Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery

Department of Obstetrics and Gynecology, Columbia University, New York, New York, United States
Obstetrics and Gynecology (Impact Factor: 5.18). 08/2006; 108(1):12-20. DOI: 10.1097/01.AOG.0000224694.32531.f3
Source: PubMed

ABSTRACT To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries.
We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery.
Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93).
A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women.

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Available from: Ronald Wapner, Sep 28, 2015
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    • "(i.e. 9–30/1000 women) [29] [30]. "
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    • "225 Review 2010;12:223–230 The Obstetrician & Gynaecologist © 2010 Royal College of Obstetricians and Gynaecologists Box 1 Causes of uterine rupture During pregnancy • Previous classical caesarean section • Previous hysterotomy (very rare) • Previous myomectomy • Placenta accreta • Motor vehicle accidents • Müllerian anomalies of uterus • Hysteroscopic metroplasty • Difficult curettage for miscarriage Rare causes described in primigravida women • Ehler–Danlos syndrome • Chronic steroid use • Use of cocaine During labour • Previous caesarean section • Previous myomectomy • Grand multiparity • Malpresentation: unrecognised brow, face and shoulder presentation • Unrecognised cephalopelvic disproportion • Obstructed labour • Prostaglandin and oxytocin augmentation in women with high parity and previous caesarean section • Use of high doses of misoprostol in parous women • Instrumental delivery (injudicious use of Kielland forceps) • Assisted breech deliveries Rare causes • Tumours obstructing the birth canal • Pelvic deformity Post delivery • Precipitate labour • Manual removal of placenta • Uterine manipulation (intrauterine balloon) • Placenta accreta Site and type of uterine scar and number of previous uterine surgeries Incidence (%) One previous lower segment scar Landon et al. (2006) 8 0.7 SOGC (2005) 25 0.2–1.5 "
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    ABSTRACT: Key content•Uterine rupture is an uncommon complication of pregnancy associated with potentially catastrophic consequences for both mother and baby.•Previous uterine surgery is the most common underlying cause; however, multiparous women without uterine scarring are also at risk if labour becomes obstructed.•A review of CEMACH reports has shown a consistent decrease in maternal mortality secondary to uterine rupture despite increasing caesarean section rates.•The risk of uterine rupture during attempted vaginal birth after caesarean section is widely recognised; however, there needs to be greater awareness of this emergency occurring in multiparous women undergoing induction/augmentation of labour.Learning objectives•To define uterine rupture.•To examine the causes and risk factors for antepartum and intrapartum uterine rupture.•To review the signs and symptoms.•To revise the management of uterine rupture.•To increase awareness of this very serious complication and to suggest how clinicians can make a case-based individual assessment of uterine rupture risk.Ethical issues•Are those women at risk of uterine rupture adequately counselled about the possibility and potential consequences?Please cite this article as: Manoharan M, Wuntakal R, Erskine K. Uterine rupture: a revisit The Obstetrician & Gynaecologist 2010;12:223–230.
    The Obstetrician & Gynaecologist 01/2011; 12(4):223 - 230. DOI:10.1576/toag.
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    • "In our opinion comparing this group with those who opted for an ERCS would have been imprudent considering the two groups were exposed to different risk profiles [13,22]. A short inter-pregnancy interval [23], birth weight [24], maternal diabetes [25], obesity and excessive weight gain [26,27] and lesser degree of cervical dilatation at admission [28] have all been found to influence the success of ToS. This was not tested for in our study as it was not our primary objective. "
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    ABSTRACT: The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes. A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009. Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes. A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.01234. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported. Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.
    BMC Pregnancy and Childbirth 10/2010; 10:62. DOI:10.1186/1471-2393-10-62 · 2.19 Impact Factor
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