Caesarean section and trial of scar

A trial of labor after cesarean section in patients with or without a prior vaginal delivery

OBJECTIVE

To determine the outcome of labor in women with a previous cesarean section, with or without prior vaginal delivery.

METHOD

Records were reviewed for 1065 women with a previous cesarean section at 'Virgen Macarena' Hospital who were attended for a subsequent labor.

RESULTS

Chi-squared tests demonstrated that women with previous vaginal delivery (n = 346) had a significantly higher rate of vaginal delivery after a trial of labor (95.24%) than those without previous vaginal delivery (n = 719) (82.95%). All the ruptures of uterine scar (n = 4) were found in women without previous vaginal delivery.

CONCLUSION

It appears that a cesarean section in a multiparous woman is not a determinant fact in her reproductive history and the risk of rupture of uterine scar did not appear to be present.

Multiple repeat caesarean section: is it safe?

OBJECTIVE

We aimed to evaluate the obstetric outcome of patients without obstetric risks, who had two or more previous caesarean sections (C/S) prior to the current pregnancy, which was managed by caesarean section in our obstetric department.

METHODS

We studied the case notes of 602 women who had a repeat caesarean section in our unit between May 2002-June 2003. We then compared the two groups: (1) those who had two or more previous caesarean sections and (2) those who had only one previous caesarean section.

RESULTS

In the study group, while dense intraperitoneal adhesions were present in 3.6% of the patients, they were not found in control group. This difference was statistically significant (P < 0.05). Uterine wound separation rate was 1.9% in the study group and none of the patients in control group had uterine wound separation, which was statistically significant also (P < 0.05). There was no statistically significant association between Apgar scores and number of previous caesarean sections. Postoperative complication rates did not differ between the two groups (P > 0.05).

CONCLUSION

Patients without any obstetric risks, with two or more previous caesarean sections had significantly more dense adhesions and uterine wound separations in the current caesarean section compared to patients with one previous caesarean section. But, maternal and fetal mortality and morbidity in women who have two or more previous caesarean sections did not differ from the patients with one previous caesarean section.

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.

Vaginal birth after Caesarean section: an Australian multicentre study. VBAC Study Group

Retrospective analysis of medical records and individual case review was undertaken at 11 major obstetric hospitals for a 5 year period from July 1992 to June 1997 to investigate rates of vaginal birth after Caesarean section (VBAC), the occurrences of uterine rupture, and the outcomes for mother and infant following rupture. Total deliveries were 234,015, of which 21,452 or 9.2% were associated with one or more previous Caesarean sections. Within this scar group, 5419 patients or 25.3% were delivered vaginally. There were 62 cases of significant uterine rupture with no maternal deaths. Perinatal mortality with rupture was 25% and serious maternal complications (usually hysterectomy) occurred in 25% of those with uterine rupture. In women attempting vaginal delivery after a previous lower segment Caesarean section, the uterine rupture rate was estimated at 0.3%, with 0.05% experiencing a perinatal death and 0.05% requiring a hysterectomy. Although VBAC rates in Australia remain lower than many overseas reported series, rates are increasing. While rupture continues to be associated with serious adverse outcomes, the incidence of rupture during trial of labour is low and appears to be associated with a better outcome than rupture of an unscarred uterus.

Obstetric outcome after one previous caesarean section

OBJECTIVE

A prospective study was undertaken to evaluate the outcome of trial of labour (TOL) after one previous cesarean section.

METHODS

A total of 2,447 deliveries were conducted during this study period over 22 months. Out of these patients 167 women had one previous cesarean birth, 112 (67.1%) of whom underwent trial of labour.

RESULTS

Seventy-two (64.28%) of these patients achieved vaginal delivery. This success rate would be much higher if fixed protocol could be applied to all the patients. Fourty-six point fifteen percent of patients with past indication for cesarean section due to cephalopelvic disproportion also delivered vaginally. This advocates that each patient should be selected on individual merits and the past indication for cesarean section should be reviewed. One maternal death occurred in this study which was due to anaesthetic complication while the perinatal mortality rate in this group was slightly higher as compared to national perinatal mortality rate, reason discussed in the text.

CONCLUSION

It is safe to offer TOL provided patient is carefully selected and monitored.

Vaginal delivery in the grand multipara following previous lower segment cesarian section

OBJECTIVE

To examine the effect of attempting vaginal birth after cesarian section in the grand multipara with one previous cesarian section scar in the uterus.

METHOD

Over 5-year period (1990-1994) mothers with 6 or more previous deliveries and with a previous section scar in the uterus were identified. The outcome in these patients who attempted vaginal birth was reviewed.

RESULTS

Of the 85 patients with the combination of both grand multiparity and a previous cesarian section scar in the uterus, 45 attempted a trial of labor. Twenty-seven patients (60%) achieved successful uncomplicated vaginal delivery. There was a relatively high incidence of serious complications.

CONCLUSION

Vaginal birth after cesarian section can be achieved in some grand multiparas with a previous scar in the uterus. There is an increased risk of serious complications. The labor should be very closely supervised and early intervention arranged if there is not smooth rapid progress.

Vaginal delivery after Caesarean section: factors influencing success rates

In a retrospective review of 333 pregnancies in women who had 1 previous Caesarean section, 244 (73.3%) underwent a trial of scar, and 89 (26.7%) had an elective Caesarean section. In the trial of scar group 197 (80.7%) had a vaginal delivery and 47 (19.3%) required an emergency Caesarean section. The success of the trial was favourably influenced by a nonrecurring indication for the original Caesarean section, a previous vaginal delivery, and a smaller baby. Maternal morbidity was greater in the groups requiring a Caesarean section, whether elective or emergency. Those patients delivered vaginally spent significantly less time in hospital. In 2 of the 244 patients (0.8%) who underwent a trial of scar the previous lower segment scar was found at Caesarean section to have dehisced or ruptured.

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.

Vaginal delivery after caesarean section

In a prospective study of 318 consecutive pregnancies complicated by previous Caesarean section, 193 (61%) had an elective repeat Caesarean section, 125 (39%) had a trial of labour and 80 (64%) of these women achieved a vaginal delivery. The incidence of uterine rupture was 0.8% (1 of 125). The vaginal delivery rate was not influenced by the indication for the first Caesarean section (including cephalopelvic disproportion), birth-weight, health insurance status, use of epidural analgesia or oxytocin in labour. Perinatal morbidity was unaffected by the mode of delivery and maternal morbidity was comparable following elective and emergency repeat Caesarean section. Patients having a vaginal deliver spent significantly less time in hospital. We conclude that vaginal delivery after lower segment Caesarean section is safe and should be considered in most patients after a critical review of the indication for the first Caesarean section.

Catastrophic complications of previous cesarean section

Of 711 patients who were delivered after one or more previous cesarean sections, 17 (2.4%) had an extremely serious complication. Uterine rupture and placenta previa or placenta accreta with accompanying hemorrhage were the major contributors to mortality and major morbidity. Nine uterine ruptures occurred, including five associated with labor with a low transverse uterine scar and one with an unknown scar (1.4% of trials of labor). There were two cases of placenta previa and five with varying degrees of placenta accreta. The nature and frequency of the observed complications emphasize the potentially serious remote consequences of cesarean section.