BACKGROUND To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. METHODS We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). RESULTS Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. CONCLUSIONS This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

中文翻译：

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影响剖腹产后阴道分娩率的临床干预措施：系统评价和荟萃分析。


背景 系统回顾影响剖宫产后阴道分娩 (VBAC) 率的临床干预措施的文献。方法通过EBSCOhost检索Ovid Medline、Ovid Embase、Wiley Cochrane Library、CINAHL；和奥维德 PsycINFO。通过搜索临床试验记录、会议记录和论文确定了其他研究。对语言（英语和法语）和出版年份（1985 年至今）进行了限制。两名评审员根据先验资格标准独立筛选比较研究（随机或非随机对照试验以及观察性设计）：既往剖宫产史的女性；任何旨在增加 VBAC 率的临床干预或暴露；任何比较器；以及报告 VBAC、子宫破裂和子宫裂开率的结果。一名评审员提取数据，另一名评审员验证准确性。使用Mantel-Haenszel（随机效应模型）相对风险（VBAC 率）和风险差异（子宫破裂和开裂）进行荟萃分析。两名评审员使用混合方法评估工具（MMAT）独立进行方法学质量评估。结果 29 项研究（6 项试验和 23 个队列）检查了不同的临床干预措施对既往剖腹产 (CD) 妇女阴道分娩率的影响。试验的方法学质量总体良好；然而，队列研究对选择偏倚、组别可比性和结果测量的担忧导致偏倚风险较高。 无论有或没有宫颈成熟，引产干预措施包括药物干预（催产素、前列腺素、米索前列醇、米非司酮、硬膜外镇痛）、非药物干预（破膜、羊膜切开术、球囊装置）和联合干预（药物和非药物）。大多数比较都是由小样本量和事件发生率的单项研究进行的，各组之间在 VBAC、子宫破裂和子宫裂开的发生率上没有明显差异。结论 这项系统评价评估了旨在提高既往患有 CD 的女性阴道分娩率的临床干预措施，发现宫颈成熟和/或引产技术的证据质量从低到极低。没有足够的高质量证据来指导在先前 CD 后尝试分娩的妇女的最佳临床干预措施。