1. Best practices centred around supportive decisions and ultrasound evaluation of risk significantly reduced perinatal and maternal morbidity.

2. No difference in perinatal or maternal morbidity was seen between groups among patients who underwent elective Caesarean delivery.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Women with a prior cesarean section face the dilemma of choosing between a repeat elective cesarean or attempting vaginal delivery, each associated with potential complications. This randomized controlled trial aimed to evaluate whether a multifaceted intervention, promoting patient-centred decision-making and best practices, could reduce major perinatal morbidity in women with a previous cesarean. Each hospital in the study was randomized to either the intervention or control group. The primary outcome was the composite risk of major perinatal morbidity, while a key secondary outcome was major maternal morbidity. According to study results, the intervention group demonstrated a significant reduction in major perinatal and maternal morbidity without increased rates of cesarean sections. This study was strengthened by cluster sampling which mitigated patient variability and increased the validity of findings.

Click to read the study in The Lancet

Relevant Reading: The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity

In-depth [randomized-controlled trial]: Between Apr 1, 2016, and Dec 13, 2019, 21 281 women were screened for eligibility across 40 hospitals in Quebec. Included were patients with a prior cesarean who faced the challenging decision of planning another cesarean or attempting vaginal delivery. Altogether, 10 514 women in the intervention group and 10 767 women in the control group were included in the final analysis. The primary outcome of major perinatal morbidity showed significant reduction in the intervention group compared to control (adjusted odds ratio [aOR] 0.72, 95% confidence interval [CI] 0.52-0.99, p=0.042). Likewise, the secondary outcome of major maternal morbidity was also significantly reduced in the intervention group (aOR 0.54, 95% CI 0.33-0.89, p=0.016) with comparable adverse events in both groups. Findings from this study suggest that a multifaceted intervention supporting women’s choice of delivery reduces perinatal and maternal morbidity without increasing cesarean or uterine rupture rates.

Image: PD

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