Delivery strategies for women with a previous classic cesarean delivery: A decision analysis

Objective: The purpose of this study was to compare four strategies for treating patients with a previous classic cesarean delivery by medical outcomes and quality-adjusted life years. Study Design: A decision tree was designed that compared four strategies for a hypothetical cohort of 10,000 women with a previous classic cesarean delivery: (1) delivery at 39 weeks of gestation, (2) delivery at 36 weeks of gestation without amniocentesis, (3) amniocentesis at 36 weeks of gestation with delivery if the fetus was mature and antenatal corticosteroids if the fetus was immature, and (4) weekly amniocentesis starting at 36 weeks of gestation with delivery when mature. Results: Strategy 2 provided the greatest maternal quality-adjusted life years. Comparing strategy 1 with strategy 2, it was determined that 27 cesarean deliveries must be performed at 36 weeks of gestation with one associated case of respiratory distress syndrome to prevent one case of uterine rupture. Sensitivity analysis revealed that the uterine rupture rate must be below 0.36% for any strategy to surpass strategy 2 (elective cesarean delivery at 36 weeks of gestation without amniocentesis). Conclusion: A 36-week delivery may be preferable because it provides a lower risk of severe adverse outcomes and higher maternal quality of life. (Am J Obstet Gynecol 2002;187:1203-8.)