Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes.
OBJECTIVE
To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section.


METHODS
Decision model.


METHODS
Women with one prior low transverse caesarean section who are eligible for trial of labour.


METHODS
Two decision models were built: the first one applying to women planning only one more pregnancy, the second one applying to women planning two more pregnancies. Probability estimates for VBAC success rate and risks of uterine rupture, placenta praevia, placenta accreta and hysterectomy were extracted from the available literature.


METHODS
Hysterectomy for uterine rupture, placenta accreta or other indications.


RESULTS
In the first model VBAC attempt led to a higher hysterectomy rate (267/100,000) compared with repeat caesarean section (187/100,000). However, in the second model a policy of elective repeat caesarean section led to higher cumulative hysterectomy rate: 1465/100,000 versus 907/100,000 for VBAC. The first model was robust to all but one variable in sensitivity analyses. The second model was robust to all variables in sensitivity analyses.


CONCLUSIONS
These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC.
Paré
Emmanuelle
E
Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
Quiñones
Joanne N
JN
Macones
George A
GA
D017604:Cesarean Section, Repeat / Q000009:adverse effects*; D003661:Decision Support Techniques; D017558:Elective Surgical Procedures; D005260:Female; D006304:Health Status; D006801:Humans; D007044:Hysterectomy / Q000379:methods; D010921:Placenta Accreta / Q000209:etiology* / Q000601:surgery; D011247:Pregnancy; D011379:Prognosis; D012307:Risk Factors; D014597:Uterine Rupture / Q000209:etiology* / Q000601:surgery; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects*