Internationally agreed strategy is needed on vaginal birth after caesarean
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《英国医生杂志》
EDITOR—The review by Guise et al concurs with other studies in showing that vaginal birth after caesarean section is harmful for fetus and mother, and repeated elective caesarean is not completely protective.1 Systematically interrogating the 160 cases of uterine rupture reported may have not only identified important predictive factors for uterine rupture but also highlighted the heterogeneity in clinical practice that clearly exists. Such differences in case selection and trial abandonment between healthcare providers probably helps to explain the unexpected 10 times greater perinatal mortality found in Scotland2 but not in the mainly US population based review by Guise et al.
The development of quality evidence based guidelines3 4 has been hampered by the absence of prospective clinical trials and reliance on retrospective observational data. Their guidance has focused on ensuring that women are adequately counselled on the reasons and risks and benefits of accepting or declining the trial of vaginal birth after caesarean, but neglected to provide exact information on how labour should be conducted—particularly safe selection, induction and augmentation strategies. This may expose the guidelines to unfavourable critical appraisal and medicolegal challenge.
We therefore believe that prospective data collection through a central coordinating body and internationally agreed strategy should be initiated urgently. This body should have a dual role in reporting international observational data sets, and actively researching preventive strategies by conducting prospective clinical trials. Both these functions require a radical improvement in local or national data collection, standardising terminology (as stated by Guise et al), and willingness to collaborate in multicentre research.
Rajesh Varma, MRC fellow in obstetrics and gynaecology
r.varma@bham.ac.uk Birmingham Women's Hospital, Birmingham B15 2TG
Janesh K Gupta, senior lecturer in obstetrics and gynaecology
j.k.gupta@bham.ac.uk Birmingham Women's Hospital, Birmingham B15 2TG
Competing interests: None declared.
References
Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 2004;329: 19-25.
Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002;287: 2684-90.
ACOG. ACOG Practice Bulletin. Number 54.Vaginal birth after previous cesarean. Obstet.Gynecol. 2004;104: 203-12.
National Institute for Clinical Excellence, Royal College of Obstetricians and Gynaecologists. Caesarean section guideline. London: NICE, 2004. (National Collaborating Centre for Women's and Children's Health Clinical Guideline No 13.) www.nice.org.uk/page.aspx?o=113190 (accessed 21 Jul 2004).
The development of quality evidence based guidelines3 4 has been hampered by the absence of prospective clinical trials and reliance on retrospective observational data. Their guidance has focused on ensuring that women are adequately counselled on the reasons and risks and benefits of accepting or declining the trial of vaginal birth after caesarean, but neglected to provide exact information on how labour should be conducted—particularly safe selection, induction and augmentation strategies. This may expose the guidelines to unfavourable critical appraisal and medicolegal challenge.
We therefore believe that prospective data collection through a central coordinating body and internationally agreed strategy should be initiated urgently. This body should have a dual role in reporting international observational data sets, and actively researching preventive strategies by conducting prospective clinical trials. Both these functions require a radical improvement in local or national data collection, standardising terminology (as stated by Guise et al), and willingness to collaborate in multicentre research.
Rajesh Varma, MRC fellow in obstetrics and gynaecology
r.varma@bham.ac.uk Birmingham Women's Hospital, Birmingham B15 2TG
Janesh K Gupta, senior lecturer in obstetrics and gynaecology
j.k.gupta@bham.ac.uk Birmingham Women's Hospital, Birmingham B15 2TG
Competing interests: None declared.
References
Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 2004;329: 19-25.
Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002;287: 2684-90.
ACOG. ACOG Practice Bulletin. Number 54.Vaginal birth after previous cesarean. Obstet.Gynecol. 2004;104: 203-12.
National Institute for Clinical Excellence, Royal College of Obstetricians and Gynaecologists. Caesarean section guideline. London: NICE, 2004. (National Collaborating Centre for Women's and Children's Health Clinical Guideline No 13.) www.nice.org.uk/page.aspx?o=113190 (accessed 21 Jul 2004).