Vaginal birth after cesarean: neonatal outcomes and United States birth setting

Abstract

Background Women seeking VBAC may find limited in-hospital options. Increasing numbers of US women are delivering by VBAC out-of-hospital. Little is known about neonatal outcomes among those delivering by VBAC in vs. out-of-hospital. Objective(s) To compare neonatal outcomes between women delivering via VBAC in hospital vs. out-of-hospital (home and freestanding birth center). Study Design Retrospective cohort study using 2007-2010 linked US birth and death records to compare singleton, term, vertex, non-anomalous, live born neonates who delivered by VBAC in or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth setting risk differences. Stratification by parity and history of vaginal birth examined association between birth setting and each outcome. Sensitivity analyses involving three transfer status scenarios were conducted. Results A small proportion of the total number of US women with a history of cesarean (n = 1,138,813) delivered by VBAC (n = 109,970, 9.65%) with a large majority of these delivering in-hospital (n = 106,823, 97.14%). The proportion of home VBAC births increased from 1.78% to 2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures: 23 (0.02%) vs. 6 (0.19%), p <0.001; Apgar score <7: 2859 (2.68%) vs. 139 (4.42%), p <0.001; Apgar score <4: 431 (0.4%) vs. 23 (0.73), p = 0.01). A similar, but non-significant, pattern of increased risk was observed for neonatal death and ventilator support among those born in the out-of-hospital setting. Multivariate regression estimated that neonates born out-of-hospital had higher odds of poor outcomes (neonatal seizures (adjusted odds ratio [aOR] 8.53, 95% confidence interval [CI] 2.87-25.4); Apgar <7 (aOR, 1.62; 95% CI, 1.35-1.96); Apgar <4 (aOR 1.77, CI 1.12-2.79)). While odds of neonatal death (aOR, 2.1; CI 0.73-6.05, p = 0.18) and ventilator support (aOR 1.36, CI 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by VBAC in out-of-hospital settings had higher odds of neonatal morbidity and mortality compared to women of higher parity. Women without a history of vaginal birth prior to out-of-hospital VBAC delivery had higher odds of neonatal morbidity and mortality compared to those with a history of vaginal birth. Sensitivity analyses generated distributions of plausible alternative estimates by outcome Conclusions Fewer than 1 in 10 US women with a prior CD delivered by VBAC in any setting and increasing proportions of these women delivered out-of-hospital. Adverse outcomes were more frequent for neonates born out-of-hospital, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availa...

Trends and state variations in out‐of‐hospital births in the United States, 2004‐2017

“…Many United States hospitals do not allow access to VBAC (18), and women denied a hospital VBAC may ultimately choose to have a VBAC in an out-of-hospital setting (20–23). Improving access to hospital VBACs could possibly reduce the demand for out-of-hospital VBACs.…”

Mode of Delivery Preference Among Pregnant Nulliparous Women

“…Only 10% of women in the United States with a previous cesarean deliver vaginally in subsequent pregnancies. 6 Therefore, the effect of women's mode of delivery at first childbirth is particularly important. However, very little is known about the association between prenatal mode of delivery preference among pregnant nulliparous women in the United States in relation to actual mode of delivery.…”

Analysis of Cesarean Section Indications According to the Robson Classification in Surgical Maternities in Dakar, Senegal: About 9185 Cases

“…However, there is a large body of evidence that shows a satisfactory lower C-section success rate of 60-90% [13,14]. The management of natural birth after C-section appears to be one of the most effective mechanisms for slowing the progression of the overall Csection rate [15]. This should be all the more important since the perinatal outcome with natural birth after Csection is better than with elective Caesarean section in singleton pregnancies [16].…”

“…According to a systematic review by Guise et al, 370 Caesarean sections would be necessary to avoid 1 case of symptomatic uterine rupture and 7142 Caesarean sections would be necessary to avoid 1 foetal death from rupture. Although the risk is low, obstetricians and their patients are less likely to attempt a lower route because they believe that iterative Caesarean section is safer [15]. However, the co-morbidities associated with Caesarean section (thromboembolic complications, infection, etc.)…”