Once a cesarean, always a cesarean? Obstetricians’ approach to counselling for Trial of Labor After Cesarean (TOLAC)

Objective: Cesarean section rates are rising worldwide despite no observed increase in obstetric complication rates. A significant proportion of planned cesarean sections are for patients with one previous Cesarean who opt for an elective repeat rather than a trial of labor after Cesarean section (TOLAC). Facilitation of informed decision-making by healthcare professionals may influence patient choices and could have an impact on TOLAC uptake rates. This study was performed to assess how obstetricians in the Middle Eastern region, approach counselling patients with a previous cesarean birth in relation to birth choices in the current pregnancy. Study design: This was a prospective survey-based study . An online survey of obstetricians in the two largest state maternity hospitals in Doha, Qatar was undertaken with participation offered on a voluntary basis. The survey gathered background demographic data and then explored the obstetrician's awareness of factors that could influence TOLAC success and their approach to counselling these women. Data collected were transferred to SPSS version 23.0 (Armonk, NY: IBM Corp) for analysis. Descriptive statistics were performed and non-parametric analysis of continuous variables and chi-squared analysis of discrete variables were cross referenced with gender, length of time of specialist qualification and personal family experience of Cesarean section. Results: A majority of the respondents had trained in the Middle East, had practiced obstetrics mostly in this region and >80% had more than 5 years’ experience in the specialty. Obstetrician's gender or length of experience did not significantly impact attitude to assessment of risk and benefits. There was little consensus amongst the group around factors which were most and least important for TOLAC success. The group emphasized the importance of the patient's wishes in choosing mode of birth. Half of Obstetricians would emphasize the various negatives of TOLAC to the patient during counselling, if a relative contraindication to TOLAC was present. Most participants favored a dedicated TOLAC clinics in an effort to reduce cesarean section rates. The participants’ did not feel that supporting TOLAC would be improved with legal department support. Conclusions: Obstetricians vary in their approach to TOLAC counselling and this can impact patients’ acceptance of TOLAC thereby affecting cesarean section rates.