Vaginal birth after Cesarean (VBAC)

Guise JM, McDonagh M, Hashima J
Record ID 32003000718
English
Authors' objectives:

The literature was systematically reviewed to compare the benefits and harms of a trial of labor (TOL) and an elective repeat cesarean delivery (ERCD), and to examine factors that influence decisionmaking.

Authors' results and conclusions: The literature concerning TOL and ERCD is flawed in several ways: imprecise measurement of outcomes (e.g., maternal infection, perinatal death), making it difficult to determine the portion of events directly attributable to maternal choice of delivery route; lack of standards for terminology (e.g., no standard classification for severity of uterine rupture, nor attribution specifically to the disruption of the cesarean scar); and limited attention to comparability between groups (e.g., studies of ERCD where it is unclear whether patients were eligible for TOL). Similarly, important definitional confounding prevents determination of whether signs, such as prolonged fetal bradycardia, have any predictive premonitory value. There is no direct evidence regarding the benefits and harms of TOL relative to ERCD in women who are similar in every respect except choice of delivery route. Several large cohort studies provide indirect evidence about relative benefits and harms of TOL versus ERCD. Overall, these studies report an increased risk of perinatal death and symptomatic uterine rupture of a cesarean scar with TOL, no increased risk of asymptomatic uterine rupture (dehiscence), maternal death or hysterectomy from either route, and increased risk of infection from ERCD. However, the magnitude of risk is uncertain due to methodologic deficiencies of the studies. Further studies are needed to test the reliability and usefulness of economic models and predictive tools. The literature concerning factors that influence patient decisionmaking and satisfaction with childbirth was poor, giving us little insights into patient's priorities.
Authors' recomendations: The deficiencies in the literature about the relative benefits and harms of TOL versus ERCD are striking. Patients, clinicians, insurers, and policymakers do not have the data they need to make truly informed decisions about appropriate delivery choices following one of the most common surgical procedures performed on women. Given the rising prevalence of this condition, and potential for devastating consequences for thousands of women and children each year, obtaining accurate data should be a high research priority.
Authors' methods: Systematic review
Details
Project Status: Completed
Year Published: 2003
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: United States
MeSH Terms
  • Cesarean Section
  • Cesarean Section, Repeat
  • Vaginal Birth after Cesarean
Contact
Organisation Name: Agency for Healthcare Research and Quality
Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;
Contact Name: martin.erlichman@ahrq.hhs.gov
Contact Email: martin.erlichman@ahrq.hhs.gov
Copyright: Agency for Healthcare Research and Quality (AHRQ)
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.