Abstract
BackgroundThere is evidence that induction of labour (IOL) around term reduces perinatal mortality and caesarean delivery rates when compared to expectant management of pregnancy (allowing the pregnancy to continue to await spontaneous labour or definitive indication for delivery). However, it is not clear whether IOL in women with a previous caesarean section confers the same benefits. The aim of this study was to describe outcomes of IOL at 39–41 weeks in women with one previous caesarean delivery and to compare outcomes of IOL or planned caesarean delivery to those of expectant management.Methods and FindingsWe performed a population-based retrospective cohort study of singleton births greater than 39 weeks gestation, in women with one previous caesarean delivery, in Scotland, UK 1981–2007 (n = 46,176). Outcomes included mode of delivery, perinatal mortality, neonatal unit admission, postpartum hemorrhage and uterine rupture. 40.1% (2,969/7,401) of women who underwent IOL 39–41 weeks were ultimately delivered by caesarean. When compared to expectant management IOL was associated with lower odds of caesarean delivery (adjusted odds ratio [AOR] after IOL at 39 weeks of 0.81 [95% CI 0.71–0.91]). There was no significant effect on the odds of perinatal mortality but greater odds of neonatal unit admission (AOR after IOL at 39 weeks of 1.29 [95% CI 1.08–1.55]). In contrast, when compared with expectant management, elective repeat caesarean delivery was associated with lower perinatal mortality (AOR after planned caesarean at 39 weeks of 0.23 [95% CI 0.07–0.75]) and, depending on gestation, the same or lower neonatal unit admission (AOR after planned caesarean at 39 weeks of 0.98 [0.90–1.07] at 40 weeks of 1.08 [0.94–1.23] and at 41 weeks of 0.77 [0.60–1.00]).ConclusionsA more liberal policy of IOL in women with previous caesarean delivery may reduce repeat caesarean delivery, but increases the risks of neonatal complications.
Highlights
Rates of caesarean section are increasing worldwide, with rates of more than 32% in the USA [1]
As elective repeat caesarean delivery is usually performed before term, the women having elective repeat caesarean section in Crowther et al’s study delivered at a significantly earlier gestation than women attempting vaginal birth after previous caesarean (VBAC)
We aimed to compare the mode of delivery in women with a previous caesarean section undergoing induction of labour (IOL) at 39,40 and 41 weeks with those expectantly managed; and to compare rates of neonatal and maternal complications in women in whom delivery is expedited by IOL or elective repeat caesarean delivery at 39, 40 and 41 weeks, both in comparison to expectant management
Summary
Rates of caesarean section are increasing worldwide, with rates of more than 32% in the USA [1]. A recent carefully designed prospective restricted cohort study suggested that, when compared to elective repeat caesarean section, attempting VBAC resulted in a significantly greater risk of a composite measure of serious morbidity and death for infants [4]. There is evidence that induction of labour (IOL) around term reduces perinatal mortality and caesarean delivery rates when compared to expectant management of pregnancy (allowing the pregnancy to continue to await spontaneous labour or definitive indication for delivery). It is not clear whether IOL in women with a previous caesarean section confers the same benefits. The aim of this study was to describe outcomes of IOL at 39–41 weeks in women with one previous caesarean delivery and to compare outcomes of IOL or planned caesarean delivery to those of expectant management
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