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- Carlsson Fagerberg, Marie
(författare)
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Birth after Caesarean Section
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Birth after caesarean section (CS) is an issue of growing importance. As a consequence of increasing CS rates, more women having experienced a prior CS will need counselling about preferred second delivery mode. There are two choices: elective repeat caesarean section (ERCS) or trial of labour (TOL). It is well known, that a TOL ending in an emergency CS carries the largest risks for mother and child. We wanted to investigate for which women and infants it would be safest to recommend an ERCS or a TOL. We assumed, that underlying conditions/indications for the first CS performed would often recur in the second pregnancy and be important for the second delivery outcome. Therefore, a hierarchical system was developed, in which efforts were made to classify according to underlying conditions instead of focusing on conditions appearing during labour, in an attempt to diminish the subjective impact of diagnoses recorded after delivery. The hierarchical system was used through the four papers. We investigated women in the Swedish medical birth register with their first two deliveries 1987-2007 (Paper I-III), or giving birth at least twice, including one CS and at least one delivery after the CS 1992-2011 (Paper IV). In Papers I-III, we have shown that all first CS indications had a statistically significant risk to recur in the second pregnancy/ delivery. Women with a first CS were older, shorter, and had a higher body mass index than women with a first vaginal delivery. The risk for unplanned CS in TOL increased by the women’s age, body mass index, and smoking, while increasing height lowered the risk. Women with a prior CS had an all-over increased risk for unplanned CS in TOL, compared with primiparous women. Infants born to mothers with one prior CS had an almost doubled risk for low Apgar score and perinatal death compared with infants of women with one prior vaginal birth. The risk was lower but still statistically significant after adjustment for possible maternal and fetal/infant confounders. For infants of women with one previous CS, the risk for low Apgar score was higher after a TOL than after an ERCS. In all studies, the risk for adverse outcomes differed substantially between hierarchical indications for the first CS performed. When the first CS was performed without medical indication, no inreased risk for low Apgar score or perinatal death could be detected. The results suggest that underlying conditions, not the previous CS per se, contributed to the risk increase. In Paper IV, we validated a widely used prediction model for chance of successful TOL after CS, developed by Grobman et al. (2007) for US conditions. As the original model was not directly applicable for Swedish settings, we modified it stepwise. The final, new model included maternal age, body mass index, prior vaginal birth, prior vaginal birth after CS, maternal height, first CS hierarchical indication, and the rates of ERCS and unplanned CS in the respective delivery wards. We reached an excellent predictability for vaginal birth in TOL after CS. Counselling about the safest delivery mode after one CS is a challenge. Our study results, combined with previous findings, add important scientific knowledge. However, non-medical factors are vital in the decision-making after one CS, and a trust between the woman, her partner, the obstetrician and the midwife is fundamental. Considering the new information would possibly make counselling easier and, hopefully, lower the rate of unplanned CS in TOL after CS and decrease the rate of low Apgar score and perinatal death in the birth after a caesarean delivery.
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| 2. |
- Carlsson Fagerberg, Marie, et al.
(författare)
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Indications for first caesarean and delivery mode in subsequent trial of labour.
- 2013
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Ingår i: Paediatric and Perinatal Epidemiology. - : Wiley. - 0269-5022. ; 27:1, s. 72-80
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Tidskriftsartikel (refereegranskat)abstract
- A previous caesarean delivery is no longer an indication per se for a subsequent, planned caesarean. We performed this study to identify women suitable for trial of labour after caesarean (TOLAC), investigating the association between the indication for the first caesarean and the risk of unplanned caesarean in the second pregnancy.
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| 3. |
- Carlsson Fagerberg, Marie, et al.
(författare)
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Neonatal outcome after trial of labor or elective cesarean section in relation to the indication for the previous cesarean delivery.
- 2013
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 1600-0412 .- 0001-6349. ; 92:10, s. 1151-1158
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To compare the neonatal outcome after a trial of labor (TOL) with that after an elective cesarean section (CS) following one previous cesarean delivery, considering the indication for the first CS. DESIGN: Population-based cohort study. SETTING: Sweden. POPULATION: Women with their first two deliveries 1992-2007 registered in the Swedish Medical Birth Registry. METHODS: The risk of low Apgar score (<7 at 5 min) after a TOL was compared with that after an elective CS among 407 159 singletons of women with one previous vaginal delivery and 59 643 singletons of women with one previous CS. The indication for the first delivery CS was estimated using a hierarchical system. For each indication group, the odds ratio and 95% confidence interval for low Apgar score, TOL vs. elective CS, was computed. MAIN OUTCOME MEASURE: Low Apgar score. RESULTS: The overall risk of low Apgar score was increased in the TOL group (adjusted odds ratio 1.8, 95% confidence interval 1.5-2.1), but the estimate differed substantially by the indication for the first CS (p-value for homogeneity=0.0001). There was a high risk for low Apgar score after TOL and first CS indication "complications during labor/delivery" (adjusted odds ratio 2.4, 95% confidence interval 1.7-3.4), but low risk with TOL and first CS "without medical indication" (adjusted odds ratio 0.7, 95% confidence interval 0.2-2.1). CONCLUSION: Neonatal outcome might be improved by considering the indication for the first CS when choosing between an elective CS or a TOL for the second delivery. This article is protected by copyright. All rights reserved.
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| 4. |
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| 5. |
- Carlsson Fagerberg, Marie, et al.
(författare)
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Third-trimester prediction of successful vaginal birth after one cesarean delivery—A Swedish model
- 2020
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 99:5, s. 660-668
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: The objective was to create a clinically useful prediction model for vaginal birth in trial of labor after one cesarean section, appropriate for a third trimester consultation. Material and methods: Women with one cesarean section and at least one following delivery (N = 38 686) in the Swedish Medical Birth Register, 1998-2013, were studied. The women were randomly divided into one development and one validation data set. From the development data set, variables associated with vaginal birth after cesarean (VBAC) were identified by univariable logistic regression. Stepwise backward selection was performed until all variables were statistically significant. From the final fitted multivariable logistic model, likelihood ratios were calculated, in order to transpose odds ratios into clinically useful measurements. A constant, based on the delivery ward VBAC in trial of labor rate, was used. By applying the likelihood ratios on the validation data set, the VBAC chance for each woman was estimated with the Bayesian theorem, and the ability of the model to predict VBAC was explored using receiver operating characteristics (ROC) curves. Results: A previous VBAC, and a previous cesarean section for non-cephalic presentation, were the strongest VBAC predictors. The lowest chances were found for a previous cesarean section due to dystocia, and among women with <18 months since the last cesarean section. The area under the ROC curve was 0.67. Conclusions: The new model was satisfactory in predicting VBAC in trial of labor. Developed as a software application, it would become a clinically useful decision-aid.
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| 6. |
- Lindegren, Lina, et al.
(författare)
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Retrospective study of maternal and neonatal outcomes after induction compared to spontaneous start of labour in women with one previous birth in uncomplicated pregnancies ≥ 41+3
- 2021
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Ingår i: Journal of Perinatal Medicine. - : Walter de Gruyter GmbH. - 0300-5577 .- 1619-3997. ; 49:1, s. 23-29
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Tidskriftsartikel (refereegranskat)abstract
- To study the association between induction and outcome among two-parous women in uncomplicated pregnancies ≥ 41+3, stratified by first labour delivery mode and conditions present at first delivery. The Swedish Medical Birth Register was used to identify 58,964 uncomplicated singleton pregnancies among women with one previous birth between 1998 and 2014. Women with any registered pregnancy complications were excluded to minimise the risk for indication bias. The outcomes considered were emergency caesarean section (CS), and poor neonatal outcome (Apgar score <7 at 5 min, neonatal death, or meconium aspiration). Women who were induced at their second labour had higher emergency CS rates compared to women in spontaneously started deliveries (adjusted risk ratio, ARR: 2.11; 95% CI: 2.00-2.23). Low Apgar score was more common after induction compared to spontaneously started labours (1.0 vs. 0.7%) (ARR: 1.44; 95% CI: 1.18-1.77). Increased CS rates were also found when comparing induction at 41 + 3 to 41 + 6 weeks to labour at 42 weeks or more, regardless of labour start (ARR 1.39; 95% CI: 1.26-1.52). We found an increased risk of CS and poor neonatal outcome after second labour induction in prolonged pregnancies. The second labour vaginal success rate after induction was highly dependent, on first labour delivery mode, but also on diagnoses and conditions present at the first delivery.
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