From the Guidelines
The physician should prioritize the patient's autonomy while emphasizing the potential medical necessity of a cesarean delivery to ensure both maternal and fetal safety, as complications can arise during labor and delivery. The patient's birth plan preferences should be acknowledged and documented in the chart, while also explaining the possible scenarios where a cesarean delivery might be required, such as fetal distress, placental abruption, or failure to progress 1. The conversation should focus on informed consent, discussing the risks, benefits, and alternatives of both vaginal delivery and cesarean delivery.
The physician should explore the patient's specific concerns about cesarean delivery, which may include recovery time, bonding concerns, or previous trauma. Providing education about emergency scenarios and offering a tour of the labor and delivery unit might help ease anxiety. The physician should suggest including contingency plans in her birth plan and recommend childbirth education classes. Documentation should include the discussion of risks, benefits, and alternatives.
Some key points to consider when discussing cesarean delivery with the patient include:
- The importance of staying on a stable dosage of opioids, if applicable, and taking the morning dose before arriving for surgery, as noted in the study on substance use disorders in pregnancy 1
- The potential benefits of a preoperative consultation with an anesthesiologist and a therapist trained in cognitive behavioral therapy, as recommended for patients planning a cesarean delivery 1
- The need for the patient to understand that a cesarean delivery may become medically necessary to ensure both maternal and fetal safety, despite her initial preferences for a natural vaginal delivery.
By taking a patient-centered approach and prioritizing informed consent, the physician can respect the patient's autonomy while preparing for potential medical necessities, as the standard of care requires prioritizing the health of both mother and baby when complications arise during labor and delivery.
From the Research
Patient's Birth Plan and Cesarean Delivery
- The patient has expressed a strong desire for a natural delivery and has created a detailed birth plan that does not include a cesarean delivery 2, 3, 4, 5.
- However, the physician has informed the patient that unexpected events can occur during labor and delivery that may require a cesarean delivery.
- The patient's refusal of a cesarean delivery is acknowledged and documented in the chart.
Risks and Benefits of Vaginal Birth After Cesarean Delivery
- Studies have shown that vaginal birth after cesarean delivery (VBAC) is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies 2, 3, 4, 5.
- However, several factors can increase the likelihood of a failed trial of labor, which is associated with increased maternal and perinatal morbidity 2, 3, 4, 5.
- Assessing the likelihood of VBAC and individual risks is important in determining who is an appropriate candidate for trial of labor after cesarean delivery (TOLAC) 2, 3, 4, 5.