Labor After Cesarean in the Community Setting

In 2013, nearly one-third (32.7%) of childbearing women in the US gave birth by cesarean delivery. In subsequent pregnancies, these women will have to choose between a repeat cesarean delivery and a labor after cesarean (LAC), as well as where and with whom to give birth. Although national guidelines encourage offering LAC to most women with one prior low transverse cesarean, vaginal birth after cesarean (VBAC) rates decreased nationwide, from 28.3 percent in 1996 to 10.6 percent in 2013. In 2014, the largest study of US home birth to date reported on the outcomes of 16,924 deliveries using data from the Midwives Alliance of North America Statistics Project (MANA Stats) 2.0 cohort (2004–2009). These data included 1,052 women with a history of cesarean delivery. Of these, 87.0 percent had a successful VBAC, although there was an increased risk of intrapartum fetal death (2.85/1,000 vs 0.66/1,000, p = 0.05) in the LAC group compared with multiparous women without a history of cesarean. For this presentation, our research team further analyzed the LAC cohort within MANA Stats (2.0 and 4.0), with three research aims: 1) to describe the demographics of women choosing community VBAC; 2) to characterize the prenatal and intrapartum care

provided; and 3) to report birth outcomes for planned community VBACs. In light of findings from this research and those of other international studies on LAC, I will present evidence-informed guidelines for shared decision-making, risk assessment, and the management of care for families planning LAC in the community setting.

Melissa Cheyney PhD CPM LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women Gender and Sexuality Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. Dr. Cheyney currently directs the International Reproductive Health Laboratory at Oregon State University where she serves as the primary investigator more than 20 maternal and infant health-related research projects in nine countries. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with dozens of peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home in the United States. Dr. Cheyney is an award-winning teacher, and in 2014 was given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.



Learning Objectives:

1) Summarize key findings from the most recent studies on labor after cesarean (LAC) in the community setting;

2) Describe the ways research findings can be used to structure shared decision making conversations in the antenatal period; and

3) Critically evaluate guidelines for reducing the risk of intrapartum mortality among LAC clients birthing in the community setting.

4) Compare differences in outcomes following LAC in the community setting from different high-resource nations and maternity care systems

5) Utilize the Four Boxes of Clinical Ethics approach to guide care for pregnant people desiring to LAC in the community setting