Maternal and Perinatal Outcomes Associated With a Trial of Labor After Prior Cesarean Delivery

Department of Obstetrics and Gynecology at Ohio State University, College of Medicine and Public Health, Columbus 43210-1228, USA.
New England Journal of Medicine (Impact Factor: 55.87). 12/2004; 351(25):2581-9. DOI: 10.1056/NEJMoa040405
Source: PubMed


The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain.
We conducted a prospective four-year observational study of all women with a singleton gestation and a prior cesarean delivery at 19 academic medical centers. Maternal and perinatal outcomes were compared between women who underwent a trial of labor and women who had an elective repeated cesarean delivery without labor.
Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). Hypoxic-ischemic encephalopathy occurred in no infants whose mothers underwent elective repeated cesarean delivery and in 12 infants born at term whose mothers underwent a trial of labor (P<0.001). Seven of these cases of hypoxic-ischemic encephalopathy followed uterine rupture (absolute risk, 0.46 per 1000 women at term undergoing a trial of labor), including two neonatal deaths. The rate of endometritis was higher in women undergoing a trial of labor than in women undergoing repeated elective cesarean delivery (2.9 percent vs. 1.8 percent), as was the rate of blood transfusion (1.7 percent vs. 1.0 percent). The frequency of hysterectomy and of maternal death did not differ significantly between groups (0.2 percent vs. 0.3 percent, and 0.02 percent vs. 0.04 percent, respectively).
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. This information is relevant for counseling women about their choices after a cesarean section.

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Available from: Ronald Wapner, Nov 10, 2015
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    • "Maternal complications associated with elective repeat cesarean include placenta accreta, visceral injury, intensive care unit admission, hysterectomy, blood transfusion, and a longer duration of hospital stay [5]. Vaginal birth after cesarean (VBAC) is not without its own risks, which include uterine rupture [6], endometritis, and the need for blood transfusion [7]. Awareness of these complications, combined with maternal anxiety about requiring an emergency cesarean, may be the reason that uptake of trial of labor after cesarean (TOLAC) is low [8]. "
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    ABSTRACT: Objective To compare the characteristics of women who select elective repeat cesarean rather than trial of labor after cesarean (TOLAC) for delivery, and to determine individual predictors for success and failure within a TOLAC group and observe differences in maternal and neonatal morbidity. Methods The present descriptive, retrospective, observational study was performed in a regional obstetric unit in the United Kingdom. Data were collected from the Northern Ireland Maternity System database on all women who gave birth between April 2010 and April 2012, and had a previous cesarean delivery, and statistical analysis was performed. Results In total, 893 patients were included in the study: 385 underwent TOLAC and 493 underwent elective repeat cesarean. On comparison, women in the elective repeat cesarean group had a shorter inter-delivery interval and fewer had had a previous vaginal delivery (P< 0.005). Predictors for success in the TOLAC group included previous vaginal delivery and a longer inter-delivery interval (P< 0.05). Successful vaginal birth after cesarean (VBAC) did not have higher rates of maternal morbidity. Conclusion The majority of patients (56%) chose elective repeat cesarean rather than TOLAC, which has long-term implications both clinically and financially. A validated prediction model might improve patient counseling and identify women with a high likelihood of successful VBAC.
    Full-text · Article · Mar 2014 · International Journal of Gynecology & Obstetrics
    • "The first was a scar rupture in a case of previous LSCS where emergency laparotomy was carried out with rent repair. In women undergoing trial of vaginal birth after caesarean section, forceps application is recommended to cut short second stage to prevent prolonged bearing down by the mother, also these patients have a risk of intra-partum scar rupture of 0.7% as found by the National Institute of Child Health and Human Development Study.[11] The other one was a multigravida with pre-labor membrane rupture where cervical priming agent prostaglandin E2 gel was used, which unfortunately caused hyperstimulation leading to fetal distress necessitating forceps delivery. "
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    ABSTRACT: The art of forceps delivery though existing for centuries has earned a disreputation due to the possibility of poor maternal and fetal outcome. However, its safe use can reduce the rising cesarean section rates in the present times. This study is to see the outcome of its use in a teaching hospital over a 2 year period. In this retrospective observational study, 120 cases of forceps delivery were studied for maternal outcome such as injuries, postpartum hemorrhage, and fetal outcome such as Apgar score at birth, neonatal intensive care unit admissions, injury, and mortality. The most common indication was fetal distress (47.5%). A total of 15 cases (12.5%) of maternal injuries occurred, with 2 uterine ruptures one of which was in a previous lower segment caesarean section case, 4 complete perineal tears and 9 minor cervical and vaginal lacerations. A total of 12 babies (10%) had poor Apgar scores who recovered after resuscitation and one out of them died, which was a case of multiple instrumentation. Forceps is a reasonable option for the obstetrician to reduce the caesarean section rates; however, extreme caution, proper expertise and judicial use of this instrument are required to prevent undue risk to mother and fetus.
    No preview · Article · Mar 2014
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    • "The 2005 SOGC guideline advocates that prostaglandins should only be used in exceptional situations and after appropriate counselling [6]. Mechanical methods for cervical ripening such as the Foley catheter seem to be a good alternative in women with a prior cesarean delivery, carrying a lower risk of uterine rupture compared to prostaglandins [11] [12] [13]. "
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    ABSTRACT: Objective. We aim to investigate methods and use of cervical ripening in women without and with a prior cesarean delivery in The Netherlands. Methods. In 2010, we conducted a postal survey in all Dutch hospitals with a labor ward. One gynecologist per hospital was addressed and was asked to respond on behalf of the staff. The questionnaire contained 31 questions concerning cervical ripening and induction of labor. We compared this survey to a similar Dutch survey conducted in 2006. Results. Response rate was 78% (70/92 hospitals). In women without a prior cesarean and in need of cervical ripening, all hospitals (100%) applied prostaglandins (either E1 or E2). In women with a prior cesarean, 21.4% of the hospitals performed an elective cesarean section if delivery was indicated (26.0% in 2006). In case of cervical ripening, 72.7% used mechanical methods (49.1% in 2006), 20.0% used prostaglandins (40.4% in 2006), 3.6% used a combination of prostaglandins and mechanical methods, and 3.6% used membrane-sweeping or oxytocin. Conclusions. In 2010, in The Netherlands, prostaglandins and Foley catheters were the preferred methods for cervical ripening in women without and with a prior cesarean, respectively. Use of mechanical methods in women with a prior cesarean has increased rapidly between 2006 and 2010, corresponding with decreasing use of prostaglandins and elective repeat cesarean sections.
    Full-text · Article · Jun 2013 · Obstetrics and Gynecology International
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