Vaginal birth after two or more previous cesarean sections

Trial of labor versus elective cesarean delivery for patients with two prior cesarean-sections: A retrospective propensity score analysis

INTRODUCTION

Despite awareness of obstetricians to the constant increase in the number of cesarean sections in recent years, the fear of a uterine scar rupture is still present and influences the choice of the mode of delivery in patients with two previous cesarean sections. However, several clinical studies have suggested that, under certain conditions, vaginal birth after two cesarean sections is usually successful and safe.

OBJECTIVE

The objective of this study was to compare maternal and neonatal issues according to the planned mode of delivery in patients with two previous cesarean sections.

METHODS

It was a retrospective observational comparative study at Rennes University Hospital between January 1, 2013, and December 31, 2020. We performed a propensity score for the comparison of neonatal outcomes: cord pH, cord lactates, Apgar scores, transfer to neonatal unit and deaths, according to the planned delivery mode. Secondary outcomes were maternal issues: uterine rupture, post-partum hemorrhage, deaths.

RESULTS

A total of 410 patients with two previous cesarean section were eligible for our study. Prophylactic cesarean was performed in 358 cases (87.3%). Trial of labor was attempted in the 52 remaining patients (12.7%), 67.3 % of whom were successful. Neonatal weight, APGAR score at 1-5-10 min, and pH on cord blood were comparable in both groups. One case of uterine rupture occurred in the trial of labor group.

CONCLUSION

Trial of labor seems to be a reasonable option for women with two previous cesarean sections in a selected population.

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.

Trial of Labor and Vaginal Birth after Three Previous Cesarean Sections: Report of Two Special Cases

BACKGROUND

Natural childbirth could represent a deeply rooted need for many women, even in exceptional situations such as after 3 previous caesarean sections.

CASE PRESENTATION

The first patient, a 28-year-old 6^th gravida and 3^rd para, first presented in the 40+3 week of pregnancy desiring a vaginal birth, after all the other hospitals in the area had refused her request. A detailed explanation of potential risks was given and, when 2 days later contractions started, she gave birth to a newborn of 4450 g spontaneously, without complications. A month later, a second woman, 42 years old, 5^th gravida, 3^rd para, read about the above-mentioned case on social media and decided to attempt a natural delivery after 3 caesarean sections at our hospital as well. She presented herself for the first time in the 41+1 week of pregnancy in our delivery room with an onset of labor after rupture of the membranes and gave birth on the same day, spontaneously without complications, to a 4150 g heavy healthy newborn.

CONCLUSIONS

The wish to attempt a spontaneous birth after 3 previous caesarean sections can be deeply anchored and should be professionally approached by obstetricians, even if counseling and management can be challenging.

No. 155-Guidelines for Vaginal Birth After Previous Caesarean Birth

OBJECTIVE

To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section.

OUTCOME

Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section.

EVIDENCE

MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

RECOMMENDATIONS

VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

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.

Guidelines for Vaginal Birth After Previous Caesarean Birth

OBJECTIVE

To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section.

OUTCOME

Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section.

EVIDENCE

MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section". The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

RECOMMENDATIONS

1. Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section (II-2B). 2. The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (II-2B). 3. For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is possible. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A). 4. Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely Caesarean section (III-B). 5. In the case of a TOL after Caesarean, an approximate time frame of 30 minutes should be considered adequate in the set-up of an urgent laparotomy (III-C). 6. Continuous electronic monitoring of women attempting a TOL after Caesarean section is recommended (II-2A). 7. Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A). 8. Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (11-2A). 9. Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B). 10. Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate counselling (II-2B). 11. Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean section (II-2A). 12. A foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A). 13. The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture (II-2B). 14. Multiple gestation is not a contraindication to TOL after Caesarean section (II-2B). 15. Diabetes mellitus is not a contraindication to TOL after Caesarean section (II-2B). 16. Suspected fetal macrosomia is not a contraindication to TOL after Caesarean section (II-2B). 17. Women delivering within 18 to 24 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B). 18. Postdatism is not a contraindication to TOL after Caesarean section (II-2B). 19. Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a low transverse incision is high, a TOL after Caesarean section can be offered (II-2B).

VALIDATION

These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

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.

Trial of labour after four Caesarean sections: a case report and literature review

We present the case of a woman who requested trial of labour following four Caesarean sections and achieved a vaginal birth. We discuss the recent legal rulings pertaining to patient consent in respect to Caesarean section and published data on outcomes following trial of labour after more than 1 Caesarean section.

Vaginal birth following two previous cesarean sections

OBJECTIVE

To evaluate the management of vaginal delivery among women with two previous cesarean sections. The maternal and fetal morbidities of this attitude were studied.

SETTING

University hospital.

DESIGN

Retrospective study made over 6 years, from January 1st 1990 to December 31st 1995.

PATIENTS

Among 180 patients with two uterine scars, 96 patients with cephalic presentation and normal pelvic dimensions were allowed trial of labor.

RESULTS

The rate of vaginal birth following trial of labor was 65.6%. Three patients had an uterine scar dehiscence; among them, one hysterectomy was performed for haemorrhage with uterine atony. Neonatal issue was always favorable. Twenty-two newborns had superior birthweights compared to those born from the preceding cesarean section.

CONCLUSION

Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity.

Childbearing research: a transcultural review

This article provides an examination of the keynote and current literature concerning traditional beliefs and practices pertinent to childbearing. Toward this aim, investigations implemented in western and non-western societies spanning 35 years are discussed. Each study is summarized in a table indicating the characteristics of the population, the methodology and the results. The key issues identified for study in developing countries are: poverty, illiteracy, malnutrition, prostitution, substance abuse, family disruption, lack of child care, high rates of maternal and infant mortality and the patterns of utilization of health services. Industrialized societies are faced with different problems: isolation of the nuclear family, economic pressure for mothers to work, deficiency of child care facilities, ambiguity in the definition of parental roles, marital instability and impersonal, medicalized health care. These reported results provide the basis for culturally-sensitive suggestions to improve social welfare schemes, health prevention and treatment programs. Dominant themes and changing trends in research content and methodology have been drawn from this literature review. These trends indicate that future investigations will: (a) focus upon populations-at-risk; (b) involve large representative samples; (c) address prominant social and health problems; (d) challenge currently held assumptions; (e) and use interdisciplinary methods, ethnographic, epidemiologic and intervention approaches in concert to produce vital and culturally-informed data for research development, policy decisions and program implementation.

Are multiple cesarean sections safe?

To assess the maternal and neonatal risk associated with high-order cesarean sections, a case-control study was carried out in two university affiliated maternity wards. The outcome of 154 pregnancies of women undergoing cesarean section for the 4th time or more was compared with 148 women sectioned for the 2nd or 3rd time and 132 women of similar age and parity after spontaneous birth. The main outcome measures were maternal operative and postoperative morbidity and neonatal prematurity and its complications, Apgar scores, and the need for intensive care. Women undergoing multiple (> or = 4) cesarean sections had significantly more intra-abdominal adhesions (P < 0.0001) than women sectioned for the 2nd or 3rd time. However, the time interval from incision to delivery and the total duration of operation were similar. The postoperative course was not adversely affected by multiple cesarean sections. A high incidence (16.2%) of preterm cesarean deliveries was noted in the study group. This was due to non-elective repeat cesarean delivery rather than to poor timing of scheduled cesarean sections. The significantly increased (P < 0.05) need for neonatal intensive care was explained by the higher occurrence of prematurity. Low Apgar scores (< or = 7) at 1 and 5 min were significantly (P < 0.01) related to multiple cesarean sections, even after controlling for the effect of gestational age. We conclude that multiple cesarean sections pose little risk for the mother, but may be associated with increased neonatal risk, attributed mainly to preterm non-elective cesarean sections.

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.

Epidemic of caesarean sections in Brazil

Brazil has one of the highest rates of caesarean section in the world. Patterns of caesarean sections were studied in a cohort of 5960 mothers followed from 1982 to 1986 in southern Brazil. Overall, 27.9% were delivered by caesarean section in 1982, this proportion being 30% for nulliparae, 80% for second deliveries when the first was by caesarean, and over 99% for third births when the first two were by caesarean. Socioeconomic status and requests for sterilisation by tubal ligation were important underlying factors. 9.4% of the women were sterilised during a caesarean section (3.7% in the lowest income group and 20.2% in the highest). 31% of women who had had their first child by a caesarean section and who were having a second operative delivery were sterilised. The high rates of caesarean sections and accompanying sterilisations reflect the lack of appropriate reproductive and contraceptive policies in the country.

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 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)

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.

Obstetric outcome of patients with more than one previous cesarean section

Records of patients with more than one previous cesarean section were reviewed for a 1-year period. Of 69 such pregnancies, 36 underwent trial of labor in concurrence with an ongoing departmental cesarean section reduction initiative; 80% culminated in vaginal delivery. Twenty of these 69 patients had three or more previous cesarean sections; 9 underwent trial of labor, with 8 subsequent vaginal deliveries. The vaginal delivery rate after more than one previous cesarean section was no different from that of patients with only one previous cesarean section. We conclude that trial of labor in patients with more than one previous cesarean section did not result in a deleterious outcome. Our findings suggest that a trial of labor after more than one previous cesarean section delivery can safely be allowed. Guidelines can be identical to those already established for patients with only one previous cesarean section.

Caesarean section and trial of scar

A retrospective study over a 16-year interval at the Mercy Maternity Hospital was made to analyse the contribution made by repeat Caesarean to the overall Caesarean section rate. The practice of trial of scar was examined with reference to the selection of patients, the conduct of labour, and the risks incurred by the mother and infant. The literature has been reviewed. The overall Caesarean section rate was 13.1% with 39.1% being repeat Caesarean sections. The primary rate has increased from 6.6% to 9.3% while the incidence of repeat Caesarean has increased from 2.7% to 6.8%. Of the 4,892 patients with one or more previous Caesarean sections, 1,577 (32.0%) were allowed a trial of scar, 1,197 (75.9%) of whom achieved a vaginal delivery. Thirteen patients sustained a ruptured uterus (0.82%) and 2 of the infants died (perinatal mortality 0.13% due to this complication alone).

Multiple caesarean sections: outcomes and complications

The outcome and complications of caesarean section were compared between 64 women who had had between three and eight previous sections (mean four) and 61 women sectioned for the first or second time. Gestational age was slightly less in the group with multiple operations. Of the women with three or more previous sections 27% had developed a fenestration in the transverse uterine scar; this was symptomless in half of them, and there was no associated severe ante- or intrapartum haemorrhage. Operation time was longer in women with multiple caesarean sections, and 13% required a caesarean hysterectomy. There were no other differences in the operative or postoperative courses between the two groups. In most women who have had multiple caesarean sections it is possible to wait for elective delivery until the fetus is mature. No absolute upper limit for the number of repeat caesarean sections can be given.

Vaginal birth after cesarean (VBAC) in the 1980s

The incidence of vaginal birth after cesarean (VBAC) and characteristics of VBAC births are investigated using 1980-85 National Hospital Discharge Survey Data collected by the National Center for Health Statistics. Only 3.4 per cent of mothers with previous cesarean delivery had VBAC in their subsequent 1980 delivery; this increased to 6.6 per cent in 1985. Because VBAC is a relatively infrequent event, 1980-85 data were combined and indicate that in this period 4.9 per cent of mothers with previous cesarean had a vaginal birth in their subsequent delivery. Combined 1980-85 VBAC rates are under 10 per cent for all age, race, marital status, region, hospital size, hospital ownership, and expected source of payment groups. Between 1980 and 1985, over 1.4 million repeat cesareans were performed for mothers having a live birth. Evidence suggests that potentially over 500,000 of these repeat cesareans could have been VBACs (over and above the 74,000 VBACs which occurred). VBAC mothers' mean length of hospital stay is 3.2 days, which compares closely with 3.0 days for other vaginal deliveries, but both contrast sharply with 5.6 days for repeat cesareans and 6.0 days for primary cesareans. Except for the uterine scar from the previous cesarean, VBAC mothers appear to have about the same history and frequency of complications as mothers with other vaginal deliveries. If the 500,000 repeat cesareans had been VBACs, surgical fees and costs for 1.2 million days of hospital stay would have been averted over the 1980-85 period.

Examination of previous caesarean section scars by ultrasound

We examined 84 lower segment caesarean section scars by ultrasonography near term. Seventy scars showed good healing with a thickness of the lower uterine segment of more than 3 mm; 14 scars showed poor healing with a thickness of less than 2 mm and loss of continuity. Among 70 patients with good healing, 24 patients delivered vaginally but the remaining 46 patients have had repeat caesarean sections for other obstetric indications. Intraoperative findings in these 46 patients were as follows: Grade I (no thinning of the lower uterine segment), 42; Grade II (thinning and loss of continuity of the lower uterine segment but fetal hair not visible), 4; Grade III (thinning of the lower uterine segment and fetal hair visible), 0. Fourteen patients with poor healing had repeat caesarean sections. Intraoperative findings in these 14 patients were as follows: Grade I, 0; Grade II, 9; Grade III, 5. These results indicate that ultrasound examination detect thinning of the lower uterine segment and may help to determine management.