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Guise JM, Eden K, Emeis C, et al. Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Mar. (Evidence Reports/Technology Assessments, No. 191.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Vaginal Birth After Cesarean: New Insights.

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Appendix JStrength of Evidence Table

Domains pertaining to strength of evidenceMagnitude of effectStrength of Evidence
# of Studies; # of SubjectsRisk of Bias (Design/Quality)ConsistencyDirectnessPrecisionVaginal Birth After Cesarean RateLow, Moderate, High
Vaginal Birth After Cesarean Rate
67
368,304
Medium
16 cohort (Good Quality);
51 cohort (Fair Quality)
InconsistentDirect for delivery outcomePrecise74% (95% CI: 72% to 75%)Moderate
# of Studies; # of SubjectsRisk of Bias (Design/Quality)ConsistencyDirectnessPrecisionProportion of Induced Trials of LaborLow, Moderate, High
Any Induction Method in Trial of Labor: Proportion with Vaginal Birth After Cesarean
28
11,938
Medium
1 RCT, 19 cohort, 9 case series (Fair Quality)
ConsistentDirectPrecise63% (95% CI: 59% to 67%)Moderate
Prostaglandin E2 Induction in Trial of Labor: Proportion with Vaginal Birth After Cesarean
5
1671
Medium
11 case series, 4 cohort (Fair Quality)
InconsistentDirectPrecise63% (95% CI: 58% to 69%)Moderate
Misoprostol Induction in TOL: Proportion with Vaginal Birth After Cesarean
2
96
Medium Cohort, (Fair Quality)InconsistentDirectImprecise61% (95% CI: 27% to 90%)Low
Oxytocin Induction in Trial of Labor: Proportion with Vaginal Birth After Cesarean
5
308
Low
2 cohort, 3 case series (Fair Quality)
InconsistentDirectImprecise62% (95% CI: 53% to 70%)Low
Oxytocin Augmentation in Trial of Labor: Proportion with Vaginal Birth After Cesarean
7
660*
Medium
5 cohort, 2 case series (Fair Quality)
InconsistentDirectImprecise68% (95% CI: 64% to 72%)Low
Oxytocin verses Prostaglandin E2 Induction in Trial of Labor: Proportion with Vaginal Birth After Cesarean
2
3301
1 RCT (Poor Quality)
1 cohort (Fair Quality)
InconsistentIndirectImpreciseNot applicableLow
Mechanical Induction in Trial of Labor: Proportion with Vaginal Birth After Cesarean
Foley Catheter
2
416
2 cohort (Fair Quality)ConsistentDirectImprecise54% (95% CI: 49% to 59%)Moderate
# of Studies; # of SubjectsRisk of Bias (Design/Quality)ConsistencyDirectnessPrecisionTrial of Labor versus Elective Repeat Cesarean DeliveryLow, Moderate, High
Maternal Mortality
14
405,827
Medium 13 cohort (2 Good, 11 Fair Quality); 1 case control (Fair Quality)ConsistentDirectPreciseTOL: 3.8/100,000 (95% CI: 0.9/100,000 to 15.5/100,000)
ERCD: 13.4/100,000 (95% CI: 4.3/100,000 to 41.6/100,000)
High
Maternal Outcomes: Uterine Rupture Rate
8
63,499
Medium 4 prospective cohort; 4 retrospective cohort (4 include both TOL and ERCD)ConsistentDirectPreciseOverall: 3% (95% CI: 0.2% to 0.4%)
TOL: 0.47% (95% CI: 0.28% to 0.68%)
ERCD: 0.04% (95% CI: 0.018% to 0.11%)
Moderate
# of Studies; # of SubjectsRisk of Bias (Design/Quality)ConsistencyDirectnessPrecisionProportion of Induced Trials of LaborLow, Moderate, High
Any Induction Method in Trial of Labor: Uterine Rupture
7
5296
Medium 5 cohort, 2 case series (Fair Quality)InconsistentDirectImprecise1.2% (95% CI: 0.7% to 1.9%)Low
Prostaglandin E2 Induction in Trial of Labor: Uterine Rupture
126 cohort (5 Fair, 1 Good Quality)
6 case series (Fair Quality)
InconsistentDirectImprecise2% (95% CI: 1.1% to 3.5%)Low
Misoprostol Induction in Trial of Labor: Uterine Rupture
1
226
Cohort (Fair Quality)NADirectImprecise13%Low
Oxytocin Induction in Trial of Labor: Uterine Rupture
9
5713
Medium 1 case control, 5 cohort, 3 case series (Fair Quality)InconsistentDirectPrecise1.1% (95% CI: 0.9% to 1.5%)Moderate
Oxytocin Augmentation in Trial of Labor: Uterine Rupture
Insufficient data to assess
Oxytocin verses Prostaglandin E2 Induction in Trial of Labor: Uterine Rupture
1
3035
Medium 1 cohort (Fair Quality)NADirectImpreciseIncreased risk found in oxytocin groupsLow
Mechanical Induction in Trial of Labor: Uterine Rupture
Insufficient data to assess
Any Induction method in Trial of Labor: Other Harms
Insufficient data to assess
Prostaglandin E2 Induction in Trial of Labor: Other Harms
Insufficient data to assess
Misoprostol Induction in Trial of Labor: Other Harms
Insufficient data to assess
Oxytocin Induction in Trial of Labor: Other Harms
Insufficient data to assess
Oxytocin Augmentation in Trial of Labor: Other Harms
Insufficient data to assess
Oxytocin verses Prostaglandin E2 Induction in Trial of Labor: Other Harms
Insufficient data to assess
Mechanical Induction in Trial of Labor: Other Harms
Insufficient data to assess
# of Studies; # of SubjectsRisk of Bias (Design/Quality)ConsistencyDirectnessPrecisionTrial of Labor versus Elective Repeat Cesarean DeliveryLow, Moderate, High
Maternal Outcomes: Hysterectomy
16
402,059
Medium 14 cohort (4 Good, 10 Fair Quality); 1 case control (Good Quality)InconsistentDirectPreciseOverall: 0.537/1,000 (95% CI: −1.49/1,000 to 0.419/1,000)
TOL: 1.73/1,000 (95% CI: 0.115/1,000 to 2.42/1,000)
ERCD: 3.1/1,000 (95% CI: 0.172/1,000 to 4.88/1,000)
Moderate
Maternal Outcomes: Transfusion
10
409,382
Medium 10 cohort (4 Good, 6 Fair Quality)ConsistentDirectPreciseOverall: −0.818/1,000 (95% CI: −0.339/1,000 to 1.76/1,000)
TOL: 8.81/1,000 (95% CI: 4.2/1,000 to 15.1/1,000)
ERCD:11.6/1,000 (95% CI: 6.39/1,000 to 18.3/1,000)
Moderate
Maternal Outcomes: Blood Loss/Hemorrhage
7
47,754
High 7 cohort (1 Good, 6 Fair Quality)InconsistentIndirectImpreciseGeneral trend toward increased blood loss with ERCD and RCD after a TOL when reportedLow
Maternal Outcomes: Effect of Induction on Hemorrhage
Insufficient data to assess
Maternal Outcomes: Infection, All Definitions
22
354,060
High 20 cohort (5 Good, 15 Fair Quality); 2 case control (Fair Quality)InconsistentIndirectImpreciseOverall: 0.93% (95% CI: 0.068% to 1.8%)
TOL: 6.3% (95% CI: 3.4% to 10.1%)
ERCD: 3.9% (95% CI: 2.3% to 5.8%)
Low
Maternal Outcomes: Fever
12;26,679High 1 cohort (1 Good, 11 Fair Quality)InconsistentDirectImpreciseOverall: −5.4% (95% CI: −9.9% to −0.80%)
TOL: 6.6% (95% CI: 4.4% to 9.3%)
ERCD: 10.2% (95% CI: 4.9% to 17.1%)
Low
Long Term Maternal Outcomes: Adhesions
Insufficient data to assess
Long Term Maternal Outcomes: Pelvic Pain
Insufficient data to assess
Long Term Maternal Outcomes: Reproductive Health
Insufficient data to assess
Infant Outcomes: Perinatal Mortality (infant death occurring ≥20 weeks-28 days life)
5
76,899
Medium 4 cohort (3 Good, 1 Fair Quality)ConsistentIndirectImpreciseTOL: 0.00133 (95% CI: 0.00059 to 0.00034)
ERCD: 0.00050 (95% CI: 0.00007 to 0.00382)
Moderate
Infant Outcomes: Fetal Mortality (infant death occurring ≥20 weeks gestation, but prior to birth)
2
63,646
Medium 2 cohort (Good Quality, 1with AP/IP deaths; 1 IP only)ConsistentIndirectImpreciseTOL (overall): 39/30,834 (1.3/1000)
ERCD (overall): 23/32,806 (0.7/1000)
Low (2 cohort studies)
Infant Outcomes: Neonatal Mortality (infant death occurring after birth but ≤ 28 days of life)
6
108,328
Medium 6 cohorts (3 Fair, 3 Good Quality)ConsistentIndirectImpreciseTOL: 0.00114 (95% CI: 0.00063 to 0.00204)
ERCD: 0.00055 (95% CI: 0.00020 to 0.00150)
Moderate
Term Infant Outcomes: Transient Tachypnea of the Newborn
3
4,927
Medium 3 cohort (Fair Quality)InconsistentDirectImpreciseTOL: 36.1/1,000
ERCD: 42/1,000
Low
Term Infant Outcomes: Neonatal Respiratory Morbidity with Bag & Mask Ventilation
3
2,110
Medium 3 cohort (Fair Quality)InconsistentDirectImpreciseTOL: 53.7/1000
ERCD: 25/1000
Low
Term Infant Outcomes: Neonatal Respiratory Morbidity with Intubation for Meconium
2
1438
Medium 2 cohort (Fair Quality)ConsistentDirectPreciseTOL: 11.5%
ERCD: 1.5%
Moderate
Term Infant Outcomes: Hypoxic Ischemic Encephalopathy and Asphyxia
3
62,829
High (definition issues) 3 cohort (Fair Quality)InconsistentLowImpreciseCannot calculate summary estimateLow
Term Infant Outcomes: Neonatal Intensive Care Unit Admissions
*8
65,121
Medium 8 cohort (2 Good, 6 Fair Quality)InconsistentIndirectImpreciseCannot calculate summary estimateLow
Term Infant Outcomes: Short and Long Term Neurologic Outcomes
Insufficient data to assess
Term Infant Outcomes: Confirmed Sepsis
Insufficient data to assessHigh (definition issues)
3 cohort (Fair Quality)
InconsistentIndirectImpreciseCannot calculate summary estimateLow
Term Infant Outcomes: Trauma
2
41,899
High (definition issues)
2 cohort (Fair Quality)
InconsistentIndirectImpreciseCannot calculate summary estimateInsufficient
Term Infant Outcomes: Breastfeeding
Insufficient data to assess
*

1 case series included 628 women with induced labor, number with augmentation not reported

Abbreviations: AP=antepartum; CI=confidence interval; ERCD=elective repeat cesarean delivery; IP=intrapartum; RCD=repeat cesarean delivery; TOL=trial of labor

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