Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery

doi:10.1016/j.ajog.2004.03.022

American Journal of Obstetrics and Gynecology

Volume 191, Issue 4, October 2004, Pages 1263-1269

https://doi.org/10.1016/j.ajog.2004.03.022 Get rights and content

Abstract

Objective

This study was undertaken to assess the safety of trial of labor after previous cesarean delivery.

Study design

Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section.

Results

Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (<500) than in high volume (≥500 births per year) obstetric units.

Conclusion

Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.

Section snippets

Material and methods

We used hospital admission and separation records collected by the Canadian Institute for Health Information (CIHI) for 13 years from 1988 to 2000. Data for women admitted to hospital for obstetric delivery were abstracted by a combination of case-mix group, diagnostic, and procedure codes defining their deliveries.¹⁷ During the study period, CIHI-coded diagnoses according to the International Classification of Diseases, Ninth Revision (ICD-9),¹⁸ and coded procedures according to the Canadian

Results

During the 13-year study period, a total of 3,576,980 obstetric deliveries were recorded by CIHI. Of these, 352,215 had a history of at least 1 previous cesarean delivery, from which the following were excluded: multifetal pregnancy (3,569), preeclampsia/eclampsia (7,694), breech or transverse or oblique presentation (18,600), preterm labor (15,419), placenta previa (2,756), placental abruption (4,218), herpes simplex (293), and maternal age less than 14 years.⁵ This left 308,755 eligible

Comment

Trial of labor for women with “1 previous low transverse cesarean section, a singleton vertex presentation, and no absolute indication for cesarean section (such as placenta previa)” was recommended in Canada in 1985.²¹ We found that the rates of trial of labor and VBAC in Canada doubled from 1988 to 1998. The rate of trial of labor among women with previous cesarean section decreased slightly in more recent years, suggesting a more cautious approach in recent years, similar to the trends seen

Acknowledgements

We thank CIHI who gave us access to their data files, and Ling Huang for assistance in computer programming. This study was conducted under the auspices of the Canadian Perinatal Surveillance System. Drs Wen, Heaman, and Kramer are recipients of career investigator awards from the Canadian Institutes of Health Research, and Dr Walker is a career scientist of the Ontario Ministry of Health and Long-term Care.

References (26)

M.J. McMahon et al.
Comparison of a trial of labor with an elective second cesarean section
N Engl J Med
(1996)
D.A. Miller et al.
Vaginal birth after cesarean: a 10 year experience
Obstet Gynecol
(1994)
B.L. Flamm et al.
Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study
Obstet Gynecol
(1994)
M.G. Rosen et al.
Vaginal birth after cesarean: a meta-analysis of morbidity and mortality
Obstet Gynecol
(1991)
C. Stone et al.
Vaginal births after caesarean (VBAC): a population study
Paediatr Perinat Epidemiol
(2000)
M. Lydon-Rochelle et al.
Risk of uterine rupture during labor among women with a prior cesarean delivery
N Engl J Med
(2001)
B.L. Flamm
Vaginal birth after cesarean: what's new in the new millennium?
Curr Opin Obstet Gynecol
(2002)
S. Bewley et al.
The unfacts of ‘request’ cesarean section
BJOG
(2002)
R.J. Lilford et al.
The relative risks of cesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances
BJOG
(1990)
N. Schuitemaker et al.
Maternalmortality after cesarean section in the Netherlands
Acta Obstet Gynecol Scand
(1997)

M.H. Hall et al.

Maternal mortality and mode of delivery

Lancet

(1999)

F.D. Frigoletto et al.

Maternal mortality associated with cesarean section: an appraisal

Am J Obstet Gynecol

(1980)

D.B. Pettitti et al.

In hospital maternal mortality in the United States: time trends and relation to method of delivery

Obstet Gynecol

(1992)

Cited by (96)

The Association between Hospital Frequency of Labor after Cesarean and Outcomes in California
2020, Women's Health Issues
Labor after cesarean (LAC) is an alternative to planned repeat cesarean delivery. The effect of hospital-level factors on LAC frequency and vaginal birth after cesarean (VBAC) has been relatively understudied. It was our goal to determine if hospital frequency of LAC (number of women undergoing LAC/number of women with previous uterine scars) is associated with increased VBAC and associated outcomes among women undergoing LAC.
We analyzed 43,331 term, singleton births to women who experienced LAC in California from 2007 to 2010. We conducted multivariable logistic regressions of infant and maternal outcomes for women at hospitals with high LAC frequency (≥median) compared with low LAC frequency (<median), adjusting for maternal and hospital characteristics. We stratified analyses by overall hospital birth volume (categories 1, low; 2, medium; 3, high).
We did not observe an association between high LAC frequency and VBAC in any category of hospital birth volume in regression models. We found that women in hospitals with high LAC frequency had higher odds of infection in category 1 (low) and 2 (medium) hospitals (category 1 hospitals adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04–2.48; category 2 hospitals, aOR, 2.12; 95% CI, 1.34–3.35) and postpartum hemorrhage in category 2 and 3 hospitals (category 2 hospitals: aOR, 2.49; 95% CI, 1.57–3.94; category 3 hospitals: aOR, 1.83; 95% CI, 1.24–2.70). We observed that high LAC frequency was associated with more adverse outcomes (e.g., infection, severe perineal lacerations, decreased Apgar scores) in category 2 than in category 1 and 3 hospitals.
We did not find that high LAC frequency was associated with more VBAC, nor with many perinatal complications in category 1 and 3 hospitals. The associations between high LAC frequency and both infection and postpartum hemorrhage are concerning and require further investigation. There may be a sensitive balance between increasing LAC access and determining appropriate LAC candidate selection.
Maternal and neonatal outcome after vaginal breech delivery at term after cesarean section – a prospective cohort study of the Frankfurt breech at term cohort (FRABAT)
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
To compare the neonatal and maternal outcomes as well as the mode of delivery of intended vaginal breech deliveries in women with a prior cesarean section to primiparous patients.
The prospective monocenter cohort study was conducted among 604 women who presented for an intended vaginal singleton breech delivery at term between January 2007 and December 2016.
Out of 37 women with a prior cesarean 19 had a successful vaginal delivery. 344 of 567 primiparous women had a successful vaginal delivery. Neonatal morbidity and mortality as well as maternal outcome were not significantly different in successful vaginal deliveries of women with prior cesarean compared to primiparous patients. The cesarean section rate was not significantly higher in the group of women with a prior cesarean (49%) compared to the group of primipara (39%).
A prior cesarean should not be taken as an exclusion criterion for a planned vaginal delivery out of a breech presentation at term. Large multicenter, case-controlled studies are necessary to implement international guidelines.
N<sup>o</sup> 382 – Épreuve de travail après césarienne
2019, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
En résumé, le risque absolu de mort maternelle est faible tant pour l'EDTAC que pour la CIP (tableau 3). En utilisant les estimations à la fois de la grande étude canadienne51 et de la revue systématique28, on observe que le risque absolu de mort maternelle lié à l'EDTAC varie de 1,6 à 3,8 par 100 000 et de 5,6 à 13,4 par 100 000 pour la CIP. On recense de nombreuses études publiées relativement à la rupture ou à la déhiscence utérines.
Offrir une directive clinique factuelle en ce qui concerne l'essai de travail (EDT) chez les femmes ayant déjà subi une césarienne.
La morbidité et la mortalité fœtales et maternelles liées à l'accouchement vaginal après une césarienne et à la césarienne itérative.
Des recherches ont été effectuées dans la base de données MEDLINE pour trouver des articles publiés entre le 1^er janvier 1995 et le 31 octobre 2017 en utilisant le mot-clé suivant : vaginal birth after Caesarean (Cesarean) section. La qualité des données probantes indiquées s'appuie sur les critères d’évaluation des données décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs.
La présente directive a été approuvée par le comité de pratique clinique – obstétrique et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada.
- 1
  Dans la mesure où elles ne présentent aucune contre-indication, il convient d'offrir l’épreuve de travail après césarienne à toutes les femmes qui ont subi une césarienne transversale basse en prenant soin de les informer adéquatement des risques et avantages maternels et périnataux par une discussion et une documentation adéquates. Il y a lieu de documenter cette discussion (II-2B).
- 2
  L’épreuve de travail après césarienne est recommandée chez les femmes qui ne présentent aucune contre-indication au travail, qui ont déjà accouché par voie vaginale ou pour qui le travail s'amorce spontanément, car elles sont de bonnes candidates à l’épreuve de travail après césarienne et présentent un taux élevé d'accouchement vaginal après césarienne (II-2B).
- 3
  Il est possible d'offrir l’épreuve de travail aux femmes qui présentent des facteurs réduisant la probabilité d'un accouchement vaginal après césarienne. Il convient toutefois de les informer du fait que leurs chances d'accouchement vaginal après césarienne sont moindres et qu'elles présentent un risque accru de complications et de césarienne itérative (II-2A).
- 4
  Les femmes doivent être informées du fait que le risque relatif de mort maternelle pour la césarienne itérative planifiée est plus élevé que pour l’épreuve de travail après césarienne, laquelle présente un risque plus élevé de rupture utérine et de morbidités maternelles graves combinées, mais aussi du fait que le risque absolu de ces issues est faible (II-2B).
- 5
  Les femmes qui ont subi une césarienne transversale basse doivent être informées que le risque de base de rupture utérine pour l’épreuve de travail après césarienne est de 0,47 % (II-2A).
- 6
  Il y a lieu d'informer les femmes du fait que la plupart des autres complications maternelles ne sont pas particulièrement différentes entre la césarienne itérative et l’épreuve de travail après césarienne (II-2B).
- 7
  Le déclenchement artificiel du travail n'est pas contre-indiqué chez les femmes qui se soumettent à une épreuve de travail après césarienne (II-2A).
- 8
  Les femmes doivent être informées du fait que le déclenchement artificiel du travail est lié à un taux moindre d'accouchement vaginal après césarienne et augmente le risque de rupture utérine et qu'il convient d'y avoir recours avec précaution après un accompagnement adéquat de la patiente. Le risque de rupture utérine durant l’épreuve de travail est le plus élevé après 40 semaines de gestation (II-2A).
- 9
  Une sonde de Foley peut être utilisée aux fins de maturation du col utérin chez les femmes qui envisagent une épreuve de travail après césarienne (II-2B).
- 10
  L'administration d'ocytocine pour le déclenchement artificiel ou l'augmentation du travail n'est pas contre-indiquée chez les femmes qui se soumettent à une épreuve de travail après césarienne. L'utilisation d'ocytocine est toutefois liée à un risque accru de rupture utérine et il convient d'y avoir recours avec précaution après un accompagnement de la patiente adéquat (II-2B).
- 11
  Le déclenchement médical du travail au moyen de prostaglandine E₂ (dinoprostone) est lié à une augmentation du risque de rupture utérine et il n'est pas recommandé d'y avoir recours dans le cadre de l’épreuve de travail après césarienne après un accompagnement de la patiente adéquat (II-2B).
- 12
  La prostaglandine E₁ (misoprostol) est liée à un risque élevé de rupture utérine et ne devrait pas être utilisée dans le cadre d'un essai de travail après césarienne d'une grossesse à terme (II-2A).
- 13
  Les femmes qui ont 2 césariennes préexistantes semblent avoir un taux d'accouchement vaginal après césarienne comparable à celui des femmes qui n'en ont subi qu'une seule. Les femmes doivent être informées du risque accru de rupture utérine dans le cadre de l’épreuve de travail après césarienne chez celles qui ont subi plus d'une césarienne (II-2B).
- 14
  Le nombre d’études qui font état des issues chez les femmes qui ont subi plus de 2 césariennes est limité (I).
- 15
  L’épreuve de travail après césarienne ne constitue pas une contre-indication absolue en cas de présentation du siège. Cependant, il convient d'informer les femmes du fait que les données sont insuffisantes pour évaluer les risques de l’épreuve de travail après césarienne en cas de présentation du siège (III-B).
- 16
  La grossesse multiple ne constitue pas une contre-indication à l'essai de travail après césarienne (II-2B).
- 17
  Les femmes dont l'intervalle entre les accouchements est de moins de 18 mois doivent être informées du risque accru de rupture utérine de l’épreuve de travail après césarienne (II-2A).
- 18
  Bien qu'il y ait un lien entre l'amincissement du segment inférieur de la paroi utérine et le risque de rupture utérine, il n'existe pas de limite absolue entre une épreuve de travail après césarienne sécuritaire ou risquée. Ainsi, pour le moment, il ne convient pas d'utiliser les mesures échographiques du segment inférieur de la paroi utérine pour conseiller les femmes de se soumettre ou non à une épreuve de travail après césarienne en toute confiance (II-2B).
- 19
  Les femmes qui ont subi une césarienne avec incision classique ou en T ne devraient pas se soumettre à une épreuve de travail après césarienne (II-2A).
- 20
  Les femmes qui ont subi une césarienne basse au cours de laquelle la fermeture de l'utérus a été effectuée en un seul plan et qui souhaitent tenter une épreuve de travail après césarienne doivent être informées du fait qu'elles présentent possiblement un risque accru de rupture utérine (II-2A).
- 21
  Aucun effort ne doit être ménagé pour obtenir le rapport opératoire de la césarienne préexistante afin de déterminer le type d'incision utérine utilisé. Dans les situations où le type de la cicatrice est inconnu, les renseignements relatifs aux circonstances de l'accouchement précédent s'avèrent utiles pour déterminer la probabilité d'une incision transversale basse. Si la probabilité de ce type d'incision est élevée, un essai de travail après césarienne peut être offert à la patiente (II-2B).
- 22
  Les femmes qui envisagent une épreuve de travail après césarienne doivent être informées du fait que le risque relatif de mortalité périnatale et de morbidité grave est plus élevé pour l’épreuve de travail après césarienne que pour la césarienne itérative planifiée, mais que le risque absolu est faible (II-2B).
- 23
  Il convient d'informer les femmes que le risque de placenta prævia et de placenta accreta augmente en fonction du nombre de césariennes subies (II-2A).
- 24
  Le processus et la documentation du consentement éclairé avec une discussion adéquate sur les risques et avantages maternels et périnataux de l’épreuve de travail après césarienne et de la césarienne itérative planifiée doivent faire partie du plan de soins chez les femmes qui ont déjà subi une césarienne (III-A).
- 25
  La volonté d'une femme de se soumettre à un essai de travail après césarienne ou de subir une césarienne itérative planifiée doit être clairement énoncée et la documentation sur la cicatrice utérine existante doit être clairement indiquée au dossier prénatal (III-A).
- 26
  Toute l’équipe doit être informée lorsqu'une épreuve de travail après césarienne est en cours à l'unité des naissances (III-A).
- 27
  La surveillance électronique fœtale continue est nécessaire chez les femmes qui se soumettent à une épreuve de travail après césarienne, car les changements au tracé de fréquence cardiaque fœtale constituent un des principaux signes de rupture utérine (II-2A).
- 28
  Toute suspicion de rupture utérine nécessite une attention immédiate et une laparotomie afin de réduire les risques de morbidité et de mortalité maternelles et périnatales (III-B).
- 29
  Pour optimiser les issues maternelles et néonatales, toute femme qui se soumet à une épreuve de travail après césarienne devrait recevoir des soins dans un hôpital doté des ressources nécessaires pour procéder à une césarienne d'urgence (III-B).
- 30
  La femme et son fournisseur de soins de santé doivent être au courant de la disponibilité du personnel d'obstétrique, d'anesthésie, de pédiatrie et de salle d'opération dans le milieu où elle a choisi de donner naissance (III-A).
No. 382-Trial of Labour After Caesarean
2019, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
In summary, the absolute risk of maternal death for both TOLAC and ERCS is low (Table 4). Using the estimates from both the large Canadian study51 and the systematic review,28 the absolute risk of maternal death associated with TOLAC is in the range of 1.6 to 3.8 per 100 000 and is 5.6 to 13.4 per 100 000 with ERCS. There are numerous studies published relating to uterine rupture and/or dehiscence.
To provide evidence-based guidelines for the provision of a trial of labour after Caesarean section.
Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean and repeat Caesarean section.
MEDLINE database was searched for articles published from January 1, 1995, to October 31, 2017 using the key words “vaginal birth after Caesarean (Cesarean) section.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.
These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.
- 1
  Provided there are no contraindications, a trial of labour after Caesarean should be offered to all women with 1 previous low-segment transverse Caesarean section after appropriate discussion and documentation of maternal and perinatal risks and benefits. The discussion should be documented (II-2B).
- 2
  Trial of labour after Caesarean is recommended in women without contraindications to labour, with a previous vaginal birth, and/or those who present in spontaneous labour as they are good candidates for a trial of labour after Caesarean and have a higher vaginal birth after Caesarean rate (II-2B).
- 3
  Women with factors negatively affecting their likelihood of vaginal birth after Caesarean can be offered a trial of labour after Caesarean. However, they should be informed that they have a lower chance of vaginal birth after Caesarean and have an increased risk of complications and repeat Caesarean birth (II-2A).
- 4
  Women should be informed that the relative risk of maternal death is higher for elective repeat Caesarean section and the risk of uterine rupture and composite serious maternal morbidity is higher for trial of labour after Caesarean, but the absolute risks of these outcomes are low (II-2B).
- 5
  Women with 1 prior low transverse Caesarean section should be informed that the baseline risk of uterine rupture with a trial of labour after Caesarean is 0.47% (II-2A).
- 6
  Women should be informed that most other maternal complications are not significantly different between elective repeat Caesarean section and trial of labour after Caesarean (II-2B).
- 7
  Induction of labour is not contraindicated in women undergoing a trial of labour after Caesarean (II-2A).
- 8
  Women should be informed that induction of labour is associated with a lower vaginal birth after Caesarean rate and an increased risk of uterine rupture and should be used carefully after appropriate counselling. The risk of uterine rupture with induction of labour appears to be highest in women over 40 weeks gestation (II-2A).
- 9
  A Foley catheter may be used to ripen the cervix in a woman planning a trial of labour after Caesarean (II-2B).
- 10
  Use of oxytocin for induction or augmentation is not contraindicated in women undergoing a trial of labour after Caesarean. However, use of oxytocin is associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B).
- 11
  Medical induction of labour with prostaglandin E₂ (dinoprostone) is associated with an increased risk of uterine rupture and its use is not recommended in trial of labour after Caesarean, after appropriate counselling (II-2B).
- 12
  Prostaglandin E₁ (misoprostol) is associated with a high risk of uterine rupture and should not be used in trial of labour after Caesarean at term (II-2A).
- 13
  Women with 2 prior Caesarean sections appear to have similar vaginal birth after Caesarean rates as those with 1 prior Caesarean section. Women should be informed of a higher risk of uterine rupture in trial of labour after Caesarean with more than 1 Caesarean section (II-2B).
- 14
  There are limited studies reporting on outcomes of women with more than 2 prior Caesarean sections (I).
- 15
  It is not an absolute contraindication for women with a breech presentation to undergo a trial of labour after Caesarean. However, women should be advised that there is insufficient information to assess risks of trial of labour after Caesarean with a breech presentation (III-B).
- 16
  Multiple pregnancy is not a contraindication to a trial of labour after Caesarean (II-2B).
- 17
  Women delivering with <18-month interdelivery interval should be informed about an increased risk of uterine rupture with trial of labour after Caesarean (II-2A).
- 18
  Although there is relationship between lower uterine thickness and risk of uterine rupture, the absolute cut-off between safe and unsafe trial of labour after Caesarean does not exist. Therefore, at this time, we cannot use ultrasonographic measurements of the lower uterine segment to counsel women to either have or not have a trial of labour after Caesarean with confidence (II-2B).
- 19
  Women with a classical Caesarean section or T incision should not have a trial of labour after Caesarean (II-2A).
- 20
  Women with a previous Low Segment Cesarean Section in which the uterus was closed in a single layer and who wish to attempt trial of labour after Caesarean should be aware that the risk of uterine rupture may be increased (II-2A).
- 21
  Every effort should be made to obtain the previous Caesarean operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, trial of labour after Caesarean can be offered (II-2B).
- 22
  Women planning a trial of labour after Caesarean should be advised that the relative risk of perinatal mortality and serious morbidity is higher with trial of labour after Caesarean compared to elective repeat Caesarean section, but the absolute risk is low (II-2B).
- 23
  Women should be informed that the risk of placenta previa and placenta accreta increases with increasing number of Caesarean sections (II-2A).
- 24
  The process and documentation of informed consent with appropriate discussion of the maternal and perinatal risks and benefits of trial of labour after Caesarean and elective repeat Caesarean section should be a part of the care plan in a woman with a previous Caesarean section (III-A).
- 25
  The intention of a woman undergoing a trial of labour after Caesarean or elective repeat Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (III-A).
- 26
  The entire team should be made aware of the presence of a woman undergoing a trial of labour after Caesarean labouring in the birthing unit (III-A).
- 27
  Continuous electronic fetal monitoring of women having a trial of labour after Caesarean is necessary, as changes to the fetal heart rate tracing are one of the key indicators of the presence of a uterine rupture (II-2A).
- 28
  Suspected uterine rupture requires immediate attention and laparotomy in order to attempt to decrease maternal and perinatal morbidity and mortality (III-B).
- 29
  To optimize maternal and neonatal outcomes, a woman having a trial of labour after Caesarean should be cared for in a hospital that has resources to perform an emergency Caesarean section (III-B).
- 30
  The woman and her health care provider must be aware of the availability of obstetric, anaesthetic, pediatric, and operating room staff in the setting where she chooses to give birth (III-A).
Outcomes of deliveries by family physicians or obstetricians: A population-based cohort study using an instrumental variable
2015, CMAJ
Citation Excerpt :
Perinatal mortality and a composite of maternal morbidity and mortality were the primary outcome measures. The perinatal outcome was defined as in-hospital death after 20 weeks’ gestational age, and the maternal outcome was defined similarly to Joseph and associates,17 with some additions from other papers.21,27 Although most definitions of perinatal mortality exclude death after 7 days of age, we included such deaths for infants who were continuously hospitalized (including transfers), to protect against bias associated with technologically advanced hospitals and providers who had the capability to keep infants alive longer than that.
Previous research has suggested that obstetric outcomes are similar for deliveries by family physicians and obstetricians, but many of these studies were small, and none of them adjusted for unmeasured selection bias. We compared obstetric outcomes between these provider types using an econometric method designed to adjust for unobserved confounding.
We performed a retrospective population-based cohort study of all Canadian (except Quebec) hospital births with delivery by family physicians and obstetricians at more than 20 weeks gestational age, with birth weight greater than 500 g, between Apr. 1, 2006, and Mar. 31, 2009. The primary outcomes were the relative risks of in-hospital perinatal death and a composite of maternal mortality and major morbidity assessed with multivariable logistic regression and instrumental variable–adjusted multivariable regression.
After exclusions, there were 3600 perinatal deaths and 14 394 cases of maternal morbidity among 799 823 infants and 793 053 mothers at 390 hospitals. For deliveries by family physicians v. obstetricians, the relative risk of perinatal mortality was 0.98 (95% confidence interval [CI] 0.85–1.14) and of maternal morbidity was 0.81 (95% CI 0.70–0.94) according to logistic regression. The respective relative risks were 0.97 (95% CI 0.58–1.64) and 1.13 (95% CI 0.65–1.95) according to instrumental variable methods.
After adjusting for both observed and unobserved confounders, we found a similar risk of perinatal mortality and adverse maternal outcome for obstetric deliveries by family physicians and obstetricians. Whether there are differences between these groups for other outcomes remains to be seen.
When a caesarean section is necessary: Analysis of cesarean sections performed in the Republic of Turkey in 2022 in accordance with the World Health Organization Multi-Country Research Guidelines
2023, Turkish Journal of Obstetrics and Gynecology

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^∗∗: Contributing members: Robert Kinch (McGill University), Reg Sauve (University of Calgary).

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General Obstetrics and Gynecology: ObstetricsComparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery

Abstract

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Acknowledgements

Comparison of a trial of labor with an elective second cesarean section

N Engl J Med

Vaginal birth after cesarean: a 10 year experience

Obstet Gynecol

Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study

Obstet Gynecol

Vaginal birth after cesarean: a meta-analysis of morbidity and mortality

Obstet Gynecol

Vaginal births after caesarean (VBAC): a population study

Paediatr Perinat Epidemiol

Risk of uterine rupture during labor among women with a prior cesarean delivery

N Engl J Med

Vaginal birth after cesarean: what's new in the new millennium?

Curr Opin Obstet Gynecol

The unfacts of ‘request’ cesarean section

BJOG

The relative risks of cesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances

BJOG

Maternalmortality after cesarean section in the Netherlands

Acta Obstet Gynecol Scand

Maternal mortality and mode of delivery

Lancet

Maternal mortality associated with cesarean section: an appraisal

Am J Obstet Gynecol

In hospital maternal mortality in the United States: time trends and relation to method of delivery

Obstet Gynecol

General Obstetrics and Gynecology: Obstetrics
Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery