Randomised trial of assigned mode of delivery after a previous cesarean section – Impact on maternal psychological dynamics

The safety of trial of labor after cesarean section (TOLAC) versus elective repeat cesarean section (ERCS): a systematic review and meta-analysis

OBJECTIVE

Women's choice of birth following a cesarean delivery either includes a trial of elective repeat cesarean section (ERCS) or a trial of labor after cesarean (TOLAC). No comprehensive overview or systematic summary is currently available.

METHODS

EMBASE, PubMed, and the Cochrane Library databases were searched from inception to 1 February 2020. Studies reporting the safety of TOLAC and ERCS in pregnant women with prior cesarean delivery were included. Statistical analysis was performed using RevMan 5.3 and Stata 15.0. Odds ratios (ORs) and 95% confidence intervals (CIs) were adopted as the effective measures.

RESULTS

A total of 13 studies covering 676,532 cases were included in this meta-analysis. The results demonstrated that the rates of uterine rupture (OR = 3.35, 95%CI [1.57, 7.15], I² = 81%), neonatal asphyxia (OR = 2.32, 95%CI [1.76, 3.08], I² = 0%) and perinatal death (OR = 1.71, 95%CI [1.29, 2.25], I² = 0%) were higher in the TOLAC group compared with the ERCS group. The rates of peripartum hysterectomy (OR = 0.70, 95%CI [0.44, 1.11], I² = 62%), blood transfusion (OR = 1.24, 95%CI [0.72, 2.12], I² = 95%), and puerperal infection (OR = 1.11, 95%CI [0.77, 1.60], I² = 95%) showed no significant differences between the two groups.

CONCLUSION

TOLAC is associated with a higher risk of uterine rupture, neonatal asphyxia, and perinatal death compared with ERCS. Nevertheless, it should be noted that the risks of all complications were small in both groups. This information is important for healthcare providers and women choosing the delivery type.

Planned cesarean delivery vs planned vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

There are over 145 million births worldwide, with over 30 million cesarean deliveries yearly. There are limited data comparing the perinatal and maternal outcomes between planned cesarean delivery and planned vaginal delivery. This study aimed to evaluate perinatal and maternal morbidity and mortality by meta-analysis of randomized controlled trials that randomly assigned patients to either planned cesarean delivery or planned vaginal delivery.

DATA SOURCES

Scopus, PubMed, CINAHL, Cochrane Library, and the World Health Organization clinical trial databases were searched from inception through August 2022.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared planned cesarean delivery with planned vaginal delivery at any gestational age and for any delivery indication were included.

METHODS

Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. The primary outcome was perinatal mortality. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals. Pooled odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel random-effects models for outcomes.

RESULTS

In 15 primary randomized controlled trials, 3265 patients were randomized to planned cesarean delivery and 3353 to planned vaginal delivery. The incidence of perinatal deaths was not different (1.3% vs 1.3%; relative risk, 0.71; 95% confidence interval, 0.33-1.52). Planned cesarean delivery was associated with lower neonatal incidences of low umbilical artery pH (0.3% vs 2.4%; relative risk, 0.18; 95% confidence interval, 0.05-0.67), birth trauma (0.3% vs 0.7%; relative risk, 0.46; 95% confidence interval, 0.22-0.96), tube feeding requirement (2.5% vs 7.1%; relative risk, 0.36; 95% confidence interval, 0.19-0.66), and hypotonia (0.4% vs 3.5%; relative risk, 0.11; 95% confidence interval, 0.03-0.47), compared to planned vaginal delivery. Chorioamnionitis was less frequent in the planned cesarean delivery group (0.3% vs 1.0%; relative risk, 0.27; 95% confidence interval, 0.08-0.98). Wound infection was more common in the planned cesarean delivery group (1.9% vs 1.1%; relative risk, 1.61; 95% confidence interval, 1.04-2.52). Lower rates were observed in the planned cesarean delivery group for urinary incontinence at both ≤3 months (8.7% vs 12.2%; relative risk, 0.71; 95% confidence interval, 0.59-0.85) and 1 to 2 years (16.9% vs 22%; relative risk, 0.77; 95% confidence interval, 0.67-0.88) and for a painful perineum at 2 years (4% vs 6.2%; relative risk, 0.64; 95% confidence interval, 0.47-0.87) compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death (0.69% vs 1.81%; relative risk, 0.45; 95% confident interval, 0.21-0.93).

CONCLUSION

Planned cesarean delivery and planned vaginal delivery were associated with similar rates of perinatal and maternal mortality in this meta-analysis of randomized controlled trials. Planned cesarean delivery was associated with significant decreases in adverse neonatal outcomes such as low umbilical artery pH, birth trauma, tube feeding requirement, and hypotonia, and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. Planned vaginal delivery was associated with significant decreases in need for general anesthesia and wound infection. Further randomized trials are needed to assess the risks and benefits of planned cesarean delivery vs planned vaginal delivery in lower-risk patients and in the general population.

Planned mode of birth after previous caesarean section and women's use of psychotropic medication in the first year postpartum: a population-based record linkage cohort study

BACKGROUND

Policy in many high-income settings supports giving pregnant women with previous caesarean section a choice between an elective repeat caesarean section (ERCS) or planning a vaginal birth after previous caesarean (VBAC), provided they have no contraindications to VBAC. Despite the potential for this choice to influence women's mental health, evidence about the associated effect to counsel women and identify potential targets for intervention is limited. This study investigated the association between planned mode of birth after previous caesarean and women's subsequent use of psychotropic medications.

METHODS

A population-based cohort study of 31 131 women with one or more previous caesarean sections who gave birth to a term singleton in Scotland between 2010 and 2015 with no prior psychotropic medications in the year before birth was conducted using linked Scottish national datasets. Cox regression was used to investigate the association between planned mode of birth and being dispensed psychotropic medications in the first year postpartum adjusted for socio-demographic, medical, pregnancy-related factors and breastfeeding.

RESULTS

Planned VBAC (n = 10 220) compared to ERCS (n = 20 911) was associated with a reduced risk of the mother being dispensed any psychotropic medication [adjusted hazard ratio (aHR) 0.85, 95% confidence interval (CI) 0.78-0.92], an antidepressant (aHR 0.83, 95% CI 0.76-0.90), and at least two consecutive antidepressants (aHR 0.83, 95% CI 0.75-0.91) in the first year postpartum.

CONCLUSIONS

Women giving birth by ERCS were more likely than those having a planned VBAC to be dispensed psychotropic medication including antidepressants in the first year postpartum. Further research is needed to establish the reasons behind this new finding.

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

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.

Questionnaire survey on women's views after a first caesarean delivery in two tertiary centres in Ireland and their preference for involvement in a future randomised trial on mode of birth

OBJECTIVE

To assess the views of women after a first caesarean section (CS) on their birth experience, preference for future mode of birth and willingness to participate in a randomised controlled trial on mode of birth in a future pregnancy.

DESIGN

Questionnaire survey.

SETTING

Two tertiary maternity centres Ireland, Galway University Hospital, Galwayand the National Maternity Hospital, Dublin.

PARTICIPANTS

Women with one previous CS.

METHODS

Eligible women consented to participate, and postal surveys were forwarded. Results were collected and analysed. Results were compared between women who had elective operations and women who had emergency operations.

PRIMARY OUTCOME MEASURES

The satisfaction levels of women after a first caesarean, their preference for mode of birth in a future pregnancy and their willingness to participate in a randomised trial on mode of birth.

RESULTS

There were 347 completed surveys of 633 women who consented to participate (54.8%), of whom 285 and 62 had emergency and elective caesarean deliveries, respectively. In general, satisfaction ratings with the delivery were greater than 90%, with similar levels of satisfaction with the care received from doctors and midwives. Women who an emergency procedure expressed lower satisfaction levels with the information about the caesarean and the debriefing received afterwards than women who had a planned operation (p<0.05). For future mode of birth, 39.5% expressed a preference for vaginal birth after caesarean (VBAC) in a subsequent pregnancy, and 80% said they would consider involvement in a randomised trial in a future pregnancy.

CONCLUSION

Debriefing and counselling women after a CS is an important part of pregnancy care and can significantly impact on a woman's overall birth experience. A significant proportion of this cohort considered VBAC as a future birth option. These data indicate that a randomised trial on mode of birth after caesarean would be viewed positively by women in our population.

Speeded Recognition of Fear and Surprise in Autism

Autism spectrum disorders (ASD) involve difficulties with socioemotional functioning; however, research on emotion recognition remains inconclusive. Children with ASD have been reported to show less susceptibility to spatial inversion. The aim of this study is to examine whether children with ASD utilize atypical abilities in socioemotional processing. This study tested 13 children with ASD (1 girl, M: 15.10 years, standard deviation [ SD]: 1.60 years), 13 children without ASD (3 girls, M: 15.92 years, SD: 1.03 years), and 20 control adults (11 women, M: 24.77 years, SD: 8.30 years) to investigate the speed and accuracy of their responses to images of neutral faces and faces expressing “easy” (happiness, anger) and “difficult” emotions (surprise, fear) in nonrotated (0°) and rotated (30°, 90°, 150°, 180°, 210°, 270°, and 330°) positions. The results showed that children with ASD recognized both easy and difficult emotions as accurately as did children and adults without ASD. Children with ASD, however, responded significantly faster to difficult emotions when the images were rotated. These results offer less support for a deficiency model than for an atypical, rapid featural type of processing used by children with ASD to encode and understand complex socioemotional stimuli.

Vaginal birth after caesarean section: Current status and where to from here?

Vaginal birth after caesarean (VBAC) delivery remains a controversial topic, and one for which there is a lack of robust data to guide clinicians and parturients regarding their best option for mode of delivery in a subsequent pregnancy. In many developed countries the trend observed in recent years is that of progressively reduced VBAC rates, and hence increased use of elective repeat caesarean section (ERCS). This factor has contributed, more than any other, to the disproportionately high caesarean section (CS) rates in many countries. With current CS rates varying between 30 and 50% in the developed world, a previous CS is the cited primary indication in approximately 30%. To compound matters, there are huge variations in the reported VBAC rates between different countries, regions and even institutions. This review has focused on the recent trends in VBAC attempt, success and overall rates internationally, with inclusion of figures for a period of 25 years from a single Irish institution. An analysis of the reported factors that influence VBAC success, or failure, is presented. The complex task of estimating risk, both perinatal and maternal, for women who pursue VBAC or ERCS, is included in this review. Finally, the current evidence base for clinical practice pertaining to VBAC is outlined, with inclusion of commentary regarding the future for this difficult area of obstetric practice.

The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review

BACKGROUND

Obstetricians are often reluctant to grant requests for an elective cesarean section (ECS) due to childbirth fear. To date, it is unknown if an ECS on request improves mental well-being in the mother in the peripartum period and if possible beneficial effects on anxiety and depression could outweigh the increased risk of complications associated with a surgical delivery. A systematic review was conducted to explore the effect of ECS on request on peripartum anxiety and depression.

METHODS

We searched on PubMed, PsychoInfo and Embase. Studies were included with primary data on anxiety and/or depression postpartum in women with childbirth fear who had requested an ECS. After full-text evaluation of 65 papers and quality analysis of four papers, three papers were included. Of one paper additional and yet unpublished data were provided. Studies varied in outcome measures, hence no meta-analysis was performed.

RESULTS

Women who requested an ECS had higher antepartum depression and anxiety levels but no different postpartum depression levels than women who delivered vaginally. One study of good quality examined the effect of vaginal delivery in women preferring ECS: These women had significantly higher symptom levels of post-traumatic stress disorder (PTSD) and depression than women with normal vaginal delivery.

CONCLUSIONS

The prospect of an ECS does not lower antepartum anxiety and/or depression levels in women requesting an ECS. If women resolutely persist in wishing an ECS despite adequate counselling and/or psychiatric treatment, the risk of developing depressive and PTSD symptoms in case of vaginal delivery should be taken into account, and an ECS may be considered as a valid alternative.

Selected maternal morbidities in women with a prior caesarean delivery planning vaginal birth or elective repeat caesarean section: a retrospective cohort analysis using data from the UK Obstetric Surveillance System

OBJECTIVE

To conduct a secondary analysis of data from the UK Obstetric Surveillance System (UKOSS) to estimate the rates of specific maternal risks associated with planned vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS).

DESIGN

A retrospective cohort analysis using UKOSS data from 4 studies conducted between 2005 and 2012.

SETTING

All hospitals with consultant-led maternity units in the UK.

POPULATION

Pregnant women who had a previous caesarean section.

METHOD

Women who had undergone a previous caesarean section were divided into 2 exposure groups: planned VBAC and ERCS. We calculated the incidence of each of the 4 outcomes of interest with 95% CIs for the 2 exposure groups using proxy denominators (total estimated VBAC and ERCS maternities in a given year). Incidences were compared between groups using χ(2) test or Fisher's exact test and risk ratios with 95% CI.

MAIN OUTCOME MEASURES

Severe maternal morbidities: peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation.

RESULTS

The risks of all complications examined in both groups were low. The rates of peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation were not significantly different between the 2 groups in absolute or relative terms.

CONCLUSIONS

While the risk of uterine rupture in the VBAC and ERCS groups is well understood, this national study did not demonstrate any other clear differences in the outcomes we examined. The absolute and relative risks of maternal complications were small in both groups. Large epidemiological studies could further help to assess whether the incidence of these rare outcomes would significantly differ between the VBAC and ERCS groups if a larger number of cases were to be examined. In the interim, this study provides important information to help pregnant women in their decision-making process.

A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals

INTRODUCTION

For women with a lower uterine incision without indication for repeat Caesarean section (CS), vaginal birth for their next pregnancy is a safe option. Although these women should be encouraged to consider vaginal birth after a Caesarean section (VBAC) it is not consistently supported in practice. There is relatively little information on the extent to which maternal preference, birthing decisions and outcomes match best available evidence.

AIM

To describe current VBAC rates for women in Queensland, Australia and compare this to safe, achievable VBAC rates reported in national and international studies.

METHOD

Perinatal data from 2004 to 2011 were reviewed to determine current VBAC rates following a primary CS for women birthing in Queensland. These were compared with VBAC rates reported in the literature.

RESULTS

Queensland has a high overall CS rate and high repeat CS rate compared with the national average. In 2010, Queensland VBAC rates for next birth following primary CS were 14% (range 13-21% public sector, 7-11% private hospitals). This is substantially lower than achievable Australian rates of 24% and international rates.

CONCLUSION

Low VBAC rates reflect low numbers of women commencing labour in a pregnancy subsequent to a primary CS. There is unexplained variation in VBAC rates between maternity facilities. Clinical reviews to support evidence-based practice are warranted.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

BACKGROUND

When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean (VBAC), current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned VBAC for women with a previous caesarean birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Two randomised trials involving 320 women and their infants were included. However, data for maternal and infant clinical outcomes were available from one trial with very low event rates, involving 22 women only.For the primary outcomes maternal death or serious morbidity (one study; 22 women; risk ratio (RR) not estimable), and infant death or serious morbidity (one study; 22 women; RR not estimable), there were no statistically significant differences between planned caesarean birth and planned vaginal birth identified.

AUTHORS' CONCLUSIONS

Planned elective repeat caesarean section and planned VBAC for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is largely drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

The long-term effects of birth by caesarean section: the case for a randomised controlled trial

Birth by caesarean section is rising rapidly around the world and is associated with a range of adverse short and long-term outcomes in offspring. The latter include features of the metabolic syndrome, type-1 diabetes, and asthma. Though there are several plausible candidate biological mechanisms, evidence of a causal relationship between mode of delivery and long-term outcomes remains lacking. Here we review the evidence to date, and examine ways in which future studies might advance understanding. We conclude that a randomised controlled trial of mode of delivery for the healthy term, cephalic pregnancy, is neither unethical nor unfeasible and should be seriously considered as the optimum means of addressing a question of great relevance to public health.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

BACKGROUND

When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004).

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

There were no randomised controlled trials identified.

REVIEWERS' CONCLUSIONS

Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.