[Trial of labor after previous cesarean section]

Elective repeat cesarean section continues to remain the standard to care at GYK and OBST. Department in Sarajevo. This paper is a study of 216 patients with previous cesarean section who requested and were allowed a trial of labor. One hundred fifty-six (72%) achieved successful vaginal delivery with no maternal or fetal mortality or significant morbidity. Review of the USA literature indicates similar results in other independent studies. Continued accumulation of cases showing the efficacy of post-cesarean section trial of labor should encourage a reassessment of the continuing practice of elective repeat cesarean section.

Unnecessary cesarean delivery in Louisiana: an analysis of birth certificate data

OBJECTIVE

The purpose of this study was to explore the temporal trends and factors that are associated with cesarean deliveries and potentially unnecessary cesarean deliveries.

STUDY DESIGN

The Louisiana birth certificate database was evaluated to identify a total of 57 potential indications/risk factors and maternal demographic factors that are associated with methods of delivery over the period from January 1993 to December 2000. A cesarean delivery without any potential indications/risk factors in the birth certificate was classified as unnecessary.

RESULTS

The primary cesarean delivery rate decreased and the repeat cesarean delivery rate increased significantly during the study period. But neither the absence nor the presence of potential indications/risk factors accounted for these changes. The average potentially unnecessary primary and repeat cesarean deliveries in Louisiana were 17 and 43, respectively, per 100 cesarean deliveries over the years 1993 through 2000.

CONCLUSION

The proportions of potentially unnecessary cesarean deliveries are relatively high in Louisiana. It is important to explore the influence of nonclinical factors on unnecessary cesarean delivery to reduce the cesarean rates.

Uterine rupture: risk factors and pregnancy outcome

OBJECTIVES

This study aimed at determining risk factors and pregnancy outcome in women with uterine rupture.

STUDY DESIGN

We conducted a population-based study, comparing all singleton deliveries with and without uterine rupture between 1988 and 1999.

RESULTS

Uterus rupture occurred in 0.035% (n=42) of all deliveries included in the study (n=117,685). Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean section (odds ratio [OR]=6.0, 95% CI 3.2-11.4), malpresentation (OR=5.4, 95% CI 2.7-10.5), and dystocia during the second stage of labor (OR=13.7, 95% CI 6.4-29.3). Women with uterine rupture had more episodes of postpartum hemorrhage (50.0% vs 0.4%, P<.01), received more packed cell transfusions (54.8% vs 1.5%, P<.01), and required more hysterectomies (26.2% vs 0.04%, P<.01). Newborn infants delivered after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P<.01; 19.0% vs 1.4%, P<.01, respectively).

CONCLUSION

Uterine rupture, associated with previous cesarean section, malpresentation, and second-stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.

Effect of maternal age on blood loss during parturition: a retrospective multivariate analysis of 10,053 cases

OBJECTIVE

An extensive study as to whether maternal age itself is a risk factor for blood loss during parturition.

METHOD

A total of 10,053 consecutive women who delivered a singleton infant were studied. The excess blood loss was defined separately for women with vaginal and cesarean deliveries as > or = 90th centile value for each delivery mode. The effects of 13 potential risk factors on blood loss were analyzed using multivariate analysis.

RESULTS

The 90th centile value of blood loss was 615 ml and 1,531 ml for women with vaginal and cesarean deliveries, respectively. A low lying placenta (odds ratio [OR], 4.4), previous cesarean (3.1), operative delivery (2.6), leiomyoma (1.9), primiparity (1.6), and maternal age > or = 35 years (1.5) were significant independent risk factors for excess blood loss in women with vaginal delivery. Placenta previa (6.3), leiomyoma (3.6), low lying placenta (3.3), and maternal age > or = 35 years (1.8) were significant independent risk factors for excess blood loss in women with cesarean sections.

CONCLUSION

A maternal age of > or = 35 years was an independent risk factor for excess blood loss irrespective of the mode of delivery, even after adjusting for age-related complications such as leiomyoma, placenta previa, and low lying placenta.

Uterine rupture, perioperative and perinatal morbidity after single-layer and double-layer closure at cesarean delivery

OBJECTIVE

This study was undertaken to evaluate the risks and benefits of single-layer uterine closure at cesarean delivery on the index and subsequent pregnancy.

STUDY DESIGN

A retrospective study of women delivered of their first live-born infants by primary low transverse cesarean delivery (1989-2001) and their subsequent pregnancy at our institution was performed.

RESULTS

Of 768 women studied, 267 had single-layer and 501 had double-layer uterine closures in the index pregnancy. Single-layer closure was associated with slightly decreased blood loss (646 vs 690 mL, P<.01), operative time (46 vs 52 minutes, P<.001), endometritis (13.5% vs 25.5%, P<.001), and postoperative stay (3.5 vs 4.1 days, P<.001). In the second pregnancy, prior single-layer closure was not associated with uterine rupture after a trial of labor (0% vs 1.2%, P=.30), or other maternal or infant morbidities. Prior single-layer closure was associated with increased uterine windows (3.5% vs 0.7%, P=.046) at subsequent cesarean delivery.

CONCLUSION

Single-layer uterine closure is associated with decreased infectious morbidity in the index surgery, but not uterine rupture or other adverse outcomes in the subsequent gestation.

Vaginal birth after cesarean section: Trial of labor or repeat cesarean section? A decision analysis

OBJECTIVE

The risk of perinatal death associated with labor after previous cesarean section appears higher than with a repeated cesarean section. On the other hand, repeated cesarean sections are associated with increased maternal morbidity and mortality from placental pathologic conditions (previa or accreta) on subsequent pregnancies. The study was undertaken to analyze the decision for a trial of labor or a repeated cesarean section, after a prior cesarean section, with varying desire for an additional pregnancy.

STUDY DESIGN

A model was formulated using a decision tree, based on the reported risks of the two approaches. Sensitivity analysis was performed over a variety of probabilities (eg, chance of uterine rupture or neonatal death, chance of rescue cesarean section, desire for an additional pregnancy) and utilities (eg, use of hysterectomy or neonatal death).

RESULTS

The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit. The model was robust over a wide range of assumptions.

CONCLUSION

An optimal decision for a trial of labor or a repeated cesarean section is substantially determined by the wish for future pregnancies. The default option of a repeated cesarean section is not directly applicable in populations in which family planning often extends over two children.

Clinical audit: obstetric performance after caesarean section

The RCOG Clinical Audit Unit has defined two auditable standards in women labouring with a previous caesarean section (LSCS). We found documentation of a discussion in 98% of patient notes on issues relating to delivery, including a trial of vaginal delivery. Excluding patients declining a trial of vaginal delivery, the successful vaginal delivery rate was 36/60 (60%). One in three patients, although suitable, declined a trial of vaginal delivery. This request was invariably made at the booking consultation. Two in three patients required a repeat LSCS for delivery. Women were twice and 2.4 times as likely to have a repeat LSCS delivery when their primary LSCS was for fetal distress and failure to progress, respectively. There was one (1%) case of confirmed scar rupture and one stillbirth of unknown aetiology at 34/40. Recommendations include vigilance and senior supervision at primigravid labours and confident recommendation of trial of vaginal delivery by obstetrics team.

[The impact of some factors on obstetrical management in women with previous cesarean section]

Considering obstetrical management we should have always in mind advantages and disadvantages of vaginal birth after cesarean (VBAC) and elective cesarean section after a previous one, financial part of the elected mode of delivery in the particular case, psychological aspect of the matter (especially after an unsuccessful trial of labour--TOL) and not on the last position-patient's right to choose the way how to deliver. We performed an inquiry of 3-year-period and 50 women with a prior cesarean section, by which we studied the factors contributed in different extent to the choice of the following approach to delivery: patient's preliminary choice, the impact of medical staff during pregnancy and when entering the Department of Obstetrics, the impact of non-medical persons, complications after the previous cesarean section, patient's acquaintance with complications and consequences associated with the operative mode of delivery, as well as doctor's personal attitude to the different modes of delivery. The aim of our research is to show that by careful selection (according to the established indices) of women, who have a high probability (more than 80%) to deliver their babies vaginally and offering adequate information by educational literature and including the woman in the decision making process, the growing rate of cesarean section will be decreased by increasing the number of VBAC--undoubtedly one of the most important issue in modern obstetrics.

Trial of labour compared to elective Caesarean in twin gestations with a previous Caesarean delivery

OBJECTIVE

To compare maternal and neonatal outcomes in twin gestations with a vertex presenting first twin undergoing either an elective repeat Caesarean section or a trial of labour subsequent to having had a Caesarean delivery in a prior pregnancy.

METHODS

Maternal and newborn data from 1980 to 1999 in twin gestations, having 1 or more previous lower-segment Caesarean section(s) and a vertex presentation of the first twin, were analyzed from the Nova Scotia Atlee Perinatal Database. Categorical data were compared using chi-square or Fisher exact tests and continuous data by the Student t test. Logistic regression was used to control for covariates.

RESULTS

Of the 121 women eligible for the data analysis, 38 chose to have a trial of labour, and 28 delivered vaginally with no uterine ruptures, scar dehiscences, maternal deaths, or increase in neonatal morbidity or mortality reported. Two Caesareans in the trial-of-labour group were for the delivery of the second twin. Women choosing elective Caesarean section had a higher incidence of infectious morbidity (p = 0.04).

CONCLUSION

In twin pregnancies with twin A presenting as a vertex, a cautious trial of labour may be an effective and safe alternative to elective repeat Caesarean section. Further research on a trial of labour after previous Caesarean section in twin gestations is warranted, as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.

Management of previous cesarean section

PURPOSE OF REVIEW

The management of cesarean sections causes much controversy among healthcare providers, patients, and insurers. A trial of vaginal birth after previous cesarean is reported to be a safe and practical method to reduce the rate of cesarean sections. The popularity of vaginal birth after previous cesarean has increased over the past two decades, but rates have recently started to decline again. This review will evaluate recent literature that might be responsible for this reversal in trend.

RECENT FINDINGS

Earlier studies on previous cesarean section pregnancies focused primarily on the success rate of vaginal birth after previous cesarean, which is reported to be 60-80%. Recent large, retrospective, population-based cohort studies examined the maternal and neonatal safety of trial of labour compared with elective repeat cesarean delivery, and confirmed that the risks of uterine rupture and neonatal mortality were significantly increased after trial of labour, particularly when induced with prostaglandins. However, the absolute risk of adverse events remains small. The maternal and neonatal morbidity risk increases when vaginal birth after previous cesarean attempts fails, which emphasizes the importance of careful case selection.

SUMMARY

Recent studies highlighted the risks of attempted vaginal birth after previous cesareans, especially when trials fail, but have not addressed the long-term risks of an elective repeat cesarean delivery. The assessment of treatment risks by observational studies is subject to bias, because the different treatment groups may not be comparable at the outset. In the absence of better data, the counselling of such women must currently be based on this evidence.

Twin delivery after a previous caesarean: a twelve-year experience

OBJECTIVES

To compare maternal and neonatal morbidities between trial of labour (TOL) and elective Caesarean section in women with twin pregnancies who have had a prior Caesarean.

METHODS

An observational study was conducted of women with a prior Caesarean who delivered twins at 28 weeks gestation or greater in Ste-Justine Hospital between 1988 and 2001. Maternal and neonatal outcomes were compared between women who had a TOL (group 1) and those who had an elective Caesarean delivery (group 2).

RESULTS

Twenty-six women and 52 fetuses were included in group 1 and compared to the 71 women and 142 fetuses in group 2. Maternal age, gestational age, and birth weight were comparable in both groups. In group 1, 22 (85%) out of 26 women delivered twin A vaginally and 19 (73%) delivered both vaginally. There was no significant difference in the umbilical artery cord pH, Apgar score, ventilatory support, and admission to the neonatal intensive care unit between the 2 groups. There was also no significant difference in the rate of postpartum maternal fever or decrease of serum hemoglobin between the 2 groups, but the median hospital stay was higher in the group with elective Caesarean (5.0 vs. 3.0 days, p <0.001). There were no uterine ruptures or other major complications in either group.

CONCLUSION

There were no significant differences in maternal and neonatal morbidity outcomes between births by trial of labour and by elective Caesarean, in twin pregnancies after a prior Caesarean section. A trial of labour is associated with a shorter hospital stay.

[Vesico-uterine fistula, a rare complication of cesarean section]

We present the case of a vesicouterine fistula secondary to a caesarean section indicated due to the disproportion the pelvis and the head of the baby. This kind of fistula is due fundamentally to obstetric causes, especially to caesarean sections in developed countries and to prolonged labour in developing countries. The commonest clinical presentation is urinary incontinence in the form of continuous or intermittent urinary leaks. Surgical treatment is generally the therapy of choice, although, in the case of small fistulas, conservative treatment is feasible. The best form of prevention is correct indication of caesarean section and careful surgical technique.

[Factor V Leiden mutation. Successful outcome of a pregnancy after heparin therapy]

Several reports have highlighted the significant correlation between maternal thromboembolism pathologies, such as factor V Leiden mutation, and the occurrence of gestational pathologies. The main causes of thromboembolism pathologies are the inherited coagulopathies. The most common genetic predispositions include autosomal dominant inheritance coagulative factors deficiencies, such as antithrombin III (AT III), C protein (CP), S protein (SP), G20210A mutation, hyperomocystinemia and the activated C protein resistance, caused by factor V Leiden mutation. Maternal thromboembolism as an inherited coagulopathy expression, may be associated with high fetal-maternal morbidity and mortality rate. Nowadays, a wide screening is not possible, but the patients with previous or familiar deep venous thrombosis episodes should at least undergo very careful examinations. In the present case the patient's knowledge of her own status as a factor V Leiden mutation carrier , the prophylactic therapy performed, and the frequent fetal and maternal monitoring allowed us to avoid the recurrence of the dramatic events occurring during her first pregnancy.

Uterine rupture associated with castor oil ingestion

A woman at 39 weeks' gestation with a previous Cesarean delivery had severe abdominal pains and rupture of membranes shortly after ingesting 5 ml of castor oil. Forty-five minutes later, repetitive variable decelerations prompted a Cesarean delivery. At surgery, a portion of the umbilical cord was protruding from a 2-cm rupture of the lower transverse scar.

Laparoscopic repair of a uteroperitoneal fistula

Repairs of pelvic fistulas using abdominal, vaginal, and laparoscopic approaches have been described. In the present case report, we describe our experience with the laparoscopic repair of a uteroperitoneal fistula.

Placenta previa percreta with urinary bladder and ureter invasion

A 26-year-old woman, with one previous cesarean delivery and two uterine curettage due to incomplete abortion, was admitted to the labor ward with the diagnosis of partial placenta previa at 35 weeks of gestation. Repeat cesarean section was performed due to profuse vaginal bleeding. Placenta previa percreta invading the bladder trigone was confirmed with cystotomy. As bilateral hypogastric artery ligation and supracervical hysterectomy performed were not successful in stopping the profuse bleeding, the abdomen was packed with laparotomy pads. Dilatation of the left ureter was noticed on the second postoperative day. Relaparotomy was performed to remove the pads, and placental invasion of the distal left ureter was noticed. Ureteroneocystostomy was performed. The postoperative course was uneventful, and the double-J-catheter was removed two months later.

Pulmonary arterial and intracranial calcification in the recipient of a twin-twin transfusion

Pulmonary arterial and intracranial calcifications are rarely found in children. A female infant, the recipient of a twin-twin transfusion syndrome was found, by ultrasound and computed tomography, to have both pulmonary arterial and intracerebral calcification. A rare condition, termed idiopathic arterial calcification of infancy, is the likely cause. This condition carries a poor prognosis and is usually fatal.