Quality Statement 3: Shared Decision-Making - Health Quality Ontario (HQO)

Resources Quality Statements Advisory Committee About

Shared Decision-Making

Pregnant people who have had a previous Caesarean birth participate in shared decision-making with their physician or midwife. The discussion and planned mode of birth is documented in the perinatal record.

Background

Eligible pregnant people who have had a previous Caesarean birth should receive counselling on both planned vaginal birth after Caesarean (VBAC) and elective repeat Caesarean section. The choice of mode of birth requires shared decision-making and considers the person’s values and preferences, the outcomes of the previous Caesarean birth and previous operative report, the person’s risk profile, and clinical factors relevant to the current pregnancy. This process also includes the person’s partner or family, if desired.

Physicians and midwives should inform pregnant people who have had a previous Caesarean birth that VBAC is safe for most people, but not without risk. Antenatal counselling should include information about preparedness during labour (e.g., electronic fetal monitoring, IV access, and immediate access to Caesarean section) and unbiased information about the benefits and potential harms of VBAC versus elective repeat Caesarean section, including:

Expected post-pregnancy function, pain, and recovery time
Potential complications
Potential maternal and neonatal morbidity and mortality
Implications for future pregnancies

The risk of uterine rupture during labour after previous Caesarean is estimated to be 1 in 200. Uterine rupture requires an emergency Caesarean section, and it increases the risk of maternal bleeding and the need for a hysterectomy. Uterine rupture may result in maternal or perinatal death if a Caesarean section is not performed quickly enough. The use of a decision aid is recommended to facilitate best practices in shared decision-making, informed consent, and documentation. Decision aids present risk information in a balanced and comprehensive manner, to help the person clarify their preferences, which supports informed decision-making.

Physicians and midwives should document antenatal counselling on VBAC, the person’s decision about their planned mode of birth, and a plan for mode of birth if spontaneous labour occurs before the scheduled delivery date when elective repeat Caesarean section is chosen.

What This Quality Statement Means

For Pregnant People

When you are choosing how you want to give birth, you and your physician or midwife should work together to make decisions. Conversations should include what is important to you about your birth experience, and the benefits and possible harms of both vaginal birth after Caesarean and a planned repeat Caesarean section.

For Clinicians

Provide antenatal counselling that supports shared decision-making for the planned mode of birth and offer VBAC when appropriate. Document the discussion and the planned mode of birth in the perinatal record.

For Health Services

Ensure that systems are in place so that physicians and midwives have the skills to support shared decision-making and document the discussion and planned mode of birth in the perinatal record.

Quality Indicators

Process Indicators

Percentage of pregnant people who have had a previous Caesarean birth and who have a documented discussion with their physician or midwife about their values and preferences, the benefits and potential harms of planned VBAC, and the benefits and potential harms of elective repeat Caesarean section

Denominator: number of pregnant people who have had a previous Caesarean birth
Numerator: number of people in the denominator who have a documented discussion with their physician or midwife about their values and preferences, the benefits and potential harms of planned VBAC, and the benefits and potential harms of elective repeat Caesarean section
Data source: local data collection

Percentage of pregnant people who have had a previous Caesarean birth and whose planned mode of birth is documented in their clinical chart

Denominator: number of pregnant people who have had a previous Caesarean birth
Numerator: number of people in the denominator whose planned mode of birth is documented in their clinical chart
Data source: Better Outcomes Registry and Network

Definitions Used Within This Quality Statement

Perinatal record

Standardized documentation of perinatal care. The Ontario Perinatal Record, 2016 version, acts as a care map for pregnancy, birth, and the very early newborn period.

Shared decision-making

A collaborative process that allows people and their health care professionals to make decisions together. The health care professional:

Invites the person to participate
Presents options
Provides information about the benefits and potential harms of each option, as well as care during labour and discussion of potential interventions
Helps people evaluate the options based on their values and preferences
Facilitates deliberation and decision-making
Helps implement decisions
Provides decision-making aids or other tools

Evidence to Improve Care