While the risk for uterine rupture of the previous cesarean incision scar is low (single CD 0.72% double CD 1.59%) there is maternal and neonatal risk. Vaginal birth after cesarean (VBAC) may be desired by some women, but the patient-level benefits associated with VBAC including avoiding repeat abdominal surgery and risk of complications in future pregnancies must be considered against the potential risks of a failed trial of labor after cesarean (TOLAC) with subsequent maternal and neonatal morbidity, including an unplanned repeat CD. The Society of Obstetricians and Gynaecologists of Canada (SOGC), the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend that a trial of labor be offered to women with one previous transverse low-segment CD. įor women who have undergone a prior CD, there is uncertainty regarding the choice of a repeat/scheduled CD or attempting a vaginal delivery for a successive pregnancy as both modes of birth have risks. Recent ‘Early Recovery After Cesarean’ (ERAS) for CD guidelines (Part 1–3) have been published to reduce maternal and neonatal morbidity and mortality. This risk warrants careful consideration of potential post-operative complications before scheduled CD, a major abdominal surgery. Short- and long-term morbidity risks for the infant and mother are further influenced by the etiology or indication of their CD however, overall risk of morbidity and mortality is more positively associated with CD compared to vaginal delivery. These influences can affect delivery options/choice and may result in complex pregnancies that ultimately require a CD. Ī number of factors influencing the increase of this surgical delivery method include changes in healthcare practice styles, patient preferences, pressures of malpractice and demographic influences (e.g., social, economic, cultural). Globally, rates of cesarean sections are considered high at an estimated 21% of livebirths in 2015, based on data from 169 countries. Since 1997, the rate of CD has increased from 18.7 to 28.2% in 2017, and frequency of this delivery method continues on an upward trend. In Canada, CDs continue to be the leading inpatient surgery with elective/scheduled CD as a main contributor. Over 103,000 cesarean deliveries (CDs) occurred in 2017 within Canadian hospitals. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD. This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Methodological quality was good overall for the trials however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections any clinical intervention or exposure intended to increase the VBAC rate any comparator and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. Limits were applied for language (English and French) and year of publication (1985 to present). Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost and Ovid PsycINFO. To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates.
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