Predicting Success and Reducing the Risks When Attempting Vaginal Birth After Cesarean

Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri 63110, USA.
Obstetrical & gynecological survey (Impact Factor: 1.86). 08/2008; 63(8):538-45. DOI: 10.1097/OGX.0b013e31817f1505
Source: PubMed


The goal of this manuscript is to review the contemporary evidence on issues pertinent to improving the safety profile of vaginal birth after cesarean (VBAC) attempts. Patients attempting VBAC have success rates of 60%-80%, and no reliable method of predicting VBAC failure for individual patients exists. The rate of uterine rupture in all patients ranges from 0.7% to 0.98%, but the rate of uterine rupture decreases in patients with a prior vaginal delivery. In fact, in patients with a prior vaginal delivery, VBAC appears to be safer from the maternal standpoint than repeat cesarean. Inevitably, the obstetrician today will encounter the situation of deciding whether or not to induce a patient with a uterine scar, and particular attention is paid to the success and risks of inducing labor in this patient population. Induction of labor is associated with a slightly lower successful vaginal delivery rate, although the rate remains above 50% in virtually all patient populations. The rate of uterine rupture increases slightly, but still remains around 2%-3%. Although misoprostol use is discouraged due to its association with increased risks of uterine rupture, transcervical catheters, oxytocin, and amniotomy may be used to induce labor in women attempting VBAC.

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    • "This risk increases when there is a classical or lower uterine segment vertical incision scar [9–12], or when labour is induced using oxytocin [13–15] or prostaglandins [7, 15, 16]. A risk reduction [17, 18] has been described for women with a prior vaginal delivery (PVD); however, no systematically reviewed data exist concerning the magnitude of the effect. This may play an important role in the decision whether to initiate TOL. "
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    ABSTRACT: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery. A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method. Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P < 0.00001). Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.
    Archives of Gynecology 08/2011; 284(5):1053-8. DOI:10.1007/s00404-011-2048-x · 1.36 Impact Factor
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    • "Within its group, the total of caesarean section rate is also very high, accounting for around 71%. Therefore, definitely if any programme should be implemented to specifically reduce caesarean section rates, this group should be highlighted and focused with special intervention procedures, perhaps better addressing the alternatives for obtaining VBAC, mainly among those women with only one previous caesarean scar [17,18]. "
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    ABSTRACT: to compare the distribution of caesarean rates in the Robson's 10 groups classification in order to see if any change occurred after the implementation of an audit and feedback intervention. Design: cross sectional, before and after an audit and feedback study. Setting: a university hospital in Brazil. clinical records of all births during two three months-periods were evaluated. Each case of CS was classified into one of ten mutually exclusive categories according to obstetric characteristics. The proportion of CS in each group was compared in both periods. total number of deliveries and the high rate of CS were similar in both periods. Group 3 (multiparous excluding previous CS, single, cephalic, >/= 37 weeks, spontaneous labour) accounted for the largest proportion of deliveries, 28.5 and 26.8% in both periods. Group 1 (nulliparous, single, cephalic, >/= 37 weeks, spontaneous labour) was the second largest one, while Group 5 (previous caesarean section, single, cephalic, and >/= 37 weeks) was the third but the largest contributor to CS, accounting for 16.6 and 14.9% among all deliveries in both periods. Groups 2 (nulliparous, single, cephalic, >/= 37 weeks, induction or CS before labour) and 4 (multiparous excluding previous CS, single, cephalic, >/= 37 weeks, induction or CS before labour) were less prevalent, however had higher rates of CS. Only in Group 10 (All single, cephalic, </= 36 weeks, including previous CS), there was a significant decrease of CS rate from 70.5 to 42.6% between periods. Robson's classification did not identify any significant change in the pattern of CS rates with the audit and feedback process, but showed to be useful for comparing trends among similar obstetric populations.
    Reproductive Health 06/2010; 7(1):13. DOI:10.1186/1742-4755-7-13 · 1.88 Impact Factor

  • Gynécologie Obstétrique & Fertilité 05/2009; 37(5):457-458. DOI:10.1016/j.gyobfe.2009.03.019 · 0.52 Impact Factor
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