 introducing Amy Payne, who will do our next session. Before we get started, I'd just like to reiterate the thanks for our sponsors, the Lillibut University College in Denmark and also the Association of Radical Midwives, who without their support this conference wouldn't be able to proceed. And particularly I'd like to thank everybody else who has been behind the scenes, getting us to this point today. If you haven't set up your audio and you think you might want to ask a question, if you just go to meeting and then work your way through the audio wizard setup, that's quite easy to do. A good idea to have your headset plugged in before you actually log into the meeting. Sometimes that makes a difference. There's a chat window, which most people have found, and you're able to type in your questions and just press enter. You can give us feedback at the top, and most people have found that place where you can raise your hand or agree with the speaker. And if you step away from the meeting, you can signal that you have stepped away. If you wish to make a comment or a question, you can put it in the text box, or you can raise your hand and the host will enable you with a microphone so that you're able to ask your question. And I spoke with Amy, and she's happy to take points of clarification during her presentation. Any major questions, probably a better reserve for the end of the presentation, which I have more time to respond to them. When you, if you are given a microphone, then you click on the microphone icon. It's next to your name in the attendee's box. And to speak, you just click on the mic symbol at the top, and it will change from white to green. And don't forget to turn it off when you have finished speaking. Otherwise, we get interference. If people can't hear you, click on the microphone symbol and adjust the microphone volume. You've started the recording. Thank you very much. So, at this point, I have great pleasure in introducing Amy Payne, who has hailed from Texas. And we've had a few conversations, and Amy's quite well-travelled internationally and has worked in several areas, just having completed her doctorate in nursing practice. So, her presentation is called Shared Decision Making for Vaginal Births after Seizurean section. So, welcome, Amy, and I'll hand it over to you. A little bit background on my... Is this better? Yes, that's much better, Amy. Okay, sorry. Thank you. I was just saying that in the U.S. there I chose was to do the doctoral program in nursing practice. And so, it was a four-year degree, and I just finished. I'm taking my boards in about 10 days. So, then I'll be an official clinical midwife. But as part of my school requirements, I had to do a project, and I decided to do a shared decision-making program for vaginal birth after Seizurean section. So, I'm not sure what everyone knows about the U.S., but you've probably heard that the C-section rates are very high, and they've risen over the past couple of decades. Sorry to interrupt you, Amy, but if you have a microphone that is a smartphone microphone, please tell it up to your mouth. Otherwise, you can adjust your volume by clicking on the arrow just next to the microphone icon. Okay, better? Okay. I just changed the earphone, so maybe my other one wasn't working. Okay, sorry about that. So, I am doing shared decision-making for vaginal birth after C-section, and the C-section rates have risen a lot over the past couple of decades in the United States. The current C-section rate in the United States is at a record high of 32.8%, and that's an increase of 53% from the years 1996 to 2000. So, that makes nearly one in three births in the United States being a C-section, and so it's the most commonly performed surgery here. Repeat C-sections account for about 534,000 of 1.5 million C-sections performed, and as you know, they're not without consequences. Repeat C-sections can lead to increased health care costs, increased adverse outcomes for mother and baby, and complicated subsequent pregnancies. So, in the U.S., they account for almost half of childbirth-related expenses, and they also result in a longer recovery period. And also, a systematic review showed that early breastfeeding is delayed with elective C-section versus vaginal delivery. So, a vaginal birth after C-section is a safe option for some women after a prior C-section. And in the U.S., the American College of Obstetricians and Gynecologists, the American College of Nurse Midwives, and the National Institutes of Health all support a trial of labor after C-section. So, I don't know what the V-back and TOLAC rate is for every other country here. So, I'm just speaking from the United States. So, according to level A evidence set by ACOG, the American College of Obstetricians and Gynecologists, they say that women who have had one previous C-section with a low transverse uterine incision and have no other conditions that require C-section, such as a prior uterine surgery or a percent of previa are eligible for TOLAC. So, about 60 to 80% of women who are candidates for the trial of labor after C-section and attempted V-back will be successful in having their V-back. So, the national V-back rate in the U.S. is very low. It's 8.5%. Lindei see that you say it's up to 30% in the U.K. It's kind of embarrassing that the U.S. is so far behind, but it is what it is. That's why I did this project. And the reason that the V-back rate is so low here is because of the resistance of key stakeholders. A lot of hospitals don't even offer TOLAC because they're afraid. And then also, the fear of adverse outcomes aren't instilled in women. So, the maximum once a caesarean always a caesarean, although not supported by scientific evidence is still used here in the U.S. by physicians. So, routine obstetric care in regard to a delivery method after a C-section often involves a healthcare provider just telling a woman which avenue she will take simply by providing a pamphlet or just giving a leaflet. So, in this practice model, women are not presented with the current evidence-based knowledge about the choices that she has and the risks and benefits of the decisions of her birth option after a prior C-section. So, the lack of patient involvement in obstetric care may lead to poor outcomes and dissatisfaction with care due to dependence on medical technology, lack of expectations, and then less inventions for both the mother and the baby. Therefore, women who meet criteria need help with the decision-making process regarding their birth options. So, one approach to assisting patients in making a healthcare decision is the shared decision-making model. And this is an approach where clinicians and patients share the best available evidence when faced with the task of making decisions. And then the patients are supported to consider their options so that they can make an informed choice. So, with shared decision-making, pregnant women actively participate with their healthcare providers and they can arrive at a decision about which option they want to do after a C-section. So, as part of this shared decision-making model, a provider would give pamphlets, they would do videos, they would offer interactive online tools or a paper tool, and then they would also do individual group counseling sessions. Sorry, didn't advance my slide. So, anyway, I did a literature review of a few topics. Just wanted to see the risks and benefits of the VBAC. And I did the current guidelines. I also looked at women's perceptions of VBAC in C-section and then also looked at shared decision-making in obstetrics. So, the potential risks of VBAC are a failed toll act, which can be anywhere from 20 to 40%. A uterine rupture, and this is the thing that scares everybody here. This is why hospitals absolutely refuse to offer a VBAC or a toll act. And it's actually low. It's 0.2 to 1.5% for low transverse incisions and 5 to 9% for vertical incisions. And then another potential risk of a VBAC is fetal death, but that is also a very low risk. Another potential benefit, or some potential benefits of VBAC are shorter hospital stays. So, here a woman would stay in the hospital for three to five days if she has a C-section, but if she has a vaginal birth then she would only stay for 24 hours or 48 hours max. Another benefit of VBAC is an increased breastfeeding success. So, we all know it's been well established that breastfeeding is best for the baby and anything to help a woman become successful in helping her baby breastfeed would be ideal. Another benefit of a VBAC is fewer maternal complications. So, women are less likely to develop a fever or need a blood transfusion after a postpartum hemorrhage or they're less likely to have blood clots or some kind of wound or uterine infection. And then also another benefit is less neonatal respiratory distress. So, shared decision-making has already been used for a variety of women's healthcare decisions such as a cephalic version. So, turning the baby if the baby's breech, it's been used for hormone replacement therapy, it's been used for epidurals, it's been used for helping someone decide about circumcision. So, it's never, there hasn't been a systematic review or a study specifically on shared decision-making for a VBAC and so that's why I did this study. So, the purpose of my project was to implement a shared decision-making program. So, in my program, I had an online or face-to-face education session about TOLAC. So, in this session, I went over risks and benefits, I followed the literature that said what makes shared decision-making more effective and I offered handouts, I offered a video, we interacted, we had an individual counseling session and also the Ottawa Institute has a great website. Good job, Canada. They have a whole list of interactive decision-aid tools. So, they're free for the public to use. So, I used the one regarding VBAC and it was really good. It just takes about five to 10 minutes and the woman goes through and just, I wanted to evaluate the extent to which each phase of the shared decision-making program was effective to prepare the women to make a decision about trying for a VBAC. I wanted to see if the women spoke to their health care provider because like I said earlier, a lot of times women had a primary C-section. The online decision tool was called pregnancy, what are my birth options? But I have the exact tool name here. Let me get it for you. I can send you a link later. It's on, if you search the Ottawa decision-aid tools, they have the resources posted there and it says there's a little link when you get to the homepage. It says A to Z, patient decision-aid tools. And so, there are several for pregnancy and I believe there were two for VBAC and I just liked the one regarding the one that I chose about the birth options. So, that's why I chose that one. I also wanted to see if the women were able to make a decision and how women felt after making their decision if they chose the VBAC or repeat C-section and how they felt. Okay, so, since I had some difficulty finding sites to help me with my recruitment, so I had to be very strict with my inclusion criteria. I only followed level A evidence for ACOG, the American College of Obstetricians and Gynecologists. Many practices go ahead and follow the level B guidelines, too, which say that you can include two previous C-sections in there, but with my settings that I had an agreement with, I could only do one. So, my inclusion criteria were currently pregnant with head down one pregnancy, one previous C-section and could read, yes, I will be explaining and describing the phases of the shared decision-making, yeah. So, the exclusion criteria were previous major uterine surgery and a classical vertical or T-shaped uterine incision with previous C-section. So, I had three settings in North Texas. They were a mixture, one was a very large group of 13 providers and there were two midwives on that staff and then the rest were 11 more physicians and then one was a group of three, two physicians and one part-time midwife. And then another one was a very large, well, large for, yeah, that's it, health-wise. Thank you for posting that. So, the other one was a very large midwife group in Texas, so there were eight midwives and for the recruitment, I put flyers in the exam and waiting rooms and then also either the medical assistant or the midwife would give a flyer hand out to the women who met the inclusion criteria and then this handout, the women would read the handout and if they're interested in participating, then they would contact me by phone or email and then say they wanted to participate. So, here you go, Sheila, the shared decision-making program. So, it was two phases. The first phase, I started off doing, offering a group education session, but everyone had difficulty meeting up at one time. There were toddlers or school-aged children. So, I did one individual one-on-one and then I ended up later on when recruitment was very slow. I just went ahead and developed an online version. So, if any of you use iMovie on the Mac, that's what I did. It was a 20-minute video. It was exactly the same as the face-to-face session and I went over risks and benefits and also included a video in there of a woman talking about her successful VBAC experience and then we had a conversation afterwards on the phone if we couldn't meet in person about how they felt and their feelings about what they learned and their experience with their first birth. We went over the current guidelines in that too. I gave them a facts and questions handout and also a question to ask a provider handout because, like I was saying earlier, it's not uniform between practice settings. So, one practice could be totally supportive of VBAC but another one would say, you know, no, we're not giving you a VBAC or no, you absolutely can't have a vaginal birth. So, phase two was this online decision aid tool, the pregnancy, should I try vaginal birth after a PASC section from HealthWise. Thank you for pushing that again. And to see how women, to get my results, I used five tools which were also from the Ottawa Institute's website. So, the first tool was called the choice predisposition or leaning scale and this I administered, I'll go over more in depth later with the results for but this one, just a brief overview, told me what the women was feeling like she wanted. So, where she was leaning, like did she want a VBAC? Was she more leaning on having another C-section? So, that tool was administered after each phase just to see, you know, did phase one help more, did phase two help more, you know, did the combination of both help more. So, then the preparation for decision making tool was also administered and it told me what the woman felt like, did she feel, how prepared did she feel for making a decision? And then the decision tool was what decision did she make? And then the inactive decision tool was what happened? Did she end up with her VBAC? Did she end up with that C-section? And this was administered two to six weeks postpartum and then the decision regret scale and this told me, you know, how did she feel about what happened? And all the women returned the data to me via email. So, I only had seven women interested in my study even though, you know, recruitment was very difficult to get people interested in wanting a VBAC. They were so scared because hospitals don't offer it, physicians don't offer it. So, I could only gather up seven people and my average age was 30.71 years. So, they ranged from 24 to 35. I had six Caucasian women and one Hispanic woman. Six were married, one was not. And the average gestational age was about 28 weeks. So, this was largely due to the fact that I wanted to graduate. So, I didn't have that much time to recruit and so, many of my women were, you know, 26 to 30 weeks and it would have been ideal if I could have recruited earlier in the pregnancy. So, this was the results of how effective was the shared decision-making program. So, for the preparation for decision-making scale, you see that orange is before phase one. So, phase one was the education session. Yellow is after phase one and then blue is after phase two. Phase two was the online decision aid tool. So, as you see before phase one education session, the women had a low self-perception of preparedness for decision-making. So, they felt like they weren't prepared to make a decision. They, you know, just weren't prepared. And then after the education session, they felt a little more prepared, as you can see with the yellowish mustard color bars. And then after the combination of the education session and then the health-wise tool, they felt really prepared. And then the results of my leaning tool, same colors, the orange is before the education session or phase one. The yellow color is after phase one and then blue is after phase two. And so, you can see that four women before the program wanted, they were strongly leaning on having a VBAC. Two were undecided and one was definitely set on having a RPC section. And then the, after the education session, six wanted a VBAC and one still wanted that RPC section. And then after the health-wise tool, same thing, six wanted the VBAC and that one was still dead set on the RPC section. And then six decided on VBAC. One had an elective C-section. That's what they decided after the program. But then after I talked to them, postpartum five ended up with their VBAC and two had the C-section. So the one who chose to have a C-section had her scheduled C-section and then one ended up having an emergency C-section. And I'll tell you a little bit more about their stories in a minute. And then five felt no regret. Zero felt low regret. And then two women felt moderate regret. So the one woman, these results are actually pretty surprising to me because I read in the literature that women who do this as shared decision-making feel lower regret. But the woman who decided to have a VBAC but received an emergency C-section told me that she felt a lot of regret because she wishes she just didn't get her hopes up and went back and had the RCS as repeat C-section. And the woman who decided to have a repeat C-section had more pain and felt like she couldn't care for her toddler during her recovery period. So she regretted choosing that C-section and wishes that she chose the other option. So the two people, the unexpected outcomes wished they chose the other alternative, which is kind of interesting. So this is a very small pilot program but it was effective to prepare women to make a decision about TOLAC. And I also found out that online education may be more preferable for women. And in regard to the two women who regretted their decisions, it could be that they didn't expect to have the outcomes that they did. The woman who scheduled a C-section, she didn't remember it being so painful. She thought that it would just be easier because she was ready for it this time. But she just didn't anticipate the pain to the pain she felt physically, you know, not being able to care for a toddler, lift her toddler, run around with her toddler. And then the one who had the failed TOLAC, she felt very depressed that her hopes were shattered is what she verbalized to me. She felt like she didn't have a chance to have a proper trial of labor. And her story, I can share it with you, she said it was okay. So she was 40 weeks, her doctor told her she could not go past 41 weeks. So they scheduled her for an induction at 40 weeks and six days. They did a balloon. And do you all know what a Cook's balloon is for induction? I don't know. Anyway, it's a catheter type device that you insert into the vagina and there are two little balloons. And one kind of sits and dilates, it mechanically dilates is basically how it works. One sits in the vagina and one sits in the uterus. So it mechanically dilates. And so the doctor that was caring for her didn't feel comfortable giving her pitocin. So instead of letting her go into natural labor, he just decided to do this Cook's balloon to induce her, didn't start side attack, which is good because side attack is not safe for people who have had privacy sections. But she was only four centimeters dilated and still at a minus two station. And the doctor really didn't want her to go to 41 weeks or beyond so he went ahead and artificially ruptured her membranes. And so of course she was high, the baby station was high, so the babies went into fetal distress and the heart rate plummeted and she had to go back and get her emergency C-section. So that's what happened with her. And so limitations of this study, small sample size, largely due to recruitment issues. I do strongly believe that this program would have succeeded. I mean it showed proof that it was worthwhile but I think I would have had more success recruiting women to participate in areas where VBAC was supported. Texas is kind of like the good old boy state and they're stuck in their ways. They don't want to kind of be progressive at times. So they're just really scared to, yeah, change their culture. So in places like New York and other places in the Northeast VBAC, their VBAC rates are very high and C-section rates are a lot lower than down here. I had time constraints, so women in the project were near beyond their third trimester and studies have shown that the shared decision-making program for VBAC or for making a decision during pregnancy is more effective earlier in the pregnancy. So even as early as preconceptually, we should be talking to women about their birth options after a prior C-section. And then there could be bias because women who seek midwifery practices, they desire a toll-lack. So a lot of women are just complacent and they do what their physician tells them and that's kind of like the normal standard of care here. And also another limitation was the scoring of the Ottawa Institute's tools. So all of them were really great, but the decision-regret scale did not have hard cutoff value. So I had to just make a decision about no low, moderate, and high regret. So recommendations for research, I would recommend a larger sample size with a comparison group. I would also evaluate if the shared decision-making program for VBAC actually reduces C-section rates and healthcare costs. And also I would like to further investigate the regret after a failed toll-lack because that came up as an issue after all my data was collected. Recommendations for practice, educate staff about the VBAC when I was trying to recruit women. I first went and taught the medical assistants and the midwives about the current guidelines of VBAC and the risks and benefits. And one of the medical assistants actually said to me, well, I don't understand why you're offering VBAC, isn't it very dangerous? And I'm like, well, no, no, this is what the research says. So it's the culture, so it's gonna take a while just by talking to people, presenting the evidence, trying to encourage the staff to date is kind of the key to get past these negative beliefs about toll-lack. And I would also follow up with women who may feel regret with their birth decision after C-section, after distressing circumstances. I did read a systematic review that focused on post-traumatic stress disorder based on birth. And it said that cognitive behavioral therapy is helpful for women. So if they meet with a therapist, then they can kind of work through these feelings and gain confidence again and reduce their anxiety and kind of just make sense of how to cope with, you know, how, you know, just cope with what happened to them. And a lot of birth centers now, they try to offer a group debriefing for women who feel like they need to talk to someone, but this actually isn't effective. It helps in the moment where the women feel like, you know, they can get this off their chest, but they really need an outlet for helping them to actually work through these feelings they have. All right, that's it. Does anyone have any questions for me? You'd like to ask Amy a question? Oh, I see. It's Rice DeHaine. Time, Marie. Mind you. Yeah, Marie, go ahead. What's your question? Is there research on the level of VBAC for midwives? What do you mean by this question? Do you mean, do midwives seem to perform VBAC more or yes, midwives do. And that's why these women were seeking out midwives because most physicians just flat out won't offer the VBAC. So the few midwifery practices that exist in this North Texas area, they, you know, they are known for their successful VBAC, so that's why these women sought them out. Kat, I actually made a pamphlet or hand out if you want, I don't mind sharing it with you. It's based on all the current evidence. We've got time for one or two more questions and then we might need to move on and thank Amy for presenting today. Is there any further questions before we do that? Sure, if anyone just, whoever wants the hand out, just put your email and I can send them to you. And I agree with you, Kami. Amy, who could also put the slides on the wiki or the website if it's okay? Oh, sure, sure, I can do that. That's a good idea. Thank you. Well, I think everybody's had quite a few questions throughout which Amy has fielded really well while not sort of interrupting her presentation. So that was excellent. Well done, Amy. And it's really interesting to see that even though it's a small study, I think it opens up some really important questions. And for me, some of the key things were that you conducted this online, that there was an opportunity to do research with women who are much more accessible online than trying to catch them in their busy lives. And I'm really interested in that aspect of it. Interesting that you pulled together those areas around decision-making tools and I'll certainly be hunting up that website in Ottawa, thank you, Ottawa. And thank you also for sharing the ups and downs of the research process and what a struggle it is within a culture that is not supportive of women experiencing a vaginal birth after caesarean section. So I wasn't left with any real questions about your research but I'm sure that you'll be able to respond to any that others have got once you've got all their emails and your slides are up to them to look at again. So thank you very much, Amy, and congratulations on putting that research project together and best wishes as you step into your midwifery role. Thank you.