In 1916, Dr Edwin Cragin, coined the phrase, “Once a cesarean, always a cesarean.” His words were intended to warn surgeons to avoid this “radical obstetric surgery” unless entirely necessary to avoid the dangers of repeat surgeries. 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.

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. 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. 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.” 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. 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.”

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. 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.

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. 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.”

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. Recent studies also suggest that patients highly value the opinion of their provider. Importantly, although these concepts are suggested in prior studies, the NIH consensus found a paucity of data documenting the extent of these shortcomings.

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.

Sample 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.” The data were analyzed using χ ² and Fisher exact tests.