptions of the physician's attitude toward vaginal birth after cesarean section are listed in Table VII. Even though the patient perceived herself as being the primary decision maker, 64% and 46%, respectively, identified the physician and the husband or partner as having "a lot" of influence on the decision. "Others" (friends, parents, siblings, nurses, childbirth educators) were more likely to influence the decision when a vaginal birth after cesarean section was chosen. This difference was more obvious with patients from hospital A (Table VIII); physician influence was stronger at hospital A than at hospital B: 69% of patients at hospital A versus 59% of patients at hospital B stated their physicians had "a lot" of influence. In the 25 patients who had a repeat cesarean section after a failed vaginal birth after cesarean section, 52% were for management of failure to progress and 40% were for management of fetal distress. Of those 25, 48% said that they would never try vaginal birth after cesarean section again, whereas 20% said that they would definitely try again. Only 27% of patients planning a vaginal birth after cesarean section and 20% of repeat cesarean section patients attended a prenatal class. Patients from hospital B were more
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Table V. Women's perceptions of their chance to deliver vaginally (percentage) Women planning vaginal birth after cesarean section
I
Women planning repeat cesarea,'l
I
Hospital A Hospital B Both Hospital A (n = 41) (n = 110) (n = 16) (n = 69)
Poor «25%) Fair (25% to 50%) Good (75%) Excellent (>90%) Unaware of vaginal birth after cesarean section as option
12 22
23
19 38 20
o
19
50
20
19
o
6 13
12
43 18
51 15
o
IHospital B I Both (n 33) (n 49) =
=
49 24 12
49 22
12
9 6
8 8
Table VI. Women's perception of who made the decision for vaginal birth after cesarean section or repeat cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Self
Physician Both Other
53 11 36 6
I
Hospital B (n = 41)
I
Women planning repeat cesarean
Both
Hospital A
(n = 111)
(n = 15)
56 8 35 4
33
61
2
36
o
likely to attend prenatal classes than those from hospital A (34% vs 17%).
Comment Although there has been extensive discussion of the lack of necessity to perform a repeat cesarean section in the light of the proven safety of vaginal birth after cesarean section, only 8% of women in the nationwide survey underwent a trial of labor in 1984. The likelihood of a trial increased with the size of the obstetric service, and it is likely that some of the reluctance to permit a trial may be related to the availability of emergency services, although it is important to note that other intrapartum catastrophes occur more frequently than uterine rupture. 14 Even on larger obstetric services, the rates of vaginal birth after cesarean section did not exceed 25%, and there is uncertainty whether this is because the physicians do not allow trials of labor, or that mothers do not want to experience them. Within the admitted limitations of a questionnaire study, some patterns appear to emerge. Both hospitals in the study have a relatively low cesarean section rate by modern standards, and each promotes vaginal birth after cesarean section. The population in hospital B is almost exclusively white, better educated, and receives prenatal care early through private physician offices. At hospital A, the population is ethnically heterogeneous, is less well educated, and is likely to receive prenatal care later from a variety of providers in different settings, most of
33
27
7
I
Hospital B (n = 33)
61 3 33 3
I
Both (n = 48)
52
13 31 4
whom would not provide longitudinal care through delivery. In general, women from hospital B gave better defined opinions (Table IV), and the troika of the patient, partner, and physician seemed more important (Table VI). They tended to make the decision for vaginal birth after cesarean section earlier in the pregnancy but left the decision for a repeat cesarean section later. Both groups were reasonably well informed about vaginal birth after cesarean section, but their information was not always accurate. The women who chose repeat cesarean section were particularly pessimistic about their chances of a vaginal delivery, which was almost certainly a factor in the management decision. The patients from hospital A, who were relying on the physician, were more likely to receive information and support from other health care providers, family, and friends. The better educated group did not appear more interested in or more likely to choose vaginal birth after cesarean section, as has been previously reported by McClain. 15 The reasons for choosing vaginal birth after cesarean section (recovery period, wanting the experience) and for choosing repeat cesarean section (knowing what to expect, avoiding the pain of labor, convenience, and timing) confirmed the social rather than the medical model of the decision making. The exception to this was "the belief that the chance of vaginal delivery was poor," which is a misappreciation of the medical probability rather than an appreciation. Although there are extensive reports in the literature
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Kirk et al.
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Table VII. Women's perception of physician's attitude toward vaginal birth after cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Encouraged vaginal birth after cesarean section Discouraged vaginal birth after cesarean section Neutral Don't know
74
95
82
10 16
10 0
10 10
o
Table VIII. Women's perception of amount of influence by "others" on decision for vaginal birth after cesarean section or repeat cesarean as "some" or "a lot" (percentage)
"Others" influencing decision
Friends Doctor Nurse Childbirth educator Husband-partner Parent(s) Siblings
Women choosing vaginal birth after cesarean section (n = variable)
Women choosing repeat cesarean (n = variable)
47 86 61 40
15 79 24 13
43 29
5
81
I Hospital B I B oth (n = 40) (n = 110)
72 21
that analyze the factors that affect the cesarean section rates in various settings, [6. [7 and various descriptions of policy that have successfully reduced the cesarean section rates, [8. [9 there is little information about the decision-making process in individual cases. Through a series of structured interviews of 100 patients, McClain [5 emphasized that all women made choices that were shaped by social exigencies and constraints, and that none engaged in probabilistic evaluation of medical risk, choosing instead to develop negotiation strategies that would enhance control of uncertainties, such as the length and pain of labor. In this study, although the physicians were identified as an important part of the decision-making process, patients in hospital A were not always able to identify what the physicians' attitudes were, possibly because of the lack of longitudinal care. Clearly, decisions are made either in favor of vaginal birth after cesarean section or repeat cesarean section, and this study raises questions about the nature of informed consent. 20 Ten years ago when vaginal birth after cesarean section was considered unsafe and 98% of women had repeat cesarean sections on the basis of the physician's concern for the risks of uterine rupture, the consent was, in a sense, uninformed because it reflected old data. It now appears that many women choose repeat cesarean section, an equally uninformed choice when assessed from
0
0
Women planning repeat cesarean Hospital A (n = 16)
31 25 19 25
I Hospital B I (n
= 33) 24 21 52
3
(n
Both = 49)
26 22 41
10
the point of view of medical risk, but one that makes social sense because it respects individual preference. It appears that physicians are likely to collude with this choice, perhaps out of respect for patient autonomy, a reluctance to change long-held positions, a wish to avoid a failed vaginal birth after cesarean sectio~ in up to 25% of cases, or fear of litigation. It is not possible to determine how well patients were informed in this study, nor how free was their consent. Seventy-three percent of patients who had a repeat cesarean section reported that their physicians either discouraged vaginal birth after cesarean section or had either neutral or unknown attitudes, although 26% chose to have a repeat cesarean section despite the physician's encouragement of vaginal birth after cesarean section. This in turn raises the question: Should the decision be simply the choice of the patient, a truly elective repeat cesarean section? By means of a mathematic probabilistic model, Feldman and Freeman 2 [ made a cogent argument for the consideration of prophylactic cesarean section at term in all pregnancies. An essential part of that argument was the significantly reduced maternal risk of elective cesarean section. Coupled with the lack of any convincing evidence that properly consented elective cesarean sections cause any prolonged postpartum depression or maternal infant interaction difficulties, the elective cesarean section appears to be a reasonable choice. Two ethical considerations remain. First, how far should the obstetric community control individual decisions within the context of increasing costs, limited resources, widespread pregnancy indigency, and managed health care programs? It is clear that clinicians do not practice in a vacuum; whenever a decision is made to perform a cesarean section, it affects the total pattern of obstetric practice, which in turn affects the standard of care. Second, should the patient be free to make a choice for repeat cesarean section? If it is reasonable for her to make that choice in the setting under discussion, then it is neither reasonable nor logical to deny that choice to a woman who does not have a history of a previous cesarean section. Obstetricians are concerned with balancing freedom
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Choosing vaginal birth or repeat cesarean section
of individual decision making by the patient, with a desire to avoid unnecessary cesarean sections. Truly informed consent can only be provided when the patients understand the medical probabilities, and the physicians understand the social influences and the stepwise process that most patients appear to use in making a decision regarding a vaginal birth after cesarean section or a repeat cesarean section. It may be that our understanding of the social issues would improve if the counseling commenced in the immediate postpartum period after the primary cesarean section. Perhaps parenting classes could be used to "debrief" patients and their families; physicians who are better informed about the patient's social reasoning would feel more confident in negotiating a management that pays more attention to medical probability. There are obvious drawbacks to this type of study. The conclusions have not been submitted to detailed statistical analysis because of the 62% return rate on the original questionnaires. The described perceptions and trends in the responses would suggest that although the physician has a central role in the decisionmaking process, we have yet not found a successful way to advocate vaginal birth after cesarean section as we have for vaginal delivery in many other clinical settings.
ternal and fetal medicine. Washington DC: American College of Obstetricians and Gynecologists, 1988; publican on no. 64 (Oct). Shiono PH, Fielden ]G, McNellis D, et al. Reo~nt trends in cesarean birth and trial of labor rates in:he United States. ]AMA 1987;257:494. Finley BE, Gibbs CE. Emergent cesarean delivery in patients undergoing a trial of labor with a transverse lowersegment scar. AM] OBSTET GYNECOL 1986;155:936-9. McClain CS. Patient decision making: the case of deliv,ery method after a previous cesarean section. Cult Med Psychiatry 1987; 11 :495-508. Newton ER, Higgins CS. Factors associated with hospitalspecific cesarean birth rates. ] Reprod Med 1989;34: 407-11. Berkowitz GS, Fiarman GS, Mojica MA, Bauman ], Haynes de Regt R. Effect of physician characteristics on the cesarean birth rate. AM] OBSTET GYNECOL 19B9; 161:146-9. Gould ]B, Davey B, Stafford RS. Socioeconomic differences in rates of cesarean section. N Engl ] Med 1989;321:233-9. Myers SA, Gleicher N. A successful program to lower cesarean-section rates. N Engl] Med 1988;319:1511-5. Consent: how informed? [Editorial]. Lancet 1984; 1: 1445-7. Feldman GB, Freiman ]A. Prophylactic cesarean section at term? N Engl] Med 1985;312:1264-7.
REFERENCES 1. Jones OH. Cesarean section in present-day obstetrics. AM ] OBSTET GYNECOL 1976;126:521. 2. Rosen MG. The National Institutes of Health Consensus Development Statement on Cesarean Childbirth. ] Reprod Med 1981;26:103-12. 3. Horenstein]M, Eglinton GS, Tahilramaney MP, Boucher M, Phelan ]P. Oxytocin use during a trial of labor in patients with previous cesarean section. ] Reprod Med 1984;29:26-30. 4. Martin]N ]r, Harris BA]r, Huddleston]F, et al. Vaginal delivery following previous cesarean birth. AM] OBSTET GYNECOL 1983; 146:255-63. 5. Meier PR, Porreco RP. Trial of labor following cesarean section-two-year experience. AM ] OBSTET GYNECOL 1982;144:671-8. 6. Lavin]P, Stephens R], Miodovnik M, Barden TP. Vaginal delivery in patients with a prior cesarean section. Obstet GynecoI1982;59:135. 7. Flamm BL, Lim OW, Jones C, Fallon D, Newman LA, Mantis ]K. Vaginal delivery after cesarean section. Results of a multicenter study. AM ] OBSTET GYNECOL 1988; 158:1079-84. 8. Tahilramaney M. Previous cesarean section and trial of scar. Factors related to uterine dehiscence. ] Reprod Med 1984;29:17. 9. Beall M, Eglinton GS, Clark SL, Phelan ]P. Vaginal delivery after cesarean section in women with unknown types of uterine scar.] Reprod Med 1984;29:31-4. 10. Strong TH ]r, Phelan ]P, Ahn MO, Sarno AP Jr. Vaginal birth after cesarean delivery in the twin gestation. AM ] OSSTET GYNECOL 1989;161:29-32. 11. Ophir E, Oettinger M, Yagoda A, Markovits Y, Rojansky N, Shapiro H. Breech presentation after cesarean section: always a section? AM] OBSTET GYNECOL 1989;161:25-8. 12. American College of Obstetricians and Gynecologists Committee Opinion. Guidelines for vaginal delivery after a previous cesarean birth. Committee on obstetrics: ma-
13. 14. 15. 16. 17.
18. 19. 20. 21.
1433
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. JAMES C. CAILLOUETTE, Pasadena, California. The author has contributed to a large body of literature published during the last decade on the subject of vaginal birth after cesarean section. Despite continued recommendations in support of vaginal birth after cesarean section, the rate of cesarean sections has increased. To better understand the dynamics of this issue, a search of the literature was conducted. What we may be surprised to learn is that obstetricians are not searching for ways to avoid a cesarean section, rather they are looking for reasons for doing a cesarean section. The following data support this presumption. The World Health Organization has estimated that approximately 500,000 women die each year from pregnancy-related causes. l More than 98% of these deaths occur in developing countries where vaginal delivery is the rule. Maternal mortality rates in these countries are as much as 100 times higher than those in industrialized countries. The stated most common causes of death are obstructed labor and ruptured uterus, postpartum hemorrhage, eclampsia, infection, and complications of illegal abortion. In a review article in 1987, Petitti 2 stated that, "Beginning in 1969 and continuing through 1983 there was a sharp decline in fetal mortality. Starting in 1969, the positive factors have been family planning, availability of abortion, Medicaid, neonatal intensive care units, electronic fetal monitoring and finally the rising cesarean section rate." In 1988 the late John Figgs Jewett coauthored a paper entitled "Cesarean section-related maternal mortality in Massachusetts from 1954 to 1985."3 The paper reports that "The cesarean section delivery rate in-
1404 Kirk et al.
creased from about 5% in 1954 to 23% in 1984. From 1976 to 1984 the rate of maternal deaths directly related to cesareans section delivery remained essentially unchanged at 5.8/100,000 cesareans as compared to 10.8 maternal deaths per 100,000 vaginal deliveries." This is clear evidence supporting the safety of cesarean section over vaginal delivery in contemporary obstetrics. To further understand the mind-set of today's obstetricians, a few medical-legal facts should be considered. In a National Institutes of Health publication on cesarean childbirth published in 1980, the subject of litigation was considered. 4 The report states that "Ninety percent of all obstetrical malpractice cases fall into two categories: failure to perform a cesarean delivery and improper use of forceps during delivery." A recent issue of Time magazine on the subject of doctors and patients reported that "In 1988, for the first time in more than a decade, medical malpractice suits abated. Claims settlements were down $100 million from the 1987 high of $4.2 billion."5 I am concerned that those who discuss the economics of vaginal birth after cesarean section never discuss the economics oflitigation. The article further stated that "Nearly one quarter of all U.S. births are currently by cesarean section, which can be less risky to the baby than vaginal delivery and makes the doctor less vulnerable in court." When a popular weekly magazine expresses such a clear view of cesarean delivery, is it so difficult to understand the mind-set of today's obstetricians? If reasonable people can agree that malpractice litigation is based on the presumption of a bad outcome, and if it is reasonable to agree that physicians strive for a good outcome, then safe medical practice becomes the issue. This returns us to the issue of vaginal birth after cesarean section. The literature is filled with articles stating that vaginal birth after cesarean section is safe, successful in many cases and should be encouraged, yet it is still not embraced. In a 1988 article titled, "A successful program to lower the cesarean-section rates," the program was not as successful as stated. 6 Myers and Gleicher6 reported a 6.25% fetal mortality rate among 48 infants who were breech deliveries with vaginal birth after cesarean section, a sixfold increase over the national average of 1.06%. In addition, their 5-minute Apgar scores below 7 increased significantly from 3.0% to 4.9%, clearly not a success for vaginal birth after cesarean section. After considering Dr. Kirk's paper, which encourages an increased attempt at vaginal birth after cesarean section, let us consider a different philosophy. Feldman and Freiman 7 have contributed a thought-provoking article titled "Prophylactic cesarean section at term."7 The authors explored a number of questions asked by a plaintiff's lawyer. The final question was: "Don't you think a mother has the right to assume the extra risks of cesarean section for the sake of her unborn if she wishes to?" After citing many of the risks of vaginal delivery, the authors concluded with four important
June 1990 Am J Obstet Gynecol
questions: "In the light of all these considerations, is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal maturity has been reached? If an informed patient opts for prophylactic cesarean section at term, can it be denied? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempt at vaginal delivery? Has something important been overlooked?" I began my resident training at LAC/USC Medical Center 34 years ago. There were 12 obstetricsgynecology residents, and only a volunteer clinical attending staff. We delivered approximately 1000 infants each month and our cesarean section rate was less than 4%. I regret not performing a cesarean in more cases that it is comfortable for me to recall. Valuable lessons were learned at the great expense of patient health and safety. These are lessons that few residents today have occasion to learn. During my training and after 30 years in private practice, I cannot recall a single cesarean that I regret having performed. However, there have been a number of occasions when I regretted a vaginal delivery. With clear evidence that the increase in cesarean sections has resulted in improved outcome, and since vaginal birth after cesarean section is associated with the risk of a bad outcome, would the author address the following questions? First, is the increase in the cesarean section rate in industrialized countries an attempt to achieve the perfect outcome? And second, since university hospitals and private hospitals have different populations and different outcomes, is not the difference of opinion and practice between academicians and clinicians to be expected? REFERENCES 1. Rosenfield A. Maternal mortality in developing countries, an ongoing but neglected epidemic. JAMA 1989;262:376. 2. Petitti D. The epidemiology of fetal death. Clin Obstet Gynecol 1987;30:253. 3. Sachs BP, Yeh J, Acker D, Driscoll S, Brown DAJ, Jewett JF. Cesarean section related maternal mortality in Massachusetts, 1954-1985. Obstet Gynecol 1988;71:385. 4. Cesarean childbirth. Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development. Washington DC: Government Printing Office, 1980; DHHS publication no (NIH) 82-2067. 5. Gibbs N, Dolan B, Gwynne SC, Simpson JC. Sick and tired. Time 1989 July 31:48. 6. Myers SA, Gleicher N. A successful program to lower cesarean section rates. N EnglJ Med 1988;319:1511. 7. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N EnglJ Med 1985;312:1264. DR. LEROY CASPERSON, Portland, Oregon. I went back to the archives after I saw this article in the program. My first patient with a vaginal birth after cesarean section was in 1963. From that time I have generally given the patient the option of a vaginal delivery or a repeat cesarean section. I have no statistics, but I have been impressed by how frequently the vaginally deliv-
Volume 162 Number 6
ered baby was larger than the baby previously delivered by cesarean section for "cephalopelvic disproportion." The current terminology, failure to progress, is more accurate and an improvement. When things go well for a long period, we can become blase over possible complications that we have been warned to anticipate. The admonitions against induction, augmentation, use of epidural anesthesia, etc. are now frequently ignored. We treat many of these women like any other multiparous patient. Approximately 6 weeks ago I cared for a patient of my associate. Her first delivery was by cesarean section because of herpes. Her surgery and recovery were uncomplicated. She entered the hospital at term in early labor and was given an epidural and Pitocin augmentation after many hours of slow progress. At a 2 + station, after a failed manual rotation, I applied Kielland's forceps but was not able to rotate from right occipitoposterior presentation nor affect descent. I decided to do a cesarean section. When the peritoneum was opened, I saw flecks of meconium floating beneath and edematous vesicouterine plica. Beneath this was a total dehiscence of the previous transverse scar with the shoulder partially extruding. With difficulty, I could reach my hand alongside the head to disengage it. A 10 pound, 13 ounce girl with Apgar scores of 3 and 9 was then delivered. There was a T-shaped vertical extension toward the cervix, which I may have created manually because of the extreme thinness of the lower segment. The defects were repaired and she recovered uneventfully. In retrospect, I could identify two episodes of variable decelerations about the time of complete dilatation and the patient said she felt a sharp pain in the right lower quadrant then. Only these two events suggest when the rupture might have occurred. DR. ROBERT GoODLIN, Denver, Colorado. The term vaginal birth after cesarean section was coined in Denver and vaginal births after cesarean sections are popular. In 1989 we had six cases in which the fetus was extruded through the uterine defect. The mothers were all in labor and all had low transverse scars. In two cases in which the patients had epidural anesthesia, the only sign of this problem was severe fetal distress. We wonder now if we should not return to having an operating room available for cases of vaginal birth after cesarean section. That was the case 25 years ago, but we have moved away from this idea. However, in both cases in our hospital, the house officers delivered the fetus within 6 minutes and the infants had good Apgar scores and cord pHs. I do think that we have been too
Choosing vaginal birth or repeat cesarean section
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casual about the problem of uterine rupture in vaginal birth after cesarean section. DR. KIRK (Closing). Dr. Caillouette, maternal mortality in underdeveloped countries is not the issue hel:e. Cesarean sections are badly needed in underdeveloped countries; they do not have proper access to cesarean section. The issue is not decision making or indications for cesarean sections, it is access. I think this is one of the few topics that we cannot learn from medicine in underdeveloped countries. Your comments about Dr. Meyers' paper, I think, are fair but I will point out With respect that Dr. Meyers' three breech infants who were lost were all in mothers without uterine scars. Thdr paper introduced a system for critical evaluation of all indications of cesarean sections. Those three breech deaths raise questions about the management of breech presentations, but not about vaginal birth after cesarean section. Of course, Dr. Goodlin, there is a risk involved wLth uterine ruptures whenever there is a scar in the uterus. I emphasized that it is important to keep that risk in perspective and I think we have not done this. We have tended to overemphasize the risk of uterine rupture but underemphasize the other risks that exist in difficult labors-cord prolapse, placentae abruptio, fetal distress, and difficult deliveries. I asked questions about indicated cesarean sections. What are the indications for repeat cesarean section and what are the social influences that are affecting these decisions? Dr. Caillouette asked two questions: Are we in search of perfection? Are the university hospitals and the private hospitals different? The answer to the first question is yes, but we are far from reaching it and we are being ingenuous if we think we will find perfection by being uncritical about the indications for cesarean section. With regard to the second question, our patient populations are different, but surely clinical judgment and intellectual curiosity are prerequisites for both the community and the academic obstetrician. I think we could learn from Inspector Clousseau of the Pink Panther movies that it is important to ask the right question and to ask it in the right way. You may recall that when Inspector Clousseau went into an inn and saw a dog lying on the floor, he said to the innkeeper "Monsieur, does your dog bite?" The innkeeper said "No." So Inspector Clousseau went up and patted the dog. The dog immediately bit him. Indignantly, Inspector Clousseau said, "But you said your dog didn't bite." And the innkeeper of course said, "Monsieur, that is not my dog."
Key words: Vaginal birth after cesarean, repeat cesarean section, decision making, informed consent
The obstetric revolution of the last two decades has been characterized by the remarkable results in neonatal intensive care units, particularly with low-birthweight infants, the development of the specialty of perinatology with the focus on the fetus as the patient, and new imaging and monitoring equipment to sharpen that focus, and the dramatically increased use of cesarean section as a method of delivery. Features of the revolution have included the virtual elimination of birth trauma and intrapartum fetal asphyxia death, decreasing maternal and perinatal mortality, decreasing morbidity from cesarean section, rising health care costs and, inevitably, an increasing number of women who enter the second pregnancy with the physical scars and the mental memories of the previous pregnancy, labor, and delivery. As this revolution progressed, another revolution was occurring as pregnant women and their advocates in the late 1960s and early 1970s sought to gain more control over their pregnancies. They were anxious to move away from what was seen as the older paternalistic style, often typified by rigid labor practices, standing orders, spinal anesthetics, and elective outlet forceps. The new style was to include more patient autonomy, more flexibility, more expectant management, fewer physical interventions, more effective childbirth prepFrom the Department of Obstetrics and Gynecology, Oregon Health Sciences University. Presented at the Fifty-sixth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Coronado, California, September 17-21,1989. Reprint requests: E. Paul Kirk, MD, Oregon Health Sciences University, 3181 S.W. Samjackson Park Road, Portland, OR 972013098. 616119912
1398
aration, fewer narcotics, and the encouragement of the delivery as a family event with early mother-infant interaction in the neonatal period. By the late 1970s the trend of the rising cesarean section rate was established and proponents were forecasting a continuing progressive rise.! Skeptics doubted that there was any direct relationship between the increased use of cesarean sections and improved perinatal outcome. Experts were called together to halt this trend and to proffer some sound advice regarding the management of abnormal, and therefore difficult labor and the diagnosis of fetal distress. They cautiously suggested that vaginal delivery after a previous transverse, low-segment cesarean section might be safe under certain rigidly controlled conditions. 2 This cautious opinion was based on the limited information available at that time, which implied that these vaginal deliveries carried a much lower risk to mother and fetus than had been assumed by the practice based on Craigin's original threatening dictum: "Once a section-always a section." The last decade has seen an accumulation of experience and data that fully support the consensus recommendation and studies have shown that the risk of uterine rupture is low. 3-6 Consequently, the risk of fetal injury from uterine rupture is very low and importantly, the probability of vaginal delivery is high: 75% to 80% in those women who attempt vaginal birth after cesarean section. More recent studies have responded to some of the previously unanswered questions regarding the safety of vaginal births after cesarean sections with Pitocin administration, epidural anesthetics,7 low vertical incisions," "unknown" scars,9 multiple pregnancies,I° and breech presentations. l1 As the data have
Choosing vaginal birth or repeat cesarean section
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13!J9
Table I. Reasons for women's choice of vaginal birth after cesarean section (percentage) All factors* Hospital A (n = 70)
Danger of cesarean section for mother Danger of cesarean section for infant Longer recovery with cesarean section Wanted experience of vaginal birth "Naturalness" of vaginal birth Financial considerations Other
23
20 61 61
3 20
I
Single most important factort Hospital B (n = 41)
41 29
89 66
7 18
Hospital A (n = 70)
o o
21
19
17
o
43
I
Hospital B (n = 41)
o o
44 27 12 2
15
* Identified from a checklist. t Identified by an open-ended question.
accumulated, public statements have been less cautious. A recent American College of Obstetricians and Gynecologists committee recommended that "The concept of routine repeat cesarean birth should be replaced by a specific indication for a subsequent abdominal delivery, and in the absence of a contraindication, a woman with one previous cesarean delivery with a low transverse incision should be counseled and encouraged to attempt labor in her current pregnancy."12 It would seem that these good results would correspond with the more autonomous style of management of a subsequent pregnancy and that the prospects of a safe delivery, with a good probability of avoiding another abdominal incision, would be enticing. The national experience does not support this assumption. A recent survey published in 1987 showed that 92% of women with a history of previous cesarean sections are delivered by repeat elective surgery and in 50% of the nation's hospitals, a vaginal birth after cesarean section has never been attempted. 13 It is not clear who makes the decision to avoid vaginal births after cesarean section, and why those decisions are made when the clinical data now available would support a much more optimistic approach. In an attempt to understand some of the issues in this clinical management decision, a questionnaire study was undertaken. Material and methods
The study was conducted at two hospitals in the Portland, Oregon metropolitan area: University Hospital (hospital A) and Good Samaritan Hospital (hospital B). Questionnaires were issued to all patients who were delivered of infants between Dec. 1, 1988, and June 30, 1989, who had a history of cesarean section in any of their previous pregnancies. The questionnaires were issued during the postpartum hospital stay; if they were not completed by the time the patient was discharged, one further attempt was made by mail at a later time to have the questionnaire completed. The questionnaires were designed to describe the ethnic and educational characteristics of the different hospital popu-
lations. Separate questionnaires were used for those patients who planned a vaginal birth after cesarean section and for those who chose repeat cesarean section. The questions attempted to identify the patient's perceptions with regard to the management decision and the factors that affected that decision. The answers were collated and comparisons were made between hospital A and hospital B, and between those who chose vaginal birth after cesarean section and those who chose repeat cesarean section. Results
Two hundred fifty-seven questionnaires were distributed; 160 (62%) were returned. Patients planning a vaginal birth after cesarean section at hospital B were more likely to return the questionnaire (73%) than the repeat cesarean section group (47%) (overall return rate from hospital B, 59%). The return rates for vaginal birth after cesarean section and repeat cesarean section groups were virtually identical at hospital A (66% versus 61 %); the overall return rate was 65%. At hospital A there was a total of 1480 births with 265 cesarean sections; the cesarean section rate was 17.8% (14.E,% primary, 3% repeat). At hospital B there were 1245 births; the cesarean section rate was 19%, (13.6% primary, 5.4% repeat). The average age of the patient with a vaginal birth after cesarean section was 27.6 years (range, 17 to ·n years), and for the repeat cesarean section group, 30.6 years (range, 18 to 42 years). Ninety-one percent were married or identified a steady partner. Hospital B respondents tended to have a higher educational level, with 69% of hospital B versus 47% of hospital A patients having some college or a college degree; 19% and 5% of hospital B and hospital A patients, respectively, had a professional degree. Eighty percent of patients from hospital A were white; the remainder came from a variety of minority backgrounds. All but one patient from hospital B were white. Eighty-four percent of patients at hospital A had had their prenatal care at a resident or county clinic, with only half attending for their first prenatal visit in the
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June 1990 Am J Obstet Gynecol
Table II. Time women reported first hearing about vaginal birth after cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A !HosPital B (n = 70) (n = 40)
Never heard about vaginal birth after cesarean section Before current pregnancy First half of current pregnancy Last half of current pregnancy During labor
I(n Both = 110)
Women planning repeat cesarean Hospital A (n = 16)
302 49 65 55 26 30 27 10
3
IHospital B I Both (n = (n = 33)
19 38 12 12
7
3 55 30 3
o
604
49)
8 49 .24 6
0
0
Table III. Timing of decision for vaginal birth after cesarean section or repeat cesarean (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Before current pregnancy First half of current pregnancy Last half of current pregnancy During labor
I
Hospital B (n = 41)
37 54 7 0
23 33 26 9
Table IV. Reasons for choice of repeat cesarean section (percentage) Women planning repeat cesarean Hospital A (n = 15)
Danger of vaginal birth after cesarean section for mother Danger of vaginal birth after cesarean section for infant Avoid pain of labor Convenience of timing birth Low probability of vaginal delivery Knew what to expect
Both (n = 48)
33
21
25
20
33
29
20 13
49 33
40 27
33
61
52
27
42
38
first trimester. At hospital B, 95% of the prenatal care was in a private office, and 90% of the first visits were in the first trimester. The responses to the question regarding reasons women chose vaginal birth after cesarean section are summarized in Table I. Half the patients were aware of vaginal birth after cesarean section as an option before conception (Table II). The patients from hospital A had no clear pattern in the timing of the decision, whereas patients at hospital B tended to make the decision for vaginal birth after cesarean section early in pregnancy and for repeat cesarean section, late in pregnancy (Table III). The patient's reason(s) for choosing an elective re-
I
(n
Both = 110)
28 40 19 5
Women planning repeat cesarean Hospital A (n = 15)
27 27 20 13
I
Hospital B (n = 33)
9 24 58 6
I
(n
Both =
48)
15 25 46 8
peat cesarean section are listed in Table IV. The patient's perceptions of her chances of vaginal delivery are shown in Table V. The majority of patients identified themselves as the decision maker either alone (55%) or in conjunction with the physician (34%), although the physician alone was identified as the decision maker in 11 % of hospital A vaginal births after cesarean sections, and 33% of hospital A repeat cesarean sections (Table VI). The patient's perceptions of the physician's attitude toward vaginal birth after cesarean section are listed in Table VII. Even though the patient perceived herself as being the primary decision maker, 64% and 46%, respectively, identified the physician and the husband or partner as having "a lot" of influence on the decision. "Others" (friends, parents, siblings, nurses, childbirth educators) were more likely to influence the decision when a vaginal birth after cesarean section was chosen. This difference was more obvious with patients from hospital A (Table VIII); physician influence was stronger at hospital A than at hospital B: 69% of patients at hospital A versus 59% of patients at hospital B stated their physicians had "a lot" of influence. In the 25 patients who had a repeat cesarean section after a failed vaginal birth after cesarean section, 52% were for management of failure to progress and 40% were for management of fetal distress. Of those 25, 48% said that they would never try vaginal birth after cesarean section again, whereas 20% said that they would definitely try again. Only 27% of patients planning a vaginal birth after cesarean section and 20% of repeat cesarean section patients attended a prenatal class. Patients from hospital B were more
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Table V. Women's perceptions of their chance to deliver vaginally (percentage) Women planning vaginal birth after cesarean section
I
Women planning repeat cesarea,'l
I
Hospital A Hospital B Both Hospital A (n = 41) (n = 110) (n = 16) (n = 69)
Poor «25%) Fair (25% to 50%) Good (75%) Excellent (>90%) Unaware of vaginal birth after cesarean section as option
12 22
23
19 38 20
o
19
50
20
19
o
6 13
12
43 18
51 15
o
IHospital B I Both (n 33) (n 49) =
=
49 24 12
49 22
12
9 6
8 8
Table VI. Women's perception of who made the decision for vaginal birth after cesarean section or repeat cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Self
Physician Both Other
53 11 36 6
I
Hospital B (n = 41)
I
Women planning repeat cesarean
Both
Hospital A
(n = 111)
(n = 15)
56 8 35 4
33
61
2
36
o
likely to attend prenatal classes than those from hospital A (34% vs 17%).
Comment Although there has been extensive discussion of the lack of necessity to perform a repeat cesarean section in the light of the proven safety of vaginal birth after cesarean section, only 8% of women in the nationwide survey underwent a trial of labor in 1984. The likelihood of a trial increased with the size of the obstetric service, and it is likely that some of the reluctance to permit a trial may be related to the availability of emergency services, although it is important to note that other intrapartum catastrophes occur more frequently than uterine rupture. 14 Even on larger obstetric services, the rates of vaginal birth after cesarean section did not exceed 25%, and there is uncertainty whether this is because the physicians do not allow trials of labor, or that mothers do not want to experience them. Within the admitted limitations of a questionnaire study, some patterns appear to emerge. Both hospitals in the study have a relatively low cesarean section rate by modern standards, and each promotes vaginal birth after cesarean section. The population in hospital B is almost exclusively white, better educated, and receives prenatal care early through private physician offices. At hospital A, the population is ethnically heterogeneous, is less well educated, and is likely to receive prenatal care later from a variety of providers in different settings, most of
33
27
7
I
Hospital B (n = 33)
61 3 33 3
I
Both (n = 48)
52
13 31 4
whom would not provide longitudinal care through delivery. In general, women from hospital B gave better defined opinions (Table IV), and the troika of the patient, partner, and physician seemed more important (Table VI). They tended to make the decision for vaginal birth after cesarean section earlier in the pregnancy but left the decision for a repeat cesarean section later. Both groups were reasonably well informed about vaginal birth after cesarean section, but their information was not always accurate. The women who chose repeat cesarean section were particularly pessimistic about their chances of a vaginal delivery, which was almost certainly a factor in the management decision. The patients from hospital A, who were relying on the physician, were more likely to receive information and support from other health care providers, family, and friends. The better educated group did not appear more interested in or more likely to choose vaginal birth after cesarean section, as has been previously reported by McClain. 15 The reasons for choosing vaginal birth after cesarean section (recovery period, wanting the experience) and for choosing repeat cesarean section (knowing what to expect, avoiding the pain of labor, convenience, and timing) confirmed the social rather than the medical model of the decision making. The exception to this was "the belief that the chance of vaginal delivery was poor," which is a misappreciation of the medical probability rather than an appreciation. Although there are extensive reports in the literature
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June 1990 Am J Obstet Gynecol
Table VII. Women's perception of physician's attitude toward vaginal birth after cesarean section (percentage) Women planning vaginal birth after cesarean section Hospital A (n = 70)
Encouraged vaginal birth after cesarean section Discouraged vaginal birth after cesarean section Neutral Don't know
74
95
82
10 16
10 0
10 10
o
Table VIII. Women's perception of amount of influence by "others" on decision for vaginal birth after cesarean section or repeat cesarean as "some" or "a lot" (percentage)
"Others" influencing decision
Friends Doctor Nurse Childbirth educator Husband-partner Parent(s) Siblings
Women choosing vaginal birth after cesarean section (n = variable)
Women choosing repeat cesarean (n = variable)
47 86 61 40
15 79 24 13
43 29
5
81
I Hospital B I B oth (n = 40) (n = 110)
72 21
that analyze the factors that affect the cesarean section rates in various settings, [6. [7 and various descriptions of policy that have successfully reduced the cesarean section rates, [8. [9 there is little information about the decision-making process in individual cases. Through a series of structured interviews of 100 patients, McClain [5 emphasized that all women made choices that were shaped by social exigencies and constraints, and that none engaged in probabilistic evaluation of medical risk, choosing instead to develop negotiation strategies that would enhance control of uncertainties, such as the length and pain of labor. In this study, although the physicians were identified as an important part of the decision-making process, patients in hospital A were not always able to identify what the physicians' attitudes were, possibly because of the lack of longitudinal care. Clearly, decisions are made either in favor of vaginal birth after cesarean section or repeat cesarean section, and this study raises questions about the nature of informed consent. 20 Ten years ago when vaginal birth after cesarean section was considered unsafe and 98% of women had repeat cesarean sections on the basis of the physician's concern for the risks of uterine rupture, the consent was, in a sense, uninformed because it reflected old data. It now appears that many women choose repeat cesarean section, an equally uninformed choice when assessed from
0
0
Women planning repeat cesarean Hospital A (n = 16)
31 25 19 25
I Hospital B I (n
= 33) 24 21 52
3
(n
Both = 49)
26 22 41
10
the point of view of medical risk, but one that makes social sense because it respects individual preference. It appears that physicians are likely to collude with this choice, perhaps out of respect for patient autonomy, a reluctance to change long-held positions, a wish to avoid a failed vaginal birth after cesarean sectio~ in up to 25% of cases, or fear of litigation. It is not possible to determine how well patients were informed in this study, nor how free was their consent. Seventy-three percent of patients who had a repeat cesarean section reported that their physicians either discouraged vaginal birth after cesarean section or had either neutral or unknown attitudes, although 26% chose to have a repeat cesarean section despite the physician's encouragement of vaginal birth after cesarean section. This in turn raises the question: Should the decision be simply the choice of the patient, a truly elective repeat cesarean section? By means of a mathematic probabilistic model, Feldman and Freeman 2 [ made a cogent argument for the consideration of prophylactic cesarean section at term in all pregnancies. An essential part of that argument was the significantly reduced maternal risk of elective cesarean section. Coupled with the lack of any convincing evidence that properly consented elective cesarean sections cause any prolonged postpartum depression or maternal infant interaction difficulties, the elective cesarean section appears to be a reasonable choice. Two ethical considerations remain. First, how far should the obstetric community control individual decisions within the context of increasing costs, limited resources, widespread pregnancy indigency, and managed health care programs? It is clear that clinicians do not practice in a vacuum; whenever a decision is made to perform a cesarean section, it affects the total pattern of obstetric practice, which in turn affects the standard of care. Second, should the patient be free to make a choice for repeat cesarean section? If it is reasonable for her to make that choice in the setting under discussion, then it is neither reasonable nor logical to deny that choice to a woman who does not have a history of a previous cesarean section. Obstetricians are concerned with balancing freedom
Volume 162 Number 6
Choosing vaginal birth or repeat cesarean section
of individual decision making by the patient, with a desire to avoid unnecessary cesarean sections. Truly informed consent can only be provided when the patients understand the medical probabilities, and the physicians understand the social influences and the stepwise process that most patients appear to use in making a decision regarding a vaginal birth after cesarean section or a repeat cesarean section. It may be that our understanding of the social issues would improve if the counseling commenced in the immediate postpartum period after the primary cesarean section. Perhaps parenting classes could be used to "debrief" patients and their families; physicians who are better informed about the patient's social reasoning would feel more confident in negotiating a management that pays more attention to medical probability. There are obvious drawbacks to this type of study. The conclusions have not been submitted to detailed statistical analysis because of the 62% return rate on the original questionnaires. The described perceptions and trends in the responses would suggest that although the physician has a central role in the decisionmaking process, we have yet not found a successful way to advocate vaginal birth after cesarean section as we have for vaginal delivery in many other clinical settings.
ternal and fetal medicine. Washington DC: American College of Obstetricians and Gynecologists, 1988; publican on no. 64 (Oct). Shiono PH, Fielden ]G, McNellis D, et al. Reo~nt trends in cesarean birth and trial of labor rates in:he United States. ]AMA 1987;257:494. Finley BE, Gibbs CE. Emergent cesarean delivery in patients undergoing a trial of labor with a transverse lowersegment scar. AM] OBSTET GYNECOL 1986;155:936-9. McClain CS. Patient decision making: the case of deliv,ery method after a previous cesarean section. Cult Med Psychiatry 1987; 11 :495-508. Newton ER, Higgins CS. Factors associated with hospitalspecific cesarean birth rates. ] Reprod Med 1989;34: 407-11. Berkowitz GS, Fiarman GS, Mojica MA, Bauman ], Haynes de Regt R. Effect of physician characteristics on the cesarean birth rate. AM] OBSTET GYNECOL 19B9; 161:146-9. Gould ]B, Davey B, Stafford RS. Socioeconomic differences in rates of cesarean section. N Engl ] Med 1989;321:233-9. Myers SA, Gleicher N. A successful program to lower cesarean-section rates. N Engl] Med 1988;319:1511-5. Consent: how informed? [Editorial]. Lancet 1984; 1: 1445-7. Feldman GB, Freiman ]A. Prophylactic cesarean section at term? N Engl] Med 1985;312:1264-7.
REFERENCES 1. Jones OH. Cesarean section in present-day obstetrics. AM ] OBSTET GYNECOL 1976;126:521. 2. Rosen MG. The National Institutes of Health Consensus Development Statement on Cesarean Childbirth. ] Reprod Med 1981;26:103-12. 3. Horenstein]M, Eglinton GS, Tahilramaney MP, Boucher M, Phelan ]P. Oxytocin use during a trial of labor in patients with previous cesarean section. ] Reprod Med 1984;29:26-30. 4. Martin]N ]r, Harris BA]r, Huddleston]F, et al. Vaginal delivery following previous cesarean birth. AM] OBSTET GYNECOL 1983; 146:255-63. 5. Meier PR, Porreco RP. Trial of labor following cesarean section-two-year experience. AM ] OBSTET GYNECOL 1982;144:671-8. 6. Lavin]P, Stephens R], Miodovnik M, Barden TP. Vaginal delivery in patients with a prior cesarean section. Obstet GynecoI1982;59:135. 7. Flamm BL, Lim OW, Jones C, Fallon D, Newman LA, Mantis ]K. Vaginal delivery after cesarean section. Results of a multicenter study. AM ] OBSTET GYNECOL 1988; 158:1079-84. 8. Tahilramaney M. Previous cesarean section and trial of scar. Factors related to uterine dehiscence. ] Reprod Med 1984;29:17. 9. Beall M, Eglinton GS, Clark SL, Phelan ]P. Vaginal delivery after cesarean section in women with unknown types of uterine scar.] Reprod Med 1984;29:31-4. 10. Strong TH ]r, Phelan ]P, Ahn MO, Sarno AP Jr. Vaginal birth after cesarean delivery in the twin gestation. AM ] OSSTET GYNECOL 1989;161:29-32. 11. Ophir E, Oettinger M, Yagoda A, Markovits Y, Rojansky N, Shapiro H. Breech presentation after cesarean section: always a section? AM] OBSTET GYNECOL 1989;161:25-8. 12. American College of Obstetricians and Gynecologists Committee Opinion. Guidelines for vaginal delivery after a previous cesarean birth. Committee on obstetrics: ma-
13. 14. 15. 16. 17.
18. 19. 20. 21.
1433
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. JAMES C. CAILLOUETTE, Pasadena, California. The author has contributed to a large body of literature published during the last decade on the subject of vaginal birth after cesarean section. Despite continued recommendations in support of vaginal birth after cesarean section, the rate of cesarean sections has increased. To better understand the dynamics of this issue, a search of the literature was conducted. What we may be surprised to learn is that obstetricians are not searching for ways to avoid a cesarean section, rather they are looking for reasons for doing a cesarean section. The following data support this presumption. The World Health Organization has estimated that approximately 500,000 women die each year from pregnancy-related causes. l More than 98% of these deaths occur in developing countries where vaginal delivery is the rule. Maternal mortality rates in these countries are as much as 100 times higher than those in industrialized countries. The stated most common causes of death are obstructed labor and ruptured uterus, postpartum hemorrhage, eclampsia, infection, and complications of illegal abortion. In a review article in 1987, Petitti 2 stated that, "Beginning in 1969 and continuing through 1983 there was a sharp decline in fetal mortality. Starting in 1969, the positive factors have been family planning, availability of abortion, Medicaid, neonatal intensive care units, electronic fetal monitoring and finally the rising cesarean section rate." In 1988 the late John Figgs Jewett coauthored a paper entitled "Cesarean section-related maternal mortality in Massachusetts from 1954 to 1985."3 The paper reports that "The cesarean section delivery rate in-
1404 Kirk et al.
creased from about 5% in 1954 to 23% in 1984. From 1976 to 1984 the rate of maternal deaths directly related to cesareans section delivery remained essentially unchanged at 5.8/100,000 cesareans as compared to 10.8 maternal deaths per 100,000 vaginal deliveries." This is clear evidence supporting the safety of cesarean section over vaginal delivery in contemporary obstetrics. To further understand the mind-set of today's obstetricians, a few medical-legal facts should be considered. In a National Institutes of Health publication on cesarean childbirth published in 1980, the subject of litigation was considered. 4 The report states that "Ninety percent of all obstetrical malpractice cases fall into two categories: failure to perform a cesarean delivery and improper use of forceps during delivery." A recent issue of Time magazine on the subject of doctors and patients reported that "In 1988, for the first time in more than a decade, medical malpractice suits abated. Claims settlements were down $100 million from the 1987 high of $4.2 billion."5 I am concerned that those who discuss the economics of vaginal birth after cesarean section never discuss the economics oflitigation. The article further stated that "Nearly one quarter of all U.S. births are currently by cesarean section, which can be less risky to the baby than vaginal delivery and makes the doctor less vulnerable in court." When a popular weekly magazine expresses such a clear view of cesarean delivery, is it so difficult to understand the mind-set of today's obstetricians? If reasonable people can agree that malpractice litigation is based on the presumption of a bad outcome, and if it is reasonable to agree that physicians strive for a good outcome, then safe medical practice becomes the issue. This returns us to the issue of vaginal birth after cesarean section. The literature is filled with articles stating that vaginal birth after cesarean section is safe, successful in many cases and should be encouraged, yet it is still not embraced. In a 1988 article titled, "A successful program to lower the cesarean-section rates," the program was not as successful as stated. 6 Myers and Gleicher6 reported a 6.25% fetal mortality rate among 48 infants who were breech deliveries with vaginal birth after cesarean section, a sixfold increase over the national average of 1.06%. In addition, their 5-minute Apgar scores below 7 increased significantly from 3.0% to 4.9%, clearly not a success for vaginal birth after cesarean section. After considering Dr. Kirk's paper, which encourages an increased attempt at vaginal birth after cesarean section, let us consider a different philosophy. Feldman and Freiman 7 have contributed a thought-provoking article titled "Prophylactic cesarean section at term."7 The authors explored a number of questions asked by a plaintiff's lawyer. The final question was: "Don't you think a mother has the right to assume the extra risks of cesarean section for the sake of her unborn if she wishes to?" After citing many of the risks of vaginal delivery, the authors concluded with four important
June 1990 Am J Obstet Gynecol
questions: "In the light of all these considerations, is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal maturity has been reached? If an informed patient opts for prophylactic cesarean section at term, can it be denied? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempt at vaginal delivery? Has something important been overlooked?" I began my resident training at LAC/USC Medical Center 34 years ago. There were 12 obstetricsgynecology residents, and only a volunteer clinical attending staff. We delivered approximately 1000 infants each month and our cesarean section rate was less than 4%. I regret not performing a cesarean in more cases that it is comfortable for me to recall. Valuable lessons were learned at the great expense of patient health and safety. These are lessons that few residents today have occasion to learn. During my training and after 30 years in private practice, I cannot recall a single cesarean that I regret having performed. However, there have been a number of occasions when I regretted a vaginal delivery. With clear evidence that the increase in cesarean sections has resulted in improved outcome, and since vaginal birth after cesarean section is associated with the risk of a bad outcome, would the author address the following questions? First, is the increase in the cesarean section rate in industrialized countries an attempt to achieve the perfect outcome? And second, since university hospitals and private hospitals have different populations and different outcomes, is not the difference of opinion and practice between academicians and clinicians to be expected? REFERENCES 1. Rosenfield A. Maternal mortality in developing countries, an ongoing but neglected epidemic. JAMA 1989;262:376. 2. Petitti D. The epidemiology of fetal death. Clin Obstet Gynecol 1987;30:253. 3. Sachs BP, Yeh J, Acker D, Driscoll S, Brown DAJ, Jewett JF. Cesarean section related maternal mortality in Massachusetts, 1954-1985. Obstet Gynecol 1988;71:385. 4. Cesarean childbirth. Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development. Washington DC: Government Printing Office, 1980; DHHS publication no (NIH) 82-2067. 5. Gibbs N, Dolan B, Gwynne SC, Simpson JC. Sick and tired. Time 1989 July 31:48. 6. Myers SA, Gleicher N. A successful program to lower cesarean section rates. N EnglJ Med 1988;319:1511. 7. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N EnglJ Med 1985;312:1264. DR. LEROY CASPERSON, Portland, Oregon. I went back to the archives after I saw this article in the program. My first patient with a vaginal birth after cesarean section was in 1963. From that time I have generally given the patient the option of a vaginal delivery or a repeat cesarean section. I have no statistics, but I have been impressed by how frequently the vaginally deliv-
Volume 162 Number 6
ered baby was larger than the baby previously delivered by cesarean section for "cephalopelvic disproportion." The current terminology, failure to progress, is more accurate and an improvement. When things go well for a long period, we can become blase over possible complications that we have been warned to anticipate. The admonitions against induction, augmentation, use of epidural anesthesia, etc. are now frequently ignored. We treat many of these women like any other multiparous patient. Approximately 6 weeks ago I cared for a patient of my associate. Her first delivery was by cesarean section because of herpes. Her surgery and recovery were uncomplicated. She entered the hospital at term in early labor and was given an epidural and Pitocin augmentation after many hours of slow progress. At a 2 + station, after a failed manual rotation, I applied Kielland's forceps but was not able to rotate from right occipitoposterior presentation nor affect descent. I decided to do a cesarean section. When the peritoneum was opened, I saw flecks of meconium floating beneath and edematous vesicouterine plica. Beneath this was a total dehiscence of the previous transverse scar with the shoulder partially extruding. With difficulty, I could reach my hand alongside the head to disengage it. A 10 pound, 13 ounce girl with Apgar scores of 3 and 9 was then delivered. There was a T-shaped vertical extension toward the cervix, which I may have created manually because of the extreme thinness of the lower segment. The defects were repaired and she recovered uneventfully. In retrospect, I could identify two episodes of variable decelerations about the time of complete dilatation and the patient said she felt a sharp pain in the right lower quadrant then. Only these two events suggest when the rupture might have occurred. DR. ROBERT GoODLIN, Denver, Colorado. The term vaginal birth after cesarean section was coined in Denver and vaginal births after cesarean sections are popular. In 1989 we had six cases in which the fetus was extruded through the uterine defect. The mothers were all in labor and all had low transverse scars. In two cases in which the patients had epidural anesthesia, the only sign of this problem was severe fetal distress. We wonder now if we should not return to having an operating room available for cases of vaginal birth after cesarean section. That was the case 25 years ago, but we have moved away from this idea. However, in both cases in our hospital, the house officers delivered the fetus within 6 minutes and the infants had good Apgar scores and cord pHs. I do think that we have been too
Choosing vaginal birth or repeat cesarean section
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casual about the problem of uterine rupture in vaginal birth after cesarean section. DR. KIRK (Closing). Dr. Caillouette, maternal mortality in underdeveloped countries is not the issue hel:e. Cesarean sections are badly needed in underdeveloped countries; they do not have proper access to cesarean section. The issue is not decision making or indications for cesarean sections, it is access. I think this is one of the few topics that we cannot learn from medicine in underdeveloped countries. Your comments about Dr. Meyers' paper, I think, are fair but I will point out With respect that Dr. Meyers' three breech infants who were lost were all in mothers without uterine scars. Thdr paper introduced a system for critical evaluation of all indications of cesarean sections. Those three breech deaths raise questions about the management of breech presentations, but not about vaginal birth after cesarean section. Of course, Dr. Goodlin, there is a risk involved wLth uterine ruptures whenever there is a scar in the uterus. I emphasized that it is important to keep that risk in perspective and I think we have not done this. We have tended to overemphasize the risk of uterine rupture but underemphasize the other risks that exist in difficult labors-cord prolapse, placentae abruptio, fetal distress, and difficult deliveries. I asked questions about indicated cesarean sections. What are the indications for repeat cesarean section and what are the social influences that are affecting these decisions? Dr. Caillouette asked two questions: Are we in search of perfection? Are the university hospitals and the private hospitals different? The answer to the first question is yes, but we are far from reaching it and we are being ingenuous if we think we will find perfection by being uncritical about the indications for cesarean section. With regard to the second question, our patient populations are different, but surely clinical judgment and intellectual curiosity are prerequisites for both the community and the academic obstetrician. I think we could learn from Inspector Clousseau of the Pink Panther movies that it is important to ask the right question and to ask it in the right way. You may recall that when Inspector Clousseau went into an inn and saw a dog lying on the floor, he said to the innkeeper "Monsieur, does your dog bite?" The innkeeper said "No." So Inspector Clousseau went up and patted the dog. The dog immediately bit him. Indignantly, Inspector Clousseau said, "But you said your dog didn't bite." And the innkeeper of course said, "Monsieur, that is not my dog."
