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Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

  1. Jodie M Dodd1,*,
  2. Caroline A Crowther2,3,
  3. Erasmo Huertas4,
  4. Jeanne-Marie Guise5,
  5. Dell Horey6

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 10 DEC 2013

Assessed as up-to-date: 30 SEP 2013

DOI: 10.1002/14651858.CD004224.pub3


How to Cite

Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD004224. DOI: 10.1002/14651858.CD004224.pub3.

Author Information

  1. 1

    The University of Adelaide, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

  2. 2

    The University of Auckland, Liggins Institute, Auckland, New Zealand

  3. 3

    The University of Adelaide, ARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

  4. 4

    Materno Perinatal Institute of Lima-Peru, Adolescence Unit, Lima 01, Peru

  5. 5

    Oregon Health and Science University, Departments of Obstetrics and Gynecology, and Medical Informatics and Clinical Epidemiology, Portland, Oregon, USA

  6. 6

    La Trobe University, Faculty of Health Sciences, Bundoora, VIC, Australia

*Jodie M Dodd, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia. jodie.dodd@adelaide.edu.au.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 10 DEC 2013

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Characteristics of included studies [ordered by study ID]
Crowther 2012b

MethodsRandomised trial conducted in 14 maternity units in Australia between November 2002 and May 2007.


ParticipantsWomen were eligible with a single prior caesarean section, live singleton fetus at 37 weeks' gestational age, and who were considered eligible to attempt VBAC by caregiver.

Women with any of the following were excluded: more than 1 prior caesarean; vertical/inverted T/unknown uterine incision; prior uterine rupture; prior uterine surgery involving entry of uterine cavity; prior uterine perforation; multiple pregnancy; any contraindication to vaginal birth (placenta praevia; transverse lie; active genital herpes); cephalopelvic disproportion; lethal congenital anomaly; fetal anomaly associated with mechanical difficulties at birth.


Interventions22 eligible women were randomised to either planned vaginal birth or to planned caesarean section.

Where women planned vaginal birth, the spontaneous onset of labour was awaited. Where women planned an elective caesarean section, this was scheduled between 38 and 40 weeks' gestation.


OutcomesThe primary outcome was a composite of death or serious adverse outcome for infant. A range of secondary clinical outcomes reflecting serious adverse outcomes for the woman and infant were reported.


NotesThis study was conducted as a randomised trial nested within a larger prospective patient preference study. The inclusion and exclusion criteria and reported outcomes were the same for both the randomised and patient preference components of the study.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random number sequence.

Allocation concealment (selection bias)Low riskTelephone randomisation service.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo losses to follow-up reported.

Selective reporting (reporting bias)Low riskOutcomes identified in the published protocol have been reported.

Other biasLow riskNo other bias identified.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskNo blinding of participants, caregivers or outcome assessors but not considered likely to bias outcomes.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskNo blinding of participants, caregivers or outcome assessors but not considered likely to bias outcomes.

Law 2010

MethodsRandomised trial conducted in a single maternity unit affiliated with University of Hong Kong, Hong Kong. 


ParticipantsWomen were eligible with a single prior caesarean section, who were considered eligible to attempt vaginal birth by their caregiver.

Women with a prior vaginal birth or any contraindication to attempting vaginal birth were excluded.


Interventions298 eligible women were randomised to either planned vaginal birth or to planned caesarean section prior to 28 weeks' gestation.

Where women planned vaginal birth, the spontaneous onset of labour was awaited. Where women planned an elective caesarean section, this was scheduled at 38 weeks' gestation.


OutcomesThe primary outcomes were maternal psychometric assessments (EPDS, Beck Depression Inventory; State-Trait Anxiety Inventory; General Health Questionnaire (GHQ-12); Client Satisfaction Questionnaire) measured at 6 months postpartum.


NotesThere are no maternal or infant clinical outcomes reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random number sequence.

Allocation concealment (selection bias)Low riskSealed, opaque, sequentially numbered envelopes.

Incomplete outcome data (attrition bias)
All outcomes
Low risk6 women refused to participate after randomisation; 1 woman was excluded after randomisation due to ineligibility.

Selective reporting (reporting bias)Low riskSpecified primary outcomes are reported; there are no clinical maternal or infant outcomes reported.

Other biasLow riskNo other bias identified.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskNo blinding of participants, caregivers or outcome assessors but not considered likely to bias outcomes.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskNo blinding of participants, caregivers or outcome assessors but not considered likely to bias outcomes.

 
Comparison 1. Primary outcome

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death or serious maternal morbidity122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Death or serious infant morbidity122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Secondary maternal outcomes

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Vaginal birth122Risk Ratio (M-H, Fixed, 95% CI)0.34 [0.09, 1.29]

 2 Caesarean section122Risk Ratio (M-H, Fixed, 95% CI)1.92 [0.92, 4.01]

 3 Uterine rupture122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Haemorrhage or need for blood transfusion122Risk Ratio (M-H, Fixed, 95% CI)1.2 [0.20, 7.05]

 5 Hysterectomy122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Vulval or perineal haematoma122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Deep vein thrombosis122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Pulmonary embolus122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Pneumonia122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 10 Adult respiratory distress syndrome122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Wound Infection122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 12 Wound dehiscence122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 13 Organ damage122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 14 Development of fistula122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 15 Bowel obstruction122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 16 Pulmonary oedema122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 17 Stroke122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 18 Cardiac arrest122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 19 Respiratory arrest122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 20 Maternal death122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 3. Secondary infant outcomes

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Perinatal death122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Apgar score less than 7 at 5 minutes122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Birthweight122Mean Difference (IV, Fixed, 95% CI)-133.0 [-513.12, 247.12]

 4 Intensive care unit admission122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Birth trauma122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Seizures122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Neonatal encephalopathy122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Severe respiratory distress syndrome122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Necrotising enterocolitis122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 10 Systemic infection122Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]