Carmen B Young1, Shiliang Liu2, Giulia M Muraca2, Yasser Sabr2, Tracy Pressey2, Robert M Liston2, K S Joseph2. 1. Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr). cbyoung@ualberta.ca. 2. Department of Obstetrics and Gynecology (Young), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta; Maternal, Child and Youth Health Division (Liu), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Department of Obstetrics and Gynaecology (Muraca, Sabr, Pressey, Liston and Joseph), Faculty of Medicine; School of Population and Public Health (Muraca, Joseph), University of British Columbia; Children and Women's Health Centre of British Columbia (Muraca, Sabr, Pressey, Liston and Joseph), Vancouver, BC; Department of Obstetrics and Gynaecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Sabr).
Abstract
BACKGROUND: The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery. METHODS: We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs). RESULTS: Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003-2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014). INTERPRETATION: Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.
BACKGROUND: The mode of delivery for women with a previous cesarean delivery remains contentious. We conducted a study comparing maternal and infant outcomes after attempted vaginal birth after cesarean delivery versus elective repeat cesarean delivery. METHODS: We used data from the Discharge Abstract Database that includes all hospital deliveries in Canada (excluding Quebec). In our analysis, we included singleton deliveries to women between 37 and 43 weeks gestation who had a single prior cesarean delivery between April 2003 and March 2015. The primary outcomes were severe maternal morbidity and mortality, and serious neonatal morbidity and mortality. We used logistic regression to estimate adjusted rate ratios (RRs) and 95% confidence intervals (CIs). RESULTS: Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively). The association between vaginal birth after cesarean delivery, and serious neonatal morbidity and mortality showed a temporal worsening (adjusted RR 0.94, 95% CI 0.77 to 1.15 in 2003-2005; adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014). INTERPRETATION: Although absolute rates of adverse outcomes are low, attempted vaginal birth after cesarean delivery continues to be associated with higher relative rates of severe morbidity and mortality in mothers and infants. Temporal worsening of infant outcomes after attempted vaginal birth after cesarean delivery highlights the need for greater care in selecting candidates, and more careful monitoring of labour and delivery.
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