Delivery After Prior Cesarean: Maternal Morbidity and Mortality
Section snippets
Practice of VBAC
The overall TOLAC among US studies was 58%, with a range of 28% to 70%.18 For studies initiated after 1996, less than half of women (44%) had a TOLAC, compared with 62% of women in studies initiated before 1996.18 Many factors, including site of delivery (rural vs urban), type of hospital (teaching vs community), history of prior vaginal delivery (including prior VBAC), and race/ethnicity (black and other minorities vs white), had been identified to modify TOLAC rates.18, 21, 22, 23, 24, 25 The
Ideal candidates for VBAC
One of the greatest challenges in counseling and managing women with previous cesarean delivery regarding whether to undergo TOLAC versus ERCD is the inability to accurately identify women who have a high probability of VBAC and those who have increased risk of morbidity with TOLAC and thus may be better candidates for ERCD. Several factors have been identified to influence the likelihood of successful VBAC; these, in turn, can influence the decision to either undergo a trial of labor or
Induction/Augmentation of Labor and VBAC
Induction of labor (IOL) for maternal or fetal indications is increasingly common in obstetric practice and has increased from 9.5% in 1990 to 22.8% in 2007 in the United States47 Although TOLAC remains an option in women for whom induction of labor is indicated, labor induction and augmentation is associated with a decreased likelihood of VBAC (OR 0.56; 95% CI 0.38–0.83.18, 19 Most studies on this topic examined the use of prostaglandin E2 (PGE2) as the cervical ripening agent: the pooled
Outcomes of trial of labor versus ERCD for index pregnancy
Because a successful VBAC cannot be guaranteed, and because risks versus benefits may be disproportionately associated with a failed trial of labor after cesarean (in which a woman undergoes a repeat cesarean delivery after a trial of labor) compared with an elective repeat cesarean or a successful VBAC, the appropriate statistical comparison for both research and patient counseling regarding mode of delivery for women with a previous cesarean is by intention to deliver: TOLAC versus ERCD.18
Considerations for future pregnancies and the impact of multiple cesareans
Women who choose an ERCD or those who have an unsuccessful TOLAC will likely require cesarean delivery for all future pregnancies, making it important to understand the risks, including hysterectomy and placental abnormalities, associated with multiple prior cesareans.
Shared decision making and counseling
For most of the twentieth century, “Once a cesarean, always a cesarean” was the standard obstetric practice. Although TOLAC is deemed an appropriate option in women with previous cesarean delivery, assessment of individual risks and the likelihood of successful VBAC are important in determining who may be appropriate candidates for TOLAC. Much effort has been put forth to improve the identification of prognostic factors associated VBAC and to develop normograms for predicting VBAC and
Summary
The annual incidence of cesarean delivery in the United States continues to increase such that today, nearly 1 in 3 pregnant women undergo cesarean.48 This trend is contrary to the national goal of decreasing cesarean delivery in low-risk women.66, 67 Although there are many potential causes, the decline in VBACs contributes to the continual increase in cesarean deliveries. Prior cesarean delivery is the most common indication for cesarean and accounts for more than one-third of all cesareans.
References (67)
- et al.
Cesarean delivery: background, trends, and epidemiology
Semin Perinatol
(2006) - et al.
Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries
Am J Obstet Gynecol
(1999) - et al.
Closed claims analysis of 65 medical malpractice cases involving nurse-midwives
J Midwifery Womens Health
(2005) - et al.
Predictors of labor and vaginal birth after cesarean section
Int J Gynaecol Obstet
(2004) - et al.
Sociodemographic factors and pregnancy events associated with women who declined vaginal birth after cesarean section
Eur J Obstet Gynecol Reprod Biol
(2009) - et al.
Preferred and actual delivery mode after cesarean in London, UK
Int J Gynaecol Obstet
(2008) - et al.
The effect of birthweight on vaginal birth after cesarean delivery success rates
Am J Obstet Gynecol
(2003) - et al.
Predictive score for vaginal delivery after cesarean section
Am J Obstet Gynecol
(1996) - et al.
Labor after previous cesarean: influence of prior indication and parity
Obstet Gynecol
(2000) - et al.
The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery
Am J Obstet Gynecol
(2005)
Trial of labor after 40 weeks’ gestation in women with prior cesarean
Obstet Gynecol
Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?
Am J Obstet Gynecol
More than one previous cesarean delivery: a 5-year experience with 435 patients
Obstet Gynecol
Vaginal birth after cesarean delivery: an admission scoring system
Obstet Gynecol
Predicting outcomes of trials of labor in women attempting vaginal birth after cesarean delivery: a comparison of multivariate methods with neural networks
Am J Obstet Gynecol
Maternal Health Study Group, Canadian Perinatal Surveillance System. Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery
Am J Obstet Gynecol
Emergency peripartum hysterectomy
Am J Obstet Gynecol
Maternal morbidity after elective repeat cesarean section after two or more previous procedures
Eur J Obstet Gynecol Reprod Biol
Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?
Am J Obstet Gynecol
Conservatism in obstetrics
NY Med J
Vaginal delivery in patients with a prior cesarean section
Obstet Gynecol
Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study
Obstet Gynecol
Vaginal birth after cesarean: a 10-year experience
Obstet Gynecol
Rates of cesarean delivery—United States 1991
MMWR Morb Mortal Wkly Rep
Cesarean Childbirth: report of a Consensus Development Conference. Sponsored by the NICHD in conjunction with the National Center for Health Care Technology and assisted by the Office for Medical Applications of Research
Appropriate technology for birth
Lancet
American College of Obstetricians and Gynecologists. Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists. Vaginal birth after previous cesarean delivery
Obstet Gynecol
Rates of cesarean birth and vaginal birth after previous cesarean, 1991–95
Mon Vital Stat Rep
The risks of lowering the cesarean-delivery rate
N Engl J Med
VBAC: time to reconsider?
OBG Management
Births: final data for 2006
Natl Vital Stat Rep
The American College of Obstetricians and Gynecologists Practice Bulletin—Clinical Guidelines for Obstetrician-Gynecologists. Vaginal birth after previous cesarean delivery. No 115, August 2010 (replaces Practice Bulletin No 54, July 2004 and Committee Opinion No 342, August 2006)
Obstet Gynecol
NIH Consensus Development Conference: vaginal birth after cesarean: new insights. Consensus Development Conference statement
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Vaginal delivery after caesarean section and its associated factors in Mizan Tepi University Teaching Hospital, Southwest Ethiopia
2021, HeliyonCitation Excerpt :Caesarean section rates have increased over the last decade, with an estimated third of women having delivered by caesarean section worldwide [1]. In particular, repeat caesarean section is the commonest factor responsible for the overall increased caesarean delivery rates [2]. In Ethiopia, the caesarean delivery rate is increasing [3, 4], which is much higher than the World Health Organizations (WHO) target of a maximum caesarean section rate of 15% [5].
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Financial disclosure: this work was funded by the Agency for Healthcare Research and Quality, contract no. HHSA 290-2007-10057-I, task order no. 4 for the Office of Medical Applications of Research at the National Institutes of Health.