Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

Middle eastern college of obstetricians and gynecologists (MCOG) practice guidelines: Role of prediction models in management of trial of labor after cesarean section. Practice guideline no. 05-O-22✰,✰✰,★,★★

Cesarean delivery rates have been steadily rising since the beginning of the 21st century. The growing incidence is even more prominent in developing countries owing to lack of evidence-based guidance and audit, and the expansion of private practice. The uprise in Cesarean delivery rate has been associated with considerable financial burden and has increased the risk otherwise uncommon serious complications such as placenta accreta disorders and uterine rupture. In addition to primary prevention of Cesarean delivery, trial of labor after cesarean section is one of the most successful strategies to reduce Cesarean deliveries and minimize risks associated with higher order Cesarean deliveries. This guideline appraises patient selection strategies and use of prediction model to promote counseling and enhance safety in women considering vaginal birth after Cesarean.

Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age

Although the influence of advanced maternal age (AMA) and delayed childbearing on adverse maternal and perinatal outcomes has been studied extensively, no universal consensus on the definition of AMA exists. This terminology currently refers to the later years of a woman's reproductive life span and generally applies to women age ≥35 years. AMA increases the risk of pregnancy complications, including ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, placenta previa and abruption, gestational diabetes, preeclampsia, and cesarean delivery. Such complications could be the cause of preterm birth and increase the risk of perinatal mortality. For women who have a chronic illness, pregnancy may lead to additional risk that demands increased monitoring or surveillance. The management of pregnant women of AMA requires understanding the relationship between age and preexisting comorbidities. The outcomes from pregnancy in AMA may have a negative impact on women's health as they age because of both the changes from the pregnancy itself and the increased risk of pregnancy-related complications. Postpartum depression affects women of AMA at higher rates. Links between preeclampsia and the risk of future development of cardiovascular disease require follow-up surveillance. The association between hypertensive pregnancy disorders and cognitive and brain functions needs further investigation of sex-specific risk factors across the life span. Educating providers and women of AMA is crucial to facilitate clinical decision making and such education should consider cultural influences, risk perception, and women's health literacy, as well as providers' biases and system issues.

Trial of Labor After Cesarean in Adolescents - A Multicenter Study

STUDY OBJECTIVE

Data regarding trial of labor after cesarean delivery (TOLAC) among young women are limited. The aim of this study was to assess the TOLAC success rate and its related factors among adolescent women who had never delivered vaginally.

DESIGN

A multicenter retrospective cohort study of all adolescent women aged ≤21 years with a history of 1 previous cesarean delivery, who delivered in 2 tertiary medical centers during 2007-2019. Women were allocated to 2 groups: 1) women who underwent TOLAC, and 2) women who had a repeat cesarean delivery with no trial of labor. Maternal and neonatal outcomes were compared between the two groups. In addition, perinatal outcomes were compared between women with successful and unsuccessful TOLAC.

RESULTS

The study cohort included 167 women who had a previous caesarean delivery; 117 underwent TOLAC and 50 underwent a repeat cesarean delivery with no trial of labor. Neonatal birthweight (median 2937 vs 3170 g, P = .03) and gestational age at delivery (median 38 weeks vs 39, P = .009) were lower in the repeat cesarean group as compared to those undergoing TOLAC. Overall, 97 of 117 participants (83%) had a successful TOLAC. Failed TOLAC was associated low birthweight as compared to successful TOLAC (5 [25%] vs 7 [7%], odds ratio [OR] 4.3, 95% confidence interval [CI] 1.2-15.3, P = .02), and birthweight difference between current and previous deliveries was higher in the failed TOLAC group (median 315 vs 197 g, P = .04). Rates of neonatal Apgar score at 1 minute < 7 and of neonatal intensive care unit admission were higher in the TOLAC failure group (4 [20%] vs 5 [5%], OR 4.6, 95% CI 1.1-19.0, P = .03, and 4 [20%] vs 4 [4%], OR 5.8, 95% CI 1.3-25.6, P = .02), respectively). In a multivariable logistic regression analysis, only low birthweight was independently associated with TOLAC failure (adjusted OR 9.9, 95% CI 2.1-45.4, P = .003). Two cases of uterine rupture occurred in the no trial of labor group, whereas none were encountered in participants undergoing TOLAC.

CONCLUSIONS

TOLAC in adolescent women who had never delivered vaginally is associated with a relatively high success rate.

Obstetric outcome of induction of labor using prostaglandin gel in patients with previous one cesarean section

Objective

After globally acceptance of planned vaginal birth after cesarean section (VBAC), the mode of induction is still a matter of debate and requires further discussion. We aimed to study obstetric outcomes in post-cesarean patients undergoing induction of labor with prostaglandin gel compared with patients who developed spontaneous labor pains.

Methods

All patients at 34 weeks or more of gestation with previous one cesarean section eligible for trial of labor after cesarean section admitted in a labor room within one year were divided in 2 groups. Group one consisted of patients who experienced the spontaneous onset of labor pains and group 2 consisted of patients who underwent induction of labor with prostaglandin gel. They were analyzed for maternofetal outcomes. Descriptive statistics, independent sample t-test, and chi-square test were applied using SPSS 20 software for statistical analysis.

Results

Both groups were comparable in maternal age, parity, and fetal weight, but different in bishop score, mode of delivery, and neonatal outcome. Admisson bishop score was 6.61±2.51 in group 1 and 3.15±1.27 in group 2 (P<0.005). In the patients who experienced spontaneous labor, 86.82% had successful VBAC. In the patients with induced labor, 64.34% had successful VBAC with an average dose of gel of 1.65±0.75. Both groups had one case each of uterine rupture. The neonatal intensive care unit admission rate was 4.1% in group one and 10.4% in group 2.

Conclusion

This study reflects that supervised labor induction with prostaglandin gel in previous one cesarean section patients is a safe and effective option.

No-271-Delayed Child-Bearing

OBJECTIVE

To provide an overview of delayed child-bearing and to describe the implications for women and health care providers .

OPTIONS

Delayed child-bearing, which has increased greatly in recent decades, is associated with an increased risk of infertility, pregnancy complications, and adverse pregnancy outcome . This guideline provides information that will optimize the counselling and care of Canadian women with respect to their reproductive choices .

OUTCOMES

Maternal age is the most important determinant of fertility, and obstetric and perinatal risks increase with maternal age . Many women are unaware of the success rates or limitations of assisted reproductive technology and of the increased medical risks of delayed child-bearing, including multiple births, preterm delivery, stillbirth, and Caesarean section . This guideline provides a framework to address these issues .

EVIDENCE

Studies published between 2000 and August 2010 were retrieved through searches of PubMed and the Cochrane Library using appropriate key words (delayed child-bearing, deferred pregnancy, maternal age, assisted reproductive technology, infertility, and multiple births) and MeSH terms (maternal age, reproductive behaviour, fertility) . The Internet was also searched using similar key words, and national and international medical specialty societies were searched for clinical practice guidelines and position statements . Data were extracted based on the aims, sample, authors, year, and results .

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

RECOMMENDATIONS

Induction of labor by Foley catheter compared with spontaneous onset of labor after previous cesarean section: a cohort study

OBJECTIVE

To evaluate the safety of induction of labor (IOL) with Foley catheter (FC) in women with a history of previous cesarean section (CS) and to assess risk factors for repeat CS and adverse maternal outcomes.

STUDY DESIGN

Cohort study of 1559 women with a history of previous CS in Helsinki University Hospital, Finland between 2013 and 2014.

RESULTS

Three hundred and sixty-one women (23.2%) underwent IOL by FC and 1198 (76.8%) had spontaneous onset of labor. The rate of repeat CS was higher in women undergoing IOL (38% vs 20.2%; P<0.001). The overall rate of uterine rupture was 0.3% in induced labor and 0.8% in spontaneous onset of labor (P=0.47). Adverse maternal outcomes were not significantly different. The intrapartum and postpartum infection rates were higher in women undergoing IOL compared with spontaneous onset of labor (6.1% vs 1.8%; P>0.001 and 5.3% vs 1.3%; P<0.001, respectively).

CONCLUSION

FC appears safe and effective method for IOL in women with a history of previous CS.

[Predictors of birth outcomes related to women with a previous caesarean section: experience of a Motherhood Center, Bizerte]

INTRODUCTION

Caesarean section (CS) rates have been significantly increasing in recent decades. For this reason, the obstetrician must frequently decide on the most appropriate mode of delivery for mother and fetus. This study aims to describe vaginal birth after previous cesarean section (VBACs) in our obstetric practice and to identify factors significantly associated with failed VBACs.

METHODS

We conducted a population-based study among women with a history of previous cesarean delivery. The study design was retrospective, longitudinal, descriptive and analytical. The case study was conducted over a two years and three months period, from January 1, 2012 to March 31, 2014 during which we collected data from 423 medical records of patients attempting VBACs at the Maternity and Neonatology Center, Bizerte.

RESULTS

The rate of attempted VBACs was 47%. The success and the failure rates of these attempts were 82,7% and 17,3% respectively. The main factors for a poor prognosis in patients attempting VBACs were: the absence of a previous vaginal delivery (p = 0.005), a previous indication for cesarean section due to stagnation of dilatation or poor labor progress, (p 0.049 and 0.002 respectively), gestational age at delivery of = 40 weeks (p = 0.046), parity <3 (p = 0,75.10-4), Bishop score <6 at the onset of labor (p = 0,23.10-47), "active labor" duration = 6h (p = 0.002), length of labor> 8 h (p = 0.0031) and the occurrence of abnormal fetal heart rate (FHR) during labor (p = 0144.10 -9). We observed seven cases of uterine rupture (1.7%). There were no cases of maternal mortality. Total maternal morbidity rate was 9,5%. The difference in rates of maternal complications between the two groups (failed and successful attempted vaginal birth after cesarean) was not statistically significant.

CONCLUSION

Attempting vaginal birth after cesarean on the basis of good and poor prognostic factors and patient consent, contributes to the reduction in maternal and neonatal morbidity and should lead to the establishment of clear and codified Tunisian guidelines as part of a policy against unjustified iterative caesarean sections.

Vaginal birth after cesarean: an effective method to reduce cesarean

Cesarean deliveries represent almost one third of US births. Given that repeat cesarean is the most common single indication for cesarean, trial of labor after cesarean (TOLAC) with subsequent vaginal birth after cesarean (VBAC) is an important mechanism to reduce the overall cesarean rate. The 2010 National Institutes of Health Conference found that one of the biggest barriers to VBAC is the lack of patient access to TOLAC. Many women who currently deliver by repeat cesarean would be candidates for a TOLAC. This manuscript will summarize the evidence on VBAC to help clinicians identify candidates, provide evidence-based counseling, and guide management of TOLAC.

Do They Stand a Chance? Vaginal Birth after Cesarean Section in Adolescents Compared to Adult Women

STUDY OBJECTIVE

To determine the rate of elective repeat cesarean delivery (CD), vaginal birth after cesarean (VBAC) attempt, and VBAC success in adolescent mothers presenting for delivery of a second child after a prior CD compared to their adult counterparts.

DESIGN

Retrospective cohort study analyzing data from the Consortium on Safe Labor Database which includes data for 228,668 deliveries from 2002 to 2008.

SETTING

19 hospitals within 12 institutions in the United States.

PARTICIPANTS

10,791 women age ≤ 35 (428 adolescents, age ≤ 19 and 10,363 adults age 20-35) with history of prior CD presenting for delivery of a second child.

METHODS

The database was accessed for information on patient characteristics, prenatal comorbidities, and delivery data. Rates of repeat CD, VBAC attempt, and VBAC success were calculated. Multiple logistic regression was applied to identify predictors of VBAC success.

RESULTS

Adolescents had a lower overall repeat CD rate and higher VBAC attempt rate compared to adults (80.61% vs 85.32%, P = .0072; 40.42% vs 30.09%, P < .0001 respectively). VBAC success was similar between adolescents and adults (47.98% vs 48.78% P = .8368). Delivery at a teaching hospital and greater gestational age were predictive of VBAC success. Gestational diabetes mellitus, induction of labor, and higher maternal body mass index were predictive of VBAC failure. Adolescence was not an independent predictor of VBAC outcome.

CONCLUSIONS

Adolescents are more likely to attempt VBAC and are likely to be as successful as their adult counterparts. Adolescents should be encouraged to attempt a trial of labor after prior CD when appropriate to lower the risks of lifelong maternal morbidity from numerous repeat CDs.

An observational study of various predictors of success of vaginal delivery following a previous cesarean section

OBJECTIVES

To study the various predictors of success for vaginal birth after cesarean (VBAC) and to study the maternal and fetal outcomes in them and their comparison with control group.

METHODS

This prospective observational study included 100 women with previous cesarean section in the study group and 100 primigravidas in the control group. Various predictors for success of VBAC were analyzed and maternal and fetal outcomes were compared with the control group using student t test, Pearson χ (2) test, and Mann-Whitney U test.

RESULTS

Of 100 women with prior cesarean Sect. 65 had successful trial of labor, while 35 underwent a repeat cesarean section. Maternal complications in the previous CS group were 15 % as compared to only 2 % in the control group (p < 0.001).

CONCLUSION

Maternal pre-pregnancy BMI, non-recurring indications of previous cesarean section, good Bishop's score at the time of admission, spontaneous onset of labor, and neonatal birth weight were significantly related to high chances of success of vaginal birth after previous cesarean section. Maternal complications were more common in study group, but the fetal outcomes were similar.

Frequency of vaginal birth after cesarean section at clinic of gynecology and obstetrics in sarajevo

At the Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo there is a trend of increasing number of cesarean deliveries in the last 15 years.

MATERIAL AND METHODS

During the 2012 percentage of Caesarean sections was 35 %, which represents a true pandemic in obstetrics profession and all scientific postulates are threatened by these practices. Of the total number of vaginal births only 48 deliveries were after previous cesarean section. Of the total number of subjects in which the delivery is completed vaginally after a previous cesarean delivery in 5 (10.42 %) was used vacuum extraction, forceps was not used, while manual exploration of the uterus in order to check the condition of the scar of a previous cesarean section was performed in 32 (66.67%) cases.

RESULTS AND DISCUSSION

The largest number of respondents who were surveyed were at age from 31 - 35 years (n=25), followed by group between 26-30 years (39.58%). The analysis of complications of vaginal birth after Caesarean delivery revealed that 93.75 % of the patients did not have any complications, at 4.17 % occured postpartum hemorrhage and in one patient febrile condition. Birth after cesarean delivery can be successfully completed vaginally, with a careful application of prostaglandins, with a good estimate of an experienced obstetrician, and adequate conditions to complete delivery by caesarean section if a vaginal birth is not going in the right direction and as planned.

Ethnic disparities in repeat caesarean rates at Auckland Hospital

BACKGROUND

New Zealand guidelines recommend that information regarding childbirth choices be given to women with previous caesarean, so they can make informed decisions about their care. We hypothesised that rates of trial of labour (TOL) and vaginal birth after caesarean (VBAC) would vary by women's ethnicity.

AIM

To estimate the association of ethnicity with TOL and VBAC rates.

MATERIALS AND METHODS

Clinical data were used to identify women who gave birth at Auckland Hospital in 2006-2009 with history of previous caesarean eligible for TOL. Multivariable models were used to estimate the association of women's characteristics (ethnicity, age, socio-economic status (SES), height, body mass index, lead maternity carer, diabetes, hypertension, haemorrhage, labour induction, gestational age) with rates of TOL and VBAC.

RESULTS

In the study cohort of 2400 women, the TOL rate was 39.5%; the VBAC rate was 57.4%. Pacific women were twice as likely to have TOL, while Asian and non-New Zealand European women were half as likely to have VBAC, compared with New Zealand European women. Women in more deprived areas were more likely to have TOL, but SES was not associated with VBAC rates. Women under the care of private obstetricians were least likely to have TOL or VBAC.

CONCLUSIONS

There are ethnic disparities in TOL and VBAC rates at our hospital. Strategies need to be developed to ensure that women of all ethnicities have access to both options for mode of delivery.

Prediction of scar integrity and vaginal birth after caesarean delivery

A statistically significant association with uterine rupture during a trial of labour after caesarean delivery was found in at least two studies for the following variables: inter-delivery interval (higher risk with short interval), birth weight (higher risk if 4000 g or over), induction of labour (higher risk), oxytocin dose (higher risk with higher doses), and previous vaginal delivery (lower risk). However, no clinically useful risk estimation model that includes clinical variables has been published. A thin lower uterine segment at 35-40 weeks, as measured by ultrasound in women with a caesarean hysterotomy scar, increases the risk of uterine rupture or dehiscence. No cut-off for lower uterine segment thickness, however, can be suggested because of study heterogeneity, and because prospective validation is lacking. Large caesarean hysterotomy scar defects in non-pregnant women seen at ultrasound examination increase the risk of uterine rupture or dehiscence in subsequent pregnancy, but the strength of the association is unknown. To sum up, we currently lack a method that can provide a reliable estimate of the risk of uterine rupture or dehiscence during a trial of labour in women with caesarean hysterotomy scar(s).

Impact Factors of Korean Women's Cesarean Section according to Ecological Approach

PURPOSE

This study examined the impact factors of cesarean section based on the ecological approach in Korea.

METHODS

Population-based data (Korea Institute for Health and Social Affairs) were used from 2,849 delivery cases during 2003~2009. Data were analyzed using geographic statistics with STATA 10.0 and hierarchical logistic regression with SPSS/WIN 12.0.

RESULTS

The range of cesarean section rate was 28.8~44.7% with geographic distribution. The proportion of mother's problem was increasing in choice of cesarean section. According to the ecological model, age of mother (OR=1.08), time of birth (OR=0.79), delivery in hospital (OR=1.83), delivery in clinic (OR=1.46), and education of mother (OR=2.61) had significant impact on cesarean section.

CONCLUSION

This study contributes to provide the impact factors of the high cesarean rate in Korea ecologically. Policy maker and health care provider can consider these results to reduce cesarean section rate.

A Description of the Management and Outcomes of Vaginal Birth After Cesarean Birth in the Homebirth Setting

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.

Impact of labor at prior cesarean on lower uterine segment thickness in subsequent pregnancy

OBJECTIVE

The objective of the study was to identify the factors associated with sonographic lower uterine segment (LUS) thickness near term in women with prior low transverse cesarean.

STUDY DESIGN

A prospective cohort study of women with a single prior low transverse cesarean was conducted. LUS thickness was quantified by transabdominal ultrasound with repeated transvaginal measurement when necessary. The thinnest measurement was considered as the dependent variable. Potential related factors were evaluated with nonparametric analyses and multivariate logistic regressions.

RESULTS

Two hundred thirty-five women were recruited at a mean gestational age of 36.7 +/- 1.3 weeks. The full LUS was thicker in women who had their previous cesarean during the latent phase (2.8 mm; interquartile [IQ], 2.0-3.3 mm) or the active phase of labor (3.1 mm; IQ 2.5-3.9 mm) than in women with previous cesarean prior to labor (2.4 mm; IQ 2.0-3.2 mm). The association remained significant after adjustment for potential confounders.

CONCLUSION

Presence of labor at previous cesarean is associated with a thicker LUS in a subsequent pregnancy.

Identifying risk factors for uterine rupture

Uterine rupture, whether in the setting of a prior uterine incision or in an unscarred uterus, is an obstetric emergency with potentially catastrophic consequences for both mother and child. Numerous studies have been published regarding various risk factors associated with uterine rupture. Despite the mounting data regarding both antepartum and intrapartum factors, it currently is impossible to predict in whom a uterine rupture will occur. This article reviews the data regarding these antepartum and intrapartum predictors for uterine rupture. The author hopes that the information presented in this article will help clinicians assess an individual's risk for uterine rupture.

Vaginal birth after caesarean delivery: does maternal age affect safety and success?

To estimate maternal age effects on the rates of vaginal birth after caesarean delivery (VBAC), the related maternal complications and patient election to attempt VBAC, we conducted a secondary analysis of a retrospective cohort study of women who were offered VBAC from 1996 to 2000 in 17 community and university hospitals. We used bivariable and multivariable analyses to assess the association between maternal age and the study outcomes. A total of 25 005 patients were included, of whom 13 706 (54.81%) elected to attempt VBAC. After controlling for several confounding variables, using ages 21-34 years as the referent group, women aged 15-20 years were 27% less likely to have a failed VBAC attempt (OR = 0.73 [0.62, 0.87], P < 0.001). Analysing maternal age as a dichotomous variable, women who were of advanced maternal age (>or=35 years) were more likely to experience an unsuccessful trial of labour (OR = 1.14 [1.03, 1.25], P = 0.009). In addition, women >or=35 years of age had 39% more risk of experiencing one of the VBAC-related operative complications (OR = 1.39 [1.02, 1.89], P = 0.039). As women increase in age, they are less likely to attempt VBAC and more likely to have an unsuccessful labour trial. While teenage patients do not appear to be at increased risk for VBAC-related complications, patients of advanced maternal age do show an increase in composite VBAC-related operative complication rates.

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.

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.