Is vaginal birth after cesarean less expensive than repeat cesarean delivery?

OBJECTIVE: This study was undertaken to compare total medical costs of trial of labor after cesarean with those of elective repeat cesarean without labor, with both short- and long-term neonatal costs associated with such procedures taken into account. STUDY DESIGN: Costs associated with All Patient Refined diagnosis-related groups and Current Procedural Terminology for a large not-for-profit health care system were applied to an algorithm describing maternal and neonatal outcomes of trial of labor. Perinatal morbidity rates and cost estimates for long-term neurologic damage associated with uterine rupture were derived from published literature. RESULTS: If a 70% vaginal birth rate for women undergoing a trial of labor and delivery in a tertiary center with a mean uterine rupture to delivery time of 13 minutes is assumed, the net cost differential ranged from a saving of $149 to a loss of $217, depending on morbidity assumptions. For vaginal birth after cesarean success rates <70%, trial of labor in the presence of two previous scars, and institutional factors increasing the perinatal morbidity rate by just 4% with respect to that seen in tertiary centers, trial of labor resulted in a net financial loss to the health care system regardless of all other assumptions made. CONCLUSIONS: When costs as opposed to charges are considered and the cost of long-term care for neurologically injured infants is taken into account, trial of labor after previous cesarean is unlikely to be associated with a significant cost saving for the health care system. Recent government-mandated length-of-stay requirements are likely to make the economic benefit of vaginal birth after cesarean even less favorable. Factors other than cost must govern decisions regarding trial of labor or repeat cesarean.     

Vaginal birth after cesarean: what's new in the new millennium?

PURPOSE OF REVIEW: This brief review will focus exclusively on very recent developments and controversial aspects of vaginal birth after cesarean. Only papers published in 2001 or 2002 are included. RECENT FINDINGS: Recent studies have addressed the intrapartum management of vaginal birth after cesarean patients and the safety of trial of labor compared with elective repeat cesarean. SUMMARY: The recent trend has been towards a more cautious approach to vaginal birth after cesarean. Some are concerned that this trend may limit childbirth options for those women who wish to avoid repeat cesarean operations.     

Vaginal birth after cesarean: do California hospital policies follow national guidelines?

OBJECTIVE: To review whether California hospitals are adhering to national practice guidelines with regard to vaginal birth after cesarean (VBAC). STUDY DESIGN: We performed a content analysis of the American College of Obstetricians and Gynecologists (ACOG) and American Association of Family Physicians published guidelines and identified 39 specific recommendations, which were categorized into the following 5 content areas: patient criteria, procedure, staff and resources, uterine rupture or other complications, and miscellaneous clinical issues. We evaluated individual hospital policies with regard to adherence to 34 recommendations made specifically by ACOG. RESULTS: Of the 225 surveyed hospitals, 167 (74%) allow VBAC, and 22% of these (36 of 167) provided VBAC protocols for review. Approximately 80% of protocols included < 50% of the ACOG items (median, 13.5; range, 3-27 items). The highest percent adherence was observed in the procedure and staff and resources categories, where over two thirds of study hospitals exhibited 75-100% adherence. One third of participating hospitals were less adherent (0-25%) in the categories of patient criteria, uterine rupture or other complications, and miscellaneous clinical issues. CONCLUSION: In a sample of written VBAC protocols, we found a wide range of adherence to ACOG recommendations, as evidenced by the number and type of items explicitly documented in the protocols.     

Vaginal birth after cesarean section: trial of labor or repeat cesarean section? A decision analysis

OBJECTIVE: The risk of perinatal death associated with labor after previous cesarean section appears higher than with a repeated cesarean section. On the other hand, repeated cesarean sections are associated with increased maternal morbidity and mortality from placental pathologic conditions (previa or accreta) on subsequent pregnancies. The study was undertaken to analyze the decision for a trial of labor or a repeated cesarean section, after a prior cesarean section, with varying desire for an additional pregnancy. STUDY DESIGN: A model was formulated using a decision tree, based on the reported risks of the two approaches. Sensitivity analysis was performed over a variety of probabilities (eg, chance of uterine rupture or neonatal death, chance of rescue cesarean section, desire for an additional pregnancy) and utilities (eg, use of hysterectomy or neonatal death). RESULTS: The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit. The model was robust over a wide range of assumptions. CONCLUSION: An optimal decision for a trial of labor or a repeated cesarean section is substantially determined by the wish for future pregnancies. The default option of a repeated cesarean section is not directly applicable in populations in which family planning often extends over two children.     

Can a vaginal birth after cesarean delivery be a normal labor and birth? Lessons from midwifery applied to trial of labor after a previous cesarean delivery

Women who undergo a trial of labor after a previous cesarean delivery (TOLAC) have special needs prenatally and during the intrapartum period. Counseling about the choice of TOLAC versus an elective repeat cesarean delivery involves complex statistical concepts. Prenatal counseling that is patient centered, individualized, and presented in a way that addresses the health literacy and health numeracy of the recipient encompasses best practices that support patient decision making. Evidence-based practices during labor that support vaginal birth and increase patient satisfaction are of special value for this population.     

Vaginal birth after cesarean delivery: a group practice’s approach to minimizing failed trial of labor

Objective: Among women attempting a trial of labor (TOL) after a prior abdominal delivery, 60–80% accomplish a vaginal birth after cesarean (VBAC). McMahon and coworkers (N Engl J Med, 1996) have indicated that at a 60% success level for TOL, the remaining 40% incurred enough major complications that the scheduled repeat cesarean section group was less morbid overall. The same authors speculated that a success rate of 80% might be necessary for the TOL group’s morbidity to be superior. We sought to review our group’s patient selection experience during an interval when successful TOL consistently exceeded 80%.Methods: The study interval ranged from January 1995 through June 1997 and was limited to patients with one previous low transverse cesarean section. Rather than using administrative or charge-related diagnoses, we analyzed a departmental database that included each delivering physician’s selection of one of four VBAC categories: successful VBAC, unsuccessful VBAC, patient declined trial of labor, or physician advised against trial of labor. All deliveries were at a single institution and were performed by one of seven obstetricians in a group practice.Results: During the study interval, 332 women provided a history of a single previous cesarean delivery. Of these 332, a total of 173 attempted a TOL and 150 of the 173 (87%) were successful. Fifty-eight of the 332 (18%) declined a trial of labor despite being assessed as excellent candidates, and 101 (30%) were advised against a TOL by their physician. Most common reasons for physicians discouraging labor included malpresentation, fetal macrosomia, and clinically small pelvis. Complications for the 23 of 173 (13%) experiencing a failed TOL included 1 asymptomatic partial separation of a uterine scar and 4 cases of puerperal fever; neither transfusion nor hysterectomy was required.Conclusions: This study demonstrates that in a population of women with one prior cesarean delivery, it is possible for a group practice to achieve a TOL success rate exceeding 80%. In our opinion the managing physician selecting out those patients least likely to attain a successful TOL contributes to a low failed TOL rate. We speculate that an analysis for best practice patterns within our group might reveal information of value for future practice guidelines.     

Vaginal birth after caesarean delivery in twin gestation: is trial of labor allowed?

OBJECTIVE: To determine if a trial of labor in twin pregnancy with previous cesarean section is an acceptable alternative to systematic cesarean section. PATIENTS AND METHODS: Based on a retrospective and comparative study from 1st January 1996 to 30th June 2003 in Maternite Jeanne-de-Flandre (Lille) and Pavillon Paul-Gelle (Roubaix), 35 trials of labor in twin pregnancies with previous cesarean section have been compared with 35 twin gestations attempting vaginal delivery without a prior cesarean. This comparative study has been led by sorting out the patients according to their gestational age, parity and maternity. RESULTS: Twenty-seven women (77%) delivered vaginally and eight (23%) by elective caesarean section. Postpartum hemorrhage was more frequent for caesarean section (75%). No scare dehiscence or rupture occurred. There was not any haemostasis hysterectomy or embolisation related to postpartum haemorrhage. Neonatal outcome was similar in both groups. DISCUSSION AND CONCLUSION: Twin trial of labor after a previous cesarean section seems to be a safe alternative to routine repeat cesarean delivery as maternal and fetal morbidity and mortality are safe.     

Vaginal delivery or cesarean section at term breech delivery – chance or risk?

Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes.

Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student's-t test, χ² likelihood ratio, and the Fisher's exact test. The level of statistical significance was set at p?<0.05.

Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p?=?0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths.

Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.     

Does the interval since vaginal delivery influence the chance of vaginal birth after cesarean?

Objective: To examine the association between interval since vaginal delivery and vaginal birth after cesarean (VBAC).

Methods: Women with one prior low transverse cesarean and a prior vaginal delivery undergoing a trial of labor after cesarean at term were included in this cohort study. Multivariable analyses were performed to determine whether length of time since prior vaginal delivery was independently associated with VBAC and, if so, whether its inclusion enhanced the predictive capacity of previously published models.

Results: Of the 5628 women included, 4901 (87%) achieved a VBAC. Each additional year since vaginal delivery decreased the odds of VBAC by 11% (95% CI: 10–13%). When added to an existing predictive model that included only factors available at early prenatal care, interval since vaginal delivery marginally improved the model’s predictive ability (area under the curve [AUC] 0.73 versus 0.71, p?<?0.01). When added to a model that included factors available proximate to the time of delivery, the addition of interval since vaginal delivery did not change the AUC (0.76 versus 0.75, p?=?0.08).

Conclusions: A longer interval since vaginal delivery is associated with a decreased odd of VBAC. However, the addition of this interval to VBAC prediction models does not substantively improve their predictive ability.     

Vaginal birth after cesarean section—The world trend and local experience in Taiwan

Objective

The trend of increasing cesarean section rates had evoked worldwide attention. Many approaches were introduced to diminish cesarean section rates. Vaginal birth after cesarean section (VBAC) is a route of delivery with diverse agreements. In this study, we try to reveal the world trend in VBAC and our experience of a 10-year period in a medical center in northern Taiwan.

Vaginal delivery after Misgav–Ladach cesarean section – Is the risk of uterine rupture acceptable?

Objective.?To evaluate whether the single-layer closure as is a routine by the Misgav–Ladach method compared to the double-layer closure as used by the Dörfler cesarean method is associated with an increased risk of uterine rupture in the subsequent pregnancy and delivery.

Methods.?The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina. All patients with one previous cesarean section who attempted vaginal birth following cesarean section were managed from 1 January 2002 to 31 December 2008. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous incision other than low transverse, gestational age at delivery less than 37 weeks and induction of delivery. We identified 448 patients who met inclusion criteria.

Results.?We found that 303 patients had a single-layer closure (Misgav–Ladach) and 145 had a double-layer closure (Dörffler) of the previous uterine incision. There were 35 cases of uterine rupture. Of those patients with previous single-layer closure, 5.28% (16/303) had a uterine rupture compared to 13.11% (19/145) in the double-layer closure group (p?<?0.05).

Conclusion.?We have not found that a Misgav–Ladach cesarean section method (single-layer uterine closure) might be more likely to result in uterine rupture in women who attempted a vaginal birth after a previous cesarean delivery. This cesarean section method should find its confirmation in everyday clinical practice.     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.