Delivery after one previous cesarean section

Trends in cesarean delivery: rate and indications

OBJECTIVES

To compare the cesarean delivery rates over the last decade and to examine the indications contributing to changed trends, if any.

METHODS

To compare the rate and indications of cesarean delivery over the last decade, the data were collected in a retrospective manner from all the deliveries that occurred between January 1 and December 31 in 2001, 2006, and 2011, in the department of obstetrics and gynecology, Seth G.S. Medical College and K.E.M. Hospital, a large tertiary care municipal hospital in Western India. A cohort of 20853 delivered women was studied. The rates and indications of primary and repeat cesarean sections were analyzed among the live births to estimate the relative contribution of each indication to the overall increase in rate.

RESULTS

The cesarean delivery rate increased from 171.70 to 289.30 per 1,000 live births, with an increase in primary cesarean delivery rate from 118.53 (69.03 %) in 2001 to 210.09 (72.62 %) in 2011 per 1,000 live births. Fetal distress, arrest of descent, multiple gestations, and fetal indications contributed to this increase.

CONCLUSIONS

There is a significant increase in the total cesarean rate with primary cesarean accounting for most of the increase.

Vaginal prostaglandin gel to induce labour in women with one previous caesarean section

This retrospective study reviewed the mode of delivery when vaginal prostaglandins were used to induce labour in women with a single previous lower segment caesarean section. Over a 4-year period, PGE 2 gel was used cautiously in low doses in 54 women. Induction with PGE 2 gel was associated with an overall vaginal birth after caesarean section (VBAC) rate of 74%, which compared favourably with the 74% VBAC rate in women who went into spontaneous labour (n = 1969). There were no adverse outcomes recorded after the prostaglandin inductions but the number reported are too small to draw any conclusions about the risks, such as uterine rupture. We report our results because they may be helpful in assessing the chances of a successful VBAC in the uncommon clinical circumstances where prostaglandin induction is being considered.

Safety of vaginal birth after cesarean delivery

OBJECTIVE

To compare the outcomes of labor induction in women with a history of 1 cesarean section (CS) who undergo trial of labor.

METHODS

A prospective observational study of 702 pregnant women who had 1 previous CS was conducted at Women's Hospital, Hamad Medical Corporation, Doha, Qatar, between April 2003 and April 2004. Those with no history of vaginal delivery were assigned to one group and those with a history of vaginal delivery were assigned to another group, and the latter group was then divided into 2 subgroups according to the results of trial of labor.

RESULTS

Of these 702 women with a history of 1 CS, 62.4% also had a history of vaginal delivery. After trial of labor, vaginal delivery occurred more often among women with no history of vaginal delivery (64.8%). Moreover, trial of labor resulted in a vaginal delivery more often in women who were delivered only once and by CS (87.7%) than in women who also had a history of vaginal delivery (79.2%).

CONCLUSION

These findings indicate that women who have had a CS should strongly consider natural delivery for subsequent pregnancies.

An audit of trial of labour after previous caesarean section

The first aim of the study was to assess the success rate of vaginal delivery after a trial of labour in women with history of caesarean delivery. The second, was to analyse the management used and suggest recommendations that might improve the outcome. The caesarean section rate in Tameside hospital, in the period of 1995 and 1996, was (11%), 20% of which were repeat caesarean sections Fifty-one per cent of those with a history of previous caesarean section were allowed a trial of labour. The success rate of vaginal delivery in cases allowed trial of labour was 70%. But, if we include the 49% of cases who had elective repeat caesarean section in the calculation, the success rate for vaginal delivery would drop to 36%. More than one previous caesarean section was the main indication for elective repeat caesarean section. The second most common indication was cephalopelvic disproportion based on X-ray pelvimetry. Other indications included pregnancy-induced hypertension, breech presentation and maternal request. The main indication for repeat emergency caesarean section was fetal distress. Other causes included failure to progress, cephalo-pelvic disproportion, tender scar, ante-partum haemorhage and one case of ruptured uterus.

What are the implications for the next delivery in primigravidae who have an elective caesarean section for breech presentation?

OBJECTIVE

To determine the mode of the next delivery for primigravid women who have an elective caesarean section for breech presentation.

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital.

POPULATION

All primigravid women who had an elective caesarean section for a singleton pregnancy in the years 1992 to 1997 and who delivered their next baby in the hospital before 1999.

METHODS

Review of hospital computerised records.

MAIN OUTCOME MEASURES

Mode of delivery and fetal presentation at next delivery.

RESULTS

Of 194 women who had an elective caesarean section with a breech presentation as a primigravida, 19 (9.8%) had a breech presentation at the time of elective caesarean section for their next baby compared with only two (1.7%) in the 121 women who had an elective caesarean section with a cephalic presentation as a primigravida (RR 5.9 [95% CI 1.4-25.0]). Despite the increased likelihood of another breech presentation, the overall repeat section rate was 43.8% (n = 85) in women with a previous breech presentation (n = 194), compared with 61.2% (n = 74) in women with a previous cephalic presentation (n = 121) (RR 0.72 [95% CI 0.58-0.89]). Of those women allowed to labour after elective caesarean section as a primigravid, the vaginal birth rate was 109/130 (84%) if the presentation previously was breech compared with 47/69 (68%) if the presentation previously was cephalic (RR 1.2 [95% CI 1.03-1.50]).

CONCLUSIONS

Women who have an elective caesarean section for a breech presentation in their first pregnancy have about a 1 in 10 chance of having an elective caesarean section for a breech presentation in their second pregnancy. Overall, the incidence of repeat caesarean section for their second baby was 43.8%, and of those allowed to labour, 84% achieved a vaginal delivery. These results compared favourably with women who had an elective caesarean section with a cephalic presentation in their first pregnancy. This information is important in advising primigravid women with a breech presentation about longer term implications of elective caesarean section. It also allows healthcare managers to anticipate the resource implications of any changes in clinical practice for women with a breech presentation in their first pregnancy.

Prediction of vaginal delivery following caesarean section for failure to progress based on the initial aberrant labour pattern

OBJECTIVE

To determine whether the pattern of cervical dilatation prior to caesarean section for 'failure to progress' can predict the outcome of subsequent labour.

STUDY DESIGN

Single hospital case note review of 171 women delivered by caesarean section for failure to progress and subsequently delivering at the same hospital. Cervicograms were categorized into one of the four patterns by an assessor blinded to the subsequent outcome. Statistical analysis was done by analysis of variance.

RESULTS

The incidence of vaginal delivery did not significantly differ between the groups.

CONCLUSION

Categorisation of failure to progress by partographic abnormality does not predict subsequent successful vaginal delivery.

Uterine rupture

Uterine rupture is an uncommon obstetric event. It is important because it continues to be associated with maternal mortality, especially in developing countries, and with major maternal morbidity, particularly peripartum hysterectomy. It is also associated with a high incidence of perinatal mortality and morbidity worldwide. This chapter examines the incidence, aetiology, clinical presentation, complications and prevention of uterine rupture. The key factor in the cause of rupture is whether or not the uterus is scarred. Rupture of an unscarred uterus is rare, usually traumatic, and its incidence decreases with improvement in obstetric practice. Rupture of the scarred uterus is more common, and usually occurs after a trial of labour in a patient with a previous Caesarean section. This chapter also explores how the incidence and complications of uterine rupture may be minimized, and yet the incidence of vaginal birth after Caesarean section (VBAC) optimized, in clinical practice.

Vaginal birth after cesarean: to induce or not to induce

OBJECTIVE

Our purpose was to determine the impact of labor induction on both the success and safety of a trial of labor in women who are candidates for vaginal birth after cesarean.

STUDY DESIGN

We performed a prospective observational analysis of 505 women consecutively presenting for delivery with a prior cesarean (September 1997-December 1999), of whom 236 (46.7%) underwent trial of labor. The following three cohorts were established: (1) repeat cesarean without trial of labor (n = 269), (2) spontaneous trial of labor (n = 179), and (3) induced trial of labor (n = 57).

RESULTS

The vaginal delivery rate was significantly higher (77.1% vs 57.9%) in the spontaneous labor group compared with the induced labor group (odds ratio, 2.45; 95% confidence interval, 1.24-4.82; P =.008). Uterine scar separation occurred more frequently in the induced labor group (7%) than in the elective repeat cesarean group (1.5%) (odds ratio, 0.20; 95% confidence interval, 0.04-0.99; P =.034).

CONCLUSION

Induction of labor in women attempting vaginal birth after cesarean is associated with a significantly reduced rate of successful vaginal delivery and an increased risk of serious maternal morbidity.

Knowledge and attitudes about vaginal birth after Caesarean section in Australian hospitals. VBAC Study Group. Vaginal Birth After Caesarean

A survey of staff attitudes and knowledge about vaginal birth after Caesarean section (VBAC) was undertaken in Australian hospitals. There was a high response rate (67%), and over 900 responses were analysed. Generally, there was a high level of awareness about outcomes and the relative importance of many issues in considering VBAC. Registrars, consultants and midwives differed significantly in some aspects of their knowledge and attitudes to VBAC. There was also a wide range of opinion within each group. Approximately half (53%) of respondents believed patients should be actively encouraged to consider VBAC, whereas 47% felt it should be simply presented as an option.

Vaginal birth after Caesarean section: an Australian multicentre study. VBAC Study Group

Retrospective analysis of medical records and individual case review was undertaken at 11 major obstetric hospitals for a 5 year period from July 1992 to June 1997 to investigate rates of vaginal birth after Caesarean section (VBAC), the occurrences of uterine rupture, and the outcomes for mother and infant following rupture. Total deliveries were 234,015, of which 21,452 or 9.2% were associated with one or more previous Caesarean sections. Within this scar group, 5419 patients or 25.3% were delivered vaginally. There were 62 cases of significant uterine rupture with no maternal deaths. Perinatal mortality with rupture was 25% and serious maternal complications (usually hysterectomy) occurred in 25% of those with uterine rupture. In women attempting vaginal delivery after a previous lower segment Caesarean section, the uterine rupture rate was estimated at 0.3%, with 0.05% experiencing a perinatal death and 0.05% requiring a hysterectomy. Although VBAC rates in Australia remain lower than many overseas reported series, rates are increasing. While rupture continues to be associated with serious adverse outcomes, the incidence of rupture during trial of labour is low and appears to be associated with a better outcome than rupture of an unscarred uterus.

Vaginal birth after cesarean delivery

VBAC is considered safe and is often successful in carefully selected populations of women. Women with prior CDs are given the option of elective repeat CD or a trial of labor; neither option is risk free. Less morbidity is encountered in women with successful VBACs versus those with elective repeat CD. Patients who undergo successful trials of labor experience fewer blood transfusions, fewer postpartum infections, and shorter hospital stays and generally have no increased perinatal mortality. The high CD rate begins with the high frequency of the first CD. Therefore, a concerted effort should be made to decrease primary CDs. Paul and Miller remind us of the importance of the decision to proceed with the initial CD in their statement, "once a cesarean, always a scar (p 1907)." Many patients present for prenatal care with one or more prior uterine scars. Careful and thoughtful counseling of patients with a previous CD regarding the risks and benefits of a labor trial based on the current available literature is prudent. Pitkin's editorial in Obstetrics and Gynecology in 1991 stated, "Without question, the most remarkable change in obstetric practice over the last decade involves management of the woman with a prior cesarean delivery (p 939)." Controversies regarding the management of women with scarred uteri remain. In his review of the CD controversy, Flamm leaves us with an important thought: "A woman with a prior cesarean is at increased risk regardless of her mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary cesarean delivery is the only way to avoid this dilemma (p 315)."