Labor Outcomes With Increasing

Number of Prior Vaginal Births After

Cesarean Delivery
(Obstet Gynecol 2008;111:285–91)

Jurnal review by dr. Ayu Angelina Ronosulistyo

Resource Person : dr. Mulyanusa A Ritonga,SpOG(K)

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(Obstet Gynecol 2008;111:285–91)

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Abstract

BACKGROUND:
The Objective of this study was to estimate the success rates and risks of an
attempted vaginal birth after cesarean delivery (VBAC) according to the number of
prior successful VBACs.

METHODS:
From a prospective multicenter registry collected at 19 clinical centers from 1999
to 2002, women with one or more prior low transverse cesarean deliveries who
attempted a VBAC in the current pregnancy was selected .

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Abstract
Results
 13,532 women meeting eligibility  The risk of uterine dehiscence and
criteria, other peripartum complications
also declined statistically after the
 VBAC success increased with
first successful VBAC.
increasing number of prior VBACs:
63.3%, 87.6%, 90.9%, 90.6%, and  No increase in neonatal morbidities
91.6% for those with 0, 1, 2, 3, and was seen with increasing VBAC
4 or more prior VBACs, number thereafter.
respectively (P<.001).
 The rate of uterine rupture de-
creased after the first successful
VBAC and did not increase
thereafter: 0.87%, 0.45%, 0.38%,
0.54%, 0.52% (P􏰀 .03).

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 Abstract

CONCLUSION:
Women with prior successful VBAC attempts are at low risk
for maternal and neonatal complications during subsequent
VBAC attempts.
An increasing number of prior VBACs is associated with a
greater probability of VBAC success, as well as a lower risk
of uterine rupture and perinatal complications in the cur-
rent pregnancy.

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Background

Frequency of cesarean delivery in the US

has progressively increased over the past
decade to 30.2% in 2005

Because of this trend, an increasing

number of women are faced with
the important decision whether or
not to attempt vaginal birth after
cesarean delivery
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Background

In general, the likelihood of VBAC success is approximately 72%

Attempted VBAC is associated with a Alternatively, repeated cesarean

0.4-0.7% risk of uterine rupture, which deliveries are associated with
is increased in condition: increased risks of:
 Prior classic or vertical uterine  Placenta accrete
incision  Trauma to internal organ
 Labor induction  Transfusion
 Possibly cervical ripening with  Hysterectomy
prostaglandins  Perioperative complications
 Fetal injury

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Background
 Considerable effort has been applied to determine factors that alter the
likelihood of a successful trial of labor after cesarean delivery and also the
maternal and fetal risks associated with attempted VBAC compared with
repeat cesarean delivery.
 The relationships between the number of prior VBACs and the probability of
successful VBAC attempt or uterine rupture in the current pregnancy remain
to be clearly elucidated.
 It is also unknown if successive labors will place an additive strain on the
uterine scar, increasing the risk of uterine rupture when VBAC is attempted.

The purpose of this analysis is to evaluate the impact of increasing number of

prior VBACs on the likelihood of VBAC success and uterine rupture in subsequent
pregnancies.

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Materials and Methods
This is a secondary analysis of a 4-year observational study conducted at 19
academic medical centers of the National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units Network (NICHD-MFMU Network)
between 1999 and 2002

Trained and certified research nurse at

each center prospectively identified
women based on inclusion criteria
Incomplete and equivocal details were
resolved through caregiver and patient
interview before discharge
Abstracted data were transmitted
weekly to the data coordinating
center
 Inclusion Criteria:
 Women with singleton pregnancies
 Who had previously undergone at
least one cesarean delivery by a
low transverse uterine incision
 Who attempted a VBAC
 Who delivered an infant of at least
20 weeks gestation or 500gr
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Materials and Methods
Pregnancy Outcomes: Neonatal Outcomes:
 VBAC success  Gestational age at delivery
 Uterine rupture (disruption or tear of the
uterine muscle and visceral peritoneum or  Birth weight
a uterine muscle separation with
extension to adjacent structures)  Major morbidities
 Uterine rupture after labor induction
 Neonatal intensive care admission
 Uterine dehiscence
 Surgical complications (broad ligament
 Neonatal hypoxic ischemic
hematoma, cystotomy, bowel or ureteral encephalopathy
injury)
 Thromboembolism
 Infant deaths
 Transfusion
 Endometritis
 Maternal death
 Umbilical cord arterial pH 7.00 or less
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Materials and Methods

Statistical Analysis
 Statistical analysis was conducted with SAS 8.2 and StatXact 5
 Mantel-Haenszel test was used for categorical variables
 Jonckheere-Terpstra test was used for continuous outcomes
 Blyth-Still-Caselle interval was used for one sample binomial interval
estimation
 A two-tailed nominal P<0.05 was considered significant

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Results

378,063 births during study period

45,988 had a singleton gestation

with previous cesarean delivery

13,532 women had low transverse

uterine incision and attempted
VBAC

Overall success rate of 71,8%

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 Results

Among those eligible for this analysis, the number of women with 0, 1, 2, 3, and
4 or more prior VBACs were 9,012, 2,900, 1,058, 371, and 191.
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Results

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Results

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Results

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Results

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Discussion

 In this analysis, we confirm earlier reports of improved VBAC success with a

previous vaginal delivery, including the occurrence of a prior successful VBAC
attempt.
 In addition, we demonstrate a progressive improvement in the likelihood of
VBAC success with increasing number of prior VBACs, with an apparent
plateau at a 91% success rate after two prior VBACs.

 Regarding VBAC attempts, we have found that 73.4%

of women
attempting a VBAC will be successful and 0.7%
will have a uterine rupture.

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Discussion
Risk of Uterine Rupture Risk of Uterine Dehiscence
 In a previous analysis of women  Contrary to prior reports of an
with one or more prior cesarean increased risk of uterine
deliveries, a history of any prior dehiscence with a prior VBAC, in
VBAC was associated with a lower this analysis we found the risk of
risk of uterine rupture (OR 0.52, uterine dehiscence to decline with
95% CI 0.34 – 0.82). increasing number of VBAC
attempts (0.25% compared with
 In the current analysis, we found
0.9%, P.001)
women with one or more prior
VBACs to have approximately half
the risk of uterine rupture when
compared with those attempting
their first VBAC (0.4 – 0.5%
compared with 0.9%, P.01).

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Discussion
Strength
 A major strength of this study is its
size.
 This cohort of over 13,000 women
who attempted VBAC offers
insights into outcomes for the
overall cohort and also for those
with 0, 1, and more than two prior
VBACs.
 Our findings were consistent
between the overall cohort
Weakness
 Evaluation of outcomes in mostly
large urban tertiary care hospitals
could bias our results due to
increased availability of resources.
 VBAC should not be attempted in
institutions without resources and
staffing available for patient
monitoring and emergent cesarean
delivery.
 Alternatively, the tendency toward
more complex patient mix in
tertiary care institutions would
predispose this population to more
complications.
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Discussion

 Webelieve that the findings of this prospective

analysis of a large cohort of pregnancies will
provide important information for counseling
women who are considering their options
regarding VBAC. Our results are particularly
important for those considering repeated
pregnancies after an initial cesarean delivery.
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Journal Appraisal

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Appraisal of a case-control study
1. Did the study address a clearly focused issue?
2. Were the cases and controls defined precisely?
3. Was the selection of cases and controls based on external, objective
and validated criteria? (selection bias)
4. Are objective and validated measurement methods used and were
they similar in cases and controls? (misclassification bias)
5. Did the study incorporate blinding where feasible? (halo-effect)
6. Was there data-dredging?
7. Could there be confounding?
8. Is the size of effect practically relevant?
9. Are the conclusions applicable? 26
Did the study address a clearly focused issue?
YES
 Frequency of cesarean delivery in the US has progressively
increased over the past decade to 30.2% in 2005
 From a prospective multicenter registry col- lected at 19
clinical centers from 1999 to 2002

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Did the authors use an appropriate method to
answer their question?
YES
 Secondary analysis of observational study is an
appropriate method to evaluate the impact of
increasing number of prior VBACs on the
likelihood of VBAC success and uterine rupture in
subsequent pregnancies

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Were the subjects recruited in an acceptable way?
YES
 Subjects in this study were recruited based on inclusion criteria
 Inclusion Criteria in this study:
 Women with singleton pregnancies
 Who had previously undergone at least one cesarean delivery by a low transverse
uterine incision
 Who attempted a VBAC
 Who delivered an infant of at least 20 weeks gestation or 500gr

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Were the measures accurately measured to
reduce bias?
YES
 Because the authors use clearly inclusion
criteria in this study to minimize bias in
this research.

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Were the data collected in a way that
addressed the research issue?
YES
 The data were collected for 4 years from 1999-2002.
 Trained and certified research nurse at each center identified women who
were fit the inclusion criteria
 The medical charts of these women were reviewed for demographic, clinical
characteristics, medical and obstetric history, pregnancy outcomes, neonatal
outcomes
 Incomplete and equivocal details were resolved through caregiver and patient
interview before discharge
 Abstracted data were transmitted weekly to the data coordinating center.
 After that, the 4-year observational data is analysed.

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Did the study have enough participants to
minimize the play of chance?
YES
 Participants in this study are 13,532 women

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How are the results presented and what is the
main result?
YES
 The results were presented in success rate, with
success rate of VBAC is 73.4% with plateu 91%
after two prior VBAC. This study also shows the
likelihood of uterine rupture (0.7%) and the
demographic and clinical characteristics of
women

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Was the data analysis sufficiently rigorous?
YES

 Yes.The data were statistically analysis using

SAS 8.2 and StatXact 5. Mantel-Haenszel test
was used for categorical variables. Jonckheere-
Terpstra test was used for continuous outcomes.
Blyth-Still-Caselle interval was used for one
sample binomial interval estimation. A two-
tailed nominal P<0.05 was considered
significant
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Is there a clear statement of findings?
YES
 There is a clear statement base on the results of the study

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Can the results be applied to the local
population?
YES

But, the results only can be applied in large tertiary

hospitals because VBAC should not be attempted
in institutions without resources ad staffing
available for patient monitoring and
emergent cesarean delivery

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How valuable is the research?

 We believe that the findings of this prospective

analysis of a large cohort of pregnancies will provide
important information for counseling women who
are considering their options regarding VBAC. The
journal was also mention about the complications of
the VBAC .The research are particularly important
for those considering repeated pregnancies after
an initial cesarean delivery.

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SUMMARY

 we have found that 73.4% of women attempting

a VBAC will be successful and 0.7% will have a
uterine rupture.

 the results only can be applied in large tertiary

hospitals because VBAC should not be attempted
in institutions without resources ad staffing
available for patient monitoring and emergent
cesarean delivery
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SOOCA III
Tuesday, July 10th, 2018

Placental Abruption
Management
in High Risk Pregnancy
By dr. Huda Toriq
Moderator: dr. Gustaf Irianto
Resource Person: dr. Dini Hidayat, SpOG(K), MKes

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