Williams Frank B, Pierce Hayley, McBride Carole A, DeAngelis Justin, McLean Kelley
Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont.
Am J Perinatol. 2023 Apr;40(6):575-581. doi: 10.1055/a-1960-2797. Epub 2022 Oct 13.
Vaginal birth after cesarean can reduce morbidity associated with multiple cesarean deliveries. Failed vaginal birth after cesarean is associated with increased maternal and neonatal morbidity. The Maternal-Fetal Medicine Units Vaginal Birth After Cesarean calculator is a validated tool to predict the likelihood of successful trial of labor after cesarean. Predicted likelihood < 60% has been associated with increased maternal and neonatal morbidity. We sought to determine if formal incorporation of calculated vaginal birth after cesarean likelihood into patient-centered counseling would reduce failed vaginal birth after cesarean.
This is a quality improvement intervention at a single tertiary-care academic medical center, in which standardized patient counseling was implemented, facilitated by an electronic medical record template featuring patient-specific likelihood of vaginal birth after cesarean success. Term singleton pregnancies with history of one to two cesareans were included; those with contraindication to labor were excluded. Historical controls (January 2016-December 2018, = 693) were compared with a postimplementation cohort (January 2019-April 2020, = 328). Primary outcome was failed vaginal birth after cesarean.
Fewer patients in the postintervention cohort had a history of an arrest disorder (PRE: 48%, 330/693 vs. POST: 40%, 130/326, = 0.03); demographics were otherwise similar, including the proportion of patients with <60% likelihood of success (PRE: 39%, 267/693, vs. POST: 38%, 125/326). Following implementation, induction of labor in patients with a <60% likelihood of successful vaginal birth after cesarean decreased from 17% (45/267) to 5% (6/125, < 0.01). The proportion of failed vaginal birth after cesarean decreased from 33% (107/329) to 22% (32/143, = 0.04). Overall vaginal birth after cesarean rate did not change (PRE: 32%, 222/693, vs. POST: 34%, 111/326, = 0.52).
An intervention targeting provider counseling that included a validated vaginal birth after cesarean success likelihood was associated with decreased risk of failed trial of labor after cesarean without affecting overall vaginal birth after cesarean rate.
· Labored cesarean increases maternal morbidity.. · Application of the Maternal-Fetal Medicine Units (MFMU) calculator to antenatal counseling decreased labored cesarean.. · Application of the MFMU calculator to antenatal counseling did not decrease overall vaginal birth after cesarean rate..
剖宫产术后经阴道分娩可降低与多次剖宫产相关的发病率。剖宫产术后经阴道分娩失败与孕产妇和新生儿发病率增加有关。母胎医学协会剖宫产术后经阴道分娩计算器是一种经过验证的工具，用于预测剖宫产术后试产成功的可能性。预测可能性<60%与孕产妇和新生儿发病率增加有关。我们试图确定将计算出的剖宫产术后经阴道分娩可能性正式纳入以患者为中心的咨询中是否会降低剖宫产术后经阴道分娩失败的发生率。
这是一项在单一三级医疗学术医学中心进行的质量改进干预措施，其中实施了标准化的患者咨询，由一个电子病历模板提供便利，该模板具有患者特定的剖宫产术后经阴道分娩成功可能性。纳入有一至两次剖宫产史的足月单胎妊娠；排除有引产禁忌证的患者。将历史对照组（2016年1月至2018年12月，n = 693）与实施后队列（2019年1月至2020年4月，n = 328）进行比较。主要结局是剖宫产术后经阴道分娩失败。
干预后队列中既往有产程停滞病史的患者较少（干预前：48%，330/693；干预后：40%，130/326，P = 0.03）；其他人口统计学特征相似，包括成功可能性<60%的患者比例（干预前：39%，267/693；干预后：38%，125/326）。实施后，剖宫产术后经阴道分娩成功可能性<60%的患者引产率从17%（45/267）降至5%（6/125，P<0.01）。剖宫产术后经阴道分娩失败的比例从33%（107/329）降至22%（32/143，P = 0.04）。总体剖宫产术后经阴道分娩率没有变化（干预前：32%，222/693；干预后：34%，111/326，P = 0.52）。
一项针对医护人员咨询的干预措施，包括经过验证的剖宫产术后经阴道分娩成功可能性，与剖宫产术后试产失败风险降低相关，且不影响总体剖宫产术后经阴道分娩率。
· 剖宫产增加孕产妇发病率。· 将母胎医学协会（MFMU）计算器应用于产前咨询可减少剖宫产。· 将MFMU计算器应用于产前咨询并未降低总体剖宫产术后经阴道分娩率。
