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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology. Medical College of Virginia Physicians and Hospitals of the Virginia Commonwealth University Health System. Richmond, Virginia.
Address reprint requests to: Mara J. Dinsmoor, MD, MPH, Department of Obstetrics and Gynecology, Evanston Northwestern Healthcare, 2650 Ridge Avenue; Room 1600WH, Evanston, IL 60201; e-mail: mdinsmoor{at}enh.org.
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ABSTRACT |
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METHODS: Patients with 1 previous cesarean delivery who then delivered between January 1, 1998, and December 31, 1998, were studied. An investigator blinded to outcome assigned scores using 3 different scoring systems. Student t test, 
2, analysis of variance, and receiver operating curve analysis were performed. P < .05 was significant.
RESULTS: Seventy-six percent (117/153) of trial of labor patients had a vaginal birth after cesarean delivery. Successful vaginal birth after cesarean delivery patients had significantly different mean scores using all 3 scoring systems, but none of the systems accurately predicted failed trial of labor resulting in cesarean delivery. Unfavorable scores were associated with high rates of major complications.
CONCLUSIONS: An unfavorable score predicting a high rate of complications and more failed trials of labor may help in counseling patients considering trial of labor. A better system to predict the success or failure of trial of labor is needed.
LEVEL OF EVIDENCE: III
Before beginning the present study in 1999, we identified 3 previously published scoring systems. Troyer and Parisi8 developed a scoring system (range 0–4) based on their analysis of 264 patients undergoing a trial of labor. They found 4 variables that significantly reduced the success rate of VBAC, including previous dysfunctional labor, absence of a previous vaginal delivery, nonreassuring fetal status at admission, and need for labor induction. Ninety-two percent of patients having none of these variables delivered vaginally, whereas only 46% of patients with all 4 variables delivered vaginally. Flamm and Geiger9 analyzed 5,003 patients undergoing a trial of labor, randomly selecting half of the patients to develop the scoring system (range 0–10), and then retrospectively applying the scoring system to the second half. Variables in their scoring system included maternal age, previous vaginal delivery, indication for previous cesarean delivery, and cervical dilation and effacement at admission. They found that 95% of patients with a score of 8–10 successfully delivered vaginally compared with 49% of those who scored 0–2. Finally, Alamia and colleagues (Alamia V, Meyer B, Selioutski O, Vohra N. Can a VBAC scoring system predict uterine rupture in patients attempting a trial of labor? [abstract] Obstet Gynecol 1999;93:64S) published results of using a VBAC scoring system in an attempt to predict uterine rupture during a trial of labor. The scoring system (range 0–10) was devised using 589 patients undergoing a trial of labor over a 2-year time period. Variables included in their scoring system included previous vaginal delivery, indication for previous cesarean delivery, fetal station, cervical dilation and effacement at admission, and the presence of spontaneous labor. In their report, they then evaluated the 9 cases of uterine rupture that occurred during that same period. They found that patients with a uterine rupture were 9 times more likely to have a score of 4 or less. To our knowledge, these scoring systems have not been applied to other patient populations outside the study institutions in either a prospective or retrospective fashion.
Our aim was to apply the different scoring systems to patients in our institution who had undergone a trial of labor after primary cesarean delivery. We sought primarily to validate the scoring system in our population, and to estimate by receiver operating curve analysis if there was a score, for example at which 75% of patients needed a repeat cesarean delivery, at which a trial of labor could be discouraged.
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MATERIALS AND METHODS |
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Maternal hospital charts were reviewed for all potential candidates, at which time data were collected on maternal demographics and characteristics, the indication for the previous cesarean delivery, and the events of labor and delivery. Major complications, as noted in the chart, were recorded, and included the development of intra-amniotic infection or endometritis, uterine dehiscence or rupture, or hemorrhage requiring transfusion.
After chart review and data abstraction, an investigator (ELB) blinded to the ultimate outcome of the pregnancy reviewed each patient’s data. Each patient was then scored using the point systems described by Troyer and Parisi,8 Flamm and Geiger,9 and Alamia and colleagues (Alamia V, et al. Obstet Gynecol 1999;93:64S). This study was reviewed and approved by the Institutional Review Board of the Medical College of Virginia of Virginia Commonwealth University. Subject confidentiality was maintained at all times.
Statistical analysis was performed using SPSS 10 (Chicago, IL) for the personal computer. Data were analyzed using 2 analysis for discrete variables and Student t test and analysis of variance for continuous variables. Receiver operating curve analysis was performed using SAS (Cary, NC). A P value of < .05 was considered significant.
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RESULTS |
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In general, the demographics of the study group were similar to those of the general obstetric population at the Medical College of Virginia, with a large proportion being indigent, a majority (68%) being African American and most (65%) receiving prenatal care in hospital and health department clinics. The most frequent indication for their primary cesarean delivery was active phase arrest (39%), with fetal distress (24%) and malpresentation (20%) also being common indications.
Successful VBAC occurred in 76% of the patients in our study. There were no significant differences between the 2 groups (successful VBAC and failed VBAC) in maternal age, race, site of prenatal care, or insurance status (Table 1
). Compared with those women who ultimately had a repeat cesarean delivery (failed VBAC), we found that those who delivered vaginally weighed less and were more likely to have had a previous vaginal delivery, although neonatal birth weights were not significantly different. Women who delivered vaginally were more likely to have entered into spontaneous labor and had more advanced cervical dilation and effacement and a lower station at the time of admission to labor and delivery. Compared with women who failed their trial of labor, successful VBAC patients also had significantly different mean scores using all 3 scoring systems.
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). Major complications were twice as common in those patients who had a failed VBAC.
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). For example, although there appears to be a "break point" in the Flamm scoring system at a score of 5, 67% of patients with a score of 5 or less still delivered vaginally. Examined individually, all 3 scoring systems were accurate in predicting those women who would ultimately deliver vaginally. Conversely, they were not accurate in predicting those patients who ultimately required repeat cesarean delivery (Table 3).
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). Patients with an unfavorable Troyer/Parisi score of 3 (n = 18) had complicated deliveries in 50% of cases, including 40% of successful VBAC and 63% of failed trial of labor resulting in cesarean delivery. Thirty-seven percent of patients with an unfavorable Flamm score of 5 or less (n = 97), including 32% of patients who delivered vaginally and 47% of those who delivered by repeat cesarean delivery, had major complications. Those patients who had an unfavorable Alamia score of 4 or less (n = 89) had complications in 35% overall, including 31% of patients who delivered vaginally and 43% of those who delivered by repeat cesarean delivery. In 2 of the 3 scoring systems, the rate of major complications was significantly higher in patients with "unfavorable" scores than in those with "favorable" scores.
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DISCUSSION |
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Our data also confirm the findings of a meta-analysis performed by Rosen and colleagues,2 who reported an increase in febrile morbidity, uterine dehiscence, and low 5-minute Apgar score in patients with a failed trial of labor compared with those with an elective repeat cesarean delivery. Although we did not record neonatal outcome in this study, we also found an increase in febrile morbidity and uterine rupture in the failed trial of labor group. Despite the increase in complications and hospital stay after a failed trial, Traynor and Peaceman6 have reported that hospital charges are higher after elective repeat cesarean delivery compared with trial of labor. Similarly, Grobman and colleagues11 have reported that a trial of labor appears to be more cost-effective than elective cesarean delivery. To optimize patient safety and optimize maternal and fetal outcomes, better systems to predict the success or failure of a vaginal trial of labor are still needed.
Limitations of this study include the fact that the scoring systems are being applied in a retrospective fashion, using data abstracted from charts. One of the scoring systems used was in fact designed to predict uterine rupture rather than success or failure of a trial of labor (Alamia V, et al. Obstet Gynecol 1999;93:64S). In some cases, the indication for the previous cesarean delivery could not be verified, and in a small number of cases, review of the contemporary labor record and/or operative note revealed a different indication than what was cited in the subsequent pregnancy. There is some inherent subjectivity in assigning scores that might be reduced if a single examiner in a prospective fashion did all exams and evaluations.
An ideal scoring system would allow patients to be evaluated and counseled at 37–39 weeks, before the onset of labor. Those women who are very likely to need a repeat cesarean delivery would be scheduled for such, whereas the practitioner and patient would await spontaneous labor in those patients who were more likely to deliver vaginally.
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Footnotes |
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Received July 8, 2003. Received in revised form November 3, 2003. Accepted November 11, 2003.
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REFERENCES |
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2. Rosen MG, Dickinson JC, Westhoff CL. Vaginal birth after cesarean: a meta-analysis of morbidity and mortality. Obstet Gynecol 1991;77:465–70.
3. Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study. Obstet Gynecol 1994;83:927–32.[Medline]
4. Hoskins IA, Gomez JL. Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery. Obstet Gynecol 1997;89:591–3.[Abstract]
5. Demianczuk NN, Hunter DJ, Taylor DW. Trial of labor after previous cesarean section: Prognostic indicators of outcome. Am J Obstet Gynecol 1982;142:640–2.[Medline]
6. Traynor JD, Peaceman AM. Maternal hospital charges associated with trial of labor versus elective repeat cesarean section. Birth 1998;25:81–4.[Medline]
7. Stone J, Lockwood CJ, Berkowitz GS, Lynch L, Alvarez M, Lapinski RH, et al. Morbidity of failed labor in patients with prior cesarean section. Am J Obstet Gynecol 1992; 167:1513–7.[Medline]
8. Troyer LR, Parisi VM. Obstetric parameters affecting success in a trial of labor: Designation of a scoring system. Am J Obstet Gynecol 1992;167:1099–104.[Medline]
9. Flamm B, Geiger AM. Vaginal birth after cesarean delivery: An admission scoring system. Obstet Gynecol 1997; 90:907–10.[Abstract]
10. Macones GA. The utility of clinical tests of eligibility for a trial of labour following a caesarean section: a decision analysis. Br J Obstet Gynaecol 1999;106:642–6.[Medline]
11. Grobman WA, Peaceman AM, Socol ML. Cost-effectiveness of elective cesarean delivery after one prior low transverse cesarean. Obstet Gynecol 2000;95:745–51.
This article has been cited by other articles:
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  Other articles noted Evid. Based Med., September 1, 2004; 9(5): e5 - e5. [Full Text] [PDF]
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