Providers' perspectives on the vaginal birth after cesarean guidelines in Florida, United States: a qualitative study

Abstract

BackgroundWomen's access to vaginal birth after cesarean (VBAC) in the United States has declined steadily since the mid-1990s, with a current rate of 8.2%. In the State of Florida, less than 1% of women with a previous cesarean deliver vaginally. This downturn is thought to be largely related to the American College of Obstetricians and Gynecologists (ACOG) VBAC guidelines, which mandate that a physician and anesthesiologist be "immediately available" during a trial of labor. The aim of this exploratory qualitative study was to explore the barriers associated with the ACOG VBAC guidelines, as well as the strategies that obstetricians and midwives use to minimize their legal risks when offering a trial of labor after cesarean.MethodsSemi-structured interviews were conducted with 11 obstetricians, 12 midwives, and a hospital administrator (n = 24). Interviews were recorded and transcribed verbatim, and thematic analysis informed the findings.ResultsFear of liability was a central reason for obstetricians and midwives to avoid attending VBACs. Providers who continued to offer a trial of labor attempted to minimize their legal risks by being highly selective in choosing potential candidates. Definitions of "immediately available" varied widely among hospitals, and providers in solo or small practices often favored the convenience of a repeat cesarean delivery rather than having to remain in-house during a trial of labor. Midwives were often marginalized due to restrictive hospital policies and by their consulting physicians, even though women with previous cesareans were actively seeking their care.ConclusionsThe current ACOG VBAC guidelines limit US obstetricians' and midwives' ability to provide care for women with a previous cesarean, particularly in community and rural hospitals. Although ACOG has proposed that women be allowed to accept "higher levels of risk" in order to be able to attempt a trial of labor in some settings, access to VBAC is unlikely to increase in Florida as long as systemic barriers and liability risks remain high.

Counseling Women with a Previous Cesarean Birth: Toward a Shared Decision‐Making Partnership

“…Moreover, a provider who is an employee of an institution that does not allow TOLAC may be pressured to counsel a woman toward an ERCD, even if his or her personal and professional views differ. Like the women they serve, providers may also experience a high level of decisional conflict, particularly if their own values conflict with their current hospital policies and practice guidelines …”

“…What these findings suggest is that providers encounter a variety of challenges in counseling women who have had a cesarean about their options for the next birth. Fear of liability, the requirement for immediate availability of both a surgeon and an anesthesia provider during labor, hospital restrictions against TOLAC, personal discomfort with TOLAC, and women's lack of knowledge about the options available are but a few of the problems that providers encounter …”

A survey of access to trial of labor in California hospitals in 2012

“…Then, in 1999, ACOG re-issued its guideline in which the only changes were to replace physicians be ‘readily available’ with “immediately available”, and stipulated that 24-hour in-hospital anesthesia should also be available [6]. In the wake of these guidelines, the cesarean delivery rate in the United States rose from 21% to 32.8% between 1996 and 2010 [7] and the vaginal birth after cesarean (VBAC) rate (per 100 women with a prior cesarean) dropped from 28% to 8% [8]. In response to the rising cesarean rate, the decline in VBAC, and the intense focus on a rare outcome (0.5% for uterine rupture among TOLAC women) [9], the National Institutes of Health (NIH) convened a Consensus Development Conference Panel in March 2010 to address key questions surrounding the practice of TOLAC.…”

Maternal and perinatal effects of vaginal delivery after caesarean section

“…The incidence of uterine rupture varies between 1-2% [11]. The risks for neonatal ventilation with mask; amniotic fluid with meconium and neonatal sepsis increases in VDAC [13]. Attempts of VDAC are more successful in patients who had previous vaginal delivery; and whose contractions started spontaneously [14].…”

“…The success rate of VDAC is 60-80%. This wide range is due to many factors like, having previous vaginal delivery, the spontaneous starting of the contractions; age of the mother, obesity, the time interval between the pregnancies and the indication of the previous surgery [13].…”