Delivery After Prior Cesarean: Maternal Morbidity and Mortality

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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.

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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.

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