Women who have previously undergone a cesarean section face a challenging decision when considering their mode of delivery for subsequent pregnancies. While planning another cesarean delivery may carry a higher risk of maternal complications, attempting vaginal delivery is associated with increased risks of uterine rupture and perinatal complications. To address this dilemma, the Canadian PRISMA trial implemented an intervention aimed at supporting decision-making for women with prior cesarean sections. The trial aimed to assess whether this multifaceted intervention, which included professional training, decision aid tools, and risk estimation, could reduce maternal and perinatal morbidity.
The results of the PRISMA trial, published in The Lancet, demonstrated that the intervention group experienced a significant reduction in perinatal morbidity compared to the control group. The adjusted odds ratio (OR) for perinatal morbidity in the intervention group was 0.72 (95% CI 0.52-0.99, P=0.042). This finding suggests that providing decision-making support to women with previous cesarean sections can have a positive impact on the health outcomes of newborns.
In addition to reducing perinatal morbidity, the intervention also significantly decreased major maternal morbidity. The adjusted odds ratio for major maternal morbidity in the intervention group was 0.54 (95% CI 0.33-0.89, P=0.016) compared to the control group. This finding highlights the potential benefits of decision-making support in reducing maternal complications associated with vaginal delivery attempts.
An important finding of the PRISMA trial was that the intervention did not lead to an increase in the rate of caesarian delivery or uterine rupture. This is a critical consideration, as the goal of the intervention was not only to reduce morbidity but also to guide women in making informed decisions about the mode of delivery. By providing training, decision aid tools, and risk estimation, the intervention aimed to support a woman’s choice while promoting best practices. The absence of an increase in caesarian delivery or uterine rupture suggests that the intervention successfully balanced the risks associated with different delivery modes.
The PRISMA trial stands out for its combination of various tools within a single multifaceted intervention. This approach supports an informed and risk-stratified approach to identifying higher-risk pregnancies, as noted by an accompanying editorial. By integrating professional training, decision aid tools, and risk estimation, healthcare professionals can better guide women with previous cesarean sections in their decision-making process.
While the PRISMA trial provides valuable insights, it is essential to acknowledge its limitations. The study was conducted in Quebec, Canada, and the baseline demographics may differ from other regions, such as the United States. Factors such as rates of obesity and racial/ethnic diversity were not reported, which could impact the generalizability of the findings. Additionally, the trial was not designed to detect differences across race and ethnicity, limiting our understanding of how these factors may influence decision-making and outcomes.
The PRISMA trial demonstrates that an intervention aimed at supporting decision making can lead to a significant reduction in both perinatal and maternal morbidity in women with previous cesarean sections. This multifaceted approach, encompassing professional training, decision aid tools, and risk estimation, provides valuable guidance for healthcare professionals and women facing the challenging decision of mode of delivery. However, further research is needed to assess the applicability of these findings in different populations and healthcare settings. By empowering women with information and resources, healthcare professionals can improve patient outcomes and promote shared decision-making in obstetric care.