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Topics: Systems-based Practice, Obstetric Complications E lective repeat cesarean delivery (CD) contributes sig-

Objective To externally validate two models from the USA (entry-to-care [ETC] and close-to-delivery [CTD]) that predict successful intended vaginal birth after caesarean (VBAC) for the Dutch population.Design A nationwide registration-based cohort study.Setting Seventeen hospitals in the Netherlands.Population Seven hundred and sixty-three pregnant women, each with one previous caesarean section and a viable singleton cephalic pregnancy without a contraindication for an intended VBAC. MethodsThe ETC model comprises the variables maternal age, prepregnancy body mass index (BMI), ethnicity, previous vaginal delivery, previous VBAC and previous nonprogressive labour. The CTD model replaces prepregnancy BMI with third-trimester BMI and adds estimated gestational age at delivery, hypertensive disease of pregnancy, cervical examination and induction of labour. We included consecutive medical records of eligible women who delivered in 2010. For validation, individual probabilities of women who had an intended VBAC were calculated.Main outcome measures Discriminative performance was assessed with the area under the curve (AUC) of the receiver operating characteristic and predictive performance was assessed with calibration plots and the Hosmer-Lemeshow (H-L) statistic.Results Five hundred and fifteen (67%) of the 763 women had an intended VBAC; 72% of these (371) had an actual VBAC. The AUCs of the ETC and CTD models were 68% (95% CI 63-72%) and 72% (95% CI 67-76%), respectively. The H-L statistic showed a P-value of 0.167 for the ETC model and P = 0.356 for the CTD model, indicating no lack of fit.Conclusion External validation of two predictive models developed in the USA revealed an adequate performance within the Dutch population.Keywords External validation, prediction, vaginal birth after caesarean.Please cite this paper as: Schoorel ENC, Melman S, van Kuijk SMJ, Grobman WA, Kwee A, Mol BWJ, Nijhuis JG, Smits LJM, Aardenburg R, de Boer K, Delemarre FMC, van Dooren IM, Franssen MTM, Kleiverda G, Kaplan M, Kuppens SMI, Lim FTH, Sikkema JM, Smid-Koopman E, Visser H, Vrouenraets FPJM, Woiski M, Hermens RPMG, Scheepers HCJ. Predicting successful intended vaginal delivery after previous caesarean section: external validation of two predictive models in a Dutch nationwide registration-based cohort with a high intended vaginal delivery rate. BJOG 2014;121:840-847.

Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians’ preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24+0/7 weeks of gestational age (GA). Obstetricians’ and neonatologists’ opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24+0/7 weeks and intensive care over 26+0/7 weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, “small for gestational age” fetus, and incomplete course of corticosteroids.Conclusion: There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. What is known: • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 +0/7  weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.

Severe early onset pre-eclampsia comes with high maternal complication rates and poor neonatal survival.