Once a cesarean always a cesarean? A computer-assisted decision analysis.
OBJECTIVE
A previous decision analysis models for two strategic choices for trial of labor or repeated cesarean after prior cesarean concluded that the degree of wish for an additional future pregnancy appeared to be a major determinant for choice between the two strategic options. We had extended the analysis model to stillbirth and hypoxic-ischemic encephalopathy in addition to placental complications while updating most of the outcomes in the decision tree.


METHODS
A model was formulated using a decision tree based on reported probabilities for various outcomes and estimated utilities. The question asked was should trial of labor or repeated cesarean be performed after a prior cesarean, with a varying desire for an additional pregnancy. The highest expected outcome determines the preference of our model.


RESULTS
Our model favors repeated elective cesarean (0.9947) over trial of labor (0.9917) after a previous cesarean and is the preferred approach. This approach was preferable irrespective of the probability of additional pregnancy.


CONCLUSIONS
In contrary to previous models, when taking into account the occurrence of a live infant birth, birth of an infant with hypoxic-ischemic encephalopathy stillbirth, neonatal death, abnormal placental implantation, hysterectomy and maternal death the preferred approach for women with previous cesarean is an elective repeated cesarean rather than trial of vaginal delivery.
Sadan
Oscar
O
Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel.
Leshno
Moshe
M
Gottreich
Ahuva
A
Golan
Abraham
A
Lurie
Samuel
S
D017604:Cesarean Section, Repeat; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D006801:Humans; D011247:Pregnancy; D011248:Pregnancy Complications; D011256:Pregnancy Outcome; D016064:Vaginal Birth after Cesarean