The Ethics of Vaginal Birth after Cesarean

Hastings Center Report

Volumn 42, Issue 4, 2012, Pages 24-27

  Charles, Sonya ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BENEFICENCE; DELIVERY; ETHICS; FEMALE; HEALTH CARE DELIVERY; HUMAN; OBSTETRICS; PATIENT RIGHT; PERSONAL AUTONOMY; PHYSICIAN ATTITUDE; PRACTICE GUIDELINE; PREGNANCY; UNITED STATES;

BENEFICENCE; FEMALE; GUIDELINE ADHERENCE; HEALTH SERVICES ACCESSIBILITY; HUMANS; OBSTETRICS; PATIENT RIGHTS; PERSONAL AUTONOMY; PHYSICIAN'S ROLE; PRACTICE GUIDELINES AS TOPIC; PREGNANCY; UNITED STATES; VAGINAL BIRTH AFTER CESAREAN;

EID: 84865302346     PISSN: 00930334     EISSN: 1552146X     Source Type: Journal    
DOI: 10.1002/hast.52     Document Type: Article

References (22)

1. F.G. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement: Vaginal Birth after Cesarean: New Insights, " Obstetrics and Gynecology 115, no. 6 (2010): 1279-95, at 1279.
2. American College of Obstetricians and Gynecologists, "Practice Bulletin 115: Vaginal Birth after Previous Cesarean Delivery, " Obstetrics and Gynecology 116, 2 (2010): 450-63. While the reports of these increased risks are true, other commentators point out that the increase in risk for uterine rupture also coincided with an increase in off-label use of Misoprostol/Cytotec for labor induction-which is also associated with adverse outcomes when attempting VBAC. J. Block, Pushed: The Painful Truth about Childbirth and Modern Maternity Care (Cambridge, Mass.: DaCapo Press, 2007), 89.
3. Ibid., 87-88.
4. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " 1290.
5. American College of Obstetricians and Gynecologists, "Practice Bulletin 115." The NIH report calls on ACOG to remove this requirement since it is based on the lowest level of evidence-consen-sus-and opponents argue that it sets a higher standard for VBAC compared to other potential obstetrical complications; Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " and American College of Nurse-Midwives, "American College of Nurse-Midwives Responds to ACOG's 2010 VBAC Recommendations, " 2010, 1-5, http:////www.midwife.org/documents/ACNMResponseACOGVBACRecommendations_Aug10.pdf. The American College of Obstetrics and Gynecology admits that the requirement limits women's access to providers and facilities that are willing to allow a trial of labor after cesarean but reaffirms its commitment to keeping it; American College of Obstetricians and Gynecologists, "Practice Bulletin 115."
6. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " 1287-88.
7. American College of Nurse-Midwives, "American College of Nurse-Midwives Responds to ACOG's 2010 VBAC Recommendations, " 3.
8. Block, Pushed, 94-97.
9. The current ACOG guidelines go further and would consider both women with two previous cesareans and women with unknown incision types as eligible for a trial of labor; American College of Obstetricians and Gynecologists, "Practice Bulletin 115." ACOG is right to be as inclusive as possible, but for the sake of simplicity, I will make a narrower argument here.
10. When we consider risks, we tend to focus only on mortality and morbidity statistics. To truly honor the informed consent process, we must also consider the potential psychological harm to the woman who feels she was coerced into accepting an unwanted surgery without the opportunity to attempt a trial of labor after cesarean. However, I will not directly address this issue here.
11. See D. Brock, "Conscientious Refusal by Physicians and Pharmacists: Who Is Obligated to Do What, and Why?" Theoretical Medicine and Bioethics 29, no. 3 (2008): 187-200. Brock argues that asking someone to go one hundred miles to pick up a prescription is an "unreasonable burden" on a patient.
12. F.A. Chervenak and L.B. McCullough, "Justified Limits on Refusing Intervention, " Hastings Center Report 21, no. 2 (1991): 12-18. While this article is an older one, Chervenak and McCullough have continued to use this basic framework when considering conflicts between patients and physicians; see F.A. Chervenak, L.B. McCullough, and B. Arabin, "Obstetric Ethics: An Essential Dimension of Planned Home Birth, " Obstetrics and Gynecology 117, no. 5 (2011): 1183-87.
13. Chervenak and McCullough, "Justified Limits on Refusing Intervention, " 13.
14. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " 1290.
15. American College of Obstetricians and Gynecologists, "Practice Bulletin 115."
16. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement"; American College of Obstetricians and Gynecologists, "Practice Bulletin 115." Some have asked how my argument would affect women who would prefer an elective cesarean delivery over a trial of labor. Given this hierarchy of outcomes, I see no reasons elective cesarean should be ruled out. My focus is on expanding reasonable choices for women who want an alternative, not on restricting reasonable medical options.
17. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement."
18. Ibid.; American College of Obstetricians and Gynecologists, "Practice Bulletin 115."
19. Chervenak and McCullough, "Justified Limits on Refusing Intervention, " 13.
20. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " 1283.
21. Ibid.; American College of Obstetricians and Gynecologists, "Practice Bulletin 115."
22. Cunningham et al., "National Institutes of Health Consensus Development Conference Statement, " 1287.