Vaginal birth after cesarean delivery: results in 310 pregnancies

Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis

Background

Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC.

Methods

A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database’s inception to March 16, 2018. Observational studies, identifying women with a trial of labor after one previous low-transverse cesarean section were included. Two reviewers independently abstracted the data. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale.

Results

We included 94 eligible observational studies (239,006 pregnant women with 163,502 VBAC). Factors were associated with successful VBAC with the following odds ratios (OR;95%CI): age (0.92;0.86–0.98), obesity (0.50;0.39–0.64), diabetes (0.50;0.42–0.60), hypertensive disorders complicating pregnancy (HDCP) (0.54;0.44–0.67), Bishop score (3.77;2.17–6.53), labor induction (0.58;0.50–0.67), macrosomia (0.56;0.50–0.64), white race (1.39;1.26–1.54), previous vaginal birth before cesarean section (3.14;2.62–3.77), previous VBAC (4.71;4.33–5.12), the indications for the previous cesarean section (cephalopelvic disproportion (0.54;0.36–0.80), dystocia or failure to progress (0.54;0.41–0.70), failed induction (0.56;0.37–0.85), and fetal malpresentation (1.66;1.38–2.01)). Adjusted ORs were similar.

Conclusions

Diabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC.

Vaginal birth after cesarean section

BACKGROUND

The rate of primary cesarean section (CS) is on the rise. More and more women report with a history of a previous CS. A trial of vaginal delivery can save these women from the risk of repeat CS.

AIMS

The study was conducted to assess the safety and success rate of vaginal birth after CS (VBAC) in selected cases of one previous lower segment CS (LSCS).

MATERIALS AND METHODS

The prospective observational study was carried out in a tertiary care teaching hospital over a period of two years. One hundred pregnant women with a history of one previous LSCS were enrolled in the study.

RESULTS

In the present study, 85% cases had a successful VBAC and 15% underwent a repeat emergency LSCS for failed trial of vaginal delivery. Cervical dilatation of more than 3 cm at the time of admission was a significant factor in favor of a successful VBAC. Birth weight of more than 3,000 g was associated with a lower success rate of VBAC. The incidence of scar dehiscence was 2% in the present study. There was no maternal or neonatal mortality.

CONCLUSION

Trial of VBAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas.

Evaluating trial of scar in patients with a history of caesarean section

Aims:

To analyze the outcome of trial of scar in patients with previous caesarean section and to assess the fetal and maternal complications after trial of scar.

Patients and Methods:

The study was conducted at Military Hospital, Rawalpindi, Pakistan, with 375 pregnant patients who had a previous delivery by caesarean and who had regular antenatal checkup. Data were recorded on special pro-forms designed for the purpose.

Results:

The results from the 375 patients who had one previous lower segment caesarean section due to non-recurrent causes were analyzed and compared with national and international studies. Indications of previous caesarean section (non-recurrent causes) included malpresentations, fetal distress/cord prolapse, failure to progress, severe pregnancy-induced hypertension/eclampsia and twins with abnormal lie of the first twin. 0 218 patients reported spontaneous labor. Among these patients, 176 delivered vaginally and 42 patients had repeat caesarean sections. There were a total of 157 patients who experienced induction of labor. 97 patients were induced by cervical ripening with mechanical method, followed by artificial rupture of membranes and augmentation (if required) with syntocinon infusion. 60 patients were induced with prostaglandin E₂ vaginal tablet.

Conclusion:

This study concludes that females with a prior caesarean are at increased risk for subsequent caesareans, regardless of mode of delivery. Eliminating vaginal-birth-after-caesarean will not eliminate the risk. Therefore, vaginal birth after caesarean should be encouraged in selected cases from obstetric units to reduce the risks of repeated caesarean sections. Failed vaginal-birth-after-caesarean can result in increased morbidity than that with elective caesarean section.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

BACKGROUND

When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004).

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

There were no randomised controlled trials identified.

REVIEWERS' CONCLUSIONS

Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature

OBJECTIVE

The purpose of this study was to determine the rate of uterine rupture and its complications as the result of trial of labor after previous cesarean delivery.

STUDY DESIGN

PubMed was searched from 1989 to 2001, with the terms "VBAC, uterine rupture," "trial of labor, uterine rupture," "cesarean delivery, uterine rupture," and "scarred uterus, rupture." For inclusion, reports had to contain data from at least 100 patients with trials of labor that included a description of adverse outcomes. Duplicate reporting from a single institution was excluded. Odds ratios and 95% CIs were calculated.

RESULTS

Seventy-two of the 361 articles (20%) that were identified met the inclusion criteria. A 6.2 per 1000 trial of labor rate of uterine rupture (total=880 uterine ruptures in 142,075 trials of labor) was determined. For every 1000 trials of labor the uterine rupture-related complication rate was 1.8 for packed red blood cell transfusion, 1.5 for pathologic fetal acidosis (cord pH<7.00), 0.9 for hysterectomy, 0.8 for genitourinary injury, 0.4 for perinatal death, and 0.02 for maternal death. The perinatal mortality rate was significantly lower among studies from the United States versus other countries (0.3 vs 0.6; odds ratio, 0.50; 95% CI, 0.26-0.94) and in series that exceeded 1000 patients (0.2 vs 1.7; odds ratio, 7.34; 95% CI, 3.94-13.69).

CONCLUSION

Although relatively uncommon, uterine rupture is associated with several adverse outcomes, depending on the time of the publication and the site and size of the population that was studied.

Management of vaginal birth after cesarean

OBJECTIVE

To raise the success rate of vaginal birth after cesarean (VBAC) without increasing maternal or perinatal morbidity and mortality rates.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Induction of labor with prostaglandin E2 vaginal tablets in parous and grandmultiparous patients with previous cesarean section

OBJECTIVES

To compare the outcome of induction of labor with prostaglandin E2 vaginal tablets between lower parity (parity 1-5) and grandmultiparous (parity >5) patients with a history of one previous lower segment cesarean section.

METHODS

A prospective study of 113 patients conducted at King Faisal Military Hospital, Khamis Mushayt, Saudi Arabia during a 5-year period spanning January 1995 to December 1999.

RESULTS

There were no statistically significant differences in the two groups regarding mean maternal age, dose of prostaglandin used, gestation at delivery, mean birth weight, P>0.05. Syntocinon augmentation was used in 16 (21.9%) of the lower parity patients compared with 8 (20.0%) in the grandmultiparas but this was not statistically significant, (P=0.677). However, there was a statistically significant difference in the cesarean section rate between the two groups, P=0.019. Although no cases of uterine hyperstimulation were recorded, there was one rupture of the uterus in each of the two groups of patients; 1.36% and 2.5%, respectively, but this was not statistically significant, P=1.000.

CONCLUSIONS

The complications of induction of labor with prostaglandin E2 vaginal tablets in grandmultiparous patients with previous cesarean section were similar to those with lower parity but the cesarean section rate was significantly higher. However, larger studies are needed for validation.

Is vaginal birth after cesarean safe? Experience at a community hospital

OBJECTIVE

We sought to evaluate the effectiveness and safety of promoting a trial of labor after prior cesarean birth in a community hospital.

STUDY DESIGN

A 4-year prospective cohort study was conducted of all patients who had prior cesarean births (N = 1481). A comparison of outcomes was performed between those who elected repeat cesarean delivery (n = 727) and those who attempted a trial of labor after previous cesarean(s) (n = 754).

RESULTS

We found that the vaginal birth after cesarean attempt rate was 50.9% and declined significantly during the last 2 years of the study. The elective repeat cesarean rate was 49.1% and increased significantly during the last 2 years of the study. In addition, we found that neonatal outcomes were similar, with the exception of 2 neonatal deaths caused by uterine rupture. Twelve uterine ruptures occurred (1.6%), and 11 of the 12 ruptures involved either induction or augmentation of labor, or both.

CONCLUSIONS

A trial of vaginal birth after cesarean is safe provided that induction of labor is not used. The uterine rupture rate of 1.6% is higher than reported in the literature; this may reflect underreporting by community hospitals.

Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999

OBJECTIVE

The aim of this study was to compare a trial of labor with elective repeat cesarean delivery among women with previous cesarean delivery.

STUDY DESIGN

We searched MEDLINE and EMBASE databases from 1989 through 1999 with the following terms: vaginal birth after cesarean delivery, trial of labor, trial of scar, and uterine rupture. We included all controlled trials from developed countries in which the control group had been eligible for a trial of labor. Outcomes of interest were uterine rupture, hysterectomy, maternal febrile morbidity, maternal mortality, 5-minute Apgar score <7, and fetal or neonatal mortality. We computed pooled odds ratios for each outcome.

RESULTS

The search strategy identified 52 controlled studies, 37 of which were excluded because many of the control subjects were not eligible for a trial of labor. Fifteen studies with a total of 47,682 women were included. Uterine rupture occurred more frequently among women undergoing a trial of labor than among those undergoing elective repeat cesarean delivery (odds ratio, 2.10; 95% confidence interval, 1.45-3.05). There was no difference in maternal mortality risk between the 2 groups (odds ratio, 1.52; 95% confidence interval, 0.36-6.38). Fetal or neonatal death (odds ratio, 1.71; 95% confidence interval, 1.28-2.28) and 5-minute Apgar scores <7 (odds ratio, 2.24; 95% confidence interval, 1.29-3.88) were more frequent in the trial of labor group than in the control group. Mothers undergoing a trial of labor were less likely to have febrile morbidity (odds ratio, 0.70; 95% confidence interval, 0.64-0.77) or to require transfusion (odds ratio, 0.57; 95% confidence interval, 0.42-0.76) or hysterectomy (odds ratio, 0.39; 95% confidence interval, 0.27-0.57).

CONCLUSION

A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates with respect to elective repeat cesarean delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion or hysterectomy may be reduced with a trial of labor.

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.