Safety of vaginal birth after cesarean: a systematic review.
OBJECTIVE
To evaluate the benefits and harms of vaginal birth after cesarean compared with repeat cesarean delivery.


METHODS
The computerized databases MEDLINE, EMBASE, HealthSTAR, Cochrane CENTRAL, and National Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effectiveness, along with reference lists and national experts, were used to conduct this review.


METHODS
All studies that reported data for maternal or infant outcomes in women with prior cesarean delivery were eligible. Methodological quality was evaluated for each study with the criteria of the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Twenty of 6,828 potentially relevant articles (55,506 patients) were included in the analysis.


RESULTS
Two authors independently abstracted information on study design, sample size, participant characteristics, and maternal and fetal health outcomes by using a standardized protocol. Rates of vaginal delivery in women undergoing a trial of labor ranged from 60% to 82%. There was no significant difference in maternal deaths or hysterectomy between trial of labor and repeat cesarean. Uterine rupture was more common in the trial-of-labor group, but rates of asymptomatic uterine dehiscence did not differ. Studies conflicted on the effect of induction of labor on these outcomes. Data regarding infant outcomes were poor.


CONCLUSIONS
Safety in childbirth for women with prior cesarean is a major public health concern. Methodological deficiencies in the literature evaluating the relative safety of vaginal birth after cesarean compared with repeat cesarean delivery are striking. The identification of high-risk and low-risk groups of women and settings for morbidity remains a key research priority.
Department of Obstetrics and Gynecology, Evidence-based Practice Center, Oregon Health & Science University, UHN-50, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA. guisej@ohsu.edu
Jeanne-Marie
JM
Guise
Michelle
M
Berlin
Marian
M
McDonagh
Patricia
P
Osterweil
Benjamin
B
Chan
Mark
M
Helfand
D017604:Cesarean Section, Repeat / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007751:Labor, Induced / Q000009:adverse effects*; D011247:Pregnancy; D011256:Pregnancy Outcome; D014219:Trial of Labor; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects*