Toward an ethically responsible approach to vaginal birth after cesarean.
Determining approach to delivery after a previous cesarean is among the most contentious areas of obstetrics. We present a framework for ethically responsible guidelines and practice regarding vaginal birth after cesarean. We describe ethical complexities of 3 key issues that mark the debate: the cesarean delivery rate, safety, and patient autonomy. We then describe a taxonomy of considerations that should inform a responsible framework for guideline development and highlight critical distinctions between types of guidelines that have been blurred in the past. We then forward 2 central claims. First, in otherwise uncomplicated birth after a single previous cesarean, both vaginal birth after cesarean and repeat cesarean should be regarded as reasonable options; women, rather than policymakers, providers, insurance carriers, or hospitals, should determine delivery approach. Second, in complicated cases, providers and policymakers should carefully calibrate the strength of evidence to ensure differential risk and cost are adequate to justify directive guidelines given important variations in values women bring to childbirth.
Lyerly
Anne Drapkin
AD
Trent Center for Bioethics, Humanities and History of Medicine and Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA. LYERL003@mc.duke.edu
Little
Margaret Olivia
MO
D002585:Cesarean Section / Q000706:statistics & numerical data; D017604:Cesarean Section, Repeat / Q000009:adverse effects; D005260:Female; D005313:Fetal Death / Q000453:epidemiology; D006801:Humans; D008428:Maternal Mortality; D057240:Patient Preference; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011247:Pregnancy; D012307:Risk Factors; D014219:Trial of Labor; D014597:Uterine Rupture; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects / Q000941:ethics*