Obstetric outcomes in women with two prior cesarean deliveries undergoing a trial of labor (original) (raw)
Related papers
Data Revues 00029378 V192i4 S000293780500058x, 2011
Objective: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. Study design: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. Results: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). Conclusion: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who
Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery
Obstetrics & Gynecology, 2008
OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs. METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery. RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P.)30.؍ The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter. CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.
A study of outcome of pregnancy in patients with previous cesarean section in a tertiary set up
IP Innovative Publication Pvt. Ltd., 2017
Rates of primary caesarean sections has increased dramatically since the 1980's. Consequently, an increasing proportion of pregnant women attending for care have had a previous caesarean and face the question of mode of delivery. These women are at increased risk of complication compared with other women. The primary choice for women in this situation is whether to have a repeat caesarean section or to attempt vaginal birth. Both repeat CS (ERCS) and VBAC have inherent risks for the mother and the baby. Antenatal counselling and informed consent is crucial. Counselling should incorporate an individualized assessment of the risks and benefits of ERCS and planned VBAC modes of delivery. Women considering their options for birth after a single previous cesarean should be informed that, overall, the chances of successful planned VBAC are 72-76%. VBAC should not be undertaken without thorough discussion of the risks during labour with the pregnant women. It should not be undertaken in units where full obstetric facilities such as emergency transfer to theatre, blood transfusion and continuous fetal monitoring are not available. Planned VBAC is associated with slightly increased perinatal risk than planned ERCS, although absolute risks are low for both modes of delivery. Planned VBAC exposes the woman to a very low (0.25%) additional risk for experiencing perinatal mortality or serious neonatal morbidity and an additional 1.5% risk of any significant morbidity compared with opting for ERCS from 39 weeks of gestation. Absolute risk of delivery-related perinatal death associated with VBAC is extremely low (4 per 10 000 (0.04%)) and comparable to the risk for nulliparous women in labour. Planned VBAC is therefore appropriate and may be offered to the vast majority of multiparous women with a singleton pregnancy of cephalic presentation at term with a single previous single lower segment caesarean delivery. From a maternal point of view, the safest outcome is spontaneous labour and spontaneous vaginal delivery while the outcome associated with the greatest morbidity is a failed VBAC resulting in caesarean section. In women with single previous lower segment caesarean section, who opted for ERCS, the major obstetric drawback is the risk of rare, but severe, adverse outcomes in future pregnancies. The two major clinical factors determining the choice for VBAC are, therefore, the likelihood of a successful attempt and the mother's plan for future pregnancies.
American journal of obstetrics and gynecology, 2017
It is not well-characterized whether attempting operative vaginal delivery is a safe and effective alternative among women who undergo a trial of labor after cesarean delivery who are unable to complete second-stage labor with a spontaneous vaginal delivery. The purpose of this study was to compare maternal and neonatal outcomes that are associated with attempted operative vaginal delivery with those that are associated with second-stage repeat cesarean delivery without an operative vaginal delivery attempt among women who undergo a trial of labor after cesarean delivery. This is a retrospective secondary analysis of data from Cesarean Registry of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Women who underwent a trial of labor after cesarean delivery who were at least 36 weeks gestation were eligible for analysis if they had a live, singleton, nonanomalous gestation in cephalic presentation and reached se...
While there is increased maternal and perinatal morbidity associated with the failure of trial of vaginal birth after cesarean section (VBAC), a successful trial of VBAC reduces the risk of complications in future pregnancies, associated with a repeat cesarean section. Studies in patients attempting VBAC have shown that the highest rate of maternal complications occur in patients who have a failed attempt at VBAC, intermediate in those who have an elective repeat cesarean section and lowest in those who have a successful VBAC[1]. There is evidence to suggest that overall success of a VBAC ranges from 72-76 % [2], with factors that can increase or decrease the chances of success. Assessment of individual risks and the likelihood of VBAC can help determine appropriate candidates for trial of labor. Screening tools consider the relative effect of multiple factors to predict an individual’s likelihood of vaginal delivery [3]. Majority of the scoring systems have used indication of previous cesarean, Bishops score and history of VBAC in their screening tools. Some have used other factors like maternal age, weight, inter-delivery period, estimated fetal weight and history of term/preterm cesarean section [4]. Although all these factors have been shown to influence VBAC trail outcome in some studies , they have not achieved statistical significance in other studies. All these factors have thus not been collectively included in various screening tools. Among all demographic factors analyzed ethnicity has shown to have a significant impact on the outcome of trail. Ethnicity has been shown to influence not only trial of labor (TOL) rates but also rates of VBAC. Indian patients have not had a large representation in former studies. We aim to assess the influence of known antenatal and intrapartum factors on the likelihood of vaginal birth in Indian patients attempting trial of vaginal birth after one previous cesarean section. Many patients in developing countries present for the first time in their pregnancy when in labor. Some of the patients do not have access to optimum antenatal care and they do not have the chance to be timely assessed by a qualified clinician. The parameters influencing TOL available on admission from history and examination can collectively be evaluated to help guide the clinician and estimate the probability of success of TOL after previous one cesarean section. This can result in timely referral of patients unlikely to have a successful VBAC
We were interested in Pare et al’s paper showing an excess increase in hysterectomy in subsequent pregnancies for women having elective repeat caesarean sections (CS) (1). Further valuable information is added to the risk assessment women, obstetricians and midwives must make; both when considering a primary CS or waiting for labour in a subsequent pregnancy. The National Institute of Clinical Excellence has examined the health risks of CS and concluded that, even for a first CS, maternal request alone is not an indication for elective major surgery and requires the use of counseling to explore women’s motives, and a second opinion (2), because of the imbalance of health risks to mothers and babies which only widens with increasing parity and increasing numbers of caesareans. It is generally better to labour (even if that ends in emergency CS) and especially in settings that achieve high vaginal delivery rates. This is not only because of the future maternal morbidity that repeat caesareans cause (which can only increase as the caesarean rate rises), but also because of increasing risks to babies. Poor fetal outcomes are sometimes used to justify avoiding vaginal birth after CS (VBAC) entirely, or to avoid VBAC at home or in midwifery-led childbirth centres in particular. For example, VBACs in childbirth centres were eliminated in the US based on an increase of 1/1000 perinatal deaths among women having a VBAC after one CS in childbirth centres (3) despite higher successful vaginal birth rates. But logic would suggest that for those women planning or experiencing further pregnancies, VBAC after one CS may be safer overall in a childbirth centre than in the hospital. This is because childbirth centers had a mean 87% successful VBAC rate compared to 10% in US hospitals (3). The UK has an overall 33% VBAC rate (4). Intrapartum perinatal mortality due to uterine rupture during labour has to be balanced against reports suggesting an increase in third trimester unexplained stillbirths in future pregnancies following CS. Although no one has yet examined the rate of unexplained third trimester stillbirths after two or more cesareans , the rate of unexplained stillbirths after one CS has been shown to be 1/500 vs. 1/1000 after one vaginal birth (5) in observational studies. If this association of CS with subsequent stillbirth is confirmed, it is a fetal argument against elective repeat CS. One theory suggests that the unexplained fetal demise is a complication resulting from the uterine scar, although a plausible mechanism is as yet unknown. Thus, it is possible that the rate of unexplained stillbirths may increase even further with increasing numbers of scars, and in any case, would not be expected to decrease. When an increased risk of stillbirth is added to the excess increase in hysterectomy (1) and long-established respiratory risks of elective CS, it is at least arguable that childbirth centres may statistically be a safer place for women after one CS who wish to have more children, unless and until hospitals match their typical 87% successful VBAC rate. Of course, using a childbirth centre in the first labour and avoiding the first CS might be the best overall preventative approach for the health of mothers and babies. References: 1. Pare E, Quinones J, Macones G. Vaginal birth after cesarean section versus elective repeat cesarean section: assessment of maternal downstream health outcomes. BJOG 2006; 113:75-85. 2. National Collaborating Centre for Women’s and Children’s Health, National Institute for Clinical Excellence. Caesarean Section. London: RCOG Press, 2004. 3. Lieberman E. Ernst E. Rooks J. Stapleton S. Flamm B. 2004. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol. Nov. 104(5 Pt 1): 933-42. 4. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. London: RCOG Press, 2001. 5. Smith GC, Pell JP Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003 Nov 29;362:1779-84.
Objective: This study aims to determine the success of vaginal birth after cesarean section (VBAC) based on previous cesarean delivery indication. Design: Retrospective cohort study Setting: University of the Philippines - Philippine General Hospital, Department of Obstetrics and Gynecology hospital masterlist data Sample: Gravidas with a previous cesarean section within a five year period (2015 - 2019) METHODS: Maternal demographics, obstetric characteristics on admission, perinatal morbidities and maternal morbidities were recorded. Data was analyzed using Student’s t-test for continuous variables, chi-square test to compare the distribution and Z-test was used to compare success rates. Main outcome measures: The main outcome measures are TOLAC rate, VBAC rate, factors which affect success of TOLAC and VBAC, and perinatal and maternal morbidities associated with successful and failed VBAC. Results: A total of 2485 patients were included. The overall TOLAC rate was 17% (95% CI: 15.6% - 18.6%) and the VBAC rate was 9.5% (95% CI: 8.3% - 10.7%). Patients with successful VBAC are younger, had less weight and body mass index, shorter interdelivery intervals, and admitted in active phase cervical dilatation. Previous cesarean section indication did not significantly affect VBAC success. Perinatal and maternal morbidities of successful and failed VBAC did not significantly differ from one another. Conclusions: This study provided local evidence and valuable perspective in success factors which influence our counselling and eventual management of patients with a previous cesarean section.
International Journal of Women's Health, 2012
To determine the effects of vaginal birth after cesarean (VBAC) versus repeated cesarean sections (RCS) after a primary cesarean section (CS), on the rate of intraoperative and postpartum maternal morbidity. Patients and methods: This is a retrospective population-based cohort study. During the study period (1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005) there were 200,012 deliveries by 76,985 women at our medical center; 16,365 of them had a primary CS, of which 7429 women delivered a singleton infant after the primary CS, met the inclusion criteria, were included in our study, and were followed for four consecutive deliveries. Patients were divided into three study groups according to the outcome of their consecutive delivery after the primary CS: VBAC (n = 3622), elective CS (n = 1910), or an urgent CS (n = 1897). Survival analysis models were used to investigate the effect of the urgency of CS and the numbers of pregnancy predating the primary CS on peripartum complications. Results: Women who failed a trial of labor had a higher rate of uterine rupture than those who had a VBAC. Patients who delivered by CS had a higher rate of endometritis than those giving birth vaginally. The rate of cesarean hysterectomy and transfer to other departments increased significantly at the fourth consecutive surgery (P = 0.02 and P = 0.003, respectively). VBAC was associated with a 55% reduction in the risk of intrapartum complications in comparison to a planned CS (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.22-0.89. A greater maternal parity at the time of primary CS was associated with lower intrapartum and postpartum morbidities (HR 0.44; 95% CI: 0.24-0.79; HR 0.54; 95% CI: 0.47-0.62, respectively). Conclusions: (1) A successful VBAC is associated with a reduction in the intrapartum complications; and (2) maternal morbidity increases substantially from the fourth consecutive cesarean delivery.
Vaginal birth after cesarean section: Trial of labor or repeat cesarean section? A decision analysis
American Journal of Obstetrics and Gynecology, 2003
The risk of perinatal death associated with labor after previous cesarean section appears higher than with a repeated cesarean section. On the other hand, repeated cesarean sections are associated with increased maternal morbidity and mortality from placental pathologic conditions (previa or accreta) on subsequent pregnancies. The study was undertaken to analyze the decision for a trial of labor or a repeated cesarean section, after a prior cesarean section, with varying desire for an additional pregnancy. STUDY DESIGN: A model was formulated using a decision tree, based on the reported risks of the two approaches. Sensitivity analysis was performed over a variety of probabilities (eg, chance of uterine rupture or neonatal death, chance of rescue cesarean section, desire for an additional pregnancy) and utilities (eg, use of hysterectomy or neonatal death). RESULTS: The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10% to 20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit. The model was robust over a wide range of assumptions. CONCLUSION: An optimal decision for a trial of labor or a repeated cesarean section is substantially determined by the wish for future pregnancies. The default option of a repeated cesarean section is not directly applicable in populations in which family planning often extends over two children.