AJOG Reviews
Predicting vaginal birth after cesarean delivery: A review of prognostic factors and screening tools

https://doi.org/10.1016/j.ajog.2003.08.045Get rights and content

Abstract

Objective

Our purpose was to identify the factors associated with vaginal delivery after trial of labor in patients with a prior cesarean and to evaluate the effectiveness of existing screening tools.

Study design

Studies were identified through MEDLINE and HealthSTAR (1980-2002), reference list reviews, and suggestions of national experts.

Results

Thirteen of the 100 eligible studies provided fair to good quality evidence for the predictive nature of 12 factors. Two of the six screening tools were considered promising and demonstrated reproducibility through validation studies.

Conclusions

There is little high-quality data to guide clinical decisions regarding which women are likely to have a successful trial of labor. Although we identified two validated screening tools that may be reasonable for practitioners to use, further development is needed to deliver them in a user-friendly manner and further research is needed to determine the clinical setting in which they are most useful. Conducting high-quality research on the factors that delineate women who are at higher likelihood of vaginal delivery without complications and developing accurate user-friendly screening tools to integrate these data should be a national research priority.

Section snippets

Searching

We searched MEDLINE and HealthSTAR databases from 1980 to March 2002, with the help of an experienced medical librarian, using MeSH terms and text words including “vaginal birth after cesarean,” “cesarean,” “trial of labor/labour,” “trial of scar,” “vaginal delivery,” and “labor/labour.” Additional studies were identified by reviewing the reference lists of all included studies and review articles and through suggestions of national experts. Further details regarding search strategies used by

Results

Our search identified 3065 citations, of which 157 were potentially relevant. An additional 22 studies were identified from reference lists or expert suggestions, for 179 full-text articles. The reapplication of eligibility criteria resulted in the inclusion of 95 individual factor studies, 9 screening studies, and 5 studies of both individual factors and screening.

Eighty-eight were rated as poor quality for failing to control for confounding. In the end, 13 individual factor studies,14., 15.,

Comment

Cesarean deliveries in 2002 were at the highest level reported since 1989, whereas the rate of vaginal birth after previous cesarean delivery fell 55% from 1996 to 2002.2 In large part, the decrease in VBAC rates is reflective of concerns for the safety of VBAC after highly publicized reports of significant morbidity from failed trial of labor, most notably, cases of catastrophic uterine rupture. One of the goals of an obstetric provider is to accurately diagnose women who are at high risk for

Acknowledgements

We thank Marian McDonagh, PharmD, Dale Kramer, PhD, Patty Davies, MS, and Kathryn Krages, AMLS, MA, for their invaluable assistance.

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    This work was performed by the Oregon Health and Sciences University Evidence-based Practice Center, under contract to the Agency for Healthcare Research and Quality (contract No.: 290-97-0018, Task Order No.: 9). Support for Dr Guise was also provided by the Agency for Healthcare Research and Quality, grant No. 1 K08 HS11338-01.

    The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

    Reprints not available from the authors.

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