Evaluation of elective repeat cesarean section as a standard of care: an application of decision analysis

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were $5 million greater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.