We found evidence of a cohort effect over time, where in the earliest years the increased odds of neonatal death were greatest over three times higher than that of the women with an ERCS , gradually disappearing over time. Post-hoc analyses summarising the case-mix of TOLAC women according to cohort time were conducted see Additional file 5.
Overall, there was no change in the percentage of women having a TOLAC across the study period as well as in the characteristics of these women including age, educational attainment, gross income and origin.
Advances in obstetrics and changes in practice, as well as perhaps changes in the women having a TOLAC are some of the driving forces behind this finding, meaning that the neonatal death rate is now not significantly different with TOLAC, making it a reasonable choice for pregnant women. We found no increased odds of late neonatal death or infant death. The association disappeared in additional adjusted analyses accounting for smoking, co-morbidities and BMI, suggesting that generally safety is improving and that better case selection is vital and could make TOLAC even safer.
When the cohort was restricted to include women with term deliveries 38—40 weeks gestation , the findings remained the same. The improved safety in terms of outcomes following TOLAC could be for a multitude of reasons including improvements in CS as an abdominal surgery for example changes in uterine incision which came into effect in Denmark and advances in the diagnosis and management of pregnancy and pregnancy-related co-morbidities.
Confounding by indication for underlying medical conditions may also explain the increased odds of early neonatal death found in women with a TOLAC due to acute events during delivery for example. Our study used population-based registry data which are regularly updated and validated for epidemiological research. The unique CPR identifier enables accurate linkage between the various registers and as a result detailed obstetric data were available for the current study allowing us to adjust for a large number of clinical and demographic potential confounders.
The cohort included more than 61, women and spanned almost three decades. Therefore, we were also able to test for evidence of a cohort effect over time. We focused on infant mortality as most of the research to date has prioritised outcomes for mothers.
Clinical trials will likely not be forthcoming as women will decline to be randomised according to mode of delivery. Therefore, large-scale observational studies like the current study detailed here remain the best way to study the effects of mode of delivery on subsequent pregnancy outcomes. In addition, we did not have access to data on type of stillbirth antepartum or intrapartum.
This calls for more delicate registrations of events and series of events, indications and procedures, etc. The study was also carried out using registry data that contain no specific information on the clinical indication for CS. We tried to reduce this problem by adjusting for a number of medical conditions but this could not cover all possible indications.
In addition to this, data were only available for certain covariates for specific time periods as outlined earlier. Unmeasured confounders are also a limitation of this study and all observational studies. The confidence intervals reported in the Scottish study are very broad and must be interpreted with caution. Furthermore, the Scottish study included intrapartum stillbirths and did not adjust for medical conditions in addition to BMI as was the case in the current study.
Although strengthened by the process of randomisation, very few women actually consented to randomisation. This is the best way to assess any risks as one would know whether or not a woman was truly eligible to attempt a TOLAC.
RCTs would be the optimal method of answering this question however they are difficult to conduct as it is hard to randomise a woman according to mode of delivery and unfeasible for rare outcomes such as perinatal death. Currently however, large population-based data such as the Danish registry data used in this study are the best methods for assessing the effects of mode of delivery and there is a continuous call for improvements in the quality and amount of data collected.
There are benefits and harms associated with each mode of delivery and the evidence for this is drawn from observational non-randomised research studies that may be prone to bias. Any results and conclusions must be interpreted with caution although large-scale population-based studies including the present one offer the best method of estimating the risks in women with one prior CS in the absence of RCTs. Our data provide essential, up to date information for expectant parents as well as healthcare workers to make a more informed decision regarding TOLAC.
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PLoS Med. BMC Pregnancy Childbirth. Spong CY. To vbac or not to vbac. Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor. J Perinatol. Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis.
Uterine sutures at prior caesarean section and placenta accreta in subsequent pregnancy: a case—control study. Vaginal birth after Cesarean: New insights on maternal and neonatal outcomes. Obstetric Anesthesia Digest. Signore C. VBAC: what does the evidence show? Also be sure your support person is committed to helping you:.
Work closely with your healthcare team. They will do all they can to promote a safe, healthy birth. Talk with your healthcare provider about your choices for anesthesia and other ways of controlling pain. Refresh your skills. Take a childbirth class. Learn ways to relax, how to breathe through pain, and how to push.
After you are admitted, you may have a blood test as well as an exam. An IV intravenous line might be started to supply fluids or medicines.
Throughout labor, you and your baby will be carefully watched to make sure of your well-being. To make the most of your effort, breathe and push as coached by your healthcare provider. All rights reserved. Skip to topic navigation. Skip to main content. Induced onset of labor was compared with spontaneous onset of labor for each condition studied. The lowest trial of labor rates were observed in diabetes type 1 The highest failure rates were observed in diabetes type 1 Conclusions: In conditions with high rates of failed trial of labor, eg diabetes, macrosomia, and obesity, a planned cesarean section might be a better option than a trial of labor, particularly if induction of delivery might be needed.
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