The National Children's Study: how obstetricians can contribute

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial

Background

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean.

Methods/design

The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis.

Discussion

The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management.

Trial registration

Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.

Vaginal birth after cesarean success in high-risk women: a population-based study

OBJECTIVE

The study aim was to identify factors associated with vaginal birth after cesarean (VBAC) in high-risk women.

STUDY DESIGN

This is a population-based retrospective cohort study of all births in Ohio during 2006 and 2007. High-risk patients were defined as singleton gestations in women with one previous cesarean who had ⩾1 of the following risk factors: body mass index (BMI)⩾30, hypertension, or diabetes. Multivariate logistic regression was utilized to estimate the relative influence of each factor on successful VBAC.

RESULT

A total of 280 882 births were analyzed: of them, 79 084 (27.1%) were high-risk pregnancies and 8658 (10.9%) women had undergone one previous cesarean; 1433 (16.6%) underwent a trial of labor after cesarean (TOLAC). Of them, 974 (68.0%) had a successful VBAC, whereas 459 (32.0%) did not. Factors significantly associated with VBAC success were as follows: a prior vaginal delivery; pregnancy weight gain ⩽30 lbs; Caucasian race; and labor augmentation.

CONCLUSION

High-risk women with one prior cesarean are unlikely to undergo a TOLAC, but have a high rate of VBAC.

Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists

OBJECTIVES

The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations.

METHODS

We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%).

RESULTS

FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001).

CONCLUSIONS

Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.

The National Children's Study in North Carolina: a study of the effect of the environment on children's health, growth, and development

The National Children's Study, a longitudinal cohort study exploring relationships among broadly defined environmental exposures and children's health, is assessing whether these exposures are harmful, harmless, or helpful. The study is presently underway in 37 locations (2 of which are in North Carolina) and will expand to enroll 100,000 children across the United States.