Elective Repeat Cesarean Delivery Research Articles

Trial of Labor After Cesarean Delivery in Twin Gestations: Systemic Review and Meta-Analysis

(Am J Obst Gynecol. 2019;220:336–347) While twin gestation pregnancy rates have increased, multiple gestation pregnancies are considered a high-risk condition with significant maternal and perinatal risks. For patients with twin pregnancy and history of previous cesarean delivery, adequate data to guide informed decision-making for planned, elective repeat cesarean delivery (RCD) or planned vaginal delivery are lacking. The aim of this study was to assess maternal and neonatal morbidity associated with trial of labor (TOL) after cesarean delivery in twin pregnancy.

340: Subsequent pregnancy outcomes after failed vacuum assisted delivery: A retrospective study

Failed attempted vacuum assisted vaginal delivery (VAD) is not uncommon, occurring in 5-10% of cases. However, little is known regarding subsequent pregnancy outcomes in this setting. We aimed to examine women's preferences for mode of delivery and trial of labor after cesarean (TOLAC) success rates and their associated factors among women with previous failed VAD A retrospective cohort study. The study group comprised all women with prior failed VAD who subsequently delivered during a-10 year period at a university hospital. Overall, 166 women with prior history of failed VAD delivered during study period, with a median inter-delivery of 28 [21-36] months. Of them, 53 (31.9%) women had an elective repeat cesarean delivery (ERCD) and 113 (68.1%) had a TOLAC. Women who elected to undergo ERCD were of older age (p=0.008) and had higher rates of gestational hypertensive disorders at both the first (p< 0.001) and subsequent deliveries (p=0.01). Of the 113 women undergoing TOLAC in the subsequent pregnancy, the overall success rate was 67.3%, with gestational diabetes mellitus associated with failed TOLAC (p=0.04). Neonatal 1- and 5- minutes Apgar scores were lower in those who experienced failed TOLAC attempt as compared to those undergoing ERCD and those with successful TOLAC (p=0.01). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among those undergoing TOLAC. TOLAC in those with previous failed VAD appears to be safe and associated with high success rates. These data should improve patients counseling and provide reassurance for those who wish to deliver vaginally in this setting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

108: Trial of labor after cesarean: Maternal and neonatal outcomes from the Consortium on Safe Labor

To evaluate maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean (TOLAC) using a more contemporary data set. This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study from 2002 to 2008. Women met inclusion criteria for our study if they had a history of any prior cesarean delivery (CD). Perinatal outcomes such as uterine rupture, uterine dehiscence, blood transfusion, hemorrhage, hysterectomy, endometritis, maternal death, neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome, neonatal seizure, and neonatal death were evaluated based on desired delivery mode (planned elective CD or TOLAC). Multivariate logistic regression was used to describe the association between TOLAC and markers of maternal and neonatal morbidity and mortality. Of 9,858 patients who had a prior CD, our study population had 4,400 patients (44.6%) who desired TOLAC and 5,458 patients (55.4%) who underwent elective repeat CD. Of 4,400 patients who desired trial of labor, 3,162 (72%) achieved a vaginal birth. Women who attempted TOLAC compared to those who had an elective CD were more likely to have uterine rupture (OR 3.11; 95% CI 1.21 – 8.02), hemorrhage (OR 2.24; 95% CI 1.86 – 2.70), and blood transfusion (OR 2.33; 95% CI 1.70 – 3.19) (Table 1). Rate of uterine rupture was higher in patients undergoing TOLAC (0.34%), however it was still described in patients undergoing elective CD (0.11%). Rate of NICU admission was higher in patients undergoing TOLAC compared to elective CD, 12.9% and 11.3% respectively (OR 1.17; 95% CI 1.03 – 1.32). Patients undergoing TOLAC are two-times more likely to have a hemorrhage or require blood transfusion compared to women with elective repeat cesarean delivery. Compared to the Cesarean Registry data, women have half the rate of uterine rupture and a 30% higher risk for blood transfusion.

Subsequent Pregnancy Outcomes After Failed Vacuum-Assisted Delivery.

To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery. We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital. Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC. Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.

The effect of maternal health conditions on maternal morbidity in women with a prior cesarean: the role of elective repeat cesarean delivery

Background: We evaluated women with a prior cesarean delivery (CD) who were eligible for elective repeat CD or trial of labor to test whether the risk of severe maternal morbidity (SMM) was: 1) directly associated with important pre-existing and gestational conditions or 2) indirectly associated (significantly increased or decreased) with the decision to undergo elective repeat CD.Methods: Women with a prior CD who had inborn, liveborn, term, singleton, vertex deliveries were identified in California 2010-2011 hospital discharge datasets. Using discharge codes, this population was stratified into two groups: attempted labor and elective repeat CD. A mediation model (stratified by younger vs. older women [&gt;35 years]) was built for each of the following maternal conditions (exposure): chronic/gestational diabetes mellitus (DM), chronic/gestational hypertension, heart disease, obesity, and mental health diagnoses. Elective repeat CD was the mediator and SMM was the outcome.Results: Of 141,535 eligible deliveries, 72.7% had an elective repeat CD; 2.3% had SMM, which occurred in 2.2% of younger vs. 2.6% of older women. For younger and older women respectively, the modeled total effect odds ratios (95% CI) for heart disease were: 10.7 (8.5, 13.5) and 8.8 (6.4, 12.2); for hypertension: 1.7 (1.4, 1.9) and 2.0 (1.6, 2.4); and for mental health diagnoses: 1.9 (1.6, 2.3) and 1.7 (1.3, 2.3). Neither DM nor obesity demonstrated a direct effect. Odds ratios for indirect effects were negligible for all models.Conclusion: Among women with a prior CD, in the presence of important health conditions, the increased risk of SMM mediated by an elective repeat CD was negligible.

Risk of Repeat Cesarean Delivery in Women Undergoing Trial of Labor: A Population-based Cohort Study

(Acta Obstet Gynecol Scand. 2018;97:1524–1529) As the rate of cesarean delivery (CD) has increased worldwide, trial of labor after one cesarean delivery (TOLAC) is often recommended for limiting the incidence of CD. Both elective repeat cesarean delivery (ERCD) and TOLAC carry maternal and neonatal risks. Compared with ERCD, cesarean delivery following TOLAC is associated with increased risks of blood transfusion, hysterectomy, and endometritis. TOLAC itself is associated with a low but increased risk of uterine rupture. Previous studies have estimated the likelihood of successful VBAC after TOLAC in relation to maternal characteristics. These studies, though, have yielded contradictory results and study sizes have been limited. This study aimed to investigate the risk of TOLAC resulting in CD based on cervical dilation during labor for the first CD as well as the indication for the first CD.

Clinical analysis of delivery mode of 576 cases of re-pregnancy after cesarean section

Objective To explore the choice of re-pregnancy delivery mode after cesarean section. Methods From January 2015 to December 2017, a retrospective study was performed on 576 pregnant women who received re-pregnancy after cesarean section in National Nuclear Corporation 416 Hospital and randomly selected 40 cases of vaginal birth after cesarean delivery(VBAC), 40 cases of cesarean section after trial of labor after cesarean delivery(TOLAC) and 40 cases of elective repeat cesarean delivery(ERCD) for comparative analysis.The postpartum hemorrhage, neonatal Apgar score, hospitalization time, hospitalization expenses and complication were compared. Results All the 159 pregnant women chose transvaginal trials and 112 had successful vaginal delivery.The success rate of delivery was 70.4%.Compared with the other two groups, the VBAC group had less postpartum hemorrhage [(172.50±59.86)mL, (281.25±192.05)mL, (260.00±125.68)mL], less average hospital stay [(3.9±0.9)d, (5.7±1.5)d, (4.6±0.7)d] and lower medical expenses [(6 491.79±1 104.78), (11 871.96±1 784.30), (10 724.69±1 843.63)], and the differences were statistically significant (F=7.086, 26.243, 123.488; P=0.001, 0.000, 0.000). The neonatal Apgar score, incidence rates of complications (incomplete uterine rupture, postpartum hemorrhage, urinary retention, thrombotic disease and neonatal conversion) had no statistically significant differences between the two groups (all P>0.05). The TOLAC failed to change to the cesarean section group compared with the ERCD group, the average hospitalization cost was more [(11 871.96±1 784.30)CNY, (10 724.69±1 843.63)CNY], the average hospitalization days was longer [(5.7±1.5)d, (4.6±0.7)d], the difference was statistically significant (P=0.000, 0.005). The postpartum hemorrhage volume, neonatal Apgar score, complications had no statistically significant differences between the two groups(all P>0.05). Conclusion It is safe and feasible to perform vaginal trials under close monitoring without vaginal trials.It is safe and feasible to perform vaginal trials under strict monitoring.Even if the vaginal trial fails to change to cesarean section, it will not increase the occurrence of serious complications.Infant outcomes are good. Key words: Cesarean section; Pregnancy; Mode of delivery

Trial of labor versus elective repeat cesarean delivery in twin pregnancies after a previous cesarean delivery—A systematic review and meta‐analysis

To perform a systematic review of success rates of trial of labor after cesarean (TOLAC) and maternal and neonatal outcomes in twin pregnancy versuselective repeat cesarean delivery (ERCD). We searched MEDLINE, EMBASE, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared twin TOLAC and ERCD for maternal and/or neonatal outcomes. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model. The pooled event rates for successful VBAC, cesarean deliveryfor twin B after vaginal delivery of twin A, and uterine rupture were determined. Of the 841 citations identified, 10 were eligible for analysis (2336 TOLAC cases and 5763 ERCD cases). The pooled event rates for successful VBAC and uterine rupture during TOLAC were 72.2% (95% CI 59.7%-83.2%) and 0.87% (95% CI 0.51%-1.31%), respectively. TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02 [95% CI 1.07-8.54])with no significant differences in mean gestational age at birth, NICU admission rates, or 5-minute Apgar <7. Although the risk for maternal infectious morbidity was significantly lower with TOLAC(RR 0.48 [95% CI 0.25-0.90]), risks of uterine dehiscence, blood transfusions, and hysterectomy were comparable. Twin TOLAC is associated with a relatively high rate of successful vaginal delivery and a low risk of uterine rupture. The finding of higher neonatalmortality rates may be influenced by prematurity, but requires further investigation.

Women's Preferences Regarding the Processes and Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery.

Background: The decrease in trial of labor after cesarean (TOLAC) at institutions that offer this option suggests that patient preference could be a factor in the declining TOLAC rate. However, data regarding how women value the potential processes and outcomes of TOLAC and elective repeat cesarean delivery (ERCD) are limited. We sought to determine how women view the processes and outcomes of TOLAC and ERCD and identify sociodemographic and clinical factors associated with these preferences. Materials and Methods: This is a multicenter cross-sectional study of mode of delivery preferences among TOLAC-eligible women at 26-34 weeks gestation. The time tradeoff metric was used to obtain utilities for the processes and outcomes of TOLAC and ERCD. Multivariable regression analysis was utilized to identify independent predictors of utilities. Results: The 299 study participants constituted a geographically and racially/ethnically diverse group. Although uncomplicated TOLAC resulting in vaginal birth after cesarean and uncomplicated ERCD resulted in high utility values, any alteration in either the process or outcome resulted in substantial utility decrements. In multivariable regression analysis, race/ethnicity, insurance status, and order of scenario presentation emerged as statistically significant predictors. Conclusions: Information regarding both maternal and infant implications is important to women in discussions about approach to delivery. Both the way in which information regarding labor interventions and potential complications is presented and the characteristics of the women contemplating this information affect its impact. These findings underscore the need for evidence-based decision support to help create realistic expectations and incorporate informed patient preferences into decision-making to optimize both clinical outcomes and individual patient experience for women with a prior cesarean delivery.

Timing of an Elective Repeat Cesarean Delivery at Term: Addressing the Controversy

Background: Although most professional societies recommend scheduling elective repeat cesarean deliveries (ERCDs) at 39 weeks, some care providers have started to practice scheduling at earlier timing for various reasons. The objective of our study was to compare the outcomes of scheduling ERCDs at 3 different weeks at term. Methods: In a prospective, observational cohort study conducted over a 2-year period, 339 parturients were scheduled for ERCD at 37, 38 or 39 weeks. In an intention-to-treat approach, we are reporting the rates of delivery before schedule, maternal and neonatal morbidity corresponding to each of these three decisions. Results: A total of 5.3% of deliveries scheduled at 37 weeks were performed before schedule, compared to 16.1% and 46.7% of those scheduled at 38 and 39 weeks, respectively (P < 0.0001). Likewise, delivery outside working hours demonstrated a trend that increased with gestation but was only statistically significant between 38 versus 39 weeks. As expected, a significant improvement was identified for neonatal intensive care unit (NICU) admissions and respiratory morbidity between 37 versus 39 weeks but was minimal between 38 versus 39 weeks. There was no difference in maternal outcome parameters among the three categories. Conclusions: Individualizing patients, according to their risk of spontaneous labor, added obstetric complications if progressed in pregnancy and maternity resources should be integrated in the decision of scheduling ERCD. Scheduling at 38 weeks might curb unplanned delivery rate at the expense of a marginal, though non-significant, increase of neonatal respiratory morbidity. J Clin Gynecol Obstet. 2019;8(1):1-8 doi: https://doi.org/10.14740/jcgo526

ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery.

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

ACOG Practice Bulletin No. 205 Summary: Vaginal Birth After Cesarean Delivery.

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Timing of an Elective Repeat Cesarean Delivery at Term: Addressing the Controversy

Timing of an Elective Repeat Cesarean Delivery at Term: Addressing the Controversy

957: Women with one cesarean: Views on VBAC, ERCD and future RCT regarding mode of delivery

After one cesarean delivery (CD) the options for future delivery include vaginal birth after cesarean (VBAC) or elective repeat cesarean delivery (ERCD), albeit practice regarding this is controversial and varied worldwide. The aims of this study were: 1. to assess women’s views of their birth experience after their first CD; 2. to compare the findings between women who had an elective CD (ECD) and those who had an emergency CD (EmCD); 3. to evaluate their views on a potential future delivery; and 4. to investigate whether they would be willing to join a clinical trial of VBAC vs ERCD in a future pregnancy. This was a prospective questionnaire survey of woman who had their first CD between January and August 2018 in Galway University Hospital. Eligible participants were contacted by telephone for consent and postal surveys sent out, with review board approval (Ref No. 1804). Survey results were collected, and statistical analysis performed using Chi-Square test. There were 297 eligible women consented to participate, of which 242 (81.5%) did, and 154 (64%) surveys were returned complete. EmCD n=104 (67.5%); ECD N= 50 (32.5%) (Table 1). Satisfaction levels for mode of delivery in both groups are shown (Table 1). Women in the EmCD group were less satisfied with the information received prior to the delivery (P<0.05). Both groups were less satisfied with the postnatal counseling provided, and a similar difference observed (P <0.05). Regarding VBAC in a future pregnancy, 45 (43.3%) and 17 (34%), in the EmCD and ECD groups respectively, expressed a preference for VBAC. A lower rate of women in the EmCD expressed a preference for ERCD than those in the ECD group. Approximately 80% of women in both groups said they would consider randomization in a future pregnancy. Debriefing and counselling women after a CD is an important part of pregnancy care and can have a significant impact on a woman’s overall birth experience, as well as her view on mode of delivery in a subsequent pregnancy. A significant proportion of women in this cohort were considering VBAC for future delivery, and a majority of women stated they would consider randomization in a future RCT. These data indicate that an RCT of VBAC versus ERCD would be viewed positively by women with one previous CD in our population.

843: Perinatal outcomes by BMI class in women with hypertension or diabetes delivered by term cesarean

We have shown that in otherwise healthy women, body mass index (BMI) ≥40 kg/m2 is independently associated with adverse neonatal outcomes; however, delivery <39-40 weeks for this indication alone further increases morbidity. It is unclear if increasing BMI has additive adverse perinatal effects when added to common comorbidities like hypertension (HTN) and/or diabetes (DM). We sought to evaluate if increasing BMI class is associated with worsening perinatal outcomes in women with HTN and/or DM delivered by pre-labor elective repeat cesarean delivery (ERCD) and to identify the gestational age (GA) at birth between 37-39 weeks at which these morbidities are minimized. We performed a secondary analysis of a prospective cohort of women undergoing ERCD performed at 19 centers in the MFMU from 1999-2002. Women with HTN and/or DM and non-anomalous singletons delivered by term pre- labor ERCD were included. Women with comorbidities other than HTN or DM or non-elective CD were excluded. Primary outcome was composite neonatal morbidity; secondary outcomes included composite maternal morbidity and individual components of the composites (Table). Incidences of outcomes were calculated for women with HTN, DM, and HTN and/or DM and stratified by BMI class. Multivariable logistic regression was used to calculate adjusted ORs (with 95% CIs) with BMI <30 as reference. Mantel-Haenszel test was used to evaluate the relationship between BMI class and each comorbidity stratified by week GA at delivery. Of 13350 women who underwent ERCD, 786 with documented BMI and either HTN, DM, or HTN and/or DM were analyzed. There was no significant difference in composite neonatal morbidity (or individual components) by BMI class in women with HTN, DM, or HTN and/or DM (Figure/Table). However, there was increasing composite maternal morbidity (p=NS) and a significant increase in incidence of wound complications (p=0.04) with increasing BMI class in women with HTN and/or DM. There were no significant relationships between BMI class, HTN and/or DM, and any outcome across week GA at delivery (p=NS). While BMI ≥40 increases neonatal morbidity in healthy women, there appears to be no additive effect of increasing BMI class, regardless of GA at delivery, in women with HTN and/or DM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Elective repeat cesarean delivery in women eligible for trial of labor in Brazil.

To assess the hospital, maternal, and obstetric characteristics associated with elective repeat cesarean delivery (ERCD) among women eligible for trial of labor after cesarean (TOLAC) delivery in Brazil. The present data were retrieved from the Birth in Brazil study, a national hospital-based cohort study conducted during 2011-2012. Data were collected from medical records and by interview. Univariate and hierarchical multiple logistic regression analyses were performed to analyze factors associated with ERCD among women with a previous cesarean delivery who were eligible for TOLAC. Among 2295 women considered eligible for TOLAC, 1516 (66.1%) had an ERCD; the overall cesarean delivery rate was 79.4%. In the private sector, almost all deliveries (95.3%) were performed by ERCD. In the public sector, ERCD was associated with socioeconomic (more years of schooling), obstetric (women's preference, no previous vaginal delivery, macrosomia), and hospital (mixed hospital, location in noncapital city, fewer than 1500 deliveries per year) characteristics. The ERCD rate in Brazil was high even in a low-risk group, indicating that nonclinical factors may be driving the decision for cesarean delivery. Efforts aiming to reduce cesarean deliveries in Brazil should target women with a previous cesarean delivery.

An integrated model with classification criteria to predict vaginal delivery success after cesarean section

Background: Cesarean delivery (CD) is the most frequently performed surgical procedure worldwide. Trial of labor after cesarean (TOLAC) is associated with an increase in perinatal complications related to uterine rupture. However, in general, vaginal birth after cesarean (VBAC) is considered safe and women have less morbidity than those who undergo an elective repeat CD.Objective: To develop an integrated model with the best performance criteria for predicting vaginal delivery success after CD.Study design: Retrospective observational study including 2367 women who underwent a TOLAC. A predictive model using classification and regression tree modeling was constructed to predict vaginal delivery using maternal demographic, medical history, and labor predictors.Results: Vaginal delivery was best predicted by spontaneous onset of labor, estimated fetal weight <3775 g, maternal body mass index <25, previous CD as an elective or for fetal distress reasons, and interdelivery interval <2290 days. The algorithm showed a sensitivity of 75%, a specificity of 53%, and the area under the curve was 0.69.Conclusions: The classification and regression tree algorithm can be used to develop a predictive model for the success of TOLAC.

Incidence and Risk Factors of Uterine Scar Dehiscence Identified at Elective Repeat Cesarean Delivery: A Case-Control Study

Background: The aim of this study was to determine the rate of uterine scar dehiscence among women undergoing elective repeat cesarean delivery and to investigate associated risk factors. Methods: This was a retrospective case-control study of patients with previous one or more lower segment transverse cesarean incisions giving birth by elective repeat cesarean delivery at two tertiary-care centers over a period of 1 year. Demographic data, previous and current obstetric events were recorded and compared among women with or without uterine scar dehiscence. Results: Among 588 patients included in this study, 27 cases of uterine scar dehiscence were identified with an incidence of 4.6%. This rate was not affected by maternal age, parity, co-morbidity, twin gestation, preoperative labor or previous preterm cesarean delivery. Factors significantly associated with uterine scar dehiscence were “preterm delivery” (OR: 2.76, 95% CI: 1.18 - 6.42), “tertiary cesarean delivery or higher” (OR: 2.56, 95% CI: 1.14 - 5.75) and “inter-delivery interval ≤ 24 months” (OR: 2.38, 95% CI: 1.04 - 5.44). No immediate adverse maternal or neonatal complications were noted. Conclusions: Uterine scar dehiscence is not uncommon among women undergoing elective repeat cesarean delivery. Increased risk was associated with preterm delivery, tertiary cesarean delivery or higher and short inter-delivery interval of ≤ 24 months. J Clin Gynecol Obstet. 2018;7(2):37-42 doi: https://doi.org/10.14740/jcgo481w

Mode of delivery after a previous cesarean birth, and associated maternal and neonatal morbidity.

The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery. We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs). Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003-2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014). Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries

BackgroundThe OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women’s involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.MethodsA decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.ResultsWithin a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.ConclusionsIn all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.