Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

Induction of Labour. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-088, December 2020)

Aim The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG) is to provide a consensus-based overview of the indications, methods and general management of induction of labour by evaluating the relevant literature. Methods This S2k guideline was developed using a structured consensus process which included representative members from various professions; the guideline was commissioned by the guidelines commission of the DGGG, OEGGG and SGGG. Recommendations The guideline provides recommendations on the indications, management, methods, monitoring and special situations occurring in the context of inducing labour.

Intracervical double-balloon catheter versus dinoprostone for cervical ripening in labor induction in pregnancies with a high risk of uterine hyperstimulation

PURPOSE

There are numerous methods for cervical ripening although not all of them are indicated in women presenting a higher risk of uterine hyperstimulation. To compare the efficacy and security of the two methods for cervical ripening in the induction of labor in these pregnancies.

METHODS

Retrospective analysis of two cohorts consisting of pregnant women who gave birth from 2016 to 2019 (112 inductions with dinoprostone and 112 with intracervical double- balloon).

RESULTS

There are statistically significant differences in favor of dinoprostone in deliveries that occurred before 12 h since the start of the induction (28.6% vs 13.4%, p = 0.005) and a higher rate of cervical ripening (55.4% vs 33.9%; p = 0.001). There were no statistically significant differences in induction time, the percentage of women delivering within 24 h or beyond, nor in the type of delivery. Additionally, a decreased need of oxytocin (60.7% vs 42.9%; p = 0.001) and a lower dose when used has been observed in the dinoprostone group. However, Dinoprostone also has a higher rate of minor maternal complications as uterine hyperstimulation (18.8% vs 3.6%; p = 0.001) and altered cardiotocography (26.8% vs 4.5%; p = 0.001). No significant difference has been found between the two groups regarding severe complications.

CONCLUSIONS

Dinoprostone presents a greater efficacy for cervical ripening and delivery in ≤ 12 h, with less need of oxytocin perfusion than inductions using an intracervical double-balloon. There is no significant difference in severe maternal complications between the two groups. In conclusion, Dinoprostone could be an effective and safe option for patients at risk of uterine hyperstimulation.

Classical Cesarean Section

Cesarean section is the most common surgery in obstetrics. Several techniques are proposed according to the indication and the degree of urgency. Usually laparotomy followed by hysterotomy with a low transverse incision is preferable. However, in cases in which it is difficult to access the lower uterine segment, such as that in preterm labor, dense adhesion, placenta previa/accrete a vertical hysterotomy (classical cesarean section) may be needed. Although a smooth and gentle delivery of the fetus is possible through the vertical incision, uterine closure is technically difficult. To decrease the risks of hemorrhage and adhesion, a speedy and skillful technique is mandatory. The most serious risk of vertical incision in the contractile corpus is uterine rupture in the subsequent pregnancy. Therefore, cases of prior classical cesarean section are contraindicated for trial of labor after cesarean section.

Concomitant Vesicouterine Rupture with Avulsion of Ureter: A Rare Complication of Vaginal Birth after Cesarean Section

Uterine rupture is the most serious and life threatening complication and occurs in 0.7-0.9% of vaginal birth after lower segment caesarean section. Cases of bladder rupture along with uterine rupture have been rarely reported and avulsion of ureter, required ureteric implantation is even rarer. This case report describe a very rare case of vesicouterine rupture with avulsion of ureter following vacuum assisted delivery in a grandmulti with previous lower segment cesarean section (LSCS). Haematuria is the most common presentation of bladder rupture. Antenatal counseling regarding this entity is recommended if woman opted for vaginal birth after cesarean section. Intrapartum and postpartum high index of suspicion are important in clinching the diagnosis.

Pathways to a rising caesarean section rate: a population-based cohort study

OBJECTIVES

To determine whether the obstetric pathways leading to caesarean section changed from one decade to another. We also aimed to explore how much of the increase in caesarean rate could be attributed to maternal and pregnancy factors including a shift towards delivery in private hospitals.

DESIGN

Population-based record linkage cohort study.

SETTING

New South Wales, Australia.

PARTICIPANTS

For annual rates, all women giving birth in NSW during 1994 to 2009 were included. To examine changes in obstetric pathways two cohorts were compared: all women with a first-birth during either 1994-1997 (82 988 women) or 2001-2004 (85 859 women) and who had a second (sequential) birth within 5 years of their first-birth.

PRIMARY OUTCOME MEASURES

Caesarean section rates, by parity and onset of labour.

RESULTS

For first-births, prelabour and intrapartum caesarean rates increased from 1994 to 2009, with intrapartum rates rising from 6.5% to 11.7%. This fed into repeat caesarean rates; from 2003, over 18% of all multiparous births were prelabour repeat caesareans. In the 1994-1997 cohort, 17.7% of women had a caesarean delivery for their first-birth. For their second birth, the vaginal birth after caesarean (VBAC) rate was 28%. In the 2001-2004 cohort, 26.1% of women had a caesarean delivery for their first-birth and the VBAC rate was 16%. Among women with a first-birth, maternal and pregnancy factors and increasing deliveries in private hospitals, only explained 24% of the rise in caesarean rates from 1994 to 2009.

CONCLUSIONS

Rising first-birth caesarean rates drove the overall increase. Maternal factors and changes in public/private care could explain only a quarter of the increase. Changes in the perceived risks of vaginal birth versus caesarean delivery may be influencing the pregnancy management decisions of clinicians and/or mothers.

Uterine rupture during a trial of labor after previous cesarean delivery

Uterine rupture, which involves complete separation of the uterine wall, occurs in about 1% of those attempting vaginal birth after cesarean. Because uterine rupture is one of the most significant complications of a trial of labor (TOL) after previous cesarean, identifying those at increased risk of uterine rupture is paramount to the safety of a TOL after previous cesarean birth. It seems that both antepartum demographic characteristics and intrapartum factors modify the risk of uterine rupture. The ability to reliably predict an individual's a priori risk for intrapartum uterine rupture remains a major area of investigation.

Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery

Uterine rupture is the primary concern when a patient chooses a trial of labor after a cesarean section. Bladder rupture accompanied by uterine rupture should be taken into consideration if gross hematuria occurs. We report the case of a patient with uterine rupture during a trial of labor after cesarean delivery. She had a normal course of labor and no classic signs of uterine rupture. However, gross hematuria was noted after repair of the episiotomy. The patient began to complain of progressive abdominal pain, gross hematuria and oliguria. Cystoscopy revealed a direct communication between the bladder and the uterus. When opening the bladder peritoneum, rupture sites over the anterior uterus and posterior wall of the bladder were noted. Following primary repair of both wounds, a Foley catheter was left in place for 12 days. The patient had achieved a full recovery by the 2-year follow-up examination. Bladder injury and uterine rupture can occur at any time during labor. Gross hematuria immediately after delivery is the most common presentation. Cystoscopy is a good tool to identify the severity of bladder injury.

A new perspective on VBAC: a retrospective cohort study

BACKGROUND

Previous studies assessing the safety of vaginal birth after caesarean section (VBAC) have compared VBAC to elective repeat caesarean section (ERCS), despite the fact that the risks posed by each are considerably different. Explaining the complications of VBAC in a way that is meaningful to women can be challenging, and thus a comparison to a similar group of women who have also not undergone previous vaginal delivery may be a more relevant comparison.

RESEARCH QUESTION

When counselling women undergoing planned VBAC, should a comparison of outcomes be made to women undergoing ERCS, or is a comparison to other nulliparous women undergoing vaginal birth a more valid comparison in terms of risk outcomes?

PARTICIPANTS AND METHODS

A retrospective cohort study was undertaken comprising a consecutive cohort of 21,389 women who delivered, stratified by Robson's criteria into Robson groups 1-5. Those in Robson groups 6-10 were not included. Demographic data and maternal/neonatal outcomes were reviewed, with main outcome measures comprising uterine rupture, post-partum haemorrhage (PPH), 3rd/4th degree tears and neonatal morbidity.

RESULTS

There was no increase in PPH, vaginal tears or neonatal complications in the VBAC group when compared to Robson groups 1 and 2 (nulliparous women in spontaneous or induced labour, respectively). Uterine rupture rates were low in all groups, with no correlation identified.

DISCUSSION

The maternal and neonatal morbidity associated with VBAC is comparable to primiparous women undergoing a vaginal birth.

CONCLUSION

In demonstrating the low relative morbidity in this comparison, these outcomes may aid in counselling women faced with the choice of VBAC versus ERCS.

Effect of gestational age at the prior cesarean delivery on maternal morbidity in subsequent VBAC attempt

OBJECTIVE

The purpose of this study was to estimate the effect of gestational age at the time of prior cesarean on maternal morbidity in women attempting vaginal birth after cesarean delivery (VBAC).

STUDY DESIGN

A retrospective cohort study of women attempting VBAC, comparing women with a prior cesarean delivery < or = 34 completed weeks to women with a prior cesarean delivery > 34 weeks. The primary outcome was maternal morbidity, including uterine rupture. Univariable, stratified, and multivariable analyses were used to estimate the effect of a prior cesarean performed at < or = 34 weeks on maternal morbidities.

RESULTS

Of 19,474 women with 1 prior cesarean, 12,535 attempted VBAC and 508 of those had a previous cesarean < or = 34 weeks. Study groups had similar risks of uterine rupture (adjusted OR [AOR], 1.5; 95% CI, 0.7-3.5; P = .32) and composite morbidity (AOR, 0.9; 95% CI, 0.5-1.8; P = .81).

CONCLUSION

Prior cesarean delivery at < or = 34 weeks' gestation does not appear to increase the risk of maternal morbidity in a subsequent VBAC attempt.

Essai de travail en cas de césarienne antérieure

OBJECTIVE

The aim of this review was to relate the evolution of obstetrical management of delivery in women who had previously undergone cesarean delivery and to search the studies supporting the choice of the mode of delivery.

MATERIAL AND METHOD

We identified relevant studies through a computer search in the Medline database.

RESULTS

After a period from 1980 to 2000 when the vaginal delivery had been increasingly recommended, a growth in the use of the planned cesarean delivery was observed. Recent studies report more evidence that uterine rupture is the result of trial of labor and that adverse perinatal outcomes are associated with uterine rupture. The risk of uterine rupture is increased with labor induction. The use of prostaglandins appears to be implicated in a significant increase of uterine rupture, and subsequently might be contraindicated in this situation. The use of oxytocin induced labor appears to increase the risk of uterine rupture. However, the level of adverse perinatal outcomes is low. The choice of the mode of delivery should take into account the likelihood of a further pregnancy, due to the increased risk of placental pathologic conditions depending on the number of repeated cesarean sections.

CONCLUSION

An optimal decision for the mode of delivery should be shared with the pregnant women and all these factors should be taken into consideration.

Temporal trends in the rates of trial of labor in low-risk pregnancies and their impact on the rates and success of vaginal birth after cesarean delivery

OBJECTIVE

The national rate of vaginal birth after cesarean delivery decreased by 55% between 1996 and 2002. The objective of this investigation was to determine, in our population in upstate New York, whether this decline in the vaginal birth after cesarean delivery rate was due to temporal changes in the trial of labor rates or in the vaginal birth after cesarean delivery success rates.

STUDY DESIGN

Regional perinatal databases were used to obtain birth certificate data from a total of 135,833 live births in upstate New York from 1998 to 2002. Trial of labor, vaginal birth after cesarean delivery, and vaginal birth after cesarean delivery success rates were calculated for the 11,446 women who had had a previous cesarean delivery and a singleton, low-risk pregnancy at > or = 37 weeks of gestation. Additional factors that were analyzed included age, race, education, insurance, body mass index, parity, gestation, area of residence, prenatal care provider, size of hospital, and level of newborn nursery specialization. Tests for trends were conducted by year for each of the variables.

RESULTS

The trial of labor rate declined 39% from 58.7 in 1998 to 35.7 per 100 eligible women in 2002 (P < .01). The decline in trial of labor rates persisted after stratification within almost all groups (P < .01). The overall vaginal birth after cesarean delivery rate decreased 44%, from 42.7 in 1998 to 24.1 per 100 eligible women in 2002 (P < .01). The decline in vaginal birth after cesarean delivery rates persisted after stratification within almost all groups (P < .01). The rate of vaginal birth after cesarean delivery success was unchanged from 1998 to 2002 (P = not significant).

CONCLUSION

We found a major decline in trial of labor and vaginal birth after cesarean delivery rates in low-risk women from 1998 to 2002. There was no change in vaginal birth after cesarean delivery success in those patients who attempted trial of labor. This suggests that the decline in the vaginal birth after cesarean delivery rates that have been observed nationally may be due to a decline in trial of labor attempts and not to a change in vaginal birth after cesarean delivery success rates. The steep declines in trial of labor attempts and vaginal birth after cesarean deliveries suggest that there was a rapid change in the perception of optimal treatment practices for these patients by obstetricians.

Comment informer sur la voie d'accouchement une patiente ayant un antécédent de césarienne ?

A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. Information and counselling aim to estimate specific risks and to balance these risks according to individual factors. Therefore, the physician has to answer two questions: (i) which would be the probability of successful vaginal delivery? (ii) which would be the risk of uterine rupture with a trial of labor? The risk factors for failure of trial of labor are: increased maternal age, obesity, and fetal macrosomia. The risk factors for uterine rupture are: increased maternal age, postpartum fever after the previous cesarean delivery, short interdelivery interval, history of at least two previous cesarean deliveries, and a history of classical incision. Conversely, other factors are of good prognosis: a prior vaginal delivery and, particularly, a prior VBAC (Vaginal Birth After Caesarean) are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery; ultrasonographic measurement of the lower uterine segment thickness>3.5 mm has an excellent negative predictive value for the risk of uterine defect. Finally, the wish for additional pregnancies following a cesarean section must be considered as an argument in favour of a trial of labor after accounting for the increasing risks correlated with repeated elective cesarean deliveries.

Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound

INTRODUCTION AND OBJECTIVE

Cesarean section (CS) is the most common operation in obstetrics, with rising incidence in most countries. As a result of this operation late scar dehiscence may occur, which may lead to uterine rupture in a subsequent pregnancy. In this case series we have described sonographic detection of scar dehiscence after CS and feasibility of vaginal or combined laparoscopic and vaginal scar excision and uterine repair.

METHODS

Five consecutive patients underwent vaginal or laparoscopic assisted vaginal approach for repair of suspected scar dehiscence following CS, during a 5 year period. In all cases, transvaginal sonography detected suspicious features of scar dehiscence over the anterior uterine wall. Except of one, all patients had reported recurrent pelvic pain and/or irregular menstrual bleedings. Furthermore all patients planned for a further pregnancy.

RESULTS

Resection of the uterine defect and re-constitution of the uterine wall was successfully achieved in all five patients. There were no intra-operative complications and none of the patients required blood transfusion. The mean operation time was 117 min (27-192). Presence of scar tissue was confirmed on histology in all specimens. Four patients remained free of symptoms with no evidence of recurrent scar dehiscence on sonography over a median follow up of 30 months (3-46). One patient had an uneventful pregnancy 24 months after scar removal and was delivered by repeat CS at 39 weeks' gestation.

CONCLUSION

Patients with a history of CS should undergo transvaginal sonography of the scar region in order to detect latent scar dehiscence in combination with uterine wall thinning prior to planning further pregnancy. In suspected cases, a combined laparoscopic - vaginal or vaginal approach can be employed to repair the defect.

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.

Results of the National Study of Vaginal Birth After Cesarean in Birth Centers

OBJECTIVE

Some women wish to avoid a repeat cesarean delivery and believe that a midwife-supported vaginal birth after cesarean (VBAC) in a nonhospital setting represents their best chance to do so; there is a small, persistent demand for out-of-hospital VBACs. We conducted a study to obtain the data necessary to formulate an evidence-based policy on this practice.

METHODS

We prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000.

RESULTS

A total of 1,453 of the 1,913 women presented to the birth center in labor. Twenty-four percent of them were transferred to hospitals during labor; 87% of these had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). Most fetal deaths (5/7) occurred in women who did not have uterine ruptures. Half of uterine ruptures and 57% of perinatal deaths involved the 10% of women with more than 1 previous cesarean delivery or who had reached a gestational age of 42 weeks. Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks.

CONCLUSION

Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs.

LEVEL OF EVIDENCE

III.

Uterine rupture during VBAC trial of labor: risk factors and fetal response

For the woman with a prior uterine scar, neither repeat elective cesarean birth nor vaginal birth after cesarean birth (VBAC) trial of labor (TOL) is risk-free. When VBAC-TOL is successful, it is associated with less morbidity than repeat cesarean birth. However, when VBAC-TOL fails due to uterine rupture, severe consequences often ensue. The challenge for clinicians today is to provide women who desire TOL after cesarean birth, a more individualized risk assessment of uterine rupture, thereby enhancing success and optimizing outcome. This article examines major risk factors for uterine rupture during VBAC-TOL. In addition, fetal response to uterine rupture and neonatal outcomes are reviewed.

VBAC--is it worth the risk?

Enthusiasm for vaginal birth after cesarean section has waned. As a result, the cesarean birth rate is again on the rise. As a medical community and society we must decide whether the most appropriate question is "What is safest for my baby?" or "Is the risk associated with vaginal birth after cesarean acceptable?" There are risks associated with vaginal birth after cesarean, but in a hospital setting with appropriate resources these risks are low and would still seem to be acceptable.

Uterine rupture

Uterine rupture is an uncommon obstetric event. It is important because it continues to be associated with maternal mortality, especially in developing countries, and with major maternal morbidity, particularly peripartum hysterectomy. It is also associated with a high incidence of perinatal mortality and morbidity worldwide. This chapter examines the incidence, aetiology, clinical presentation, complications and prevention of uterine rupture. The key factor in the cause of rupture is whether or not the uterus is scarred. Rupture of an unscarred uterus is rare, usually traumatic, and its incidence decreases with improvement in obstetric practice. Rupture of the scarred uterus is more common, and usually occurs after a trial of labour in a patient with a previous Caesarean section. This chapter also explores how the incidence and complications of uterine rupture may be minimized, and yet the incidence of vaginal birth after Caesarean section (VBAC) optimized, in clinical practice.

Is vaginal birth after cesarean safe? Experience at a community hospital

OBJECTIVE

We sought to evaluate the effectiveness and safety of promoting a trial of labor after prior cesarean birth in a community hospital.

STUDY DESIGN

A 4-year prospective cohort study was conducted of all patients who had prior cesarean births (N = 1481). A comparison of outcomes was performed between those who elected repeat cesarean delivery (n = 727) and those who attempted a trial of labor after previous cesarean(s) (n = 754).

RESULTS

We found that the vaginal birth after cesarean attempt rate was 50.9% and declined significantly during the last 2 years of the study. The elective repeat cesarean rate was 49.1% and increased significantly during the last 2 years of the study. In addition, we found that neonatal outcomes were similar, with the exception of 2 neonatal deaths caused by uterine rupture. Twelve uterine ruptures occurred (1.6%), and 11 of the 12 ruptures involved either induction or augmentation of labor, or both.

CONCLUSIONS

A trial of vaginal birth after cesarean is safe provided that induction of labor is not used. The uterine rupture rate of 1.6% is higher than reported in the literature; this may reflect underreporting by community hospitals.

Techniques for performing caesarean section

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.

Vaginal birth after caesarean (VBAC)

This review of vaginal birth after caesarean (VBAC) focuses on practical issues that will be useful for the physician in training and the obstetrician in clinical practice. Although VBAC has long been a common practice in many European nations, the same has not been true in North America. As recently as 1970 essentially all hospitals in the United States maintained a policy that women with a history of previous caesarean delivery would undergo repeat caesarean operations for any and all subsequent births. Although VBAC rates in many nations increased dramatically in the 1980s and 1990s, many aspects of trial of labour (also known as trial of scar) remain controversial at the dawn of the 21st century.