Mode de déclenchement du travail et conduite du travail en cas d’utérus cicatriciel

Retrospective evaluation of labor induction with scar uterus at the university hospital of Rennes

OBJECTIVE

The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section.

STUDY DESIGN

This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen.

RESULTS

The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25-0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08-0,35).

CONCLUSION

With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.

Predictors of vaginal delivery following balloon catheter for labor induction in women with one previous cesarean

BACKGROUND

The aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix.

METHODS

This 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL.

RESULTS

A total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight (< 4000 g) (odds ratio [OR]5.26; 95% confidence interval [CI] 2.09,13.27), lower body mass index (BMI,<30 kg/m²) (OR 2.27; CI 1.21, 4.26), Bishop score after cervical ripening > 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC.

CONCLUSIONS

The influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.

Balloon catheter vs oxytocin alone for induction of labor in women with one previous cesarean section and an unfavorable cervix: a multicenter, retrospective study

PURPOSE

To compare the rate of vaginal birth between double-balloon catheter and oxytocin alone for induction of labor in women with one previous cesarean section and an unfavorable cervix.

MATERIALS AND METHODS

A retrospective and observational study was conducted from 2013 to 2017, at the Saint-Etienne University Hospital where women received induction with a double-balloon catheter for 12 h and at the Grenoble Alpes University Hospital where women received induction with a low-dose oxytocin infusion. Primary outcome was the rate of vaginal birth.

RESULTS

Out of 1920 women eligible for attempting a vaginal birth after one previous cesarean section, 501 had a labor induction. Among women with an unfavorable cervix, 160 received a double-balloon catheter in Saint Etienne and 152 received oxytocin alone in Grenoble. The vaginal birth rate was higher in the double-balloon catheter group (61% versus 47% in the oxytocin group). An induction of labor with oxytocin alone reduced chances of vaginal birth (aOR 0.38 CI-95% [0.22-0.66]) compared to cervical ripening with double-balloon catheter. The perinatal morbidity was similar in the two groups. There was, however, 3.9% uterine rupture in the oxytocin group versus 0.6% in the double-balloon group (p = 0.11).

CONCLUSION

For induction of labor in women with one previous cesarean section and with unfavorable cervix, cervical ripening with a double-balloon catheter increases the rate of vaginal birth without increased risk of uterine rupture.

Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies

BACKGROUND

Trial of labor after a previous cesarean delivery (TOLAC) has reduced the rate of cesarean sections (CS). Nevertheless, the widespread use of TOLAC has been limited by an increase in adverse outcomes, the most serious one being the risk of symptomatic uterine rupture, which is possibly associated with oxytocin. In this meta-analysis, we explored the risk association between oxytocin use and uterine rupture in TOLAC.

METHODS

Multiple electronic databases (PubMed, Embase, Web of Science, and Google Scholar) were searched for cross-sectional studies reporting on TOLAC, oxytocin and uterine rupture, which were published between January 1986 and October 2019. The bias-corrected Hedge's g was calculated as the effect size using the random-effects model. A two-sample Z test was used to compare the differences in synthetic rates between groups. The Newcastle-Ottawa Scale (NOS) was used to evaluate the risk of bias. Quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty ratings system.

RESULTS

A total of 14 studies, which included 48,457 women who underwent TOLAC, met the inclusion criteria. The pooled rate of vaginal birth after a cesarean section (VBAC) and the rate of uterine rupture in spontaneous labor were 74.3 and 0.7%, respectively. In addition, the pooled rate of VBAC and the rate of uterine rupture in the induction labor group was 60.7 and 2.2%, respectively. The women who had spontaneous labor had a significantly higher rate of VBAC (p = 0.001) and a lower rate of uterine rupture (p = 0.0003) compared to induced labor. The pooled rates of uterine rupture in women using oxytocin and women not using oxytocin in TOLAC were 1.4% and 0.5%, respectively, and the difference was significant (p = 0.0002). Also, the synthetic rate of uterine rupture in oxytocin augmentation among women with spontaneous labor and women who had a successful induction of labor were 1.7% and 2.2%, respectively, without significant difference (p = 0.443).

CONCLUSIONS

Women with induced labor had a higher risk of uterine rupture compared to women with spontaneous labor following TOLAC. Oxytocin use may increase this risk, which could be influenced by the process of induction or individual cervix condition. Consequently, simplified and standardized intrapartum management, precise protocol, and cautious monitoring of oxytocin use in TOLAC are necessary.

Effect of the addition of osmotic dilators to medical induction of labor abortion: A before-and-after study

OBJECTIVES

The main objective of this study was to assess the induction-to-delivery interval with or without the use of osmotic dilators for induced abortion. As secondary objectives, women outcomes were assessed.

STUDY DESIGN

This retrospective single-center observational before and after study reviewed records from a university hospital maternity unit from 2002 through 2016 and included all women undergoing abortion for medical reasons at and after 14 weeks of gestation. Two groups were compared: group "no dilators", which used first misoprostol without dilators, and group "dilators", which used osmotic dilators before misoprostol administration. The main outcome was the induction-to-delivery interval.

RESULTS

The study included 491 women: 383 in group "no dilators" and 108 in group "dilators". The induction-delivery interval was significantly lower in the group "dilators" compared to "no dilators" (427.7 min vs 639.7 min, P < 0.001), as was the cumulative misoprostol dose (990 μg vs 1449 μg, P < 0.001). The delivery rate within 6 h was significantly higher in the "dilators" group compared to "no dilators" group (50.0% vs 29.8%, P = 0.002).

CONCLUSION

The use of osmotic dilators for cervical ripening before administration of misoprostol for induced abortion appears to be effective in reducing the induction-delivery interval.

Balloon catheter vs oxytocin alone for induction of labor in women with a previous cesarean section: A randomized controlled trial

INTRODUCTION

The aim of this study was to compare the efficacy and maternal-neonatal morbidity between balloon catheter and oxytocin for induction of labor in women with a previous cesarean section and an unfavorable cervix.

MATERIAL AND METHODS

This open-label randomized controlled trial took place in seven French hospitals. Inclusion criteria were medical indication for labor induction in pregnant women, ≥37 weeks, with lower segment cesarean section, Bishop score ≤4, no pre-labor rupture of membranes, singleton fetus in cephalic presentation. Women were allocated randomly to induction with a 50-mL balloon catheter for 12 hours or a low-dose oxytocin infusion. Primary outcome was the rate of vaginal birth. Secondary outcomes were maternal and neonatal complications.

RESULTS

The study enrolled 204 women from 26 December 2010 to 31 December 2013: 101 were allocated to receive balloon catheter and 103 to oxytocin. Vaginal birth rate was 50% (n = 51) in the balloon catheter group vs 37% (n = 38) in the oxytocin group (P = 0.050). Maternal and neonatal morbidity did not differ between balloon catheter and oxytocin groups: two uterine dehiscences vs one, one vs four maternal infections, five vs two hemorrhages and 11 vs five neonatal transfers, respectively. Heterogeneity of treatment effect for vaginal delivery was observed across initial Bishop scores. Balloon catheter was more effective for low values of bishop score.

CONCLUSIONS

Balloon catheter tended to be associated with a higher probability of vaginal delivery as compared with low-dose intravenous oxytocin when used for induction of labor in women with a previous cesarean section and low Bishop score at induction.

[Induction of labor in women with previous caesarean delivery with balloon catheter: Is it worth it?]

OBJECTIF

Balloon catheters for labor induction at term after previous cesarean section is an alternative option to iterative cesarean section. The aim of this study was to analyze the maternal and neonatal outcomes of the trial of labor after cesarean (TOLAC) in women with unfavorable cervix and balloon catheter induction, 2 years after introduction of this process.

METHODS

Unicentric observational study of women with term cephalic singleton, unfavorable cervix (simplified Bishop score<5) after TOLAC using double-balloon catheter. Were analyzed the mode of delivery and severe maternal (uterine rupture, post-partum hemorrhage, severe perineal tears) and neonatal (neonatal unit admission, APGAR<7 at 5minutes, pH<7.1) outcomes. Predictive factors for failed TOLAC were analyzed by using multivariate logistic regression.

RESULTS

Between 2016-2017, 455 (75.4%) women had TOLAC, whose 59 (13%) women with balloon catheter. The overall vaginal delivery (VD) was 73.9%. After Balloon catheter, the VD rate was 50.8%, versus 79.1% after spontaneous labor, and 68.2% after alone oxytocin/artificial membrane rupture induction (P<0.05). Previous VD (aOR 0.176 CI-95% [0.048-0.651]) and prior sweeping membrane (aOR 0.161 CI-95% [0.034-0.761]) was protective for cesarean section after TOLAC. Severe maternal and neonatal morbidities were observed in 10 (17%) and 8 (13.6%) cases, respectively.

CONCLUSION

Double-Balloon catheter is an option for unfavorable cervix and term induction after previous cesarean section. However, the TOLAC in women whose unfavorable cervix is not without maternal and neonatal risk, especially due to its failure.

[Predictors of birth outcomes related to women with a previous caesarean section: experience of a Motherhood Center, Bizerte]

INTRODUCTION

Caesarean section (CS) rates have been significantly increasing in recent decades. For this reason, the obstetrician must frequently decide on the most appropriate mode of delivery for mother and fetus. This study aims to describe vaginal birth after previous cesarean section (VBACs) in our obstetric practice and to identify factors significantly associated with failed VBACs.

METHODS

We conducted a population-based study among women with a history of previous cesarean delivery. The study design was retrospective, longitudinal, descriptive and analytical. The case study was conducted over a two years and three months period, from January 1, 2012 to March 31, 2014 during which we collected data from 423 medical records of patients attempting VBACs at the Maternity and Neonatology Center, Bizerte.

RESULTS

The rate of attempted VBACs was 47%. The success and the failure rates of these attempts were 82,7% and 17,3% respectively. The main factors for a poor prognosis in patients attempting VBACs were: the absence of a previous vaginal delivery (p = 0.005), a previous indication for cesarean section due to stagnation of dilatation or poor labor progress, (p 0.049 and 0.002 respectively), gestational age at delivery of = 40 weeks (p = 0.046), parity <3 (p = 0,75.10-4), Bishop score <6 at the onset of labor (p = 0,23.10-47), "active labor" duration = 6h (p = 0.002), length of labor> 8 h (p = 0.0031) and the occurrence of abnormal fetal heart rate (FHR) during labor (p = 0144.10 -9). We observed seven cases of uterine rupture (1.7%). There were no cases of maternal mortality. Total maternal morbidity rate was 9,5%. The difference in rates of maternal complications between the two groups (failed and successful attempted vaginal birth after cesarean) was not statistically significant.

CONCLUSION

Attempting vaginal birth after cesarean on the basis of good and poor prognostic factors and patient consent, contributes to the reduction in maternal and neonatal morbidity and should lead to the establishment of clear and codified Tunisian guidelines as part of a policy against unjustified iterative caesarean sections.

[Cervical ripening after previous cesarean section with dinoprostone vaginal insert]

OBJECTIVES

Because, to date in France, 20 % of pregnant women had a scared uterus and because the best mean of cervical ripening is unknown and controversial, we want to evaluate efficacy and safety of dinoprostone for cervical ripening in women with previous cesarean.

MATERIALS AND METHODS

We conducted a retrospective unicentric study, from 2010 to 2014, at Limoges regional university hospitals. Two hundred and sixty nine patients, with medical indication for induction of labor and scared uterus, were included and ripened with dinoprostone (Propess^® and/or Prostine^®). Women had unfavorable cervix with Bishop score inferior to 6.

RESULTS

Overall rate of vaginal delivery was 62 %. Patients have had more of one prostaglandin in 19 % of cases; the cesarean rate was significantly higher in this case (cesarean: 55.6 % vs. vaginal delivery: 44.4 %; P=0.0043). Overall, there were respectively 4 % and 0.7 % of post-partum hemorrhage and uterine rupture. One percent of newborns had a severe acidosis (pH<7 in umbilical artery) and 1 % was admitted to the Intensive Neonatal Care Unit.

CONCLUSION

Dinoprostone is an effective procedure in patients with previous cesarean section requiring labor induction, with a morbidity comparable to other methods of induction of labor.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 μg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 μg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

[Use of misoprostol for induction of labor in case of fetal death or termination of pregnancy during second or third trimester of pregnancy: Efficiency, dosage, route of administration, side effects, use in case of uterine scar]

OBJECTIVE

Study, based on the literature, of the use of misoprostol for induction of labor in cases of second or third trimester fetal death or termination of pregnancy and define the different mode of administration.

MATERIALS AND METHODS

Bibliographic review using the Medline and Pubmed databases and the guidelines of the international professional societies. Selection of papers in French and English. Keywords used: misoprostol, termination of pregnancy, mid and third trimester, scarred uterus, previous cesarean section, uterine rupture.

RESULTS

Misoprostol is effective for induction of labor in case of second or third fetal death or termination of pregnancy. Comparing to oral route, vaginal route reduces the induction-expulsion time and the rate of patients remaining undelivered in the first 24 hours without increasing side effects. Oral route is a possible alternative if preferred by the patient. Sublingual route seems interesting but data are limited. The use of moderate doses (800-2400 μg/day) every 3 to 6 hours seems to be the best compromise between efficiency and tolerance. It is not possible to recommend a specific dosing schedule. The risk of uterine rupture in case of previous cesarean section justifies the use of minimum effective dose for these patients. In this case, it is recommended not to exceed a dose of 100 μg for each dose. The induction-birth period and doses of misoprostol required to induce labor are reduced when combined with mifepristone administered 36 to 48 hours before.

CONCLUSION

Misoprostol is effective and safe for induction of labor in case of second or third trimester fetal death or termination of pregnancy.

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

[Cervical ripening with balloon catheter for scared uterus: a three-year retrospective study]

OBJECTIVES

To evaluate, for women with scared uterus, the mechanical cervical ripening with balloon catheter.

METHODS

We conducted a retrospective study of our practice of ripening for scared uterus from january 2010 to august 2012. Feasibility, Bishop's score, birth modalities and complications for mothers and babies during this ripening were studied.

RESULTS

Thirty-nine medical files were analysed. All patients could have mechanical ripening independently of the internal os status (open or not). The cervical ripening with balloon catheter improved Bishop's score before induction of labour, from 3.54 ± 1.23 to 5.38 ± 1.47 (p=0.02). 64.1% of women had a vaginal delivery. Concerning the predictive factors for vaginal delivery, we only found significant influence of a body mass index less than 30kg/m² (p=0.03). We didn't find any maternal or neonatal complications in our population.

CONCLUSION

Mechanical ripening for scared uterus seems to be a useful option to improve vaginal delivery without increasing maternal and foetal morbidity. Anyway, these results have to be confirmed by a randomized controlled trial on a specific scared uterus population.