Barriers to labor after cesarean: A survey of United States midwives

Abstract

Introduction Despite calls for increased vaginal birth after cesarean (VBAC), <14% of candidates have VBAC. Requirements for documentation of scar type, and prohibitions on induction or augmentation of labor are not supported by evidence but may be widespread. The purpose of this study was to document midwives’ perceptions of barriers to labor after cesarean (LAC) and their effects on midwives’ ability to accommodate patient desires for LAC. Methods Midwives certified by the American Midwifery Certification Board (AMCB) were surveyed in 2019. Multiple option and open‐ended text responses were analyzed using quantitative statistics and thematic content analysis. Select barriers to LAC, ability to accommodate LAC, and supportiveness of collaborators among midwives offering LAC were explored. Results Responses from 1398 midwives were analyzed. Eighty‐four percent felt able to accommodate LAC “most of the time,” and 39% reported one or more barriers to LAC. Barriers decreased ability to accommodate LAC by as much as 80%. Analysis of text responses revealed specific themes. Conclusions Thirty‐nine percent of midwives reported their practice was limited by one or more barriers that were inconsistent with professional guidelines. Imposition of barriers was driven primarily by collaborating physicians, and superceded supportive practices of midwives, nurses, and system administrators. Affected midwives were significantly less able to accommodate patient requests for LAC than those not affected. Midwives also reported pride in providing VBAC care, restrictions specific to midwifery scope of practice, and variation in physician support for LAC within practices affecting their ability to provide care.

How to Foster Effective Midwife–Obstetrician Collaboration on Labor and Birth Units: Qualitative Analysis of Experiences of Clinicians in the United States

“…Individual variability and need for clear guidelines was another major theme in this study that has been highlighted in prior publications 18,20 . A study on the perspectives of CNMs/CMs on barriers to childbearing persons laboring after cesarean birth highlighted the impact of variability in the collaborating physician's comfort level on supporting access to this option 29 . Avery and colleagues mentioned the importance of using practice guidelines and clinical evidence to resolve disagreements in plans of care and listening to the needs of the childbearing person 18 .…”

“…The qualitative methodology of this study would have been more robust with conduction of in‐depth semistructured interviews to specifically explore participants’ experiences with collaborative practice. However, this study is similar to other studies that have used the methodology of qualitative analysis of in‐depth comments to produce insightful information 29,33 . The use of qualitative methodology in this study limits the ability to give weight to the various themes in terms of their impact on collaborative practice; however, it allowed for more nuanced exploration of lived experiences.…”

“…18,20 A study on the perspectives of CNMs/CMs on barriers to childbearing persons laboring after cesarean birth highlighted the impact of variability in the collaborating physician's comfort level on supporting access to this option. 29 Avery and colleagues mentioned the importance of using practice guidelines and clinical evidence to resolve disagreements in plans of care and listening to the needs of the childbearing person. 18 Professional organizations have guidelines on collaborative practice, team-based care, and clinical management.…”

“…However, this study is similar to other studies that have used the methodology of qualitative analysis of in-depth comments to produce insightful information. 29,33 The use of qualitative methodology in this study limits the ability to give weight to the various themes in terms of their impact on collaborative practice; however, it allowed for more nuanced exploration of lived experiences.…”

Hospital factors associated with maternal and neonatal outcomes of deliveries to patients with a previous cesarean delivery: an ecological study

“…The 1998 and 1999 guidelines of the American College of Obstetricians and Gynecologists (ACOG) required hospitals attempting trials of labour to have “ready availability of emergency care” or “immediate availability of emergency care.” 12 , 13 After the publication of these guidelines, about 30% of hospitals in the US stopped offering trial-of-labour services to patients with a previous cesarean delivery because they could not provide immediate surgical and anesthesia services, which compelled many patients who had opted for a trial of labour to travel to hospitals far from their homes and families. 14 – 16 More recently, guidelines have attempted to balance clinical safety with the challenges associated with such social disruption. The current ACOG guideline states that a trial of labour can be attempted in a level 1 maternity care facility (i.e., a hospital providing basic obstetric services), which has “the ability to begin emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits.” 17 Similarly, the current SOGC guideline states that hospitals providing trial-of-labour services should have “the resources to perform an emergency cesarean section.” 18 This change in recommendations has led to an increase in the number of hospitals that offer trials of labour, though concerns about inadequate access to such delivery options persist.…”