Guidelines for Vaginal Birth after Previous Caesarean Birth

Guidelines for vaginal birth after previous caesarean birth

Guidelines for Vaginal Birth After Previous Caesarean Birth

The MFMU cesarean registry: risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery

Trial of labour after two or three previous caesarean sections

Along with the increasing rate of cesarean section (CS) births has been a concomitant decrease in the rate of vaginal birth after cesarean (VBAC), mostly due to concerns about uterine rupture during a trial of labor (TOL). The risk of uterine rupture in laboring women with a previous CS must be balanced against the increasing current and future risk of peripartum hysterectomy with repeat cesarean. Improved prediction of uterine rupture could allow women at low risk to have a TOL, and those at high risk for uterine rupture could undergo a planned CS. Thinning in the lower uterine segment (LUS) measured by ultrasonography is a possible predictor of uterine rupture. The present study was performed to identify an optimal LUS thickness cutoff value and to define groups of women with a history of previous CS to whom TOL either should not be offered or could be offered safely. PubMed and EMBASE were searched for relevant articles published during 1980 to 2011. Included studies reported on pregnant women with at least 1 prior CS and on the sonographic appearance of the LUS during pregnancy in relation to uterine defects observed during or immediately after delivery. Studies were scored on methodologic and clinical characteristics. For each study, a 2 x 2 table was constructed, cross-classifying LUS thickness measured by ultrasound and the presence of LUS defect after delivery. Sensitivity and specificity were determined for each study in the receiver operating characteristic (ROC) space along with a corresponding summary ROC curve. From an initial 147 citations, 21 studies (all cohort design) were included and involved 2776 women. The median sample size was 71 (range, 10-642; interquartile range, 149.5). Lower uterine segment measurements were obtained at 34 to 39 weeks' gestation. Cutoff values used to define an insufficient LUS ranged from 0.5 to 3.0 mm in studies measuring myometrial LUS thickness and from 1.5 to 5.1 mm in those using full LUS thickness. Full LUS thickness measurement using cutoffs of 2.0 to 3.0 mm had a specificity of 0.91 (95% confidence interval [CI], 0.80-0.96) at a sensitivity of 0.61 (95% CI, 0.42-0.77). Full LUS thickness measurement using cutoffs of 3.1 to 5.1 mm had a specificity of 0.63 (95% CI, 0.30-0.87) at a sensitivity of 0.96 (95% CI, 0.89-0.98). The accuracy of transvaginal or transabdominal sonography could not be compared statistically because of the limited number of studies. The main finding is the strong negative correlation between LUS thickness and risk of uterine defect. The similar shapes of the ROC curves for myometrial and full LUS thickness indicated no significant difference in accuracy, shape, and position. An ideal screening test to predict uterine rupture could affect medical decision making by allowing accurate selection of women with a scarred uterus unlikely to have uterine rupture and thus able to have a TOL

Birth after caesarean section (CS) is an issue of growing importance. As a consequence of increasing CS rates, more women having experienced a prior CS will need counselling about preferred second delivery mode. There are two choices: elective repeat caesarean section (ERCS) or trial of labour (TOL). It is well known, that a TOL ending in an emergency CS carries the largest risks for mother and child. We wanted to investigate for which women and infants it would be safest to recommend an ERCS or a TOL. We assumed, that underlying conditions/indications for the first CS performed would often recur in the second pregnancy and be important for the second delivery outcome. Therefore, a hierarchical system was developed, in which efforts were made to classify according to underlying conditions instead of focusing on conditions appearing during labour, in an attempt to diminish the subjective impact of diagnoses recorded after delivery. The hierarchical system was used through the four papers. We investigated women in the Swedish medical birth register with their first two deliveries 1987-2007 (Paper I-III), or giving birth at least twice, including one CS and at least one delivery after the CS 1992-2011 (Paper IV). In Papers I-III, we have shown that all first CS indications had a statistically significant risk to recur in the second pregnancy/ delivery. Women with a first CS were older, shorter, and had a higher body mass index than women with a first vaginal delivery. The risk for unplanned CS in TOL increased by the women’s age, body mass index, and smoking, while increasing height lowered the risk. Women with a prior CS had an all-over increased risk for unplanned CS in TOL, compared with primiparous women. Infants born to mothers with one prior CS had an almost doubled risk for low Apgar score and perinatal death compared with infants of women with one prior vaginal birth. The risk was lower but still statistically significant after adjustment for possible maternal and fetal/infant confounders. For infants of women with one previous CS, the risk for low Apgar score was higher after a TOL than after an ERCS. In all studies, the risk for adverse outcomes differed substantially between hierarchical indications for the first CS performed. When the first CS was performed without medical indication, no inreased risk for low Apgar score or perinatal death could be detected. The results suggest that underlying conditions, not the previous CS per se, contributed to the risk increase. In Paper IV, we validated a widely used prediction model for chance of successful TOL after CS, developed by Grobman et al. (2007) for US conditions. As the original model was not directly applicable for Swedish settings, we modified it stepwise. The final, new model included maternal age, body mass index, prior vaginal birth, prior vaginal birth after CS, maternal height, first CS hierarchical indication, and the rates of ERCS and unplanned CS in the respective delivery wards. We reached an excellent predictability for vaginal birth in TOL after CS. Counselling about the safest delivery mode after one CS is a challenge. Our study results, combined with previous findings, add important scientific knowledge. However, non-medical factors are vital in the decision-making after one CS, and a trust between the woman, her partner, the obstetrician and the midwife is fundamental. Considering the new information would possibly make counselling easier and, hopefully, lower the rate of unplanned CS in TOL after CS and decrease the rate of low Apgar score and perinatal death in the birth after a caesarean delivery. (Less)

In April 2003, a disciplinary court of the Dutch Medical Council ruled in a case of uterine rupture in a woman with a prior cesarean delivery, which took place in February 2001. The woman was gravida 2, para 1, whose first child was delivered by cesarean section because of breech presentation. In the present pregnancy she had prolonged rupture of membranes (PROM) at term. Priming with 1 mg of prostaglandin E2 gel (PGE2) was started 36 h after PROM. A second application of 2 mg was given six hours later. Three hours later contractions started and four hours after the onset of labor the woman suffered a uterine rupture, had an emergency cesarean section, and an asphyxiated child was born. The child died 10 days later. Several complaints were put forward by the mother, but perhaps the most intriguing issue is whether she should have been induced with PGE2 or not. In the court’s ruling of the case, a study from Washington State (USA), which indicates a higher incidence of uterine scar rupture after PGE2 induction, played a major role (1). Finally the court acquitted the obstetrician of liability during appeal in April 2004, taking into consideration that the US study and the accompanying editorial was published in July 2001 as the lead article in the renowned New England Journal of Medicine, five months after uterine rupture occurred (2). The verdict, however, suggested that if rupture had have happened after the publication, the Court’s ruling might have been different. Until the 1980s the rule ‘once a cesarean, always a cesarean’ was common practice, especially in the USA. Since then a trend has been seen towards vaginal birth after cesarean (VBAC), peaking in the mid 1990s, as one of the ways to curb the increasing cesarean section rate. The VBAC rate in the USA at that time was, however, never higher than 29%, while in Europe the rate was above 50%. Although the incidence of uterine scar rupture in VBAC is low (B/1%) and several large multicenter studies have confirmed the relative safety of VBAC, concern persists that uterine rupture may occur during a trial of labor (TOL) after a prior cesarean section (3 /6). VBAC is therefore still a controversial topic, which has been subjected to intense scrutiny. The quoted paper from the USA with related editorials and correspondence reignited this discussion. Several findings of this study are consistent with results of other studies. The incidence of uterine scar rupture in a TOL without induction (0.52%), and the slightly higher incidence when labor is induced without prostaglandins (0.77%) are in line with the results of other studies (5). However, the finding of a 2.45% risk of uterine rupture when PGE2 is used for * Present address: Atrium Medical Centre, Heerlen, The Netherlands.

BackgroundOffering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda.MethodsAudit of women’s records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014.ResultsOut of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n = 23, 7.7%) compared with women who had an ERCS (n = 5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2–5.4). There was no difference in neonatal admissions between women who underwent ToL (n = 64/297; 21.5%) and those who delivered by ERCS (n = 35/138; 25.4%: aOR 0.8; CI 0.5–1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n = 40, 13.4%) compared to those who delivered by ERCS (n = 15, 10.9%: aOR 1.9; CI 1.6–3.6). Perinatal mortality was similar among infants whose mothers had ToL (n = 8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n = 4; 29/1000 ERCSs).ConclusionsA considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL.

The Never Ending Debate Single-Layer Versus Double-Layer Closure of the Uterine Incision at Cesarean Section

Background. Repeat caesarean section (CS) carries an increased risk of both maternal and neonatal morbidity and mortality. Planned vaginal birth after CS (VBAC), with an estimated success rate of 60 - 80%, is clinically safer than elective repeat CS, and also limits the rise in CSs. There is no single generalised validated tool to predict success of VBAC. Objectives. To determine predictors of successful VBAC among mothers with one previous CS at selected hospitals in Lusaka, Zambia. Method. Determination of independent predictors with significant high odds of a successful VBAC among mothers offered a trial of labour (TOL) was conducted in a cross-sectional study. Women with a history of one previous lower-segment CS, who were carrying a singleton fetus and were in established labour or draining amniotic fluid and scheduled for TOL after CS, were included in the study. Convenience sampling was used to enrol 290 participants. Using SPSS version 22, bivariate analysis and logistic regression analysis were used to analyse data. An independent factor associated with successful VBAC and with a p-value <0.05 was considered significant. Results. Of the participants, 236 (81.4%) had a successful vaginal delivery and 54 (18.6%) failed to deliver vaginally and required emergency CS. Key independent predictors of success of VBAC were primary education level (adjusted odds ratio (AOR) 2.21; 95% confidence interval (CI) 1.01 - 4.84), multiparity (AOR 4.81; 95% CI 1.16 - 19.93), previous successful VBAC (AOR 9.94; 95% CI 1.29 - 76.70), inter-delivery interval after the primary CS (AOR 18.54; 95% CI 5.98 - 57.48), a history of fetal distress (AOR 9.33; 95% CI 2.48 - 35.08), malpresentation (AOR 6.13; 95% CI 1.65 - 22.70) or failed induction of labour (AOR 20.52; 95% CI 3.32 - 127.03) as indications for the primary CS, Bishop score (AOR 7.06; 95% CI 1.92 - 25.97), cervical dilation (AOR 11.62; 95% CI 3.86 - 35.03), duration of labour (AOR 20.78; 95% CI 5.62 - 76.80), birthweight (AOR 6.80; 95% CI 3.33 - 13.91) and Apgar score (AOR 28.42; 95% CI 5.67 - 142.38). Conclusion. A combination of independent sociodemographic and obstetric factors that have significant high odds for a good outcome of VBAC could help predict success of delivery in a given population. This information could also aid in counselling mothers on mode of delivery.

Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands

Objective. To determine the vaginal birth after cesarean section (VBAC) rate and risk of uterine rupture in women with a previous early preterm cesarean section.Methods. Women who delivered their first child by cesarean section between 26 and 34 weeks of gestation were included in a retrospective cohort study. Medical charts were reviewed for characteristics of the index pregnancy and delivery. Information of the subsequent delivery was obtained from the medical charts or from information of the attending gynecologist if the delivery was elsewhere.Results. Two hundred and forty-six women were included: 131 (53.3%) women had a subsequent pregnancy, 64 (26.0%) had no subsequent pregnancy, and from 51 (20.7%) women no information could be obtained. Of the 131 women with a subsequent pregnancy, 93 (71.0%) underwent a trial of labor (TOL) and 80 (86.0%) achieved a vaginal delivery, resulting in a VBAC rate of 61.1%. One uterine rupture occurred with favorable neonatal outcome. The uterine rupture rate for the whole cohort was 0.8% (95% CI 0.02–4.0) and for the group of women undergoing a TOL 1.1% (95% CI 0.03–5.8).Conclusion. In this small series of women with a previous early preterm cesarean section the VBAC rate was high (61.1%) and the uterine rupture rate was 1.1%.

Rates of Caesarean Section (CS) have been increasing worldwide with varying rates of [5] percent in Sub-Saharan Africa to 43 percent in Latin America and the Caribbean [1]. In Australia too rates have increased from 32 percent in 2011 to 38 percent in 20212. Attempts have been made to seek ways at slowing the rise in rates of CS but with little success [3]. Women who have had a previous CS may elect to have a Elective Repeat CS (ERCS) or have an attempt at a Vaginal Birth (VBAC) in their subsequent pregnancy. A planned VBAC, considering the woman’s individual history and needs, is viewed as a safe option for many women with a single previous lower segment caesarean section [4]. Studies have shown that a Trial of Labour (TOL) ending in a VBAC is most favourable for the mother, newborn, and the health service [5,6]. Likelihood of success rates are reported to be between 60 and 80 percent [7]. A recent meta-analysis [8] noted successful vaginal birth rates of 74.3 percent if labour was spontaneous and 60.7 percent if induced. Achieving successful VBAC has also been reported to be less expensive and more effective than undergoing an ERCS [9,10]. There has recently been an international multi-centre trial that aims to increase the proportion of women having VBAC by increasing woman-centred care and facilitating women’s empowerment in their choice of birth in three countries – Germany, Ireland and Italy [1]. An attempt at vaginal birth is also supported by various colleges across countries [4,7,12]. One of the reasons for the preference of ERCS may be a concern of a failed trial at vaginal birth resulting in an emergency CS. In one study of 29 352 women who attempted a vaginal birth after CS compared to 169 377 women without previous CS, Odds Ratio (OR) for emergency CS was 3.65 (CI: 3.26-4.08) higher when compared to women without previous CS [13]. The scibasejournals.org aim of this retrospective study however was to use a large dataset with a specific objective to report on the success and failure rate and to identify any specific predictors of a successful or an unsuccessful vaginal birth in women who are pregnant after one previous CS.

Introduction : Ultrasonography has been used to examine the scarred uterus in women who have had previous caesarean sections in an attempt to assess the risk of rupture of the scar during subsequent labour. This study aims to evaluate the usefulness of sonographic measurement of the lower uterine segment before labour in predicting the risk of intrapartum uterine rupture. Methods : This is a prospective cohort study. Eligible parturients were those with one previous caesarean section who meet the inclusion criteria and were booked for delivery at Irrua Specialist Teaching Hospital. 153 patients underwent transvaginal ultrasound examination at 35-37 weeks' gestation, and were allocated to four groups (≤2.5mm, 2.6-3.5mm, 3.6-4.5mm and ≥4.6mm) according to the thickness of the lower uterine segment. A systematic random sampling technique was used for patient selection. All labor was actively managed. Inclusion criteria included women with 1 previous transverse lower uterine segment caesarean section scar presenting in spontaneous labor, singleton fetus with vertex presentation, non-recurrent indications for previous caesarean section e.g. malpresentation such as breech presentation, fetal distress and an estimated fetal weight (EFW) of less than or equal to 3.8 kg. The exclusion criteria included Women with a previous history of uterine rupture, women with fetal macrosomia, placenta previa, multiple gestation as well as abnormalities in amniotic fluid volumes such as polyhydramnious or oligohydramnious, women with co-existing medical conditions like hypertensive disease in pregnancy, uncontrolled diabetes mellitus in pregnancy, and women whose previous caesarean section was complicated by wound sepsis or wound breakdown. Main Outcome Measure(s) : The primary outcome in this study was the association between echographic measurements of the LUS and the risk of intrapartum uterine rupture. The secondary outcomes were trial of labor outcome (successful VBAC versus repeat Cesarean section), and determination of clinical (obstetric) factors that could serve as predictors for uterine rupture or dehiscence. Results : The overall frequency of defective scar was 3.9% (2 ruptures, 4 dehiscences). The frequency of defects rose as the thickness of the lower uterine segment decreased: there were no defects among 49 women with measurements greater than 4.5 mm, 1 (1.4%) among 70 women with values of 3.6-4.5 mm, 2 (10%) among 20 women with values of 2.6-3.5 mm, and 3 (21.4%) among 14 women with values of 2.5 mm and below. With a cut-off value of 3.5 mm, the sensitivity of ultrasonographic measurement was 83.3%, the specificity was 80.3%, positive predictive value was 14.7%, and negative predictive value was 99.2% with an accuracy of 80.4%. Conclusion : The results from this study showed that the risk of a defective scar is directly related to the degree of thinning of the lower uterine segment at around 37 weeks of pregnancy. The high negative predictive value of the study may encourage obstetricians to offer a trial of labour to patients with a thickness value of 3.5 mm or greater.

Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. Cohort study. University Hospital. All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011). Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. Incidence of uterine rupture. Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.