Women unaware of TOLAC delivery option

By Ingrid Grasmo

Study findings suggest that women eligible for trial of labor after a cesarean (TOLAC) know little about their options for mode of delivery, with many leaving the decision up to their physician.

The findings are of importance, given that most women who are clinically eligible for TOLAC routinely undergo an elective repeat cesarean section (ERCS).

"[Women in the study] showed insufficiencies in the area of comprehension, a major tenet of informed consent…it appears that provider bias may affect the opinion of some patients, with unduly influence on patients' voluntary decision making," say Sarah Bernstein (St Lukes-Roosevelt Hospital Center, New York, USA) and co-authors.

For the study, the team asked 155 women eligible for TOLAC to complete a questionnaire prior to their scheduled ERCS or upon admission for TOLAC. The questionnaire included questions on patient demographics, prior cesarean experience, family planning goals, perceived provider preference, factors affecting patient choice, and the risks and benefits of ERCS and TOLAC.

No significant differences in age, level of education, ethnicity, and provider type were seen between the 87 women who presented for TOLAC and the 68 who underwent ERCS.

Women demonstrated an overall lack of knowledge about the risks and benefits of each procedure. Indeed, only 13% and 4% of those who underwent TOLAC and ERCS, respectively, knew that the likelihood for a successful TOLAC is 60-80%.

Furthermore, just 49% and 26% of women who underwent TOLAC and ERCS, respectively, understood that the risk for uterine rupture is 0.5-1.0%, while 64% of ERCS patients stated that they did not know what this risk was.

The study also revealed that 52% of patients undergoing ERCS did not know that recovery from a cesarean takes substantially longer than a vaginal delivery in the absence of delivery complications, with 46% not informed that complication rates increase significantly with each successive cesarean.

When women were questioned about the risks associated with ERCS versus TOLAC, only 30% or less knew that an ERCS is associated with an increased risk for maternal death, neonatal respiratory compromise, and admission to the neonatal intensive care unit.

Importantly, when women perceived that their physician showed a preference for ERCS or TOLAC, 86% and 78%, respectively, chose this method. Conversely, women who stated that their physician had no preference, half chose TOLAC.

Writing in the American Journal of Obstetrics and Gynecology, the researchers call for studies evaluating counseling styles and decision aids to educate this patient population.

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