Middle eastern college of obstetricians and gynecologists (MCOG) practice guidelines: Role of prediction models in management of trial of labor after cesarean section. Practice guideline no. 05-O-22✰,✰✰,★,★★

The rate of Cesarean delivery (CD) has been substantially raising worldwide. In the United States, the incidence of CD increased from 5% to 31.9% between 1970 and 2016 [1,2]. This rising trend has been endorsed by the American College of Obstetricians and Gynecologists (ACOG) [1,2] and the American Academy of Family Physicians (AAFP) [3], which state that one in every three births in the United States are delivered via CD. According to the Society of Obstetricians and Gynecologists in Canada (SOGC) [4], CD rate ranges from 15% to 25% of all births [5], [6], [7], [8], [9], with the rates being relatively stable since the beginning of the century [10]. In Northern Ireland [11], Wales [12], Scotland [13], and England [14], CD rates were 29.8%, 27.5%, 27.3%, and 25.5%, respectively. In France, incidence of CD rose from 15.5% in 1995 to 20.8% in 2015 [15]. In the same time period, prevalence of CD reached 33% in Australia, and 25.5% in New Zealand [16,17].

The dramatic rise in CDs may be attributed to several emerging factors in contemporary practice. Of these factors, wide implementation of continuous electronic fetal monitoring, and regression of operative vaginal deliveries and vaginal breech deliveries may play the foremost part. In addition, women who undergo one CD have 50% chance of a repeat CD in the next pregnancy, after which the probability of CD would approach 100% [2,[18], [19], [20]]. Therefore, one of the most practical approaches to control CD rate is to support trial of labor after cesarean section (TOLAC), which would break the vicious cycle of repeated CDs, and reduce incidence of complications associated with increased number of previous CDs [21], [22], [23], [24], [25].

TOLAC refers to trial of vaginal delivery in women who had a previous CD, and is associated with successful vaginal delivery in 72–74% of cases (vaginal birth after Cesarean; VBAC) [26], [27], [28], [29], [30]. However, risk of intrapartum CD, which is associated with higher risk of perioperative complications compared to planned repeat CD, is approximately 25% of all women undergoing TOLAC [31]. TOLAC is also associated with risk of uterine rupture, which accounts for 1:200 of cases (0.5%). Risks of emergency CD and uterine rupture should be explained antenatally before an informed decision is made, and superiority of elective over emergency CD should be transparently highlighted. On the other side, advantages of successful VBAC over any surgical intervention should also be affirmed [32], [33], [34], [35], [36], [37], [38], [39]. Since counseling on risks of TOLAC could be concerning to most women, decision-making may be challenging, and many women would be discouraged to consider TOLAC. Similarly, risks could be discouraging to private sector, which contributes drastically to medical practice specially in low-resource countries.

Although TOLAC is known to yield successful VBAC in 72–74% on average, the actual success rate may vary between 40 and 90% [7,8,24,[40], [41], [42], [43]]. The probability of success is influenced by several factors that has been variably recognized in the literature, such as previous successful VBAC, indication of previous CD, need for induction of labor, maternal and fetal weight [21,22,44]. Therefore, assessment of individual risks could facilitate patient counseling and decision-making. Likewise, quantifying probability of successful VBAC could facilitate broader implantation of TOALC within equipped facilities. Risk stratification is not universally adopted and there is no single globally accepted model for TOLAC selection or counseling. This guideline aims at appraising evidence beyond application of prediction models and patient selection in management of women considering TOLAC.

Although concerns on CD rates have been raised in several developed countries, the magnitude of the problem may be substantially higher in developing countries. A recent report concluded that CD rate has reached 49 to 67.8% in 6 Egyptian governorates included in the study [45]. Such an extreme rate is unlikely to reflect genuine medical indications and it may, otherwise, indicate widespread incompliance with evidence-based recommendations of labor management, lack of audits and benchmarking, and dominance of unsupervised private practice. Unfortunately, decision of CD is amenable to bias, and can vary according to practice setting. Governmental hospitals typically serve wide population with potential constant overflow, and the decision of CD may be prematurely made to accelerate patient turnover. Women undergoing TOLAC are even less likely to be expectantly managed unless delivery is imminent. For similar reasons, TOLAC may be intentionally avoided in busy facilities that cannot grantee continuous fetal monitoring and one-to-one care due to overflow. Private sector may consider CD over vaginal delivery due to financial privilege per duration of direct obstetric care and flexibility of delivery scheduling.

From patient perspective, lack of effective pain control options in many low-resource hospitals is a major contributor to patient preferences. Specifically, many hospitals do not provide epidural analgesia, nitrous oxide gas, or even opioids. Therefore, many women would opt for CD to minimize anxiety and avoid labor pain. For the same reason, women may decide to undergo CD during labor due to pain intolerance. These challenges would contribute to the high rate of CD as well as the low rates of TOLAC in developing countries. In addition, this would reduce the probability of success of TOLAC even in the presence of favorable factors due to premature decision making. A study conducted in Southwest Ethiopia on TOLAC showed that VBAC rate was 41%, despite the fact that 47.1% of study cohort had prior vaginal deliveries [46].

The development of this guideline was initiated by defining clinical questions and their regional and global magnitude. In this guideline, our objective was to study prediction models that stratify risk in women undergoing TOLAC. A literature search was conducted on the most recent version of internationally recognized guidelines between January 2000 and January 2022. These guidelines were ACOG practice bulletins, Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, SOGC guidelines, Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines, and guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF). The second step was to divide the topic into specific linked research questions, each was assigned to a panel of 2 researchers. these panels commenced reviewing how current guidelines addressed these questions, to determine whether the question was adequately and consistently fulfilled and to what level of evidence. The third step was to conduct systematic review of the literature to retrieve relevant studies including systematic reviews, meta-analyses, clinical trials, and large cohort studies, which addressed these questions. Another literature search was made to review studies originating from the Middle East or alternatively, in other low-resource countries with similar challenges. A search on PUBMED, SCOPUS and Cochrane library was conducted between January 2010 and January 2022, using the following terms: [“trial of labor after cesarean” OR “vaginal birth after cesarean”] AND [“prediction” OR “selection” OR [“success”].

The fourth step was to survey obstetricians based in the Middle East to assess their current practice and constraints against standard practice. Responses were requested from obstetricians practicing at different levels including community-based, private-based, and university-based practice with different years of experience. They will be requested to answer multiple choice questions to key practice points in the topic. The fifth step was to appraise available evidence and consider recommendations that meet the highest level of evidence and fulfill requirements and specifications of low-resource settings.

Level of evidence is classified according to Oxford Centre for Evidence-based Medicine–Levels of Evidence, which stratifies studies depending on their design to level 1 (A to C), level 2 (A to C), level 3 (A and B), level 4, and level 5. Grades of recommendation range from A to D. Level A refers to level 1 studies, level B is consistent with level 2 or 3 studies, level C refers to level 4 studies, while D is consistent with level 5 studies.

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