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Clinical Decisionmaking

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Review illuminates women's childbirth preferences following a previous cesarean delivery

For women who have previously had a cesarean delivery, evidence is conflicting about maternal and fetal safety for vaginal and cesarean childbirth for subsequent births. Thus, women and doctors are often uncertain about whether to pursue a trial of labor, hoping for a vaginal delivery, or simply schedule an elective repeat cesarean delivery.

A comprehensive review of studies conducted from 1980 to August 2002 on delivery preference for women with a previous cesarean delivery was carried out by the Oregon Evidence-based Practice Center (EPC). The review was supported by the Agency for Healthcare Research and Quality (contract 290-97-0018 and grant HS11338). It showed that a woman's choice for delivery was often based on family obligations, such as the need for a shorter recovery so that she could care for her infant and children at home, rather than the safety of herself or her infant.

Women with a previous vaginal delivery were more likely to select a trial of labor than women who did not have one. The most commonly cited reasons for selecting trial of labor was ease of recovery and desire to return quickly to caring for other children (reported in six of seven studies). Safety for the mother and/or infant was cited as an important reason for delivery choice in 4 of 11 studies.

Important ethnic differences were also reported. Minority women were more likely than white women to identify their provider as an important influence on their choice of delivery (39 vs. 19 percent), and they perceived labor as something to be avoided if another option resulted in a healthy baby. In contrast, white women perceived labor as a challenge and an experience not to be missed. Limitations in methodology and documentation of current studies make it difficult to ascertain how well-informed women are in making decisions for trial of labor or repeat cesarean delivery.

See "Childbirth preferences after cesarean birth: A review of the evidence," by Karen B. Eden, Ph.D., Jason N. Hashima, M.D, M.P.H., Patricia Osterweil, B.S., and others, in the March 2004 Birth 31(1), pp. 49-60.

Editor's Note: The evidence report and summary on this topic prepared for AHRQ by the Oregon EPC are Vaginal Birth After Cesarean Section (VBAC), Evidence Report/Techology Assessment No. 71. (AHRQ Publication No. 03-E018, report; 03-E017, summary; available from the AHRQ Publications Clearinghouse.

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