Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland.

Background Policy consensus in high-income countries supports offering pregnant women with previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or attempting a vaginal birth, known as a planned vaginal birth after previous cesarean (VBAC), provided they do not have contraindications to planned VBAC. However, robust comprehensive information on the associated outcomes to counsel eligible women about this choice is lacking. This study investigated the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section among women delivering a term singleton and considered eligible to have a planned VBAC. Methods and findings A population-based cohort of 74,043 term singleton births in Scotland between 2002 and 2015 to women with one or more previous cesarean sections was conducted using linked Scottish national datasets. Logistic or modified Poisson regression, as appropriate, was used to estimate the effect of planned mode of delivery on maternal and perinatal outcomes adjusted for sociodemographic, maternal medical, and obstetric-related characteristics. A total of 45,579 women gave birth by ERCS, and 28,464 had a planned VBAC, 28.4% of whom went on to have an in-labor nonelective repeat cesarean section. Compared to women delivering by ERCS, those who had a planned VBAC were significantly more likely to have uterine rupture (0.24%, n = 69 versus 0.04%, n = 17, adjusted odds ratio [aOR] 7.3, 95% confidence interval [CI] 3.9-13.9, p < 0.001), a blood transfusion (1.14%, n = 324 versus 0.50%, n = 226, aOR 2.3, 95% CI 1.9-2.8, p < 0.001), puerperal sepsis (0.27%, n = 76 versus 0.17%, n = 78, aOR 1.8, 95% CI 1.3-2.7, p = 0.002), and surgical injury (0.17% versus 0.09%, n = 40, aOR 3.0, 95% CI 1.8-4.8, p < 0.001) and experience adverse perinatal outcomes including perinatal death, admission to a neonatal unit, resuscitation requiring drugs and/or intubation, and an Apgar score < 7 at 5 minutes (7.99%, n = 2,049 versus 6.37%, n = 2,570, aOR 1.6, 95% CI 1.5-1.7, p < 0.001). However, women who had a planned VBAC were more likely than those delivering by ERCS to breastfeed at birth or hospital discharge (63.6%, n = 14,906 versus 54.5%, n = 21,403, adjusted risk ratio [aRR] 1.2, 95% CI 1.1-1.2, p < 0.001) and were more likely to breastfeed at 6-8 weeks postpartum (43.6%, n = 10,496 versus 34.5%, n = 13,556, aRR 1.2, 95% CI 1.2-1.3, p < 0.001). The effect of planned mode of delivery on the mother's risk of having a postnatal stay greater than 5 days, an overnight readmission to hospital within 42 days of birth, and other puerperal infection varied according to whether she had any prior vaginal deliveries and, in the case of length of postnatal stay, also varied according to the number of prior cesarean sections. The study is mainly limited by the potential for residual confounding and misclassification bias. Conclusions Among women considered eligible to have a planned VBAC, planned VBAC compared to ERCS is associated with an increased risk of the mother having serious birth-related maternal and perinatal complications. Conversely, planned VBAC is associated with an increased likelihood of breastfeeding, whereas the effect on other maternal outcomes differs according to whether a woman has any prior vaginal deliveries and the number of prior cesarean sections she has had. However, the absolute risk of adverse outcomes is small for either delivery approach. This information can be used to counsel and manage the increasing number of women with previous cesarean section, but more research is needed on longer-term outcomes. Author summaryWhy was this study done? Many countries have seen a rise in their cesarean section rate, leading to an increasing proportion of women having a subsequent pregnancy with a history of previous cesarean section. Pregnant women who have had previous cesarean section may be offered a choice between planning an elective repeat cesarean section or attempting a vaginal birth, providing they do not have medical reasons why a planned cesarean is considered the safer or more advisable option. Clinical guidelines recommend that women should be counseled about the benefits and harms of planning to have another cesarean section compared to attempting a vaginal delivery to help with this decision. However, there is a lack of robust comprehensive information on the associated outcomes to counsel eligible women about this choice. What did the researchers do and find? We undertook a cohort study of 74,043 term singleton births in Scotland to women with one or more previous cesarean sections to determine the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section. We found that attempting a vaginal birth compared to having an elective repeat cesarean section is associated with an increased risk of the mother having serious birth-related complications such as uterine rupture and blood transfusion, as well as an increased risk of adverse perinatal outcomes. Conversely, we found that attempting a vaginal birth is associated with an increased likelihood of breastfeeding, whereas the association with other maternal outcomes appears to differ according to whether a woman has any prior vaginal deliveries and the number of previous cesarean sections she has had. However, the absolute risk of adverse maternal and perinatal outcomes was found to be small for either delivery approach: overall, just 1.8% of those attempting a vaginal birth and 0.8% of those having an elective repeat cesarean section experienced serious maternal complications, and 8.0% of those attempting a vaginal birth and 6.4% of those having an elective repeat cesarean section experienced one or more of the adverse perinatal outcomes considered. What do these findings mean? Our findings can be used to counsel and manage women with previous cesarean section and should be considered alongside existing evidence on the increased risk of serious maternal morbidity in subsequent pregnancies associated with elective repeat cesarean section.