Vaginal delivery following previous cesarean birth

Trial of Labor after Three or More Previous Cesarean Sections: Systematic Review and Meta-Analysis of Observational Studies

Aims To assess the success rate and prevalence of maternal or neonatal complications in women undergoing a trial of labor after three or more (≥3) previous cesarean sections (CSs).

Methods A systematic literature review and meta-analysis was conducted from inception to May 2022 in Medline, Scopus, ENBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials and Reviews. Items detailing success rate and complications in women with a history of≥3 previous CSs were considered. Selected articles were evaluated for quality, heterogeneity, and publication bias. A pooled prevalence or odds ratio was calculated.

Findings Twelve articles were included for a total of 540 women with a history of≥3 CSs, accounting for the 2% (CI 95% 1–4%) of the whole cohort of trial of labor. Our findings show a 0.67 (CI 95% 0.53–0.78) rate of successful vaginal delivery. A higher success rate was observed in women having a history of a prior vaginal delivery (0.90, CI 95% 0.77–0.96) and when prostaglandins, peridural anesthesia or oxytocin were allowed (respectively 0.73, CI 95% 0.62–0.83, 0,73, CI 95% 0.57–0.85 and 0.73, CI 95% 0.64–0.81). Uterine rupture rate was 0.01 (CI 95% 0.00–0.01). No cases of fetal asphyxia or maternal or neonatal death were registered.

Conclusions The success rate and low frequency of severe complications observed seem to support a trial of labor in selected patients desiring a natural birth. However, a potential underestimation of serious maternal and neonatal complications should be considered in the decision-making process.

Decision making for primary cesarean delivery: the role of patient and provider preferences

Primary cesarean delivery requires both the clinical assessment and judgment of the provider performing the procedure and the consent of the patient. The interaction between patient and provider and the relative weight and influence of patient preferences and provider recommendations may vary depending on whether a cesarean delivery is planned or unplanned, elective or indicated; understanding the range of contexts in which decision making takes place and the interplay of patient and provider factors in each of these situations is crucial to identifying ways to impact the cesarean rate that are safe and acceptable to both patients and providers. We conducted a review of the literature on patient and provider preferences and obstetrical decision making in the context of primary cesarean delivery, and offer recommendations for future research directions, including potential interventions that may impact the patient and provider factors affecting the primary cesarean rate.

Understanding risk, patient and provider preferences, and obstetrical decision making: approach to delivery after cesarean

Decision making regarding approach to delivery after cesarean is complex and requires consideration of the probabilities of clinical outcomes and the preferences of pregnant women. Depending on the clinical situation, a range of management options may be appropriate, and understanding women's beliefs and values regarding the process and outcomes of obstetrical interventions, as well as providing them with clear information regarding risk, is a necessary part of providing evidence-based, patient-centered care. We conducted a review of the literature on risk communication, patient and provider preferences, and obstetrical decision-making and offer recommendations on how to incorporate patient preferences in the context of delivery after cesarean.

Vaginal birth after cesarean delivery

By 2004, only 9.2% of women in the United States with prior cesareans underwent a term of labor (TOL), although nearly two thirds of these women are actually candidates for a TOL. In this article, the author notes that the principal risk associated with vaginal birth after cesarean delivery (VBAC)-TOL is uterine rupture, which can lead to perinatal death, fetal hypoxic brain injury, and hysterectomy. Risk factors for uterine rupture include number of prior cesareans, prior vaginal delivery, interdelivery interval, and uterine closure technique. The author concludes by noting that a pregnant woman with prior cesarean delivery is at risk for maternal and perinatal complications, whether undergoing TOL or choosing elective repeat operation. Complications of both procedures should be discussed and an attempt made to individualize the risk for uterine rupture and the likelihood of successful VBAC.

General obstetrics: Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes

OBJECTIVE

To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section.

DESIGN

Decision model.

POPULATION

Women with one prior low transverse caesarean section who are eligible for trial of labour.

METHODS

Two decision models were built: the first one applying to women planning only one more pregnancy, the second one applying to women planning two more pregnancies. Probability estimates for VBAC success rate and risks of uterine rupture, placenta praevia, placenta accreta and hysterectomy were extracted from the available literature.

MAIN OUTCOME MEASURES

Hysterectomy for uterine rupture, placenta accreta or other indications.

RESULTS

In the first model VBAC attempt led to a higher hysterectomy rate (267/100,000) compared with repeat caesarean section (187/100,000). However, in the second model a policy of elective repeat caesarean section led to higher cumulative hysterectomy rate: 1465/100,000 versus 907/100,000 for VBAC. The first model was robust to all but one variable in sensitivity analyses. The second model was robust to all variables in sensitivity analyses.

CONCLUSIONS

These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC.

Maternal complications with vaginal birth after cesarean delivery: a multicenter study

OBJECTIVE

This study was undertaken to determine incidence and risk factors for uterine rupture in women attempting vaginal birth after cesarean delivery (VBAC) in a wide range of hospital settings.

STUDY DESIGN

We performed a case-control study nested within a cohort of women who have had a prior cesarean to determine the incidence and risk factors for uterine rupture in women attempting VBAC.

RESULTS

The incidence rate of uterine rupture in those who attempt VBAC was 9.8 per 1000. A prior vaginal delivery was associated with a lower risk of uterine rupture (adjusted odds ratio [OR] = 0.40, 95% CI 0.20-0.81). Although prostaglandins alone were not associated with uterine rupture, sequential use of prostaglandin and pitocin was associated with uterine rupture (adjusted OR = 3.07, 95% CI 0.98-9.88).

CONCLUSION

Women with a prior cesarean should be offered VBAC, and women with a prior cesarean and prior vaginal delivery should be encouraged to VBAC. Although other studies have suggested that prostaglandins should be avoided, we suggest that inductions requiring sequential agents be avoided.

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE

This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery.

STUDY DESIGN

We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons.

RESULTS

The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37).

CONCLUSION

The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.

Evidence-based vaginal birth after Caesarean section

Caesarean section rates are rising globally. Whether vaginal birth after Caesarean (VBAC) is safe and under what circumstances is increasingly important. This chapter reviews the literature about the risks of VBAC, patient and management factors that may alter risk, and discusses ongoing research as well as suggestions for improving future research.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

BACKGROUND

When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004).

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

There were no randomised controlled trials identified.

REVIEWERS' CONCLUSIONS

Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section

OBJECTIVE

To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section.

DESIGN

Systematic review.

DATA SOURCES

Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full.

REVIEW METHODS

Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic.

RESULTS

We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10,000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly.

CONCLUSIONS

Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.

Safety of vaginal birth after cesarean: a systematic review

OBJECTIVE

To evaluate the benefits and harms of vaginal birth after cesarean compared with repeat cesarean delivery.

DATA SOURCES

The computerized databases MEDLINE, EMBASE, HealthSTAR, Cochrane CENTRAL, and National Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effectiveness, along with reference lists and national experts, were used to conduct this review.

METHODS OF STUDY SELECTION

All studies that reported data for maternal or infant outcomes in women with prior cesarean delivery were eligible. Methodological quality was evaluated for each study with the criteria of the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Twenty of 6,828 potentially relevant articles (55,506 patients) were included in the analysis.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently abstracted information on study design, sample size, participant characteristics, and maternal and fetal health outcomes by using a standardized protocol. Rates of vaginal delivery in women undergoing a trial of labor ranged from 60% to 82%. There was no significant difference in maternal deaths or hysterectomy between trial of labor and repeat cesarean. Uterine rupture was more common in the trial-of-labor group, but rates of asymptomatic uterine dehiscence did not differ. Studies conflicted on the effect of induction of labor on these outcomes. Data regarding infant outcomes were poor.

CONCLUSION

Safety in childbirth for women with prior cesarean is a major public health concern. Methodological deficiencies in the literature evaluating the relative safety of vaginal birth after cesarean compared with repeat cesarean delivery are striking. The identification of high-risk and low-risk groups of women and settings for morbidity remains a key research priority.

Childbirth preferences after cesarean birth: a review of the evidence

BACKGROUND

Conflicting evidence on maternal and fetal safety of vaginal and cesarean childbirth after a previous cesarean makes patients and practitioners uncertain about pursuing a trial of labor or an elective repeat cesarean delivery. This review systematically evaluated and summarized the evidence related to women's preference for delivery.

METHODS

The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthSTAR, PsycINFO, and CINAHL databases were searched from 1980 to August 2002. We reviewed controlled trials, case-control studies, and observational studies that contained original patient data on preference for women with a previous cesarean delivery and that were of "good" or "fair" quality.

RESULTS

Women with a previous vaginal delivery were more likely to select trial of labor than women who did not have one. The most commonly cited reason for selecting trial of labor was ease of recovery and desire to return quickly to caring for other children (reported in 6 of 7 studies). Safety for the mother and/or infant was cited as an important reason for delivery choice in 4 of 11 studies. Important ethnic differences were reported. Nonwhite women were more likely to identify their provider as an important influence (39% vs 19%), and perceived labor as something to be avoided if another option resulted in a healthy baby compared with white women, who perceived labor as a challenge and an experience not to be missed.

CONCLUSIONS

A woman's choice for delivery was often based on family obligations, such as the need for a shorter recovery so that she could care for her infant and children at home, rather than the safety of herself or her infant. It remains unclear if education on vaginal birth after cesarean increases the proportion of women who choose trial of labor. Future studies should evaluate the impact of education and timing of education on patient preference.

Management of vaginal birth after cesarean

OBJECTIVE

To raise the success rate of vaginal birth after cesarean (VBAC) without increasing maternal or perinatal morbidity and mortality rates.

METHODS

Of 468 women with a prior scar, 365 gave valid informed consent for our management of VBAC at Akashi Municipal Hospital during 1986-1999. Trials of labor (TOL) were attempted in 322 cases principally by waiting for spontaneous labor onset and teaching the patients a breathing method to avoid straining until expulsion by vacuum extraction become possible, controlling the intrauterine pressure. Our selection criteria for TOL changed during the trial; from 1991-1999 patients with a prior scar extending into fundus were excluded.

RESULTS

Of the 322 TOL, 88.2% were successful, and VBAC was successful in 77.8% (284 of the 365 patients). Uterine rupture was observed in 2 cases (0.62%). Fetal death occurred in 1 case. Three women gave birth to neonates with a 1-minute Apgar score < or = 6.

CONCLUSION

The rate of VBAC was 77.8% in all women with a prior scar. During our management of VBAC, maternal or perinatal morbidity and mortality rates did not increase significantly.

Risk factors for uterine rupture during a trial of labor after cesarean

The rate of vaginal birth among women with a previous cesarean increased from 18.9% in 1989 to 28.3% in 1996. By 1998, the rate had decreased to 26.3% and preliminary data from 1999 suggest that the rate for that year would be even lower (23.4%). It is not known whether that decrease represents a trend related to increasing concern by providers and women about the risk of uterine rupture. Whereas the overall risk of rupture is 1%, our review demonstrates that there is considerable variation of that risk. More than one previous scar, induction of labor, a short interdelivery interval, or a history of postpartum fever during a previous cesarean may increase the risk of a uterine rupture during a trial of labor. However, there does not appear to be an increase in risk associated with low-vertical scars, and a previous vaginal delivery may be somewhat protective. Further delineation of the factors that increase the risk of uterine rupture will permit better prediction of individualized risk and identification of women for whom attempting a vaginal delivery after cesarean represents a safe option.

The utility of clinical tests of eligibility for a trial of labour following a caesarean section: a decision analysis

OBJECTIVE

There is evidence to suggest that women who have a failed trial of labour following caesarean section are at the highest risk of major morbid events, compared with those who have a successful trial of labour or elective repeat caesarean section. Attempts are being made to predict, either by radiological or ultrasonic measurements or clinical factors, who should attempt a trial of labour after a prior caesarean section and who should not, in the hopes of reducing the number of failed trials of labour with their associated morbidity. The goal of this study was to determine the necessary sensitivity and specificity for such a test to be clinically useful in this setting.

METHODS

A decision analytic approach was used which compared two strategies for treating women with a prior caesarean section: trial of labour for all or application of a hypothetical test, the results of which would determine whether a woman would be offered a trial of labour. It was assumed that the goal of the strategies was to minimise the number of major maternal morbid events (hysterectomy, uterine rupture, operative injury) with an acceptable caesarean section rate. Probability estimates for these outcomes were obtained from the existing literature. We evaluated several combinations of sensitivity and specificity to determine the impact of these characteristics on the number of major complications and the number of caesarean sections, compared with the strategy of trial of labour for all women. The results are reported per 1000 women with a previous caesarean section.

RESULTS

Under baseline assumptions, a clinical test for determining eligibility for a trial of labour must have both a sensitivity and specificity in excess of 75% to obtain a reasonable trade-off between reduction in morbidity and the total rate of caesarean sections. In women with a low empiric likelihood of a successful trial of labour, tests with lesser degrees of both sensitivity and specificity are reasonable. In women with a high empiric likelihood of a successful trial of labour, much higher sensitivities and specificities are required.

CONCLUSIONS

In developing tests to determine to whom to offer a trial of labour, investigators and clinicians must realise that in most cases, a highly sensitive and specific test is needed, although this is dependent on the empiric likelihood of the success of a trial of labour.

The case for trial of labor in the patient with a prior low-segment vertical cesarean incision

OBJECTIVE

Our purpose was to review recent obstetric literature detailing the subsequent delivery experience of patients with a prior low-segment vertical cesarean incision and to derive recommendations for practice on the basis of this information.

STUDY DESIGN

Ten studies that included information about pregnancy outcome in patients with prior low-segment vertical cesarean operations were retrieved and reviewed from the American obstetric literature since 1981 and from a review of all abstracts presented annually since 1981 to the Society of Perinatal Obstetricians.

RESULTS

Altogether, information about subsequent pregnancy outcome for 382 patients with prior low-segment vertical cesarean delivery was available for analysis. Among the 372 patients with complete patient population information, vaginal delivery was safely accomplished in 306 (82%). Four uterine ruptures (1.05%) have been reported, only one of which occurred after a single prior unextended low-segment vertical cesarean incision. Two ruptures occurred elsewhere on the lateral or posterior aspect of the uterus in subsequent pregnancies, and the fourth rupture occurred at the juncture of prior low vertical and transverse incisions. No perinatal mortality or permanent perinatal morbidity was encountered with these pregnancies.

CONCLUSIONS

In the otherwise uncomplicated pregnancy the patient with one previous nonextended low-segment vertical cesarean incision should be considered to have a prior low-segment scar and as such be a candidate for trial of labor in her current singleton pregnancy. The same care, counseling, and caution should be exercised for this patient as for one with a prior low-segment transverse incision.

Maternal urological injuries associated with vaginal deliveries: change of pattern

Injury to the maternal lower urinary tract is related to the standard of obstetric care and to different techniques utilized in delivery. In comparison with operative delivery, maternal urinary tract injury in association with vaginal delivery had always been exceptionally rare. However, with the recent progress in obstetric care and the introduction of new concepts such as vaginal delivery after caesarian section (VDAC), the pattern of maternal urological injuries associated with vaginal deliveries might have changed. In a retrospective study it was found that significant injuries to the lower urinary tract occurred in seven females in the course of vaginal delivery in the period between 1992 and 1994 in two major hospitals in the Riyadh area. These included rupture of the posterior bladder wall, trigone and bladder neck. Distal ureteric and urethral injuries, as well as bladder contusion were also encountered. Two patients developed vesico-uterine and vesico-vaginal fistulas. History of previous caesarian section was present in 4 patients. All deliveries were with cephalic presentation and six patients received oxytocin for induction or acceleration of labour. Episiotomy was done in 6 patients and instrumental delivery was performed in 3 patients. Gross haematuria immediately after delivery was the most common presentation, followed by urinary incontinence. Flank pain and fever were associated with ureteric injury and were delayed for few days. Urological injury should be suspected after vaginal delivery in females with previous caesarian section, if instrumental delivery is applied, and in patients with deep vaginal tears. The presence of gross haematuria, incontinence and flank pain should indicate full urological evaluation.

Vaginal birth after cesarean section in twin gestation

OBJECTIVE

We report a 10-year experience with vaginal birth after cesarean section in women with twins.

STUDY DESIGN

Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences.

RESULTS

Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality.

CONCLUSIONS

In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.

Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE

Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section.

STUDY DESIGN

A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated.

RESULTS

Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted.

CONCLUSION

A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.

Pregnancy following rupture of the pregnant uterus

OBJECTIVE

To review the cases of ruptured uterus at King Khalid University Hospital (KKUH) over the 11 years of the hospital's existence (1984-1994), to analyze the causative factors of uterine rupture with a view to its prevention, and to highlight the management approach in relation to maintaining the patients' future fertility.

METHODS

Case notes were reviewed for all patients with ruptured uterus at KKUH over a period of 11 years from January 1984 to December 1994. Relevant data relating to the clinical features, characteristics of labor, operative procedures, and maternal and perinatal outcome were assessed.

RESULTS

There were 11 cases of ruptured uterus, six of which occurred in patients with previous cesarean scars. Two patients were primigravidas, one of whom ruptured her uterus following a road traffic accident. In one patient with six previous preterm labors, rupture resulted from non-removal of cervical cerclage during labor. The rupture occurred in the fundus in one case, and in the lower segment in the remaining 10. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in three cases, two of which were total and the third subtotal. The remaining eight patients had suture repair, all of whom became pregnant later and were delivered by cesarean section.

CONCLUSION

Even though rupture of the uterus was a rare complication of pregnancy at KKUH, it occurrence should be suspected when there are sudden fetal heart abnormalities during labor, or unexplained postpartum shock. Suture repair should be considered whenever possible in order to preserve the patients' reproductive potential.

Predictive score for vaginal birth after cesarean section

OBJECTIVE

Our purpose was to evaluate the relative weight of the different variables that may influence the chances of vaginal birth after one cesarean delivery, with the aim of developing a predictive score for success of such a trial.

STUDY DESIGN

In this retrospective study, which covered a 10-year period (1981 to 1990), 471 women who attempted vaginal birth at a level III university hospital after one abdominal delivery were studied as to the subsequent delivery outcome. An attempt to identify possible prognostic factors for success of such a trial was made.

RESULTS

A trial of labor was successful in 368 (78.1%) of women and 103 (21.9%) had a repeat cesarean section. Variables of significant predictive value were vaginal birth before cesarean section (odds ratio 1.8), malpresentation (odds ratio 1.9), pregnancy-induced hypertension (odds ratio 2.3), and Bishop score > or = 4 (odds ratio 6.0). Cephalopelvic disproportion and failure to progress did not demonstrate a significant predictive value (odds ratio 0.81) for success or failure in subsequent delivery. In fact, 63.8% of women with this indication have successfully undergone vaginal delivery. Maternal age (odds ratio 0.9) had no bearing on vaginal delivery success rates, whereas both macrosomia (odds ratio 0.2) and intrauterine growth retardation tended to decrease the chances for vaginal birth after cesarean section.

CONCLUSIONS

A trial of labor after one cesarean section should be encouraged in most women who are willing to attempt it, provided no obstetric contraindication exists. A scoring system that may help to identify women with a greater chance for vaginal delivery is proposed.

Trial of labor after cesarean delivery with a lower-segment, vertical uterine incision: is it safe?

OBJECTIVE

Our purpose was to assess maternal and perinatal outcomes associated with a trial of labor and attempted vaginal birth after prior low-segment vertical cesarean delivery.

STUDY DESIGN

During a 10-year period in a single tertiary hospital, all patients with a prior low-segment uterine incision (whether vertical or transverse) were considered candidates for a trial of labor in the absence of other contraindications or patient refusal. Among the 1137 women who underwent low-segment vertical cesarean delivery, 262 were subsequently delivered of 322 live-born infants, and 174 (54%) of them were identified retrospectively as having attempted vaginal birth. The maternal and perinatal outcomes of patients who did or did not undergo a trial of labor were analyzed and compared.

RESULTS

No significant differences between the two patient groups were observed regarding demographic characteristics, antepartum complications, gestational age at delivery (mean 37.4 weeks), birth weight, and cord pH at delivery. Vaginal delivery was accomplished successfully in 144 of 174 (83%) patients who underwent a trial of labor. Abdominal delivery was necessary for 17 mothers with labor disorders and 13 with suspected fetal distress. Postpartum hemorrhage occurred more often in the trial of labor group (7/174 [4.0%] vs 2/148 [1.4%], p not significant), but endometritis developed significantly more often in patients with elective repeat cesarean delivery (16.9% vs 6.3%, p = 0.006). Rupture of the low-segment vertical cesarean scar occurred in 2 patients during a trial of labor (1.1%) versus none in the elective repeat cesarean group. Neither mother experienced fetal extrusion or adverse maternal or fetal sequelae. Frequency of serious neonatal complications (8.1% vs 10%) and neonatal mortality (1.7% vs 2.0%) were similar between groups. All neonatal deaths were a result of extreme prematurity or congenital anomalies.

CONCLUSIONS

Our experience indicates that a mother with a prior low-segment vertical cesarean delivery can undertake a trial of labor with relative maternal-perinatal safety. The likelihood of successful outcome and the incidence of complications are comparable to those of published experience with a trial of labor after a previous low-segment transverse incision.

Meta-analytic tools for medical decision making: a practical guide

This paper is an extension of notes used for the short course in meta-analysis given at the 13th and 14th annual meetings of the Society for Medical Decision Making. The material covers both standard and evolving methods of meta-analysis. The methods include those for combining p-values, for analyzing general fixed-effects models, for analyzing contingency tables, and for analyzing count and continuous outcomes. For each general method, the authors present simplified formulas first, followed by more precise formulas when necessary. Similarly, both classic and Bayesian methods are presented where appropriate. Actual examples are used for methods.

Caesarean section rate reduced

The Caesarean section rate in consecutive years was decreased from 20.5% to 11.1% of total public deliveries (p < 0.0001). On retrospective analysis the emergency Caesarean section rate decreased from 10.9% to 6.0% (p < 0.0001) and elective Caesarean section rate from 9.6% to 5.1% (p < 0.0001) in consecutive years. Interventions which have accounted for the decrease were 3-fold. Firstly, vaginal birth after Caesarean delivery was encouraged, secondly, the active management of labour and thirdly, extensive, regular peer review were introduced as unit policy. The decrease in the Caesarean section rate was not achieved at the expense of the fetus as judged by perinatal mortality rates and 5-minute Apgar scores of less than 7.

The management of labor in women with more than one uterine scar: is a repeat cesarean section really the only "safe" option?

A prospective trial to investigate feasibility of vaginal delivery after more than one cesarean section, and the safety of vaginal delivery for mother and neonate. Twenty-six pregnant women with a history of two or more cesarean sections were admitted to the delivery room and accepted trial of labor under internal fetal and uterine monitoring. Epidural anesthesia and oxytocin were applied when needed. A similar group of patients (controls) preferred repeated cesarean section. Nineteen women (73%) were successfully delivered by the vaginal route. There were no cases of uterine rupture or perinatal loss. The maternal complication rate was lower than that of the control group. Trial of labor in selected cases of two or more low-segment cesarean sections may be considered safe for mother and fetus.

Post caesarean section delivery

Recent clinical attention has focused upon the rising rate of caesarean sections being performed and whether patients with a previous caesarean section should be allowed a vaginal delivery. In this paper, the worldwide trend of caesarean section and the role of trial of scar following single and multiple caesarean surgery is reviewed. The role of oxytocin and regional epidural analgesia is evaluated as well as perinatal and maternal mortality. On the basis of the available data, there is no justification for the current clinical practice of almost 99% prevalence of elective repeat caesarean section in some hospitals in the North America. Oxytocin and epidural analgesia, when carefully monitored, are safe and reasonable in these patients. Watchful waiting has always been an essential virtue in obstetric management and should not be replaced by hopeful expectancy. This aspect of the art of obstetrics would appear to require rejuvenation if we are to stem the rising tide of caesarean sections.

Vaginal birth after cesarean delivery: are there useful and valid predictors of success or failure?

OBJECTIVE

Before parturition are there useful and valid predictors of successful or unsuccessful vaginal birth after previous cesarean birth that could be used to enhance the obstetric care of a patient and her pregnancy?

STUDY DESIGN

The clinical course and outcome of all patients who attempted vaginal birth after cesarean delivery at one level III center during 1989 were evaluated to identify factors prognostic of a successful or unsuccessful patient group; use of this information in stepwise logistic regression and cluster analysis was disappointing.

RESULTS

No single criterion or optimal clusters of factors were found and no equation achieved greater than 75% predictability of outcome with acceptable sensitivity and specificity.

CONCLUSIONS

Before parturition prediction of outcome of vaginal birth after cesarean delivery is tenuous regardless of past obstetric history or recent clinical parameters. Thus it seems appropriate to encourage a trial of labor in almost all patients with a prior low-segment uterine incision (transverse or vertical) unless there is a strong physician or patient-derived contraindication to such an undertaking.

Vaginal delivery after previous cesarean section in a rural West African hospital

Two hundred twenty women with prior cesarean section were delivered at our institution between January 1987 and February 1990. Vaginal delivery was achieved in 111 (66%) of 169 patients given a trial of labor (TOL). Success of TOL correlated positively with the number of prior vaginal deliveries (P less than 0.05) and inversely with the number of prior cesarean sections (P less than 0.005). Maternal and fetal outcome were not significantly different between the TOL and non-TOL groups.

Vaginal birth after two or more cesarean sections: a five-year experience

Allowing a trial of labor in patients who have had a single low transverse cesarean section has become increasingly accepted and widespread in the United States. Evidence with regard to the safety of this practice in patients with two or more prior cesarean births has, however, been sparse. We performed a retrospective review of the charts of 170 patients who had undergone two or more low transverse cesarean deliveries and subsequently delivered at Wishard Memorial Hospital between January 1, 1983, and December 31, 1987. Of 35 of these women who underwent a trial of labor, 27 (77%) had a successful vaginal delivery. No increase in maternal or fetal morbidity or mortality was associated with labor. The women who underwent trial of labor had fewer postpartum complications and shorter hospital stays. Although the number of patients in this study was small, growing evidence appears to support a trial of labor in patients with two or more prior cesarean sections as a safe and successful alternative to elective repeat cesarean section.

Vaginal birth after cesarean or repeat cesarean section: medical risks or social realities?

Despite the known medical safety and success of vaginal birth after cesarean section, rates of planned repeat cesarean sections remain high. The process involved in women's decisions to choose vaginal birth after cesarean section or repeat cesarean section was investigated by a questionnaire study at a private and a public hospital. Women were questioned regarding timing, influence of others, reasons for their choice, satisfaction with the decision, etc. Results from 160 respondents showed that over half the women identified themselves as the primary decision maker. Physicians exerted more influence on the decisions of patients at the public hospital than on the patients at the private hospital. Overall, social exigencies appeared to play a more important role than an assessment of the medical risks in making these decisions.

Vaginal delivery in Nigerian women after a previous cesarean section

A total of 154 consecutive Nigerian women at term pregnancy who had undergone one previous cesarean delivery were prospectively studied during the year March 1987 to February 1988. A repeat elective cesarean section was performed in 52 (33.8%) patients. Vaginal delivery was achieved in 73 (71.6%) of the 102 subjects who were allowed into labor, and in over 90% of the comparison group. High vaginal delivery rates occurred among the women within the selection criteria irrespective of the indication for the previous cesarean section. A repeat emergency cesarean section was performed in 29 (24.5%) women. Rupture of the uterine scar occurred in 5 (4.9%) instances with the loss of 2 babies; there was no maternal loss. Excluding the high incidence of fetal asphyxia and uterine rupture which occurred among women in the study group, maternal morbidity and perinatal mortality and morbidity were similar to those of the comparison group. There was a statistically significant difference between the study and comparison group. There was a statistically significant difference between the study and comparison groups with regard to the mode of delivery. Among the study group, a significant correlation existed between the vaginal delivery rate of the patients and the indication for the primary cesarean section. There was however, no significant difference between the mean parities of the women who were delivered by cesarean section and those who delivered vaginally. Similarly, no significant difference existed in the mean birthweights of the babies delivered vaginally and those who were delivered abdominally during labor.(ABSTRACT TRUNCATED AT 250 WORDS)

Vaginal delivery following one previous cesarean birth: nation wide survey

The present state of vaginal delivery following a previous cesarean section (CS) was evaluated through a nation wide survey, including 22,815 deliveries. The overall cesarean rate was 9.6%. Of all the parturients with one previous cesarean section 55.1% delivered vaginally. A previous CS and labor arrest were the major indications for a repeated CS in 28.7% and 26.4%, respectively. Rupture of the uterus following vaginal delivery was found more often in the group with a previous CS than in those with no uterine scar (1.2% and 0.03%, respectively), (P less than 0.0001). None of the uterine ruptures was fatal neither to the mother nor to the fetus. Post partum fever appeared more often among vaginal deliveries following a CS than among those with no uterine scar. However, CS is followed by fever 10.8 times more than vaginal delivery. Intrapartum and neonatal death rates following vaginal delivery were similar for those with or without a previous CS (3.42% and 3.38%, respectively). An average of 3 hospitalization days were saved for each vaginal birth replacing a repeated CS. It is concluded that vaginal delivery, following CS, does not cause substantial morbidity, nor mortality either to the mother or the neonate, and may be practiced with a reasonable margin of safety in well selected cases.

The use of oxytocin after a previous caesarean section--a review and report on a series

We briefly present our experience with trial labour in the presence of a Caesarean section scar and review some of the literature on the management of such patients.

Vaginal delivery after cesarean section

We retrospectively analyzed 194 pregnancies in women with a history of previous cesarean section (CS) who were offered a trial of labor. We offered every woman a trial of labor as long as she did not have a known previous classical scar. One hundred fifty-one women delivered vaginally (79%), 24 women had multiple uterine scars. Multiple gestations and breech presentation were not considered a sole indication to perform CS. Fetal and maternal morbidity are presented. We conclude that women with multiple previous CS scars can safely deliver vaginally as can women with unknown uterine scars, with careful intrapartum surveillance. Although our numbers of women with breech presentation and multiple gestations are small, in the absence of significant morbidity, we continue to allow these women to labor and deliver vaginally.

A successful program to lower cesarean-section rates

Despite the consensus that national cesarean-section rates are excessive, they continue to rise. Currently, approximately one of every four deliveries is by cesarean section. We developed an initiative to reduce the number of cesarean deliveries to a rate of 11 percent of all deliveries at our inner-city hospital. Participation by attending physicians was voluntary and not linked to any sanction. The program included a stringent requirement for a second opinion, objective criteria for the four most common indications for cesarean section, and a detailed review of all cesarean sections and of individual physicians' rates of performing them. During the first two years of the program, the cesarean-section rate fell from 17.5 percent of 1697 deliveries in 1985 to 11.5 percent of 2301 deliveries in 1987 (P less than 0.05). The proportion of infants with five-minute Apgar scores lower than 7 increased from 3 percent in 1985 to 4.9 percent in 1987 (P less than 0.05), but neither the fetal mortality rate (11.9 per 1000) nor the neonatal mortality rate (11.2 per 1000) in 1987 differed significantly from the rates in 1985. A single maternal death, unrelated to cesarean delivery, occurred during the study. Rates of both primary and repeat cesarean sections decreased, although only the decline in the rate of primary cesarean sections, from 12 to 6.8 percent, was statistically significant (P less than 0.05). During the same period, operative vaginal deliveries (i.e., forceps deliveries and midpelvic procedures) declined from 10.4 to 4.3 percent (P less than 0.05) of total deliveries. We conclude that an initiative within an obstetrics department can reduce cesarean-section rates substantially without adverse effects on the outcome for mother or infant.