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Trial of labor versus repeat cesarean: are patients making an informed decision?

      Objective

      Most women eligible for a trial of labor after a cesarean (TOLAC) undergo an elective repeat cesarean section (ERCS). We hypothesized that this is largely because of poor patient education.

      Study Design

      This was a prospective study of women who presented to our hospital from November 2010 through July 2011 who were candidates for TOLAC. Women filled out a questionnaire prior to their scheduled ERCS or upon admission for TOLAC. A χ2 and a Student t test were used, as appropriate.

      Results

      The study included 155 women, 87 for TOLAC and 68 for ERCS. Women in both groups demonstrated a lack of knowledge on the risks and benefits of TOLAC and ERCS. When patients perceived their providers as having a preference for ERCS, very few chose TOLAC, whereas the majority chose TOLAC if this was their provider's preference.

      Conclusion

      Candidates for TOLAC appear to know little about the risks and benefits associated with their mode of delivery, and provider preference affects this choice.

      Key words

      In 1916, Dr Edwin Cragin, coined the phrase, “Once a cesarean, always a cesarean.”
      • Cragin E.B.
      Conservatism in obstetrics.
      His words were intended to warn surgeons to avoid this “radical obstetric surgery” unless entirely necessary to avoid the dangers of repeat surgeries.
      • Cragin E.B.
      Conservatism in obstetrics.
      However, over the last 100 years, as cesarean section became a relatively safe option, the context of his words was lost. If a woman had a prior cesarean delivery, another cesarean delivery was recommended.
      For Editors' Commentary, see Contents
      This all-or-nothing approach was first questioned in the 1950s with the publication of a review from M. Hague Maternity Hospital in New Jersey. The author presented the nearly 100 cases of successful vaginal birth following cesarean section to the American Medical Association, sparking much debate.
      • Cosgrove R.A.
      Management of pregnancy and delivery following cesarean section.
      The rate of vaginal birth after cesarean (VBAC) continued to fluctuate over the years as physicians were guided by changes in the official recommendations of various organizations and the medical-legal environment.
      In the early 1980s, VBAC rates were lingering at less than 5% across the country, inspiring the first National Institutes of Health (NIH) Consensus Development Conference. At this meeting, the necessity of repeat cesarean section was questioned, and guidelines were set for situations in which VBAC could be offered.
      Cesarean childbirth.
      As a result, the VBAC rate began to climb steadily and peaked in 1996, at approximately 28.3% after the publication of the American College of Obstetricians and Gynecologists (ACOG) guideline stating that “in the absence of contraindications, a woman with 1 previous delivery with a lower transverse uterine incision is a candidate for VBAC and should be counseled and encouraged to undergo a trial of labor.”
      Agency for Healthcare Research and Quality
      Healthcare Cost and Utilization Project (HCUP).
      American College of Obstetricians and Gynecologists
      Vaginal delivery after a cesarean birth Practice patterns no. 1.
      However, this peak was short lived and began to fall soon after the publication of a landmark paper that same year pointing to the increased rate of complications after failed trial of labor.
      Agency for Healthcare Research and Quality
      Healthcare Cost and Utilization Project (HCUP).
      • McMahon M.J.
      • Luther E.R.
      • Bowes Jr, W.A.
      • Olshan A.F.
      Comparison of a trial of labor with an elective second cesarean section.
      This downward trend continued with the publication of the new ACOG guidelines in 1999 stating the following: “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 5: vaginal birth after previous cesarean section.
      Even further decline was seen after the publication of an article in 2001, which examined the risk of uterine rupture and postpartum complications with respect to induction of labor.
      Agency for Healthcare Research and Quality
      Healthcare Cost and Utilization Project (HCUP).
      • Lydon-Rochelle M.
      • Holt V.L.
      • Easterling T.R.
      • Martin D.P.
      Risk of uterine rupture during labor among women with a prior cesarean delivery.
      As of 2006, the rate had reached a nadir of 8.7% and as the rate of VBAC has fallen, the cesarean section rate has been on the rise across the country reaching almost 33% in 2007.
      • Hamilton B.
      • Martin J.
      • Ventura S.
      Births: preliminary data for 2007.
      One of the main objectives of the most recent NIH Consensus Conference in 2010 was to explore the influence of nonmedical factors on utilization patterns of trial of labor after cesarean (TOLAC). The nature and extent of informed decision making and the influence of the care provider were both explored.
      Vaginal birth after cesarean: new insights.
      The 1999 ACOG guideline stated that “after thorough counseling that weighs the individual risks and benefits of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the woman and her physician.”
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 5: vaginal birth after previous cesarean section.
      Contrary to this guideline, the literature suggests that patient education is lacking and that this lack of discussion with the clinician is often associated with choosing cesarean delivery.
      • Cleary-Goldman J.
      • Cornelisse K.
      • Simpson L.L.
      • Robinson J.N.
      Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.
      • Renner R.M.
      • Eden K.B.
      • Osterweil P.
      • Chan B.K.
      • Guise J.M.
      Informational factors influencing patient's childbirth preferences after prior cesarean.
      Recent studies also suggest that patients highly value the opinion of their provider.
      • Cleary-Goldman J.
      • Cornelisse K.
      • Simpson L.L.
      • Robinson J.N.
      Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.
      • Renner R.M.
      • Eden K.B.
      • Osterweil P.
      • Chan B.K.
      • Guise J.M.
      Informational factors influencing patient's childbirth preferences after prior cesarean.
      • Moffat M.A.
      • Bell J.S.
      • Porter M.A.
      • et al.
      Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study.
      Importantly, although these concepts are suggested in prior studies, the NIH consensus found a paucity of data documenting the extent of these shortcomings.
      Vaginal birth after cesarean: new insights.
      Our study sought to fill this critical gap and explore the hypothesis that the national low rate of VBAC is due in part to insufficient informed consent about the risks and benefits of trial of labor.

      Materials and Methods

      Our study was an institutional review board–approved, prospective, observational study of women admitted to the Roosevelt Hospital for delivery between November 2010 and July 2011 eligible for TOLAC. Women were excluded if they had more than 1 prior cesarean, a prior classical uterine scar, a prior myomectomy, multiple gestations, or any other medical or obstetric complication that precluded a trial of labor.
      They received prenatal care and counseling in either a private physician's office or in our hospital-based clinic. A questionnaire was administered to women after admission to the obstetric unit either just prior to their scheduled repeat elective cesarean or after admission for a trial of labor. Most of the TOLAC patients completed the questionnaire after receiving epidural analgesia. The questionnaire was not administered to women who had received narcotic medications. The Figure shows a sample of relevant questions included in the questionnaire. The full questionnaire can be viewed online (Appendix). Specific points of inquiry included the following: demographics, the prior cesarean experience, family planning goals, perceived provider preference, factors affecting patient's choice, risks and benefits of elective repeat cesarean section (ERCS) and TOLAC.
      Figure thumbnail gr1
      FIGURESample questions
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      Patient knowledge of the risks and benefits were assessed with respect to key points covered in the ACOG practice bulletin no. 115 published in August 2010, “Vaginal Birth After Cesarean Delivery.”
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 115: vaginal birth after previous cesarean.
      The data were analyzed using χ2 and Fisher exact tests.

      Results

      The study included a total of 155 women, 87 who presented for TOLAC and 68 who presented for ERCS. There were no statistical differences with respect to age, level of education, ethnicity, and provider type between the groups. As seen in Table 1, greater than 75% of women were over age 30 years in both groups and at least 75% of subjects had an associates or higher degree. Forty percent of patients in both groups received their prenatal care in our hospital-based clinic, and approximately 60% of patients were cared for by a private physician. Approximately 46% of patients in both groups classified themselves as white and 20-30% as Hispanic.
      TABLE 1Demographic data
      VariableTOLACERCSP value
      All P values > .05.
      Age, y(n = 87)(n = 68)
       18-255 (6%)4 (6%).5
       26-2912 (14%)5 (7%).2
       30-3433 (38%)24 (35%).4
       35-4031 (36%)28 (41%).3
       ≥406 (7%)7 (10%).3
      Education(n = 87)(n = 68)
       <12 years6 (7%)2 (3%).2
       High school only11 (16%)6 (9%).3
       Associate's degree7 (8%)10 (15%).1
       Bachelor's degree30 (34%)24 (35%).5
       Graduate degree25 (29%)17 (25%).3
       High-level degree8 (9%)9 (13%).3
      Provider type(n = 80)(n = 68)
       Hospital clinic31 (39%)27 (40%).5
       Private physician46 (58%)41 (63%).4
       Private midwife3 (4%)0 (0%)
      Ethnicity(n = 87)(n = 68)
       White40 (46%)32 (47%).5
       Black7 (8%)10 (15%).1
       Asian7 (8%)6 (9%).5
       Hispanic26 (30%)15 (22%).2
       Other7 (8%)5 (7%).6
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      a All P values > .05.
      Patients demonstrated an overall lack of knowledge about the risks and benefits of TOLAC and ERCS. Only 13% of TOLAC patients and 4% of ERCS patients knew that the chances for a successful TOLAC are 60-80%, whereas the majority in both groups (54% in the TOLAC group vs 73% in the ERCS group) stated that they did not know (Table 2). Forty-nine percent of TOLAC patients and 26% of ERCS patients knew that the risk of uterine rupture is 0.5-1%, whereas the majority of ERCS patients (64%) stated that they did not know what the risk of uterine rupture is during TOLAC (Table 3). In addition, 52% of patients undergoing ERCS did not know that the recovery from a cesarean is longer than after a vaginal delivery (Table 4), and 46% did not know that the complication rates increase with each successive cesarean (Table 5). Twenty percent of ERCS patients believed that the indication for the previous cesarean played no role in their chances of a subsequent successful vaginal delivery, whereas an additional 32% did not know whether indication had any effect (Table 6).
      TABLE 2“If I were to try for a trial of vaginal labor, my overall chances of success are”
      OptionsTOLAC (n = 85)ERCS (n = 67)
      1-5%06 (9%)
      20-40%04 (6%)
      40-60%14 (16%)5 (7%)
      60-80%11 (13%)3 (4%)
      90%14 (16%)0
      Do not know46 (54%)49 (73%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      TABLE 3“If I try for a vaginal delivery (VBAC), the chance my uterus will rupture (opening of the uterine scar) is”
      OptionsTOLAC (n = 83)ERCS (n = 66)
      0.5-1%40 (49%)17 (26%)
      5-10%5 (6%)2 (3%)
      10-20%01 (2%)
      50%1 (1%)4 (6%)
      Do not know37 (45%)42 (64%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      TABLE 4“My recovery from a successful vaginal delivery versus a repeat cesarean is”
      OptionsTOLAC (n = 84)ERCS (n = 65)
      The same3 (4%)5 (8%)
      Longer for a repeat cesarean59 (70%)26 (40%)
      Longer for a vaginal delivery4 (5%)0
      I do not know18 (21%)34 (52%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      TABLE 5“The risk of complications increases each time I have a cesarean”
      OptionsTOLAC (n = 85)ERCS (n = 68)
      Yes54 (66%)31 (46%)
      No4 (5%)4 (6%)
      Do not know27 (32%)31 (46%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      TABLE 6“The reason for my previous cesarean is important in determining my chances of a successful vaginal delivery (VBAC)”
      OptionsTOLAC (n = 84)ERCS (n = 66)
      Yes56 (67%)32 (48%)
      No11 (13%)13 (20%)
      Do not know17 (20%)21 (32%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      When questioned about the risks associated with ERCS versus TOLAC, at least 50% of women in both groups were aware that there is a greater risk of damage to organs, excessive bleeding, and infection. However, only 30% or fewer knew that an ERCS is associated with an increased risk of maternal death, neonatal respiratory compromise, and admission to the neonatal intensive care unit (Table 7).
      TABLE 7“Which of the following risks is greater for a repeat cesarean compared with a VBAC. Please check all that apply”
      OptionsTOLAC (n = 80)ERCS (n = 60)
      Injury to organs50%62%
      Maternal infection59%54%
      Hemorrhage50%57%
      Risk of hysterectomy29%50%
      Maternal death29%23%
      Admission to the NICU23%17%
      Neonatal respiratory compromise30%19%
      ERCS, elective repeat cesarean section; NICU, neonatal intensive care unit; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.
      When patients perceived their providers as having a preference for ERCS, 19 of 22 (86%) chose ERCS, whereas when patients felt their doctor preferred a TOLAC, 36 of 46 (78%) chose TOLAC (Table 8). Of the patients who stated their doctor had no preference or did not know their doctor's preference, 50% chose TOLAC and 50% chose ERCS (Table 8).
      TABLE 8“Do you think your doctor/midwife preferred 1 method of delivery over another?”
      OptionsTOLAC (n = 84)ERCS (n = 65)
      Preferred TOLAC36 (43%)10 (15%)
      Preferred ERCS3 (4%)19 (29%)
      No preference24 (29%)24 (37%)
      Unaware of doctor's preference21 (25%)12 (19%)
      ERCS, elective repeat cesarean section; TOLAC, trial of labor after cesarean.
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.

      Comment

      Women in both groups were insufficiently informed about the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, our patients were not familiar with the chances of a successful TOLAC, the effect of indication for previous cesarean section on success, the risk of uterine rupture, the increased length of recovery with ERCS versus TOLAC and the increased risk of maternal death, neonatal respiratory compromise, and neonatal intensive care unit admission with ERCS. In addition, if our patient felt her provider had a preference, she was more likely to choose that mode of delivery, whereas when patients felt their providers were indifferent or if they were unaware of their providers' preferences, 50% chose one mode and 50% chose the other.
      Our questionnaire was related to information from the American Congress of Obstetricians and Gynecologists Bulletin revised in August 2010.
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 115: vaginal birth after previous cesarean.
      This resource is widely available to all obstetricians and gynecologists in the United States. According to the Guidelines for Perinatal Care published by the same organization, patients with uncomplicated pregnancies should see their doctors every 4 weeks when they are less than 28 weeks, every 2 weeks when they are 28-36 weeks, and every week when they are 36 weeks or beyond.
      American College of Obstetricians and Gynecologist and American Academy of Pediatrics
      Guidelines for perinatal care.
      This leaves ample opportunity for counseling, especially at the end of the pregnancy.
      Informed consent is defined as a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care and has become a mainstay of contemporary medical practice. It is viewed by many as a collaborative process between physician and patient intended to facilitate the patient's autonomy in the process of ongoing choices. Our respondents showed insufficiencies in the area of comprehension, a major tenet of informed consent. They lacked awareness and understanding of their situation and possibilities. From our data, it appears that provider bias may affect the opinion of some patients, with undue influence on a patient's voluntary decision making.
      American College of Obstetricians and Gynecologists
      ACOG committee opinion no. 439: informed consent.
      Our data were obtained from an institution with a high VBAC rate of 33%
      Quality Improvement Database.
      and an older and more highly educated population than the average across the United States. Our results may therefore represent a better-informed population, suggesting wider knowledge gaps throughout the country. We acknowledge a relatively small sample size and a lack of standardization in both patient counseling and the questionnaire itself. Our study should best be regarded as a preliminary investigation of current practice patterns intended to provoke further interest in the subject of informed consent in patients who are eligible for TOLAC. Future studies might evaluate counseling styles and decision aids and their influence on delivery preference and the patient knowledge base.

      Appendix

      Dear patient,
      We are distributing a survey to women who have had a previous cesarean section. We are conducting research to better understand the factors influencing a woman's decision to have a repeat cesarean section versus a trying for a vaginal delivery. Your participation is completely voluntary, the survey is anonymous and measures will be taken to ensure complete confidentiality. Once collected the surveys will be assigned a random number and separated from any identifying information. We would greatly appreciate if you could take the time to fill out this simple survey. Please answer as many questions as possible.
      Thank you!
      ________________________________
      ID: 
      • 1
        I am here for a:
        •  □ Cesarean Section
        •  □ Trial of Labor (I've had a cesarean section before and I want to try for a vaginal delivery)
      • 2
        Circle your Age:
        • 18-25 25-29 30-34 35-40 40+
      • 3
        Check next to your highest level of education:
        •  □ I did not finish high school
        •  □ High School
        •  □ Associate's Degree
        •  □ Bachelor's Degree (BA, BS)
        •  □ Graduate Degree (MA)
        •  □ High Level Graduate Degree (PhD, MD, DO, JD)
      • 4
        I got my care during this pregnancy at:
        •  □ Roosevelt Clinic with a doctor
        •  □ St. Luke's Clinic with a doctor
        •  □ Roosevelt Clinic with a nurse midwife
        •  □ St. Luke's Clinic with a nurse midwife
        •  □ Other Clinic
        •  □ Private Physician
        •  □ Private Nurse Midwife
      • 5
        What is the name of your attending doctor or nurse midwife? _________
      • 6
        If you do not have an attending/nurse midwife, the person with whom you discussed your plans for delivery was:
        •  □ My partner
        •  □ A family member
        •  □ A friend
        •  □ Other
      • 7
        Ethnicity:
        •  □ Caucasian
        •  □ African American
        •  □ Asian
        •  □ Hispanic
        •  □ Other (please specify)_________
      • 8
        Do you have any medical problems? (heart disease, non pregnancy related diabetes, thyroid hormone problems, high blood pressure outside pregnancy, etc)
        •  □ Yes
        •  □ No
      • 8a
        If yes, what are they?
      • 9
        Have you had any complications in your pregnancy?
        •  □ Yes
        •  □ No
      • 9a
        If yes, what?
        •  □ Diabetes in pregnancy
        •  □ Preterm Contractions
        •  □ Shortened cervix
        •  □ Early rupture of membranes
        •  □ Admitted to hospital for vaginal bleeding
        •  □ Other (please specify) _________
      • 10
        How did you get pregnant?
        •  □ Spontaneously
        •  □ Fertility treatments
      • 11
        How many vaginal deliveries have you had?
        •  □ 1
        •  □ 2
        •  □ 3
        •  □ More than 3
      • 12
        How many more children are you planning to have after this child?
        •  □ None
        •  □ 1
        •  □ 2
        •  □ 3 or more
      • 13
        Have you ever had a successful vaginal delivery following your cesarean section?
        •  □ Yes
        •  □ No
        Please answer these questions about your previous cesarean section:
      • 14
        What was the reason you had a cesarean section?
        •  □ The baby would not come out
        •  □ The baby’s heart rate dropped or was concerning
        •  □ The baby was in the breech position
        •  □ Other. Please specify___________
      • 15
        How far did you dilate?
        •  □ Not at all
        •  □ No more than 6 cm
        •  □ I was fully dilated
        •  □ I was fully dilated and pushed
        •  □ The doctor attempted a vacuum/forceps delivery but failed
      • 16
        How satisfied are you with your previous cesarean section experience?
        •  □ Very satisfied
        •  □ Satisfied
        •  □ Dissatisfied
        •  □ Very dissatisfied
      • 17
        How well was your pain controlled after the surgery:
        •  □ Very well controlled
        •  □ Moderately well controlled
        •  □ Poorly controlled
        •  □ Very poorly controlled
      • 18
        Recovery from the surgery was:
        •  □ As hard as I expected
        •  □ Harder than I expected
        •  □ Easier than I expected
      • 19
        I am bothered by the scar on my belly:
        •  □ Very much
        •  □ Somewhat
        •  □ Not at all
      • 20
        I still have pain from my surgery:
        •  □ Yes
        •  □ No
        Please answer these questions about yourcurrentfeelings and your decision making process inthis delivery:
      • 21
        I feel that my pain will be more well-controlled:
        •  □ In a cesarean section
        •  □ In a trial of vaginal labor
      • 22
        Please rate the importance of the following factors in your decision to try for a vaginal delivery or elect for a repeat cesarean section:
        •  1= Not important at all
        •  2= Not very important
        •  3= Somewhat important
        •  4= Very important
        •  My safety: _____________
        •  My baby’s safety: _____________
        •  Convenience: _____________
        •  My wish to experience a vaginal delivery: _____________
        •  Pain during delivery and recovery after delivery: _____________
        •  Cosmetic outcome: _____________
        •  Fear of damage to my vaginal area: _____________
        •  I plan to have a large family: _____________
        •  My partner’s opinion (skip if partner not involved): _____________
        •  My doctor/midwife’s opinion: _____________
        Please answer these questions based on the counseling you receivedin this pregnancyfrom medical professionals and your own general knowledge:
      • 23
        Do you feel your doctor/midwife preferred one method of delivery over another?
        •  □ My doctor/midwife did not have a preference
        •  □ My doctor/midwife preferred that I have a repeat cesarean section
        •  □ My doctor/midwife preferred that I try for a vaginal delivery
        •  □ My doctor/midwife did not express an opinion one way or another
      • 24
        If I were to try for a trial of vaginal labor, my overall chances of success are:
        •  □ 1-5%
        •  □ 20-40%
        •  □ 40-60%
        •  □ 60-80%
        •  □ 90%
        •  □ Don’t know
      • 25
        If I try for a vaginal delivery (VBAC), the risk that my uterus will rupture (opening of the uterine scar) is:
        •  □ 0.5-1%
        •  □ 5-10%
        •  □ 10-20%
        •  □ 50%
        •  □ Don’t know
      • 26
        My recovery from a successful vaginal delivery versus a repeat cesarean section is:
        •  □ The same
        •  □ Longer for a repeat cesarean section
        •  □ Longer for a vaginal delivery
        •  □ I do not know
      • 27
        The risk that I have a complication increases each time I have another cesarean section:
        •  □ Yes
        •  □ No
        •  □ I do not know
      • 28
        The reason for my previous cesarean section is an important factor in determining my chances of a successful vaginal delivery:
        •  □ Yes
        •  □ No
        •  □ I do not know
      • 29
        Which of the following risks are greater for a woman having a repeat cesarean section compared to a VBAC (vaginal delivery after a cesarean section)?
        • Check all that apply
        •  □ Death of the mother
        •  □ Death of the baby
        •  □ Injury to organs (in the mother)
        •  □ Excessive bleeding (in the mother)
        •  □ Infection (in the mother)
        •  □ Difficulty breathing (in the baby)
        •  □ Admission of baby to the NICU (intensive care nursery)
        •  □ Risk of hysterectomy (removal of the uterus)
      • 30
        Please state the most important factor in your decision to try for a vaginal delivery (VBAC) or elect for a repeat cesarean delivery:
      Bernstein. TOLAC vs RCS: are patients making an informed decision? Am J Obstet Gynecol 2012.

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        • Cragin E.B.
        Conservatism in obstetrics.
        NY Med. 1916; 104: 1-3
        • Cosgrove R.A.
        Management of pregnancy and delivery following cesarean section.
        JAMA. 1951; 145: 884-891
      1. Cesarean childbirth.
        NIH Consensus Statement Online. 1980; 3: 1-30
        • Agency for Healthcare Research and Quality
        Healthcare Cost and Utilization Project (HCUP).
        (Accessed Dec. 9, 2009)
        • American College of Obstetricians and Gynecologists
        Vaginal delivery after a cesarean birth.
        American College of Obstetricians and Gynecologists, Washington, DC1995
        • McMahon M.J.
        • Luther E.R.
        • Bowes Jr, W.A.
        • Olshan A.F.
        Comparison of a trial of labor with an elective second cesarean section.
        N Engl J Med. 1996; 335: 689-695
        • American College of Obstetricians and Gynecologists
        ACOG practice bulletin no. 5: vaginal birth after previous cesarean section.
        American College of Obstetricians and Gynecologists, Washington, DC1999
        • Lydon-Rochelle M.
        • Holt V.L.
        • Easterling T.R.
        • Martin D.P.
        Risk of uterine rupture during labor among women with a prior cesarean delivery.
        N Engl J Med. 2001; 345: 3-8
        • Hamilton B.
        • Martin J.
        • Ventura S.
        Births: preliminary data for 2007.
        (Natl Vital Stat Rep, web release) National Center for Vital Statistics, Hyattsville, MD2009
      2. Vaginal birth after cesarean: new insights.
        in: NIH Consensus and State-of-Science Statements. Vol. 27, no. 3. National Institutes of Health, Bethesda, MD2010
        • Cleary-Goldman J.
        • Cornelisse K.
        • Simpson L.L.
        • Robinson J.N.
        Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.
        Am J Perinatol. 2005; 22: 217-221
        • Renner R.M.
        • Eden K.B.
        • Osterweil P.
        • Chan B.K.
        • Guise J.M.
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