Trial of labour following prior section; a 5 year prospective study (1982-1987)

Prevalence of uterine rupture among women with one prior low transverse cesarean and women with unscarred uterus undergoing labor induction with PGE2: A systematic review and meta-analysis

BACKGROUND

As uterine rupture may affect as many as 11/1000 women with 1 prior cesarean birth and 5/10.000 women with unscarred uterus undergoing labor induction, we intended to estimate the prevalence of such rare outcome when PGE2 is used for cervical ripening and labor induction.

METHODS

We searched MEDLINE, ClinicalTrials.gov and the Cochrane library up to September 1st 2020. Retrospective and prospective cohort studies, as well as randomized controlled trials (RCTs) on singleton viable pregnancies receiving PGE2 for cervical ripening and labor induction were reviewed. Prevalence of uterine rupture was meta-analyzed with Freeman-Tukey double arcsine transformation among women with 1 prior low transverse cesarean section and women with unscarred uterus.

RESULTS

We reviewed 956 full text articles to include 69 studies. The pooled prevalence rate of uterine rupture is estimated to range between 2 and 9 out of 1000 women with 1 prior low transverse cesarean (5/1000; 95%CI 2-9/1000, 122/9000). The prevalence of uterine rupture among women with unscarred uterus is extremely low, reaching at most 0.7/100.000 (<1/100.000.000; 95%CI <1/100.000.000-0.7/100.000, 8/17.684).

CONCLUSIONS

Uterine rupture is a rare event during cervical ripening and labor induction with PGE2.

Induction of labour with previous caesarean delivery: where do we stand?

PURPOSE OF REVIEW

This paper reviews the literature to elucidate the international stance on induction of labour in women with previous caesarean section.

RECENT FINDINGS

There is no evidence to suggest that current induction methods are less effective in women with previous caesarean section. It would, therefore, seem logical to use the same regimens as for women with intact uteri, including prostaglandins, particularly in women with unfavourable cervices. The clinical decision making and counselling, however, will always focus on safety, not effectiveness. There is no question that induction of labour is associated with higher risk of uterine rupture, but quantifying this risk remains elusive.

SUMMARY

For the present, we will continue our practice, based on the sources of the best evidence available. Improvements in obstetric care have not only reduced the risks associated with uterine rupture but also risks associated with caesarean section. Therefore, both elective caesarean section and induction of labour, with or without prostaglandins, are reasonable choices for women who need induction with previous caesarean section. The efforts to better quantify the benefits/risks of various policies and regimens should continue, but should be complemented with qualitative studies to obtain crucial insight into the demands and challenges confronting women and clinicians to identify factors influencing their decision-making or their preferences.

The benefits and risks of inducing labour in patients with prior caesarean delivery: a systematic review

OBJECTIVE

To evaluate the risks and benefits of inducing labour in women with a prior caesarean delivery.

DESIGN

Systematic review.

SAMPLE

Pregnant women with prior caesarean delivery.

METHODS

Studies were identified using MEDLINE, EMBASE, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effectiveness, reference lists and experts.

MAIN OUTCOME MEASURES

All studies reporting data for outcomes in women with induced labours and prior caesarean were eligible. Methodologic quality was evaluated using the criteria of the U.S. Preventive Services Task Force and the NHS Centre for Reviews and Dissemination. We assigned studies good, fair or poor rating.

RESULTS

We reviewed 162 full text articles, identified 14 fair-quality studies, and found no good-quality studies. Compared with spontaneous labour, induction was more likely to result in caesarean delivery. Of women undergoing spontaneous labour, 20% had a caesarean (range 11-35%) compared with 32% receiving oxytocin (range 18-44%). In studies of PGE2, spontaneous labour resulted in caesarean delivery in 24% (range 18-51%) compared with 48% with PGE2 (range 28-51%). There was a non-significant increase in uterine ruptures among those induced compared with spontaneous labours. There were no maternal deaths; other maternal complications were infrequently reported. Only four studies reported on infant deaths; other infant outcomes were inadequately reported.

CONCLUSION

Women with a history of caesarean attempting trial of labour who require induction have a higher rate of caesarean delivery and have a slightly elevated risk of rupture compared with similar women with spontaneous labour. More consideration is needed for potential confounders: dose, reasons for induction and appropriate comparison groups.

Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section

OBJECTIVE

To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section.

DESIGN

Systematic review.

DATA SOURCES

Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full.

REVIEW METHODS

Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic.

RESULTS

We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10,000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly.

CONCLUSIONS

Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.

Safety of vaginal birth after cesarean: a systematic review

OBJECTIVE

To evaluate the benefits and harms of vaginal birth after cesarean compared with repeat cesarean delivery.

DATA SOURCES

The computerized databases MEDLINE, EMBASE, HealthSTAR, Cochrane CENTRAL, and National Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effectiveness, along with reference lists and national experts, were used to conduct this review.

METHODS OF STUDY SELECTION

All studies that reported data for maternal or infant outcomes in women with prior cesarean delivery were eligible. Methodological quality was evaluated for each study with the criteria of the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Twenty of 6,828 potentially relevant articles (55,506 patients) were included in the analysis.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently abstracted information on study design, sample size, participant characteristics, and maternal and fetal health outcomes by using a standardized protocol. Rates of vaginal delivery in women undergoing a trial of labor ranged from 60% to 82%. There was no significant difference in maternal deaths or hysterectomy between trial of labor and repeat cesarean. Uterine rupture was more common in the trial-of-labor group, but rates of asymptomatic uterine dehiscence did not differ. Studies conflicted on the effect of induction of labor on these outcomes. Data regarding infant outcomes were poor.

CONCLUSION

Safety in childbirth for women with prior cesarean is a major public health concern. Methodological deficiencies in the literature evaluating the relative safety of vaginal birth after cesarean compared with repeat cesarean delivery are striking. The identification of high-risk and low-risk groups of women and settings for morbidity remains a key research priority.

Post caesarean section delivery

Recent clinical attention has focused upon the rising rate of caesarean sections being performed and whether patients with a previous caesarean section should be allowed a vaginal delivery. In this paper, the worldwide trend of caesarean section and the role of trial of scar following single and multiple caesarean surgery is reviewed. The role of oxytocin and regional epidural analgesia is evaluated as well as perinatal and maternal mortality. On the basis of the available data, there is no justification for the current clinical practice of almost 99% prevalence of elective repeat caesarean section in some hospitals in the North America. Oxytocin and epidural analgesia, when carefully monitored, are safe and reasonable in these patients. Watchful waiting has always been an essential virtue in obstetric management and should not be replaced by hopeful expectancy. This aspect of the art of obstetrics would appear to require rejuvenation if we are to stem the rising tide of caesarean sections.

Mode of delivery after one caesarean section: audit of current practice in a health region

OBJECTIVE

To audit the subsequent obstetric management of women who had had one previous baby delivered by caesarean section.

DESIGN

Retrospective analysis of a regional obstetric database.

SETTING

Data derived from the 17 obstetric units in North West Thames region.

SUBJECTS

1059 women who delivered a singleton fetus of at least 37 weeks' gestation with a cephalic presentation in 1988 who had a history of one previous caesarean section and no other deliveries.

MAIN OUTCOME MEASURES

Mode of delivery, postnatal morbidity, and duration of hospital stay.

RESULTS

395 (37%) women were delivered by elective repeat caesarean section and 664 (63%) were allowed a trial of labour. Maternal height and birth weight of the previous infant differed significantly between those who were and those who were not allowed to labour. 471 (71%) of those allowed to labour achieved a vaginal delivery. In individual units there was no significant correlation between the proportion of patients allowed to labour and the rate of the successful trial of labour. There was a trend towards greater success rates in units that allowed a longer duration of labour (p less than 0.05) and units with greater use of oxytocin for augmentation of labour (not significant). Both elective and intrapartum caesarean section was associated with a significantly higher rate of postnatal infection than vaginal delivery (14.7% and 16.0% v 3.4%).

CONCLUSIONS

In patients with a history of caesarean section there is no evidence that the likelihood of successful vaginal delivery after trial of labour is modified by the proportion of such patients allowed the option of attempted vaginal delivery. Until selection criteria of adequate prognostic value can be identified a more liberal approach to allowing women a trial of labour seems justified.