Vaginal Birth After Cesarean Rates Research Articles

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

Objective To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. Materials and methods During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. Results There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2–14.3, OR 4.8, 95% CI 1.6–14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04–5.0). Conclusion The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin.

Uterine scar rupture after a previous cesarean section and induction of labor with prostaglandins

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.

Vaginal Birth After Cesarean Rates Are Declining Rapidly in the Rural State of Maine

Cesarean delivery became the most common major operation in the United States in the 1980s. The rate rose from 5.5% in 1970 to 24.7% in 1986. In the late 1990s, the American College of Obstetricians and Gynecologists (ACOG) began requiring the presence of a surgeon, anesthesiologist, and operating personnel throughout the trial of labor for patients having a past cesarean delivery. This study reviewed birth certificate and hospital data for the state of Maine from 1998 to 2001 to estimate the change in rate for vaginal birth after cesarean (VBAC) and to detect possible reasons for the change. Hospital-specific rates were determined for primary, repeat, and total cesarean deliveries and for VBAC. Present providers of obstetric care were asked about the reasons for any change in VBAC rates at their hospitals. The study was limited to women giving birth at 20 or more weeks gestation. Statewide rates of VBAC delivery decreased by 56% between 1998 and 2001 based on birth certificate data and by 62% based on hospital-reported data. The respective relative risk figures for VAC in 1998 versus 2001 were 2.8 and 3.5. In 2001, but not in 1998, some hospitals reported no VBAC deliveries. According to hospital-reported data only, smaller hospitals performed significantly fewer VBACs. The rate of primary cesarean delivery increased by 1% to 2.6% during the period under review. Total cesarean deliveries increased from 19.4% to 24.0%. A survey disclosed that a large majority of those practicing at hospitals doing VBACs reported meeting the ACOG guidelines. Many family practice physicians stated that a lack of backup from the obstetric service was the most common reason for declining VBAC rates. Some patients refused VBAC after counseling, and some institutions failed to meet the ACOG guidelines. These findings, demonstrating a marked drop in VBAC after the change in ACOG guidelines, probably apply to rural states other than Maine. It is important to continue monitoring national VBAC rates so as to better define risk factors for fetal death and uterine rupture.

Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine

Objective: The American College of Obstetricians and Gynecologists (ACOG) revised its practice bulletin on vaginal birth after Cesarean (VBAC) in October 1998 and July 1999 to require the presence of a surgeon, anesthesiologist and operating personnel throughout the trial of labor for patients with prior Cesarean. This study measures the change in VBAC rates from 1998 to 2001 and examines possible reasons for this change.Study design: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001. Hospital-specific rates for primary Cesareans, total Cesareans, repeat Cesareans and vaginal deliveries after previous Cesarean were obtained. Additionally, we surveyed current obstetric-care providers in Maine regarding reasons for change in VBAC rates at their institutions.Results: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines.Conclusion: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.

Effects of maternal characteristics on cesarean delivery rates among U.S. Department of Defense healthcare beneficiaries, 1996-2002.

National rates of cesarean birth continue a three decade-long escalation, despite widespread recognition that a reduction in the use of the procedure is a continuing appropriate public health goal, as evidenced by the Healthy People 2010 reduction targets. Nonclinical factors associated with cesarean delivery include maternal age, race, socioeconomic status, and insurance coverage. This study compared cesarean delivery rates and trends for the U.S. Department of Defense healthcare beneficiary population from 1996 to 2002 with those observed nationally, and assessed the association of these nonclinical factors with cesarean rate variation in the U.S. Department of Defense healthcare beneficiary population. Hospital discharge and claims records for babies born in the military and civilian hospitals that comprise the Department of Defense healthcare network were used to calculate total and primary cesarean delivery rates and vaginal birth after cesarean (VBAC) rates from 1996 to 2002. Annual cesarean rates for subgroups defined by maternal age, race, and socioeconomic status were calculated to examine rate variations and rate trends within the study population. Pooled data from 1999 to 2002 were used to compare rates across socioeconomic status, stratified by age and race. Statistical significance of the differences calculated for subgroups was assessed using chi-square. Total and primary cesarean delivery rates among the U.S. Department of Defense population were lower than those reported nationally for every year examined. Cesarean delivery and VBAC rate trends in the national and Department of Defense populations were similar. Within the Department of Defense population, total cesarean delivery increased with increasing maternal age and was more highly associated with racial minorities relative to white women. The higher socioeconomic subgroup (defined as active duty, retired, and warrant officers and their families in this study) was generally associated with reduced cesarean delivery rates. Cesarean deliveries are performed less frequently for the U.S. Department of Defense healthcare beneficiary population relative to the national population. Associations between socioeconomic factors and cesarean rates reported for the national population were not apparent in the study population. The consistent pattern of rate variation across racial subgroups in the Department of Defense population suggests that factors beyond those examined in this study are needed to explain the elevated cesarean rates for racial minorities.

Vaginal Birth After Caesarean Section: Review of Antenatal Predictors of Success

Objective: To determine antenatal factors that may predict successful vaginal birth after Caesarean (VBAC).Data Sources: The MEDLINE database was searched for all English-language articles describing the impact of various factors on outcomes when VBAC is attempted. Articles reviewed included published abstracts, retrospective and prospective studies, and meta-analyses.Criteria for Study Selection: Studies were included if they reported both a control group of pregnant women without the factor under evaluation and a study group with this factor, both undergoing a trial of labour (TOL). Other criteria included accountability for all individuals enrolled at study outset, and vaginal delivery rates in both study and control groups stated or easily calculated.Results: A nonrecurrent indication for previous Caesarean section (CS), such as breech presentation or fetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS. Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Fetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases.Conclusion: There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.

Management of vaginal birth after cesarean.

To raise the success rate of vaginal birth after cesarean (VBAC) without increasing maternal or perinatal morbidity and mortality rates. Of 468 women with a prior scar, 365 gave valid informed consent for our management of VBAC at Akashi Municipal Hospital during 1986-1999. Trials of labor (TOL) were attempted in 322 cases principally by waiting for spontaneous labor onset and teaching the patients a breathing method to avoid straining until expulsion by vacuum extraction become possible, controlling the intrauterine pressure. Our selection criteria for TOL changed during the trial; from 1991-1999 patients with a prior scar extending into fundus were excluded. Of the 322 TOL, 88.2% were successful, and VBAC was successful in 77.8% (284 of the 365 patients). Uterine rupture was observed in 2 cases (0.62%). Fetal death occurred in 1 case. Three women gave birth to neonates with a 1-minute Apgar score < or = 6. The rate of VBAC was 77.8% in all women with a prior scar. During our management of VBAC, maternal or perinatal morbidity and mortality rates did not increase significantly.

Vaginal birth after caesarean (VBAC)

This review of vaginal birth after caesarean (VBAC) focuses on practical issues that will be useful for the physician in training and the obstetrician in clinical practice. Although VBAC has long been a common practice in many European nations, the same has not been true in North America. As recently as 1970 essentially all hospitals in the United States maintained a policy that women with a history of previous caesarean delivery would undergo repeat caesarean operations for any and all subsequent births. Although VBAC rates in many nations increased dramatically in the 1980s and 1990s, many aspects of trial of labour (also known as trial of scar) remain controversial at the dawn of the 21st century.

Acog’s 1999 VBAC guidelines: a survey of western massachusetts obstetric services

Objective: ACOG Practice Bulletins provide management standards for obstetric and gynecologic services. The recent ACOG guidelines for vaginal birth after cesarean (VBAC) (Number 5, July 1999) are controversial concerning hospital VBAC policy. We surveyed all western Massachusetts obstetric services regarding their VBAC policy.Methods: A survey regarding procedure rates and VBAC policy was presented to chiefs of western Massachusetts obstetric services and the data summarized.Results: All services completed the survey. Of the approximately 8,000 annual deliveries performed in western Massachusetts, 18.5% are cesarean. From 1994, all services reported a decline in overall cesarean rate and an increase in VBAC rate. All institutions reported an unchanged primary cesarean rate, except for the only level 3 center surveyed, where it rose slightly. Regarding recent ACOG VBAC guidelines, five of six services were aware of the new guidelines. Fifty percent describe “immediately available” as cesarean delivery initiated within 30 minutes and 50% as within 15 minutes. Sixty-seven percent describe “physician availability for cesarean delivery” as anesthesia coverage in-hospital and 33% as anesthesia coverage on labor and delivery. The only service mandating an obstetrician’s attending presence during VBAC trials is the tertiary care center due to residency training. Five of six services have anesthesia availability in hospital, but not specific to labor and delivery.Conclusions: The recent ACOG VBAC guidelines were inconsistently interpreted among the services surveyed. At these institutions, declines in cesarean deliveries are due to the increase in VBAC trials. While failure to incorporate guidelines could increase liability for institutions, strict implementation may discourage VBAC trials and increase cesarean deliveries by as much as 50%. In our opinion, closer review of data regarding VBAC complication rates is necessary to develop workable guidelines applicable to institutions of all levels.

Vaginal Birth After Cesarean and Uterine Rupture Rates in California

In Brief Objective To describe attempted and successful vaginal birth after cesarean (VBAC) rates and uterine rupture rates for women with and without prior cesareans, and compare delivery outcomes in hospitals with different attempted VBAC rates. Methods We used California hospital discharge summary data for 1995 to calculate attempted and successful VBAC rates and uterine rupture rates. We used multivariate logistic regression models to evaluate and adjust for age, ethnicity, and payment source. We report the relative risk (RR), attributable fraction, and 95% confidence intervals (CIs) for uterine rupture. Results There were 536,785 delivery discharges during 1995. The cesarean rate was 20.8%, and 12.5% of women had histories of cesareans. Of women with histories of cesareans, 61.4% attempted VBAC and 34.8% were successful. There were 392 uterine ruptures (0.07%). Women with prior cesareans were 16.98 (95% CI 13.51, 21.43) times more likely to experience uterine rupture, attributable fraction 66% (95% CI 60%, 73%). Among women with prior cesareans, those who attempted VBAC were 1.88 (95% CI 1.45, 2.44) times as likely to have uterine rupture, attributable fraction 34% (95% CI 21%, 46%). Women who delivered in hospitals with high attempted VBAC rates were less likely to have cesarean deliveries, more likely to have successful VBACs, and more likely to experience uterine ruptures. Conclusion Uterine rupture occurs at a low rate in women with and without prior cesarean delivery. Risk of rupture is increased among women with prior cesarean delivery and among those who attempt VBAC. California state discharge data confirm a low rate of uterine rupture among women attempting vaginal birth after cesarean.

Vaginal birth after cesarean and uterine rupture rates in California

Objective: To describe attempted and successful vaginal birth after cesarean (VBAC) rates and uterine rupture rates for women with and without prior cesareans, and compare delivery outcomes in hospitals with different attempted VBAC rates. Methods: We used California hospital discharge summary data for 1995 to calculate attempted and successful VBAC rates and uterine rupture rates. We used multivariate logistic regression models to evaluate and adjust for age, ethnicity, and payment source. We report the relative risk (RR), attributable fraction, and 95% confidence intervals (CIs) for uterine rupture. Results: There were 536,785 delivery discharges during 1995. The cesarean rate was 20.8%, and 12.5% of women had histories of cesareans. Of women with histories of cesareans, 61.4% attempted VBAC and 34.8% were successful. There were 392 uterine ruptures (0.07%). Women with prior cesareans were 16.98 (95% CI 13.51, 21.43) times more likely to experience uterine rupture, attributable fraction 66% (95% CI 60%, 73%). Among women with prior cesareans, those who attempted VBAC were 1.88 (95% CI 1.45, 2.44) times as likely to have uterine rupture, attributable fraction 34% (95% CI 21%, 46%). Women who delivered in hospitals with high attempted VBAC rates were less likely to have cesarean deliveries, more likely to have successful VBACs, and more likely to experience uterine ruptures. Conclusion: Uterine rupture occurs at a low rate in women with and without prior cesarean delivery. Risk of rupture is increased among women with prior cesarean delivery and among those who attempt VBAC.

Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery

To determine whether the extent of cervical dilatation at cesarean delivery affects the subsequent vaginal birth after cesarean (VBAC) rate. Relevant records of the index pregnancy (group I) were reviewed for cervical dilatation at cesarean delivery, oxytocin use, indication, neonatal weight, and epidural use. The records of the subsequent pregnancy (group II) were reviewed for successful VBAC rates, neonatal weight, oxytocin, and epidural use. There were 1917 patients in the study. The indications for cesarean in group I were malpresentation (5.1%), fetal distress (14.9%), and arrest disorders (80%). In group II, the VBAC success rates were 73% for previous malpresentation and 68% for previous fetal distress. In those with previous cesarean deliveries for arrest disorders with cervical dilatation at 5 cm or less, the VBAC success rate was 67%. It was 73% for 6-9 cm dilatation and 13% for the fully dilated group (P < .05). Patients who attempt a VBAC may be counseled that a cesarean delivery at full dilatation is associated with a reduced chance of a subsequent successful VBAC.

Attempt and success rates for vaginal birth after caesarean section in relation to complications of the previous pregnancy.

The relationships between prior obstetrical complications and subsequent trial of labour and vaginal birth after Caesarean (VBAC) success likelihood were examined among a cohort of Washington State women with a first livebirth via Caesarean delivery and a second livebirth between 1987 and 1993 (n = 10110). Overall, 64% of the cohort undertook a labour trial, and 62% of those who attempted VBAC delivery were successful, for an overall VBAC rate of 40%. Women with fetal macrosomia, cephalopelvic disproportion, prolonged labour, diabetes, or placental problems in the first pregnancy were less likely to undergo a labour trial in the second pregnancy than those without these factors, while women with prior induced labour, genital herpes, fetal distress, or breech presentation were more likely to attempt vaginal birth. Approximately half of women with prior macrosomia, labour problems, or chronic medical conditions who attempted VBAC succeeded, as did three-quarters of women with prior breech presentation or placental conditions. Overall VBAC rates were around 33% for women with previous fetal macrosomia, labour problems, or chronic medical conditions, and 45-55% among those with herpes, fetal distress or breech presentation at the first birth. Trial of labour should especially be encouraged among women without prior labour problems.

Effect of external peer review on cesarean delivery rates: A statewide program

To assess the effectiveness of a joint-specialty society and health department statewide peer-review program to reduce cesarean rates. Forty-five of the 165 hospitals with active delivery services were reviewed between 1989 and 1993. Differences in total and repeat cesarean rates and vaginal birth after cesarean (VBAC) rates were compared by hospital review status using Student t tests and linear regression for the years before and after completion of the program. Reviewed hospitals reduced their total cesarean rate by 3% and repeat cesarean rate by 0.7%, and increased their VBAC rate by 14.6% compared with nonreviewed hospitals, for which the respective reduction in rates was 1%, 0.6%, and 12.7%. Statistically, there was no difference between reviewed and nonreviewed hospitals in terms of rate changes. This joint-specialty society and health department peer review had no apparent impact on cesarean rates.

Vaginal birth after cesarean: a 5-year experience in a family practice residency program.

The national health objective for the year 2000 is to have an overall Cesarean section rate of 15 percent, a primary Cesarean section rate of 12 percent, and a vaginal birth after Cesarean (VBAC) rate of 35 percent. The current national statistics for the most recent year available, 1991, are 23.5 percent, 17 percent, and 24.2 percent, respectively. This study evaluates a VBAC program at a community-hospital-based family practice residency program. This study was a retrospective chart review of 996 family practice service deliveries from 1988 to 1992. Of the 98 patients who had a previous Cesarean section, 87 patients (89 percent) were eligible for a trial of labor. Fifty-six patients (64 percent) accepted a trial of labor and 31 patients (36 percent) refused. The overall Cesarean section rate was 15 percent, the primary Cesarean section rate was 11 percent, the VBAC rate was 44 percent, and the successful VBAC rate was 77 percent. We report a successful VBAC program at a community-hospital-based family practice residency program.

Vaginal birth after cesarean (VBAC) in the 1980s.

The incidence of vaginal birth after cesarean (VBAC) and characteristics of VBAC births are investigated using 1980-85 National Hospital Discharge Survey Data collected by the National Center for Health Statistics. Only 3.4 per cent of mothers with previous cesarean delivery had VBAC in their subsequent 1980 delivery; this increased to 6.6 per cent in 1985. Because VBAC is a relatively infrequent event, 1980-85 data were combined and indicate that in this period 4.9 per cent of mothers with previous cesarean had a vaginal birth in their subsequent delivery. Combined 1980-85 VBAC rates are under 10 per cent for all age, race, marital status, region, hospital size, hospital ownership, and expected source of payment groups. Between 1980 and 1985, over 1.4 million repeat cesareans were performed for mothers having a live birth. Evidence suggests that potentially over 500,000 of these repeat cesareans could have been VBACs (over and above the 74,000 VBACs which occurred). VBAC mothers' mean length of hospital stay is 3.2 days, which compares closely with 3.0 days for other vaginal deliveries, but both contrast sharply with 5.6 days for repeat cesareans and 6.0 days for primary cesareans. Except for the uterine scar from the previous cesarean, VBAC mothers appear to have about the same history and frequency of complications as mothers with other vaginal deliveries. If the 500,000 repeat cesareans had been VBACs, surgical fees and costs for 1.2 million days of hospital stay would have been averted over the 1980-85 period.