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1.  Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study 
PLoS Medicine  2012;9(3):e1001184.
A case-control study using UK data estimates the risk of uterine rupture in subsequent deliveries amongst women who have had a previous caesarean section.
Background
Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.
Methods and Findings
A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16–7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62–6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00–15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2–4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75–189).
Conclusions
Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Uterine rupture is a serious complication of pregnancy in which the wall of the uterus (womb) tears during pregnancy or early labor. Signs and symptoms of uterine rupture include fetal heart rate abnormalities, abdominal pain, and vaginal bleeding. If uterine rupture happens during labor, the woman must have an immediate caesarean section (surgical delivery of her baby) to save both her life and that of her baby. The woman's womb and nearby organs can be damaged at rupture or removed during surgery and she may need a blood transfusion because of severe bleeding. Moreover, her baby may develop respiratory distress syndrome and other life-threatening complications. In high income countries, uterine rupture most commonly occurs in women who have delivered a previous pregnancy by caesarean section. In a caesarean section, the baby is delivered through a cut made through the abdominal wall and the uterine wall. The stretching that occurs during pregnancy or the strong contractions of labor can tear the scar left by this cut, resulting in uterine rupture.
Why Was This Study Done?
Women who have had a caesarean delivery are generally encouraged to try to deliver subsequent babies vaginally. However, recent reports of an increased risk of complications (morbidity) and death (mortality) due to uterine rupture are thought to reduce women's willingness to attempt vaginal birth after caesarean (VBAC) in some countries. In the UK, for example, where one in four babies is delivered by caesarean section, a previous caesarean delivery is one of commonest reasons for a repeat section. Obstetricians (doctors who care for women during child birth) need to know as much as possible about the incidence of uterine rupture and about the risk factors for it so that they can advise women who have had a previous caesarean section about their delivery options. In this national case-control study (a study that compares the characteristics of people with and without a specific condition), the researchers estimate the incidence of uterine rupture in the UK by intended mode of delivery and investigate and quantify the risk factors for and outcomes of uterine rupture.
What Did the Researchers Do and Find?
The researchers used the UK Obstetric Surveillance System (UKOSS) to identify all the women in the UK who had a uterine rupture over a 13-month period (159 women, 139 of whom had had a previous caesarean delivery). Controls for the study were women who had not had a uterine rupture but who had previously delivered by caesarean section. Overall, the incidence of uterine rupture was 0.2 per 1,000 maternities. In women with a previous caesarean delivery, 2.1 and 0.3 per 1,000 maternities ended in uterine rupture in women planning vaginal delivery and caesarean delivery, respectively. Amongst women who had had a previous caesarean delivery, the risk of uterine rupture was greater among those who had had two or more previous caesarean deliveries or a caesarean delivery less than 12 months previously, or whose labor was induced. Two women died following uterine rupture (a case fatality of 1.3%) and 18 babies died around the time of birth (a perinatal mortality rate of 124 per 1,000 live births; the UK perinatal mortality rate is 7.5 per 1,000 live births). 15 of the women who had a uterine rupture had their womb removed, 10 had other organs damaged, and nearly half had other complications; 19 of the surviving babies had health problems.
What Do These Findings Mean?
These findings indicate that, in the UK, although uterine rupture is associated with significant mortality and morbidity, it is a rare occurrence even among women who have had a previous caesarean delivery and are planning a vaginal delivery. They also indicate that, for women who have previously had a caesarean section, the risk of rupture increases with the number of previous caesarean deliveries, with a short interval since the last caesarean section, and with labor induction. Although the researchers may not have identified all the women who had a uterine rupture during the study period or may have identified only the worst cases, these findings provide valuable information about the factors that obstetricians need to consider when advising women who have previously had a caesarean section and when managing their labor.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001184.
This study is linked to a PLoS Medicine Research Article by Caroline Crowther and a PLoS Medicine Perspective by Catherine Spong
Wikipedia has a page on uterine rupture (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The American Congress of Obstetricians and Gynecologists has information sheets for patients on caesarean sections and on vaginal birth after caesarean delivery
The Royal College of Obstetricians and Gynaecologists in the UK has information for women on birth after previous caesarean
Childbirth Connection, a US-based not-for-profit organization, provides information about caesarean sections and about vaginal birth after caesarean
The National Childbirth Trust, a UK charity, provides information for parents on all aspects of pregnancy and birth, including caesarean sections and vaginal birth after caesarean delivery
The UK charity Healthtalkonline has personal stories from women making decisions about birth after a caesarean section
A personal story of uterine rupture during an attempted VBAC is available
The UK Obstetric Surveillance System studies rare disorders of pregnancy in the UK
doi:10.1371/journal.pmed.1001184
PMCID: PMC3302846  PMID: 22427745
2.  Birth after caesarean study – planned vaginal birth or planned elective repeat caesarean for women at term with a single previous caesarean birth: protocol for a patient preference study and randomised trial 
Background
For women who have a caesarean section in their preceding pregnancy, two care policies for birth are considered standard: planned vaginal birth and planned elective repeat caesarean. Currently available information about the benefits and harms of both forms of care are derived from retrospective and prospective cohort studies. There have been no randomised trials, and recognising the deficiencies in the literature, there have been calls for methodologically rigorous studies to assess maternal and infant health outcomes associated with both care policies.
The aims of our study are to assess in women with a previous caesarean birth, who are eligible in the subsequent pregnancy for a vaginal birth, whether a policy of planned vaginal birth after caesarean compared with a policy of planned repeat caesarean affects the risk of serious complications for the woman and her infant.
Methods/Design
Design: Multicentred patient preference study and a randomised clinical trial.
Inclusion Criteria: Women with a single prior caesarean presenting in their next pregnancy with a single, live fetus in cephalic presentation, who have reached 37 weeks gestation, and who do not have a contraindication to a planned VBAC.
Trial Entry & Randomisation: Eligible women will be given an information sheet during pregnancy, and will be recruited to the study from 37 weeks gestation after an obstetrician has confirmed eligibility for a planned vaginal birth. Written informed consent will be obtained. Women who consent to the patient preference study will be allocated their preference for either planned VBAC or planned, elective repeat caesarean. Women who consent to the randomised trial will be randomly allocated to either the planned vaginal birth after caesarean or planned elective repeat caesarean group.
Treatment Groups: Women in the planned vaginal birth group will await spontaneous onset of labour whilst appropriate. Women in the elective repeat caesarean group will have this scheduled for between 38 and 40 weeks.
Primary Study Outcome: Serious adverse infant outcome (death or serious morbidity).
Sample Size: 2314 women in the patient preference study to show a difference in adverse neonatal outcome from 1.6% to 3.6% (p = 0.05, 80% power).
Clinical Trial Registration
ISCTRN5397431
doi:10.1186/1471-2393-7-17
PMCID: PMC1988834  PMID: 17697343
3.  The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation 
Background
The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.
Methods
A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009
Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.
Results
A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0[1-4]. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.
Conclusions
Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.
doi:10.1186/1471-2393-10-62
PMCID: PMC2964563  PMID: 20946628
4.  A Five-year Survey of Caesarean Delivery at a Nigerian Tertiary Hospital 
Background:
The rising global rate in caesarean delivery has been a source of concern to obstetricians worldwide. In spite of remarkable improvement in the safety of anaesthesia and surgical techniques, caesarean section has higher risks of maternal death when compared with normal vaginal delivery. Thus, the current emphasis is to limit the rising rate of caesarean section to as much as possible.
Objective:
To determine the rate of caesarean section, pregnancy out-come, major indications and complications of caesarean section.
Methods:
A five year (January 1st 2005 to December 31st 2009) retrospective analysis of clinical data from the ward admissions and discharge books, patients’ folders and the operating theatre record books at the University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu.
Results:
Out of the 3,554 deliveries during the study period, 980 cases were by caesarean section, giving a rate of 27.6%. Most cases 918 (93.7%) were by emergency caesarean sections, with elective procedure accounting only for 6.3% of the cases. The age range of the women was between 16-48yrs. Four hundred and seven (41.5%) were primigravidae, 503(51.4%) were between para one and para four, while 70 (7.1%) were grand-multipara. The rate of caesarean section was higher amongst the booked patients, 563 (57.5%) than the unbooked patients 355 (36.2%). Two previous caesarean section was the commonest indication for caesarean section 211(21.5%), followed by cephalopelvic disproportion 198 (20.2%), and foetal distress188 (19.2%). A total of 1009 babies were delivered through caesarean section by the 980 women; 955 cases of singleton gestations and 25 cases of multiple gestations (21 twins and 4 triplets). Majority of the babies 918 (91%) were delivered by emergency procedure. More than half of the babies 582(57.7%) had birth asphyxia and there were 39 (3.9%) perinatal deaths. All the cases of perinatal deaths and 549 (94.3%) of birth asphyxia were following emergency procedure. Anaemia was the commonest postpartum morbidity and the maternal case fatality rate was 0.7%.
Conclusion:
There is now a further rise in rate of caesarean section after a slight drop that followed the initial high 1.5fold rise from previous studies. The perinatal outcome is poor especially following emergency caesarean section. Reducing primary caesarean section rate and more encouragement of vaginal delivery after one previous caesarean section may reduce the prevalence of two previous caesarean sections which is the leading indication for caesarean section in the hospital.
PMCID: PMC3507098  PMID: 23209958
Caesarean section; survey; tertiary hospital: Nigeria
5.  Caesarean section versus vaginal delivery for preterm birth in singletons 
Background
Planned caesarean delivery for women thought be in preterm labour may be protective for baby, but could also be quite traumatic for both mother and baby. The optimal mode of delivery of preterm babies for both cephalic and breech presentation remains, therefore, controversial.
Objectives
To assess the effects of a policy of planned immediate caesarean delivery versus planned vaginal birth for women in preterm labour.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (24 April 2012).
Selection criteria
Randomised trials comparing a policy of planned immediate caesarean delivery versus planned vaginal delivery for preterm birth.
Data collection and analysis
Two review authors independently assessed trials for inclusion. Two review authors independently extracted data and assessed risk of bias. Data were checked for accuracy.
Main results
We included six studies (involving 122 women) but only four studies (involving only 116 women) contributed data to the analyses.
Infant
There were very little data of relevance to the three main (primary) outcomes considered in this review: There was no significant difference between planned immediate caesarean section and planned vaginal delivery with respect to birth injury to infant (risk ratio (RR) 0.56, 95%, confidence interval (CI) 0.05 to 5.62; one trial, 38 women) or birth asphyxia (RR 1.63, 95% CI 0.84 to 3.14; onetrial, 12 women). The only cases of birth trauma were a laceration of the buttock in a baby who was delivered by caesarean section and mild bruising in another allocated to the group delivered vaginally.
The difference between the two groups with regard to perinatal deaths was not significant (0.29, 95% CI 0.07 to 1.14; three trials, 89 women) and there were no data specifically relating to neonatal admission to special care and/or intensive care unit.
There was also no difference between the caesarean or vaginal delivery groups in terms of markers of possible birth asphyxia (RR 1.63, 95% CI 0.84 to 3.14; one trial, 12 women) or Apgar score less than seven at five minutes (RR 0.83, 95% CI 0.43 to 1.60; four trials, 115 women) and no difference in attempts at breastfeeding (RR 1.40, 95% 0.11 to 17.45; one trial, 12 women). There was also no difference in neonatal fitting/seizures (RR 0.22, 95% CI 0.01 to 4.32; three trials, 77 women), hypoxic ischaemic encephalopathy (RR 4.00, 95% CI 0.20 to 82.01;one trial, 12 women) or respiratory distress syndrome (RR 0.55, 95% CI 0.27 to 1.10; three trials, 103 women). There were no data reported in the trials specifically relating to meconium aspiration. There was also no significant difference between the two groups for abnormal follow-up in childhood (RR 0.65, 95% CI 0.19 to 2.22; one trial, 38 women) or delivery less than seven days after entry (RR 0.95, 95% CI 0.73 to 1.24; two trials, 51 women).
Mother
There were no data reported on maternal admissions to intensive care. However, there were seven cases of major maternal postpartum complications in the group allocated to planned immediate caesarean section and none in the group randomised to vaginal delivery (RR 7.21, 95% CI 1.37 to 38.08; four trials, 116 women).
There were no data reported in the trials specifically relating to maternal satisfaction (postnatal). There was no significant difference between the two groups with regard to postpartum haemorrhage. A number of non-prespecified secondary outcomes were also considered in the analyses. There was a significant advantage for women in the vaginal delivery group with respect to maternal puerperal pyrexia (RR 2.98, 95% CI 1.18 to 7.53; three trials, 89 women) and other maternal infection (RR 2.63, 95% CI 1.02 to 6.78; three trials, 103 women), but no significant differences in wound infection (RR 1.16, 95% CI 0.18 to 7.70; three trials, 103 women), maternal stay more than 10 days (RR 1.27, 95% CI 0.35 to 4.65; three trials, 78 women) or the need for blood transfusion (results not estimable).
Authors’ conclusions
There is not enough evidence to evaluate the use of a policy of planned immediate caesarean delivery for preterm babies. Further studies are needed in this area, but recruitment is proving difficult.
doi:10.1002/14651858.CD000078.pub2
PMCID: PMC4164504  PMID: 22696314
*Delivery, Obstetric; *Obstetric Labor, Premature; Birth Injuries [etiology]; Cesarean Section [adverse effects]; Infant, Newborn; Infant, Premature; Infant, Small for Gestational Age; Perinatal Mortality; Randomized Controlled Trials as Topic; Surgical Procedures, Elective; Female; Humans; Pregnancy
6.  Rate of spontaneous onset of labour before planned repeat caesarean section at term 
Background
Guidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks.
Methods
We conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as ‘low risk’. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis.
Results
Of 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as ‘low-risk’. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity.
Conclusions
These findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly.
doi:10.1186/1471-2393-14-125
PMCID: PMC3975468  PMID: 24694261
Cohort study; Elective repeat caesarean section; Labour; Record linkage
7.  Maternal and neonatal factors associated with mode of delivery under a universal newborn hearing screening programme in Lagos, Nigeria 
Background
Emerging evidence from a recent pilot universal newborn hearing screening (UNHS) programme suggests that the burden of obstetric complications associated with mode of delivery is not limited to maternal and perinatal mortality but may also include outcomes that undermine optimal early childhood development of the surviving newborns. However, the potential pathways for this association have not been reported particularly in the context of a resource-poor setting. This study therefore set out to establish the pattern of delivery and the associated neonatal outcomes under a UNHS programme.
Methods
A cross-sectional study in which all consenting mothers who delivered in an inner-city tertiary maternity hospital in Lagos, Nigeria from May 2005 to December 2007 were enrolled during the UNHS programme. Socio-demographic, obstetric and neonatal factors independently associated with vaginal, elective and emergency caesarean deliveries were determined using multinomial logistic regression analyses.
Results
Of the 4615 mothers enrolled, 2584 (56.0%) deliveries were vaginal, 1590 (34.4%) emergency caesarean and 441 (9.6%) elective caesarean section. Maternal age, parity, social class and all obstetric factors including lack of antenatal care, maternal HIV and multiple gestations were associated with increased risk of emergency caesarean delivery compared with vaginal delivery. Only parity, lack of antenatal care and prolonged/obstructed labour were associated with increased risk of emergency compared with elective caesarean delivery. Infants delivered by vaginal method or by emergency caesarean section were more likely to be associated with the risk of sensorineural hearing loss but less likely to be associated with hyperbilirubinaemia compared with infants delivered by elective caesarean section. Emergency caesarean delivery was also associated with male gender, low five-minute Apgar scores and admission into special care baby unit compared with vaginal or elective caesarean delivery.
Conclusions
The vast majority of caesarean delivery in this population occur as emergencies and are associated with socio-demographic factors as well as several obstetric complications. Mode of delivery is also associated with the risk of sensorineural hearing loss and other adverse birth outcomes that lie on the causal pathways for potential developmental deficits.
doi:10.1186/1471-2393-9-41
PMCID: PMC2749799  PMID: 19732443
8.  Pathways to a rising caesarean section rate: a population-based cohort study 
BMJ Open  2012;2(5):e001725.
Objectives
To determine whether the obstetric pathways leading to caesarean section changed from one decade to another. We also aimed to explore how much of the increase in caesarean rate could be attributed to maternal and pregnancy factors including a shift towards delivery in private hospitals.
Design
Population-based record linkage cohort study.
Setting
New South Wales, Australia.
Participants
For annual rates, all women giving birth in NSW during 1994 to 2009 were included. To examine changes in obstetric pathways two cohorts were compared: all women with a first-birth during either 1994–1997 (82 988 women) or 2001–2004 (85 859 women) and who had a second (sequential) birth within 5 years of their first-birth.
Primary outcome measures
Caesarean section rates, by parity and onset of labour.
Results
For first-births, prelabour and intrapartum caesarean rates increased from 1994 to 2009, with intrapartum rates rising from 6.5% to 11.7%. This fed into repeat caesarean rates; from 2003, over 18% of all multiparous births were prelabour repeat caesareans. In the 1994–1997 cohort, 17.7% of women had a caesarean delivery for their first-birth. For their second birth, the vaginal birth after caesarean (VBAC) rate was 28%. In the 2001–2004 cohort, 26.1% of women had a caesarean delivery for their first-birth and the VBAC rate was 16%. Among women with a first-birth, maternal and pregnancy factors and increasing deliveries in private hospitals, only explained 24% of the rise in caesarean rates from 1994 to 2009.
Conclusions
Rising first-birth caesarean rates drove the overall increase. Maternal factors and changes in public/private care could explain only a quarter of the increase. Changes in the perceived risks of vaginal birth versus caesarean delivery may be influencing the pregnancy management decisions of clinicians and/or mothers.
doi:10.1136/bmjopen-2012-001725
PMCID: PMC3437430  PMID: 22952166
OBSTETRICS; Maternal medicine; Statistics & Research Methods; SURGERY; Adult surgery
9.  Caesarean section for non-medical reasons at term 
Background
Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and a greater risk of stillbirth and neonatal morbidity. The differences in neonatal physiology following vaginal and caesarean births are thought to have implications for the infant, with caesarean section potentially increasing the risk of compromised health in both the short and the long term. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics.
Objectives
To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 January 2012) and reference lists of relevant studies.
Selection criteria
All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section.
Data collection and analysis
We identified no studies that met the inclusion criteria.
Main results
There were no included trials.
Authors’ conclusions
There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth.
doi:10.1002/14651858.CD004660.pub3
PMCID: PMC4171389  PMID: 22419296
*Cesarean Section [adverse effects; psychology]; *Term Birth; Female; Humans; Pregnancy
10.  Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial  
BMJ : British Medical Journal  2007;334(7607):1305.
Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.
Design Randomised trial, conducted from May 2004 to August 2006.
Setting Four maternity units in south west England, and Scotland.
Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded.
Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.
Main outcome measures Total score on decisional conflict scale, and mode of delivery.
Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.
Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section.
Trial Registration Current Controlled Trials ISRCTN84367722.
doi:10.1136/bmj.39217.671019.55
PMCID: PMC1895676  PMID: 17540908
11.  Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study 
BMJ : British Medical Journal  2007;335(7628):1025.
Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery.
Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health.
Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data
Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage).
Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.
Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.
Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.
doi:10.1136/bmj.39363.706956.55
PMCID: PMC2078636  PMID: 17977819
12.  Evaluating trial of scar in patients with a history of caesarean section 
Aims:
To analyze the outcome of trial of scar in patients with previous caesarean section and to assess the fetal and maternal complications after trial of scar.
Patients and Methods:
The study was conducted at Military Hospital, Rawalpindi, Pakistan, with 375 pregnant patients who had a previous delivery by caesarean and who had regular antenatal checkup. Data were recorded on special pro-forms designed for the purpose.
Results:
The results from the 375 patients who had one previous lower segment caesarean section due to non-recurrent causes were analyzed and compared with national and international studies. Indications of previous caesarean section (non-recurrent causes) included malpresentations, fetal distress/cord prolapse, failure to progress, severe pregnancy-induced hypertension/eclampsia and twins with abnormal lie of the first twin. 0 218 patients reported spontaneous labor. Among these patients, 176 delivered vaginally and 42 patients had repeat caesarean sections. There were a total of 157 patients who experienced induction of labor. 97 patients were induced by cervical ripening with mechanical method, followed by artificial rupture of membranes and augmentation (if required) with syntocinon infusion. 60 patients were induced with prostaglandin E2 vaginal tablet.
Conclusion:
This study concludes that females with a prior caesarean are at increased risk for subsequent caesareans, regardless of mode of delivery. Eliminating vaginal-birth-after-caesarean will not eliminate the risk. Therefore, vaginal birth after caesarean should be encouraged in selected cases from obstetric units to reduce the risks of repeated caesarean sections. Failed vaginal-birth-after-caesarean can result in increased morbidity than that with elective caesarean section.
doi:10.4297/najms.2011.3201
PMCID: PMC3336913  PMID: 22540092
Caesarean section; vaginal birth after caesarean section (VBAC); trial of labor
13.  Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods 
BMJ : British Medical Journal  2002;324(7343):942.
Objectives
To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.
Design
Population based birth cohort study, using ethnographic and epidemiological methods.
Setting
Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.
Participants
5304 women who gave birth in any of the city's hospitals in 1993.
Main outcome measures
Birth by caesarean section or vaginal delivery.
Results
In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.
Conclusions
Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.
What is already known on this topicWomen's preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveriesWhat this study addsIn Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient
PMCID: PMC102326  PMID: 11964338
14.  Mode of delivery after one caesarean section: audit of current practice in a health region. 
BMJ : British Medical Journal  1991;303(6806):818-821.
OBJECTIVE--To audit the subsequent obstetric management of women who had had one previous baby delivered by caesarean section. DESIGN--Retrospective analysis of a regional obstetric database. SETTING--Data derived from the 17 obstetric units in North West Thames region. SUBJECTS--1059 women who delivered a singleton fetus of at least 37 weeks' gestation with a cephalic presentation in 1988 who had a history of one previous caesarean section and no other deliveries. MAIN OUTCOME MEASURES--Mode of delivery, postnatal morbidity, and duration of hospital stay. RESULTS--395 (37%) women were delivered by elective repeat caesarean section and 664 (63%) were allowed a trial of labour. Maternal height and birth weight of the previous infant differed significantly between those who were and those who were not allowed to labour. 471 (71%) of those allowed to labour achieved a vaginal delivery. In individual units there was no significant correlation between the proportion of patients allowed to labour and the rate of the successful trial of labour. There was a trend towards greater success rates in units that allowed a longer duration of labour (p less than 0.05) and units with greater use of oxytocin for augmentation of labour (not significant). Both elective and intrapartum caesarean section was associated with a significantly higher rate of postnatal infection than vaginal delivery (14.7% and 16.0% v 3.4%). CONCLUSIONS--In patients with a history of caesarean section there is no evidence that the likelihood of successful vaginal delivery after trial of labour is modified by the proportion of such patients allowed the option of attempted vaginal delivery. Until selection criteria of adequate prognostic value can be identified a more liberal approach to allowing women a trial of labour seems justified.
PMCID: PMC1671146  PMID: 1932972
15.  Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study 
BMJ : British Medical Journal  2004;329(7462):375.
Objective To determine the factors associated with an increased risk of perinatal death related to uterine rupture during attempted vaginal birth after caesarean section.
Design Population based retrospective cohort study.
Setting Data from the linked Scottish Morbidity Record and Stillbirth and Infant Death Survey of births in Scotland, 1985-98.
Participants All women with one previous caesarean delivery who gave birth to a singleton infant at term by a means other than planned repeat caesarean section (n = 35 854).
Main outcome measures All intrapartum uterine rupture and uterine rupture resulting in perinatal death (that is, death of the fetus or neonate).
Results The overall proportion of vaginal births was 74.2% and of uterine rupture was 0.35%. The risk of intrapartum uterine rupture was higher among women who had not previously given birth vaginally (adjusted odds ratio 2.5, 95% confidence interval 1.6 to 3.9, P < 0.001) and those whose labour was induced with prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factors were also associated with an increased risk of perinatal death due to uterine rupture. Delivery in a hospital with < 3000 births a year did not increase the overall risk of uterine rupture (1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with ≥ 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04).
Conclusion Women who have not previously given birth vaginally and those whose labour is induced with prostaglandin are at increased risk of uterine rupture when attempting vaginal birth after caesarean section. The risk of consequent death of the infant is higher in units with lower annual numbers of births.
doi:10.1136/bmj.38160.634352.55
PMCID: PMC509342  PMID: 15262772
16.  Outcomes of Induction of Labour in Women with Previous Caesarean Delivery: A Retrospective Cohort Study Using a Population Database 
PLoS ONE  2013;8(4):e60404.
Background
There is evidence that induction of labour (IOL) around term reduces perinatal mortality and caesarean delivery rates when compared to expectant management of pregnancy (allowing the pregnancy to continue to await spontaneous labour or definitive indication for delivery). However, it is not clear whether IOL in women with a previous caesarean section confers the same benefits. The aim of this study was to describe outcomes of IOL at 39–41 weeks in women with one previous caesarean delivery and to compare outcomes of IOL or planned caesarean delivery to those of expectant management.
Methods and Findings
We performed a population-based retrospective cohort study of singleton births greater than 39 weeks gestation, in women with one previous caesarean delivery, in Scotland, UK 1981–2007 (n = 46,176). Outcomes included mode of delivery, perinatal mortality, neonatal unit admission, postpartum hemorrhage and uterine rupture. 40.1% (2,969/7,401) of women who underwent IOL 39–41 weeks were ultimately delivered by caesarean. When compared to expectant management IOL was associated with lower odds of caesarean delivery (adjusted odds ratio [AOR] after IOL at 39 weeks of 0.81 [95% CI 0.71–0.91]). There was no significant effect on the odds of perinatal mortality but greater odds of neonatal unit admission (AOR after IOL at 39 weeks of 1.29 [95% CI 1.08–1.55]). In contrast, when compared with expectant management, elective repeat caesarean delivery was associated with lower perinatal mortality (AOR after planned caesarean at 39 weeks of 0.23 [95% CI 0.07–0.75]) and, depending on gestation, the same or lower neonatal unit admission (AOR after planned caesarean at 39 weeks of 0.98 [0.90–1.07] at 40 weeks of 1.08 [0.94–1.23] and at 41 weeks of 0.77 [0.60–1.00]).
Conclusions
A more liberal policy of IOL in women with previous caesarean delivery may reduce repeat caesarean delivery, but increases the risks of neonatal complications.
doi:10.1371/journal.pone.0060404
PMCID: PMC3615029  PMID: 23565242
17.  Internet information on birth options after caesarean compared to the RCOG patient information leaflet; a web survey 
Background
Repeat caesarean sections make a substantial contribution to the overall caesarean section rate. It is important to understand what influences women to choose this option when the alternative of attempting vaginal birth after caesarean section is available. As many such women use the internet while seeking information on their options, the aim of this study was to assess content of websites on birth after previous caesarean and identify website characteristics which predict content.
Methods
An internet survey of the forty eight most frequently encountered websites retrieved from a search using various terms relating to birth after caesarean section via a popular search engine was performed. Websites were assessed for their content supportive of either vaginal birth after caesarean (VBAC) or elective repeat caesarean section (ERCS), using the RCOG patient information document, ‘Birth after previous caesarean; Information for You’ as a ‘gold standard’. A simple scoring method which categorised information into either supportive of VBAC (14 facts available) or ERCS (10 facts available) was employed and mean scores compared. Poisson regression analysis was used to assess the extent to which the score was predicted by website funding source, country of origin, author status and intended audience.
Results
A mean of 42.4% (SD 23.8) of facts supportive of VBAC and 44.8% (SD 25.0) of facts supportive of ERCS were featured across the 48 websites, with corresponding scores in the five most frequently encountered websites being 40.0% (SD 13.9) and 66.0% (SD 20.7). Extent of featured information supportive of ERCS was related to country of origin with the UK having higher scores on average than the US.
Conclusions
Women searching for internet information on birth after previous caesarean are exposed to incomplete information. Origin of website has a significant effect on website content.
doi:10.1186/1471-2393-14-361
PMCID: PMC4288659  PMID: 25306551
Caesarean section; Vaginal birth; Internet information
18.  Long-term outcome by method of delivery of fetuses in breech presentation at term: population based follow up. 
BMJ : British Medical Journal  1996;312(7044):1451-1453.
OBJECTIVE--To compare the long-term outcome of infants delivered in breech presentation at term by intended mode of delivery. DESIGN--A population based comparison of outcomes up to school age. Data obtained from maternity, health visitor, and school medical records and handicap register. SETTING--Grampian region 1981-90. SUBJECTS--1645 infants delivered alive at term after breech presentation. MAIN OUTCOME MEASURES--Handicap, developmental delay, neurological deficit, psychiatric referral. RESULTS--Elective caesarean section was performed in 590 (35.9%) cases. The remainder (1055; 64.1%) were intended vaginal deliveries. Handicap or other health problem was recorded in 269 (19.4%) of 1387 infants for whom records were available. Proportions of elective caesarean sections and intended vaginal deliveries in this group were 37.2% (100 cases) and 62.8% (169) respectively, almost the same as in the total cohort. There were no significant differences between elective caesarean section and planned vaginal delivery in terms of severe handicap or any other outcome measure. Case records were obtained for 23 of 27 infants with severe handicap. 11 (47.8%) were delivered by elective caesarean section. Of these, three had undiagnosed congenital abnormalities and seven were unexplained. Of the 12 (52.2%) planned vaginal deliveries, in only one was handicap possibly attributable to delivery and four cases were unavoidable even if elective caesarean section had been planned. CONCLUSION--In selected cases of breech presentation at term planned vaginal delivery with caesarean section if necessary remains as safe as elective caesarean section in terms of long term handicap. It was not possible to determine whether particular babies would have fared better had they been delivered by elective caesarean section.
PMCID: PMC2351189  PMID: 8664622
19.  Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study 
Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors.
Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model.
Setting 146 English NHS trusts.
Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008.
Main outcome measure Rate of caesarean sections per 100 births (live or stillborn).
Results Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section.
Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.
doi:10.1136/bmj.c5065
PMCID: PMC2950923  PMID: 20926490
20.  Unwanted caesarean sections among public and private patients in Brazil: prospective study 
BMJ : British Medical Journal  2001;323(7322):1155-1158.
Objective
To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil.
Design
Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum.
Setting
Four cities in Brazil.
Participants
1612 pregnant women: 1093 public patients and 519 private patients.
Main outcome measures
Rates of delivery by caesarean section in public and private institutions; women's preferences for delivery; timing of decision to perform caesarean section.
Results
1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector.
Conclusions
The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery.
What is already known on this topicIn Brazil, one quarter of all women deliver in the private sectorThe rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policyPrevious studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal deliveryWhat this study addsIn two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal birthsContrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section
PMCID: PMC59849  PMID: 11711406
21.  Is vaginal delivery safe after previous lower segment caesarean section in developing country? 
Background:
To analyse the mode of delivery in trial of labour (TOL), incidence of successful vaginal deliveries and indications of repeat caesarean section (CS).
Materials and Methods:
Prospective selective study. Study population consisted of 367 pregnant women with previous one lower segment caesarean section (LSCS) in reproductive age group. These were grouped in to three groups, Group 1 (n = 239): Women, who were elected for repeat CS without a TOL. Group 2 (n = 76): Women, who were given TOL and delivered vaginally. Group 3 (n = 52): Women, who were given a TOL but due to failed trial, had to be taken for emergency repeat section. The maternal and foetal outcome was studied in all the groups.
Statistical Method Used:
The data was entered in the Microsoft excel worksheet, values expressed as mean ± SD. Chi-square test was done to compare the categorical variables among the groups. ANOVA (one-way analysis of variance) was done to compare the baseline characteristics of patients and time to delivery among the groups.
Results:
Out of 128 women who were given TOL, 76 (59.37%) vaginal birth after caesarean (VBAC) occurred, out of which 40 (52.63%) had spontaneous vaginal deliveries without augmentation of labour and 36 (47.36%) subjects had augmentation of labour with artificial rupture of membranes (ARMs) and oxytocin. A total of 52 women (40.62%) underwent emergency LSCS.
Conclusion:
Proper selection and counselling about clinically significant risks, women can be given TOL with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management of previous one CS in labour.
doi:10.4103/0300-1652.132067
PMCID: PMC4089058  PMID: 25013261
Caesarian section; safe; trial of labour; vaginal birth after caesarean section
22.  Delivery after caesarean section: review of 2176 consecutive cases. 
A total of 2176 consecutive patients who had had one previous caesarean section were studied retrospectively. A repeat elective caesarean section was performed in 395 (18.2%). Labour started spontaneously in 1363 patients, 301 of whom were given oxytocin to accelerate inert labour, and was induced by amniotomy and infusion of oxytocin in 418 women; 1618 of these 1781 patients (90.8%) delivered vaginally. Patients who had had a previous vaginal delivery were more likely to deliver vaginally again. Those women in whom the initial caesarean section had been performed during labour before the cervix was 4 cm dilated were less likely to deliver vaginally than those who had progressed further in labour or those who had had an elective caesarean section. Similarly, those who received oxytocin to stimulate inert labour were more likely to require a repeat caesarean section than those who did not. The uterine scar ruptured in only eight (0.45%) of the 1781 patients allowed into labour. The risk of rupture of the scar was not increased by the use of oxytocin alone either to induce or to accelerate labour. The combination of oxytocin to accelerate labour and epidural analgesia to provide pain relief, however, was associated with an increased incidence of scar rupture. Labour may be safely allowed in women who have had a previous caesarean section, most of whom will deliver vaginally. Induction of labour does not increase the risk of either a repeat caesarean section or rupture of a uterine scar.
PMCID: PMC1246822  PMID: 3113567
23.  First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000–2008 
Human Reproduction (Oxford, England)  2013;28(12):3349-3357.
STUDY QUESTION
Is first birth Caesarean delivery associated with a lower likelihood of subsequent childbearing when compared with first birth vaginal delivery?
SUMMARY ANSWER
In this study of US women whose first delivery was in 2000, those who had a Caesarean delivery were less likely to have a subsequent live birth than those who delivered vaginally.
WHAT IS ALREADY KNOWN
Some studies have reported lower birth rates subsequent to Caesarean delivery in comparison with vaginal delivery, while other studies have reported no difference.
STUDY DESIGN, SIZE, DURATION
We conducted a retrospective cohort study of 52 498 women who had a first singleton live birth in the State of Pennsylvania, USA in 2000 and were followed to the end of 2008 via Pennsylvania birth certificate records to identify subsequent live births during the 8- to 9-year follow-up period.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Birth certificate records of first singleton births were linked to the hospital discharge data for each mother and newborn, and linked to all birth certificate records for each mother's subsequent deliveries which occurred in 2000 to the end of 2008. Poisson regression models were used to evaluate the association between first birth factors and whether or not there was a subsequent live birth during the follow-up period.
MAIN RESULTS AND THE ROLE OF CHANCE
Over an average of 8.5 years of follow-up, 40.2% of women with a Caesarean first birth did not have a subsequent live birth, compared with 33.1% of women with a vaginal first birth (risk ratio (RR): 1.21, 95% confidence interval (CI): 1.18–1.25). Adjustment for the demographic confounders of maternal age, race, education, marital status and health insurance coverage attenuated the RR to 1.16 (95% CI: 1.13–1.19). Specific pregnancy and childbirth-related complications associated with not having a subsequent live birth included diabetes-related disorders, abnormalities of organs and soft tissues of the pelvis, fetal abnormalities, premature or prolonged rupture of membranes, hypertensive disorders, amnionitis, fetal distress and other maternal health problems. However, adjustment for the pregnancy and childbirth complications had little effect on the RR of not having a subsequent live birth (RR = 1.15, 95% CI: 1.11–1.19).
LIMITATIONS, REASONS FOR CAUTION
We were unable to distinguish between women who did not have a subsequent live birth and those who moved out of the state, which may have introduced a selection bias if those who had Caesarean births were more likely to emigrate than those who delivered vaginally. In addition we were unable to measure pre-pregnancy body mass index, weight gain during pregnancy and prior infertility, which would have been helpful in our efforts to reduce selection bias.
WIDER IMPLICATIONS OF THE FINDINGS
The results of this study provide further corroboration of previous studies that have reported reduced fertility subsequent to Caesarean section in comparison with vaginal delivery.
STUDY FUNDING/POTENTIAL COMPETING INTERESTS
This study was funded by the US National Institute of Child Health and Human Development (NICHD, R01-HD052990). No competing interests are declared.
doi:10.1093/humrep/det343
PMCID: PMC3829579  PMID: 24021550
Caesarean section; fertility; parturition; reproduction; pregnancy complications
24.  Maternal and perinatal outcomes of delivery after a previous Cesarean section in Enugu, Southeast Nigeria: a prospective observational study 
Background
Obstetricians in developing countries appear generally reluctant to conduct vaginal delivery in women with a previous Cesarean because of lack of adequate facilities for optimal fetomaternal monitoring.
Objective
To describe delivery outcomes among women with one previous Cesarean section at a tertiary hospital in Southeast Nigeria.
Methods
This was a prospective observational study to determine maternal and perinatal outcomes of attempted vaginal birth after Cesarean sections (VBAC) following one previous Cesarean section. Analysis was done with SPSS statistical software version 17.0 for Windows using descriptive and inferential statistics at 95% level of confidence.
Results
Two thousand six hundred and ten women delivered in the center during the study period, of whom 395 had one previous Cesarean section. A total of 370 women with one previous Cesarean section had nonrecurrent indications, of whom 355 consenting pregnant women with one previous Cesarean section were studied. A majority of the women (320/355, 90.1%) preferred to have vaginal delivery despite the one previous Cesarean section. However, only approximately 54% (190/355) were found suitable for trial of VBAC, out of whom 50% (95/190 had successful VBAC. Ninety-five women (50.0%) had failed attempt at VBAC and were delivered by emergency Cesarean section while 35 women (9.8%) had emergency Cesarean section for other obstetric indications (apart from failed VBAC). There was no case of uterine rupture or neonatal and maternal deaths recorded in any group. Apgar scores of less than 7 in the first minute were significantly more frequent amongst women who had vaginal delivery when compared to those who had elective repeat Cesarean section (P=0.03).
Conclusion
Most women who had one previous Cesarean delivery chose to undergo trial of VBAC, although only about half were considered suitable for VBAC. The maternal and fetal outcomes of trial of VBAC in selected women with one previous Cesarean delivery for non-recurrent indications were good. Obstetricians in this area should do more to allow VBAC in women with one previous Cesarean section for nonrecurrent indications.
doi:10.2147/IJWH.S56147
PMCID: PMC3958543  PMID: 24648774
previous Cesarean section; vaginal birth; pregnancy; VBAC
25.  Cesarean Section and Rate of Subsequent Stillbirth, Miscarriage, and Ectopic Pregnancy: A Danish Register-Based Cohort Study 
PLoS Medicine  2014;11(7):e1001670.
Louise Kenny and colleagues conduct a population-based cohort study in Denmark to assess the likelihood of stillbirth, miscarriage, and ectopic pregnancy following cesarean section compared to women who gave birth by vaginal delivery.
Please see later in the article for the Editors' Summary
Background
With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication.
Methods and Findings
We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage.
Conclusions
This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, increasing numbers of babies are being delivered by cesarean section (a surgical operation in which the baby is delivered through a cut made in the mother's abdomen and womb) instead of naturally through their mother's vagina. In England in 2010, for example, nearly 25% of all babies were delivered by cesarean section (also called C-section) compared to only 2% in the 1950s; in China and some parts of South America cesarean rates are now between 40% and 50%. A cesarean section is usually performed when a vaginal birth would endanger the life of the mother or her unborn child because, for example, the baby is in the wrong position. Some cesareans are performed as emergency procedures, but others are planned in advance when the need for the operation becomes clear during pregnancy (an elective cesarean). Some planned cesarean sections are also undertaken because the mother has requested a cesarean delivery in the absence of any medical reasons for such a delivery.
Why Was This Study Done?
Cesarean sections save lives but do they have any negative impacts on the outcome of subsequent pregnancies? With so many cesarean sections being undertaken, it is important to be sure that the procedure does not increase the rates of subsequent miscarriage, stillbirth, or ectopic pregnancy. Miscarriage—the loss of a fetus (developing baby) that is unable to survive independently—is the commonest complication of early pregnancy, affecting about one in five women who know they are pregnant. Stillbirth is fetal death after about 20–24 weeks of pregnancy; the exact definition of stillbirth varies between countries. About four million stillbirths occur each year worldwide. Ectopic pregnancy—development of the fetus outside the womb—occurs in 1%–2% of all pregnancies. In this population-based cohort study, the researchers investigate the rates of subsequent stillbirth, miscarriage, and ectopic pregnancy following a cesarean section among women living in Denmark. A population-based cohort study determines the baseline characteristics of the individuals in a population, and then follows the population over time to see whether specific characteristics are associated with specific outcomes.
What Did the Researchers Do and Find?
The researchers obtained data for 832,996 women from Danish national registers about their first live birth (including whether they had a cesarean) then followed the women (again using the registers) until they had a stillbirth, miscarriage, or ectopic pregnancy, or a second live birth. The researchers used these data and statistical models to estimate the risk of stillbirth, miscarriage, and ectopic pregnancy following a cesarean compared to a spontaneous vaginal delivery after controlling for the possibility that the cesarean was performed because of an indication that might increase the risk of a subsequent event (confounding). Women who had had a cesarean had a 14% increased risk of a stillbirth in their next pregnancy compared to women who had had a vaginal delivery, corresponding to an absolute risk increase of 0.03%. In other words, 3,333 women would need to have a cesarean to result in one extra stillbirth in subsequent pregnancy (a “number needed to harm” of 3,333). Compared to vaginal delivery, having a cesarean increased the risk of a subsequent ectopic pregnancy by 9% (an absolute risk increase of 0.1% and a number needed to harm of 1,000) but did not increase the rate of subsequent miscarriages.
What Do These Findings Mean?
These findings show that, among women living in Denmark, cesarean section is associated with a slightly increased rate of subsequent stillbirth and ectopic pregnancy. Part of this increase can be accounted for by underlying medical conditions and by confounding by the indication for the primary cesarean section. The accuracy of these findings may be affected by limitations in the study such as incomplete data on some factors (for example, the smoking history of the mother) that might have affected the risk of stillbirth, miscarriage, and ectopic pregnancy, and by misclassification or underreporting of the study outcomes. Given the global increase in cesarean rates, these findings suggest that cesarean delivery is not associated with an increased rate of subsequent stillbirth, miscarriage, or ectopic pregnancy, an important finding for both expectant mothers and health-care professionals that nonetheless needs to be confirmed in further large-scale studies. Finally, these findings highlight the need for women to consider all their options thoroughly before requesting a cesarean section on non-medical grounds.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001670.
The American Congress of Obstetricians and Gynecologists provides patient fact sheets on cesarean birth, miscarriage, and ectopic pregnancy
The US-based non-profit Nemours Foundation provides information about cesarean sections, miscarriage and stillbirth, and ectopic pregnancy (in English and Spanish)
The UK National Health Service Choices website provides information for patients about cesarean section, miscarriage, stillbirth, and ectopic pregnancy
MedlinePlus provides links to additional resources about cesarean section, miscarriage, stillbirth, and ectopic pregnancy (in English and Spanish)
The UK non-profit organization Healthtalkonline provides personal stories about cesarean delivery, miscarriage, and stillbirth
doi:10.1371/journal.pmed.1001670
PMCID: PMC4077571  PMID: 24983970

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