Implementation of a shared decision-making tool for patient considering trial of labor after cesarean section (TOLAC).

Abstract

Introduction: The American healthcare system has seen a renewed shift of focus towards improving care quality and patient satisfaction. Part of ensuring care quality and satisfaction stems from engaging patients in their health care decisions. Shared decision-making is one mechanism used to engage patients in a conversation with their doctor about the different clinical options available to them. This study specifically looks at the implementation of a shared decision-making tool to help women who have previously had a cesarean section come to a decision about whether to have another cesarean section or try labor. Methods: Qualitative, semi-structured phone interviews were conducted among 20 individuals (3 administrators, 7 providers, and 10 patients). All respondents were from one of three pilot sites, all residing in the Puget Sound region of Washington state. Results: All three sites struggled in some form or another with implementation, the most consistent struggle being workflow integration. While provider attitudes towards shared decision-making were generally positive, there was continued hesitancy among providers towards implementing a shared decision-making tool. This push back may stem from a chronic shortage of OBGYNs creating a high patient load and limited time. The inability of certified nurse midwives to follow trial of labor after cesarean section (TOLAC) patients adds to the patient load of OBGYNs, and thus furthers the burden. Patient attitudes were positive towards the tool and the shared decision-making process as a whole. Women who had a traumatic previous birth experience seemed to appreciate the intervention more, stating that it helped them understand and acknowledge the uncertainty that can accompany childbirth. Conclusion: While the implementation of a shared decision-making tool may receive provider push-back at first, there is evidence of patient satisfaction and provider willingness to continue its use.