Meeting the challenge of maternal choice in mode of delivery with vaginal birth after caesarean section: a medical, legal and ethical commentary

Abstract

Please cite this paper as: Dexter SC, Windsor S, Watkinson SJ. Meeting the challenge of maternal choice in mode of delivery with vaginal birth after caesarean section: a medical, legal and ethical commentary. BJOG 2014;121:133-140. IntroductionBirths by caesarean section constitute about 25% of our births in the UK.1 Therefore a substantial number of our obstetric patients will have this risk factor in their future pregnancies. Every labour and delivery carries risks to both the mother and baby, and obstetric care is centred on identifying risks, counselling women on the relative risks of various options, and seeking to adopt the choice that carries a favourable risk-benefit profile. Evidence shows that vaginal birth after caesarean section (VBAC) is sufficiently safe for the majority of women with one previous lower segment incision, and is supported by the Royal College of Obstetricians (RCOG). It is advised that VBAC labours are undertaken in hospitals with facilities for emergency surgery and advanced neonatal resuscitation, with continuous electronic fetal monitoring and intravenous access. 2In most VBAC cases, women will follow medical advice on labour and delivery. However, there are a small number of women who wish to consider VBAC in circumstances other than those recommended. Such nonconventional circumstances are perceived to bring maternal autonomy into conflict with a reasonable degree of maternal and fetal safety, which can be distressing and challenging to healthcare professionals.Patient-centred practice is the current UK standard of care, and is actively promoted by the UK Government and the National Institute for Health and Clinical Excellence. The NHS Constitution 4 sets out patients' rights within the NHS, fundamentally placing patients at the centre of the decision-making process about the care they receive. The days when paternalistic doctors would dictate patient treatment should be gone.With a rising caesarean section rate across the world, 5VBAC labours are relatively commonplace and so we are more likely to come across nonconventional birth plans. In this article, we discuss some of the factors that influence decisions regarding mode of delivery following a previous caesarean section, and briefly cover the English legal background to these discussions and decisions. We recognise that the legal framework in regard to women's rights, fetal rights and the age of majority, vary between individual countries and as such it would be impossible to discuss all permutations. We encourage readers to ensure that they know the legal requirements in their country of practice, but believe that the general ethical principles and approach to challenging cases are similar.In the hope of avoiding alienating women from standard obstetric and midwifery care, we also suggest ways to optimally manage these insistent women in the antenatal period to achieve a balance between empowering a woman to maintain maternal choice and autonomy, and promoting reasonable safety for both mother and baby in the current and ...

Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making

“…This involves a process of shared decision making that utilizes effective risk communication techniques to provide full disclosure of the risks and benefits of the situation while respecting autonomy . In the event the birth does not proceed as planned, open communication and documentation of decision making have been shown to reduce provider liability . This may serve to alleviate reluctance of practitioners that are currently wary of offering TOLAC.…”

“…In a recent commentary from the United Kingdom, Dexter et al proposed that safe and acceptable compromises are possible when a woman with a previous cesarean requests an “unconventional” birth plan, such as a home VBAC . In this model, the consultant obstetrician works with the woman, her family, and the midwives to negotiate a safe, acceptable plan for the birth . This involves a process of shared decision making that utilizes effective risk communication techniques to provide full disclosure of the risks and benefits of the situation while respecting autonomy .…”

“…In this model, the consultant obstetrician works with the woman, her family, and the midwives to negotiate a safe, acceptable plan for the birth . This involves a process of shared decision making that utilizes effective risk communication techniques to provide full disclosure of the risks and benefits of the situation while respecting autonomy . In the event the birth does not proceed as planned, open communication and documentation of decision making have been shown to reduce provider liability .…”

“…Two recent studies of birth outcomes in German out‐of‐hospital settings indicate that good outcomes are possible with stringent client selection criteria and a low threshold for transfer . In a recent commentary from the United Kingdom, Dexter et al proposed that safe and acceptable compromises are possible when a woman with a previous cesarean requests an “unconventional” birth plan, such as a home VBAC . In this model, the consultant obstetrician works with the woman, her family, and the midwives to negotiate a safe, acceptable plan for the birth .…”

Antenatal discussion of the risks and benefits of VBAC and ERCS

“…We read with interest the BJOG themed issue on ‘Management of pregnancy after caesarean section’. The articles were informative and directly applicable to patient care, in particular the commentary by Dexter et al . and the cohort study by Knight et al .…”