Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth

What is the issue?

When clinicians believe that intervention is needed in a pregnancy, which is the better option for a pregnant woman who has had one or more previous caesarean births - a planned caesarean section (a ‘repeat elective caesarean section’) or planned induction of labour?

Why is this important?

Risks and benefits are known to occur with a repeat elective caesarean section and with planned induction of labour. However, we don’t know whether evidence indicates that we can expect better outcomes with one form of care over the other. Studies done so far have had strong potential for bias, which means that results may not be reliable.

What evidence did we find?

We looked for randomised trials that compared outcomes in mothers and babies when an elective repeat caesarean section was planned and when induction of labour was planned. We found no trials of this type.

What does this mean?

Caregivers and women faced with making a decision about labour and birth after a previous caesarean section cannot be informed by randomised trial evidence. A woman should discuss with her caregivers the benefits and risks of both courses of action. She and her caregivers should come to a shared decision for action that is based on the woman’s wishes and priorities.

Authors' conclusions: 

Both planned elective repeat caesarean section and planned induction of labour for women with a prior caesarean birth are associated with benefits and harms. Evidence for these care practices has been drawn from non-randomised studies, which are associated with potential bias. Therefore, any results and conclusions presented must be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned induction of labour for women with a previous caesarean birth.

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Background: 

When a woman has had a previous caesarean birth and requires induction of labour for a subsequent pregnancy, two options are available for her care: an elective repeat caesarean and planned induction of labour. Although risks and benefits are associated with both elective repeat caesarean birth and planned induction of labour, current sources of information are limited to non-randomised cohort studies, and studies designed in this way have significant potential for bias. Consequently, any conclusions based on results of these studies are limited in their reliability and should be interpreted with caution.

Objectives: 

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section versus a policy of induction of labour for women with a previous caesarean birth who require induction of labour for a subsequent pregnancy. Primary outcomes include success of induction of labour, need for caesarean section, maternal and neonatal mortality, and maternal and neonatal morbidity.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Trials Register (31 May 2017) and planned to search reference lists of retrieved studies.

Selection criteria: 

Randomised controlled trials with reported data on comparison of outcomes in mothers and babies between women who planned an elective repeat caesarean section and women who planned induction of labour when a previous birth was performed by caesarean. Cluster trials and quasi-randomised trials were also eligible for inclusion. We would consider trials published only as abstracts if they provided enough information to meet review inclusion criteria.

Data collection and analysis: 

We performed no data extraction. For future updates, if randomised controlled trials are identified, two review authors will independently assess trials for inclusion and risk of bias, and will extract data and check extracted data for accuracy. Review authors will assess the quality of the evidence using the GRADE approach.

Main results: 

Review authors identified no randomised controlled trials.

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