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Title of the item:

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery.

Title :
Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery.
Authors :
Luchristt D; Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC. Electronic address: .
Brown O; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Pidaparti M; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Kenton K; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Lewicky-Gaupp C; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
Miller ES; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Source :
American journal of obstetrics and gynecology [Am J Obstet Gynecol] 2021 Aug; Vol. 225 (2), pp. 173.e1-173.e8. Date of Electronic Publication: 2021 Feb 19.
Publication Type :
Journal Article
Language :
English
Imprint Name(s) :
Publication: <2005->: New York : Elsevier
Original Publication: St. Louis.
MeSH Terms :
Vaginal Birth after Cesarean*
Anal Canal/*injuries
Extraction, Obstetrical/*statistics & numerical data
Lacerations/*epidemiology
Obesity, Maternal/*epidemiology
Obstetric Labor Complications/*epidemiology
Tobacco Use/*epidemiology
Adult ; Anesthesia, Epidural/statistics & numerical data ; Decision Making, Shared ; Female ; Humans ; Maternal Age ; Obstetrical Forceps ; Pregnancy ; Reproducibility of Results ; Risk Assessment ; Trial of Labor ; Vacuum Extraction, Obstetrical/statistics & numerical data ; Young Adult
Contributed Indexing :
Keywords: antenatal counseling*; elective repeat cesarean delivery*; obstetrical anal sphincter injuries*; predictive modeling*; trial of labor after cesarean delivery*; vaginal birth after cesarean delivery*
Entry Date(s) :
Date Created: 20210222 Date Completed: 20210910 Latest Revision: 20210910
Update Code :
20210911
DOI :
10.1016/j.ajog.2021.02.014
PMID :
33617798
Academic Journal
Background: Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery.
Objective: This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery.
Study Design: This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016.
Results: In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m 2 ), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz.
Conclusion: Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.
(Copyright © 2021 Elsevier Inc. All rights reserved.)

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