Trent Center for Bioethics, Humanities and History of Medicine and Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA.
Semin Perinatol. 2010 Oct;34(5):337-44. doi: 10.1053/j.semperi.2010.05.007.
Determining approach to delivery after a previous cesarean is among the most contentious areas of obstetrics. We present a framework for ethically responsible guidelines and practice regarding vaginal birth after cesarean. We describe ethical complexities of 3 key issues that mark the debate: the cesarean delivery rate, safety, and patient autonomy. We then describe a taxonomy of considerations that should inform a responsible framework for guideline development and highlight critical distinctions between types of guidelines that have been blurred in the past. We then forward 2 central claims. First, in otherwise uncomplicated birth after a single previous cesarean, both vaginal birth after cesarean and repeat cesarean should be regarded as reasonable options; women, rather than policymakers, providers, insurance carriers, or hospitals, should determine delivery approach. Second, in complicated cases, providers and policymakers should carefully calibrate the strength of evidence to ensure differential risk and cost are adequate to justify directive guidelines given important variations in values women bring to childbirth.
确定前次剖宫产术后的分娩方式是产科领域最具争议的问题之一。我们提出了一个关于剖宫产后阴道分娩的伦理责任准则和实践框架。我们描述了 3 个关键问题的伦理复杂性，这些问题标志着争论的焦点：剖宫产率、安全性和患者自主权。然后，我们描述了一个分类考虑因素，这些因素应该为负责的准则制定框架提供信息，并强调过去在过去被混淆的不同类型准则之间的关键区别。然后，我们提出了 2 个主要观点。首先，在单前次剖宫产术后的其他情况下不复杂的分娩中，剖宫产后阴道分娩和重复剖宫产都应被视为合理的选择；应该由女性，而不是政策制定者、提供者、保险公司或医院，来决定分娩方式。其次，在复杂情况下，提供者和政策制定者应仔细调整证据的强度，以确保不同的风险和成本足以证明指令性准则是合理的，因为女性在分娩方面的价值观存在重要差异。
