Vaginal Birth After Cesarean Section:

Sonographic diagnosis of a uterine defect in a pregnancy at 6 weeks' gestation with a history of curettage

We present the early diagnosis and successful surgical treatment of uterine perforation. This was a rare case of cystic change of a uterine perforation, which was diagnosed by sonography during the first trimester of pregnancy. Surgical closure of the uterine wall defect was successful.

Trial of labor after cesarean delivery: the effect of previous vaginal delivery

OBJECTIVE

This study examined the effects of order of previous modes of delivery on the rate of cesarean delivery and duration of a trial of labor among women with a history of 1 previous cesarean delivery and 1 previous vaginal delivery.

STUDY DESIGN

The medical records of 4393 women at our institution who were seen June 1984-July 1996 for a trial of labor after a previous cesarean delivery were abstracted. The 800 women with a history of 1 previous cesarean and 1 previous vaginal delivery were included in this analysis. They were split into 2 groups by obstetric history: (1) 1 cesarean delivery followed by 1 vaginal delivery (vaginal last) and (2) 1 vaginal delivery followed by 1 cesarean delivery (cesarean last). Patient characteristics, durations of labor, and rates of cesarean delivery were compared with chi2 analysis, the Student t test, and the Wilcoxon rank sum test. Possible confounding variables were controlled for with multivariate logistic regression.

RESULTS

The rates of cesarean delivery for the vaginal last and cesarean last groups were 7.2% and 14.7%, respectively (P = .002). The median durations of labor for the vaginal last and cesarean last groups were 5.6 and 7.0 hours, respectively (P = .01). The differences in cesarean rates and durations of labor were seen regardless of the indication for the previous cesarean delivery.

CONCLUSIONS

Among women with 1 previous cesarean and 1 previous vaginal delivery, those whose most recent delivery was vaginal had a lower rate of cesarean delivery and shorter duration of labor than did those whose most recent delivery was cesarean.

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.

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 birth after cesarean: issues and implications

Vaginal birth after cesarean is still an uncommon practice in the United States despite fewer contraindications to it. This article examines issues related to cesarean section practice patterns, malpractice, rising health care costs, changing childbearing patterns, and risks and benefits to mother and baby. Implications for nurses are discussed as they relate to nursing education, practice, and research.

Management of antepartum spontaneous membrane rupture after one previous caesarean section

The management of patients with one previous caesarean section whose membranes rupture spontaneously (SROM) before labour poses a clinical problem. This paper reports the outcome in a consecutive series of 56 such patients who presented after 37 weeks' gestation over 5 years (1983-1987). Vaginal examination was avoided before labour to minimise the risk of infection. Oxytocin was not used for induction, and the spontaneous onset of labour was awaited. The mean SROM-to-delivery interval was 42.6 hours. Only five (9%) patients required a repeat caesarean section. There was no case of scar dehiscence, and only five patients required oxytocin augmentation in labour. There was one case of postpartum endometritis, and none of the neonates showed clinical evidence of infection. In patients with one previous caesarean section whose membranes rupture spontaneously before labour, we suggest that awaiting the spontaneous onset of labour can safely achieve a high rate of vaginal delivery and avoid the need to induce labour with oxytocin.