Repeat cesarean section and primary elective cesarean section: Recently trained obstetrician-gynecologist practice patterns and opinions
Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States American Journal of Obstetrics and Gynecology
(Impact Factor: 4.7).
07/2005; 192(6):1872-5; discussion 1875-6. DOI: 10.1016/j.ajog.2005.01.046
This study was undertaken to determine opinions of obstetrician-gynecologists regarding vaginal birth after cesarean (VBAC) section and elective cesarean section.
A questionnaire was administered to obstetrician-gynecologists attending 2 review courses.
Of 500 obstetrician-gynecologists, 304 completed the survey for a response rate of 61%. Most (92%) counseled VBAC candidates differently, and 84% quoted differential VBAC completion rates on the basis of the indication for prior cesarean section. Uterine rupture was virtually always discussed (99%). Pelvic floor risks were infrequently discussed with urinary incontinence, pelvic organ prolapse, and fecal incontinence discussed by less than one third of obstetricians (30%, 28%, and 25%, respectively). Fifty-nine percent of physicians would perform a primary elective cesarean section, and 67% would perform a primary elective cesarean section specifically to prevent pelvic floor disorders.
Two thirds of recent graduates are willing to perform an elective cesarean section to prevent pelvic floor injury. Most offer VBAC; however, less than a third include risk of pelvic floor injury in their informed consent discussions.
Available from: Marylène Dugas
- "Support for a model of shared medical decision making, in which clinicians and women openly discuss the risks and benefits of their options, reveal their preferences and jointly make a decision , is a growing expectation in obstetric care (Deutchman & Roberts, 2003; Dodd, Crowther, Hiller, Haslam, & Robinson, 2007; Kenton, Brincat, Mutone, & Brubaker, 2005). This model of decision making requires that adequate information about risks and benefits is effectively communicated and weighed up according to personal needs and values, so that women or families can make informed decisions that are best for them (Nassar, Roberts, Raynes-Greenow, Barratt, & Peat, 2007; Roberts et al., 1997; Shorten, Shorten, Keogh, West, & Morris, 2005). "
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ABSTRACT: Support for a model of shared medical decision making, where women and their care providers discuss risks and benefits of their different options, reveal their preferences, and jointly make a decision, is a growing expectation in obstetric care. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of different decision aid tools compared to regular care for women facing several options in the specific field of obstetric care. We included published studies about interventions designed to aid mothers' decision making and provide information about obstetrical treatment or screening options. Following a search of electronic databases for articles published in English and French from 1994 to 2010, we found ten studies that met the inclusion criteria. In this systematic review and meta-analysis we found that all decision aid tools, except for Decision Trees, facilitated significant increases in knowledge. The Computer-based Information Tool, the Decision Analysis Tools, Individual Counseling and Group Counseling intervention presented significant results in reducing anxiety levels. The Decision Analysis Tools and the Computer-based Information tool were associated with a reduction in levels of decisional conflict. The Decision Analysis Tool was the only tool that presented evidence of an impact on the final choice and final outcome. Decision aid tools can assist health professionals to provide information and counseling about choices during pregnancy and support women in shared decision making. The choice of a specific tool should depend on resources available to support their use as well as the specific decisions being faced by women, their health care setting and providers.
Available from: Victoria H Coleman-Cowger
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ABSTRACT: To determine obstetrician-gynecologists' practice patterns of cesarean delivery on maternal request (CDMR) following the 2006 National Institutes of Health (NIH) State-of-the-Science conference on this topic, and compare them with those in their practice prior to the conference.
Questionnaires were mailed to 612 American College of Obstetricians and Gynecologists fellows who participated in a 2006 preconference survey, with 59% responding. The survey assessed demographic characteristics, practice, attitudes, knowledge regarding potential risks and benefits, counseling practices, and department policies with regards to CDMR.
The majority of obstetrician-gynecologists in our sample continues to believe that a woman has the right to CDMR, but fewer than in 2006 would agree to perform this procedure. In general, obstetrician-gynecologists associate more risks and fewer benefits with CDMR than in 2006.
Some physicians have shifted their perception of CDMR risks and benefits since the NIH State-of-the-Science conference; however, practice patterns have not changed significantly.
Available from: Julian Librero
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ABSTRACT: To explore the attitudes of obstetricians to perform a caesarean section on maternal request in the absence of medical indication.
Cluster sampling cross-sectional survey.
Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries.
Obstetricians with at least 6 months clinical experience.
NICU-associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self-administered questionnaire was used for data collection.
Obstetricians' willingness to perform a caesarean section on maternal request.
One hundred and five units and 1,530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman's request for elective caesarean section simply because it was 'her choice' was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P<0.001), fear of litigation (P= 0.004) and working in a university-affiliated hospital (P= 0.001) were associated with physicians' likelihood to agree to patient's request. The subset of female doctors with children was less likely to agree (OR 0.29, 95% CI 0.20-0.42).
The differences in obstetricians' attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman's request for elective caesarean delivery.
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