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Baruch Y, Gold R, Eisenberg H, Yogev Y, Groutz A. Is vaginal birth after cesarean section a risk factor for obstetric anal sphincter injury? Int J Gynaecol Obstet 2024. [PMID: 38803102 DOI: 10.1002/ijgo.15698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To investigate whether women undergoing their first vaginal delivery after a previous cesarean section (secundiparous) are at increased risk for obstetric anal sphincter injury (OASI) compared with primiparous women. METHODS A retrospective cohort study of 85 428 women who delivered vaginally over a 10-year period in a single tertiary medical center. Incidence of OASI, risk factors, and clinical characteristics were compared between primiparous women who delivered vaginally and secundiparous women who underwent their first vaginal birth after cesarean section (VBAC). A multivariable logistic regression analysis was used to study the association between VBAC and OASI. RESULTS Overall, 36 250 primiparous and 1602 secundiparous women were enrolled, 309 of whom had OASI. The rates of OASI were similar among secundiparous women who had VBAC and primiparous women who underwent vaginal delivery (15 [0.94%] vs 294 [0.81%], P = 0.58). The proportions of third- and fourth-degree tears were also similar among secundiparous and primiparous women who experienced OASI (87% vs 91.5%, and 13% vs 8.5%, respectively, P = 0.68). Furthermore, the rates of OASI were similar in both study groups, although secundiparous women who underwent VBAC had higher rates of birth weights exceeding 3500 g (414 [25.8%] vs 8284 [22.8%], P = 0.016), and higher rates of vacuum-assisted deliveries (338 [21%] vs 6224 [17.2%], P < 0.001). A multivariate logistic regression analysis failed to establish a statistically significant association between VBAC and OASI (odds ratio 0.672, 95% confidence interval 0.281-1.61, P = 0.37). CONCLUSIONS No increased risk for OASI was found in secundiparous women who underwent VBAC compared with primiparous women at their first vaginal birth.
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Affiliation(s)
- Yoav Baruch
- Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Gold
- Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Eisenberg
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Asnat Groutz
- Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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van Bavel J, Ravelli ACJ, Roovers JPWR, Abu-Hanna A, Mol BW, de Leeuw JW. Risk indicators for obstetrical anal sphincter injury in vaginal birth after caesarean section compared to first vaginal delivery. Eur J Obstet Gynecol Reprod Biol 2023; 288:198-203. [PMID: 37572448 DOI: 10.1016/j.ejogrb.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/02/2023] [Accepted: 07/27/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES Comparison of the rate of obstetric anal sphincter injury (OASI) between women having their first vaginal birth after caesarean section (CS) and true nulliparous women with a vaginal delivery. Assessment of risk indicators for OASI in women with vaginal birth after one CS (VBAC). STUDY DESIGN 28 535 women with their first VBAC and a cohort of 275 439 nulliparous women with a vaginal delivery of a liveborn infant in a cephalic position from the Dutch perinatal registry were analyzed. We compared the OASI rate with univariate and multivariate analysis. In women with VBAC possible risk indicators for OASI were assessed using univariate and multivariate logistic regression analysis. RESULTS The rate of OASI was 5.2% in women with vaginal birth after CS and 4.0% in women with a first vaginal delivery. The adjusted OR (aOR) for vaginal birth after an elective CS was higher (aOR 1.34, 95% CI 1.23-1.47) compared to vaginal birth after an emergency CS (aOR 1.16, 95% CI 1.08-1.25). In women with vaginal birth after emergency CS, the aOR for the indication non-progressive labor was 1.18 (95% CI 1.08-1.29), whereas CS for suspected fetal distress was not significantly associated with obstetric anal sphincter injury in VBAC. In the 28 535 women with a VBAC, mediolateral episiotomy (MLE), birth weight < 3000 g and maternal age < 25 years were associated with a significantly lower rate of OASI. A gestational age of 42 weeks, birth weight ≥ 3500 g, operative vaginal delivery and duration of the 2nd stage of labour of ≥ 60 min were associated with a significantly higher rate of OASI. CONCLUSIONS Women with a VBAC have a higher rate of OASI in comparison with women with a first vaginal delivery, with the exception of women with a vaginal birth after an emergency CS for suspected fetal distress. Factors associated with a significantly lower rate for OASI were MLE, maternal age < 25 and birth weight < 3000 g. A gestational age of 42 weeks, birth weight between 3500 and 4000 g and ≥ 4000 g, operative vaginal delivery and duration of the 2nd stage of delivery longer dan 60 min were associated with a significantly higher rate of OASI.
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Affiliation(s)
- J van Bavel
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, The Netherlands.
| | - A C J Ravelli
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - J P W R Roovers
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - A Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Amsterdam, The Netherlands.
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia; Aberdeen Centre for Women's Health Research, School of Medicine, University of Aberdeen, Aberdeen, UK.
| | - J W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands.
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Fitzpatrick KE, Quigley MA, Kurinczuk JJ. Planned mode of birth after previous cesarean section: A structured review of the evidence on the associated outcomes for women and their children in high-income setting. Front Med (Lausanne) 2022; 9:920647. [PMID: 36148449 PMCID: PMC9486480 DOI: 10.3389/fmed.2022.920647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/08/2022] [Indexed: 12/05/2022] Open
Abstract
In many high-income settings policy consensus supports giving pregnant women who have had a previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or planning a vaginal birth after previous cesarean (VBAC), provided they have no contraindications to VBAC. To help women make an informed decision regarding this choice, clinical guidelines advise women should be counseled on the associated risks and benefits. The most recent and comprehensive review of the associated risks and benefits of planned VBAC compared to ERCS in high-income settings was published in 2010 by the US Agency for Healthcare Research and Quality (AHRQ). This paper describes a structured review of the evidence in high-income settings that has been published since the AHRQ review and the literature in high-income settings that has been published since 1980 on outcomes not included in the AHRQ review. Three databases (MEDLINE, EMBASE, and PsycINFO) were searched for relevant studies meeting pre-specified eligible criteria, supplemented by searching of reference lists. Forty-seven studies were identified as meeting the eligibility criteria and included in the structured review. The review suggests that while planned VBAC compared to ERCS is associated with an increased risk of various serious birth-related complications for both the mother and her baby, the absolute risk of these complications is small for either birth approach. The review also found some evidence that planned VBAC compared to ERCS is associated with benefits such as a shorter length of hospital stay and a higher likelihood of breastfeeding. The limited evidence available also suggests that planned mode of birth after previous cesarean section is not associated with the child's subsequent risk of experiencing adverse neurodevelopmental or health problems in childhood. This information can be used to manage and counsel women with previous cesarean section about their subsequent birth choices. Collectively, the evidence supports existing consensus that there are risks and benefits associated with both planned VBAC and ERCS, and therefore women without contraindications to VBAC should be given an informed choice about planned mode of birth after previous cesarean section. However, further studies into the longer-term effects of planned mode of birth after previous cesarean section are needed along with more research to address the other key limitations and gaps that have been highlighted with the existing evidence.
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Affiliation(s)
- Kathryn E. Fitzpatrick
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Meyer R, Shai D, Horesh N, Alcalay M, Ram E, Levin G. Risk factors for obstetric anal sphincter injury among women undergoing a trial of labor after cesarean. Eur J Obstet Gynecol Reprod Biol 2021; 260:37-41. [PMID: 33721622 DOI: 10.1016/j.ejogrb.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Data regarding the risks of obstetrical anal sphincter injury (OASI) among women who never delivered vaginally undergoing a trial of labor after cesarean (TOLAC) are scarce. We aimed to evaluate the risk factors and the rate of OASI among women undergoing TOLAC who never delivered vaginally. STUDY DESIGN A retrospective cohort study of all women undergoing a TOLAC and never delivered vaginally between 3/2011 and 6/2020. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to earliest gestational age in which OASI has occurred. A further comparison was made between the study cohort and a cohort of primiparous women undergoing a vaginal delivery, including gestational ages at which OASI has occurred in that cohort. RESULTS During the study period there were 2061 TOLACs among women without prior vaginal delivery. Of these, 76 % (1566/2061) had a successful vaginal delivery. Overall, 22/2061 (1.1 %) cases of OASI occurred. There was no difference in maternal demographic, obstetrical and medical history characteristics between the study groups. The mean gestational age at TOLAC was lower in the OASI group (390/7 ± 12/7 vs. 395/7 ± 12/7, p = 0.012). In multivariable regression analysis, gestational age was negatively associated with OASI [adjusted odds ratio, 95 % (confidence interval) 0.95 (0.91-0.99), for each day increase in gestational age)]. The rate of OASI in the study cohort did not differ from the rate of OASI among primiparous women during the same study period (347/27975, 1.2 %, p = 0.686). CONCLUSION Gestational age at delivery is the only predictor of OASI among women with no prior vaginal deliveries undergoing a TOLAC. The incidence of OASI in this population is 1.1 % and does not differ from that of primiparous women.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Daniel Shai
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Horesh
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; The Department of Surgery and Transplantation, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Menachem Alcalay
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel; The Department of Obstetrics and Gynecology, Urogynecology Unit, Baruch Padeh-Poria Medical Center, Tiberias, Israel; The Faculty of Medicine at Galille, Bar Ilan University, Ramat Gan, Israel
| | - Edward Ram
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; The Department of Surgery and Transplantation, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Levin G, Tsur A, Shai D, Alcalay M, Ram E, Meyer R. Risk of anal sphincter injury in trial of labor post cesarean section. Acta Obstet Gynecol Scand 2020; 100:147-153. [PMID: 32853395 DOI: 10.1111/aogs.13977] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION We wanted to evaluate whether secundiparas who achieved vaginal birth after cesarean (VBAC) were at an increased risk for obstetric anal sphincter injury (OASI) compared to primiparas who delivered vaginally, with a stratification by the mode of delivery-spontaneous or operative vaginal delivery. MATERIAL AND METHODS We conducted a retrospective cohort study of primiparous women who delivered by vacuum-assisted delivery between March 2011 and June 2019. Primiparas delivering vaginally and secundiparas undergoing VBAC were compared. The cohort was further stratified into two categories: spontaneous vaginal delivery and operative vaginal delivery. RESULTS Overall, 23 822 primiparas who delivered vaginally and 1596 secundiparas who underwent VBAC were analyzed. Operative vaginal delivery was performed in 4561 deliveries. OASI rate did not differ between the VBAC and primipara groups (1.3% vs 1.8%, P = .142). A total of 20 857 women delivered by spontaneous vaginal delivery, among them 1180 (5.7%) women were secundiparas and 19 677 (94.3%) were primiparas. OASI rate was comparable between the secundiparas undergoing VBAC and primiparas delivering vaginally (17 [1.4%] vs 338 [1.7%], P = .436). A total of 4561 women delivered by operative vaginal delivery, among them 416 (9.1%) were secundiparas and 4145 (90.9%) were primiparas. The rate of operative vaginal deliveries was higher among the VBAC group compared with the primipara group (6.1% vs 17.4%, P < .001). However, women undergoing successful VBAC had lower rates of OASI compared with primiparas (3 [0.7%] vs 96 [2.3%]; odds ratio [OR] 0.30, 95% CI 0.09-0.97, P = .032). After multivariate logistic regression including all statistically significant factors, OASI was not associated with VBAC in spontaneous or operative vaginal deliveries (adjusted OR 0.85, 95% CI 0.51-1.40 and 0.39, 95% CI 0.12-1.28, respectively). CONCLUSIONS Secundiparas undergoing VBAC were not at a higher risk of OASI when compared with primiparas delivering vaginally, either in spontaneous or operative vaginal deliveries. This information might aid when counseling women contemplating a trial of labor after cesarean--to address their concerns regarding the risks and benefits of VBAC.
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Affiliation(s)
- Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Abraham Tsur
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Shai
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Menachem Alcalay
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Department of Obstetrics and Gynecology, Urogynecology Unit, Baruch Padeh-Poria Medical Center, Tiberias, Israel.,Faculty of Medicine at Galille, Bar Ilan University, Ramat Gan, Israel
| | - Edward Ram
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Department of Surgery and Transplantation, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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O'Leary BD, Kane DT, Kruseman Aretz N, Geary MP, Malone FD, Hehir MP. Use of the Robson Ten Group Classification System to categorise operative vaginal delivery. Aust N Z J Obstet Gynaecol 2020; 60:858-864. [PMID: 32350863 DOI: 10.1111/ajo.13169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD. AIMS We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD. MATERIALS AND METHODS This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated. RESULTS There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1). CONCLUSION OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.
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Affiliation(s)
- Bobby D O'Leary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Daniel T Kane
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | | | - Michael P Geary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Mark P Hehir
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
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