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Guidelines for vaginal birth after previouus caesarean birth

SOGC CLINICAL PRACTICE GUIDELINES
SOGC CLINICAL PRACTICE
155 (Replaces guideline No 147), February 2005 Guidelines for Vaginal Birth After Previous
Caesarean Birth
This guideline has been prepared and reviewed by the Clinical 1. Provided there are no contraindications, a woman with 1 previous Practice Obstetrics Committee and approved by the Executive transverse low-segment Caesarean section should be offered a and Council of the Society of Obstetricians and Gynaecologists of trial of labour (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birthplan in a woman with a previous Caesarean section (II-2B).
Marie-Jocelyne Martel, MD, FRCSC, Saskatoon SK Catherine Jane MacKinnon, MD, FRCSC, Brantford ON 2. The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the CLINICAL PRACTICE OBSTETRICS COMMITTEE
previous uterine scar should be clearly marked on the prenatal Catherine Jane MacKinnon, MD, FRCSC, Brantford ON record (II-2B).
Marc-Yvon Arsenault, MD, FRCSC, Montreal QC 3. For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is available. The Elias Bartellas, MD, FRCSC, St John's NL woman and her health care provider must be aware of the hospital Yvonne M. Cargill, MD, FRCSC, Ottawa ON resources and the availability of obstetric, anesthetic, pediatric,and operating-room staff (II-2A).
Sue Daniels, RN, Dartmouth NS Tom Gleason, MD, FRCSC, Edmonton AB 4. Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for Stuart Iglesias, MD, Gibsons BC a possible timely Caesarean section (III-B).
Michael C. Klein, MD, CCFP, Vancouver BC 5. In the case of a TOL after Caesarean, an approximate time frame Marie-Jocelyne Martel, MD, FRCSC, Saskatoon SK of 30 minutes should be considered adequate in the set-up of anurgent laparotomy (III-C).
Ann Roggensack, MD, Kingston ON 6. Continuous electronic fetal monitoring of women attempting a TOL Ann Kathleen Wilson, BHSc, RM, Ilderton ON after Caesarean section is recommended (II-2A).
7. Suspected uterine rupture requires urgent attention and expedited Gregory A. Davies, MD, FRCSC, Kingston ON laparotomy to attempt to decrease maternal and perinatal morbidityand mortality (II-2A).
8. Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (II-2A).
9. Medical induction of labour with oxytocin may be associated with an Objective: To provide evidence-based guidelines for the provision of
increased risk of uterine rupture and should be used carefully after a trial of labour (TOL) after Caesarean section.
appropriate counselling (II-2B).
Outcome: Fetal and maternal morbidity and mortality associated with
10. Medical induction of labour with prostaglandin E2 (dinoprostone) vaginal birth after Caesarean (VBAC) and repeat Caesarean is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate Evidence: MEDLINE database was searched for articles published
from January 1, 1995, to February 28, 2004, using the key words 11. Prostaglandin E1 (misoprostol) is associated with a high risk of "vaginal birth after Caesarean (Cesarean) section." The quality of uterine rupture and should not be used as part of a TOL after evidence is described using the Evaluation of Evidence criteria Caesarean section (II-2A).
outlined in the Report of the Canadian Task Force on the PeriodicHealth Exam.
12. A foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A).
13. The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successfulbut is associated with a higher risk of uterine rupture (II-2B).
Key Words: Vaginal birth after Caesarean, trial of labour, uterine
14. Multiple gestation is not a contraindication to TOL after Caesarean rupture, induced labour, oxytocin, prostaglandins, misoprostol section (II-2B).
These guidelines reflect emerging clinical and scientific advances as of the date issued and are subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.
lFEBRUARY JOGC FÉVRIER 2005
Guidelines for Vaginal Birth After Previous Caesarean Birth
15. Diabetes mellitus is not a contraindication to TOL after Caesarean significant difference in maternal and perinatal outcomes; section (II-2B).
and finally, a woman's choice to attempt TOL after Caesar- 16. Suspected fetal macrosomia is not a contraindication to TOL after ean is heavily influenced by her health care provider and Caesarean section (II-2B).
local resources, often leading to selection bias in published 17. Women delivering within 18 to 24 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B).
The level of evidence and quality of the recommendations 18. Postdatism is not a contraindication to a TOL after Caesarean section (II-2B).
in this guideline have been determined using the criteriadescribed by the Canadian Task Force on the Periodic 19. Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision Health Examination (Table).17 used. In situations where the scar is unknown, informationconcerning the circumstances of the previous delivery is helpful in TRIAL OF LABOUR VERSUS ELECTIVE
determining the likelihood of a low transverse incision. If thelikelihood of a lower transverse incision is high, a TOL after REPEAT CAESAREAN SECTION
Caesarean section can be offered (II-2B).
The success rate of a TOL after Caesarean ranges between Validation: These guidelines were approved by the Clinical Practice
Obstetrics and Executive Committees of the Society of 50% and 85%.3,4,14,18–21 In a study examining 1776 women Obstetricians and Gynaecologists of Canada.
undergoing TOL after Caesarean, the overall success rate J Obstet Gynaecol Can 2005;27(2):164–174 was 74%.14 A Canadian study reported similar results, quot-ing a success rate of 76.6%.2 Predictors of successful VBAC include nonrecurring indication for Caesarean birth, such asmalpresentation (odds ratio [OR], 1.9; 95% confidence This document reviews the contraindications to and maternal and fetal risks of a trial of labour (TOL) after interval [CI], 1.0–3.7)22 or gestational hypertension (OR, Caesarean birth and makes recommendations for 2.3; 95% CI, 1.0–5.8),22 and a previous vaginal delivery (OR, achieving vaginal birth after Caesarean (VBAC) safely.
1.8; 95% CI, 1.1–3.1),22 where success rates are as high as Delivery by Caesarean section occurs in 15% to 25% of 82%.1,22,23 When the previous Caesarean birth was for births.1–5 In 2000 and 2001, the Caesarean section rate in dystocia, failure to progress, or cephalopelvic dispropor- Canada was 21.2%.6 The most frequent indications for Cae- tion, some studies found the rates of successful VBAC sarean delivery are previous Caesarean delivery, dystocia, comparable,24,25 while others reported lower-than-expected malpresentation, and nonreassuring fetal status.7,8 In any given region, the rate of birth by Caesarean section and the In 1996 McMahon et al. published a report of maternal mor- rate of VBAC tend to be inversely related.4 Schell first bidity in TOL compared with ERCS in Nova Scotia from reported VBAC in 1923, describing the successful vaginal 1986 to 1992.1 In an examination of 3249 women undergo- delivery of 34 infants in 23 mothers with previous Caesar- ing a TOL and 2889 women who delivered by ERCS, the risk of major complications (for example, hysterectomy, A trial of labour after Caesarean should be considered in uterine rupture, and operative injury) was almost doubled women who present for prenatal care with a history of pre- (1.6% vs. 0.8%) in the TOL group (OR, 1.8; 95% CI, vious Caesarean birth.10–12 In certain situations, a TOL after 1.1–3.0).1 Complications like puerperal fever, transfusion, Caesarean will be contraindicated3 and a repeat Caesarean and abdominal wound infection were comparable. When section will be advised, but in most cases, successful vaginal comparing women who had a successful TOL with those birth can be safely achieved for both mother and infant.13–15 who required a repeat Caesarean section after failed TOL, Women and their health care providers will need to discuss the risks were greater of operative injury (3.0% vs. 0.1%; the risks and benefits of VBAC when planning the birth.
OR, 5.1; 95% CI, 2.5–10.7) and fever (8.0% vs. 3.5%; OR,1.5; 95% CI, 1.3–1.8) in the failed TOL group.1 Hibbard et A Canadian consensus statement on VBAC was published al. also reported a greater rate of complication in women in 1985, and Clinical Practice Guidelines were published by who attempted a TOL and failed.27 the Society of Obstetricians and Gynaecologists of Canada(SOGC) in 1997.3 This document updates the 1997 SOGC In 1999 Rageth et al. reviewed 17 613 TOL and 11 433 Guidelines with articles published from January 1, 1995, to ERCS deliveries.20 The rates of hysterectomy (relative risk February 28, 2004. Articles were obtained by searching the [RR], 0.36; 95% CI, 0.23–0.56), febrile morbidity (RR, 0.65; MEDLINE database, using the key words "vaginal birth 95% CI, 0.55–0.77), and thromboembolic complications after Caesarean (Cesarean) section." The data are limited by (RR, 0.52; 95% CI, 0.34–0.78) were less in the TOL group 3 important factors: first, there are no randomized trials of than in the ERCS group.20 There is less blood loss with a TOL versus elective repeat Cesarean section (ERCS); sec- successful VBAC (OR, 0.50; 95% CI, 0.3–0.9)27 and a ond, adverse maternal or perinatal outcomes are rare, and shorter hospital stay with a more rapid recovery and return large study populations are necessary to observe a to full activity.
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SOGC CLINICAL PRACTICE GUIDELINES
Table Criteria for quality of evidence assessment and classification of recommendations
Level of results* Classification of recommendations†
Evidence obtained from at least one properly randomized There is good evidence to support the recommendation that the controlled trial.
condition be specifically considered in a periodic healthexamination.
Evidence from well-designed controlled trials withoutrandomization.
There is fair evidence to support the recommendation that thecondition be specifically considered in a periodic health Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more thanone centre or research group.
There is poor evidence regarding the inclusion or exclusion ofthe condition in a periodic health examination, but recommenda- Evidence obtained from comparisons between times or places tions may be made on other grounds.
with or without intervention. Dramatic results in uncontrolledexperiments (such as the results of treatment with penicillin in There is fair evidence to support the recommendation that the the 1940s) could also be included in this category.
condition not be considered in a periodic health examination.
Opinions of respected authorities, based on clinical experience, There is good evidence to support the recommendation that the descriptive studies, or reports of expert committees.
condition be excluded from consideration in a periodic health *The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Forceon the Periodic Health Exam.
†Recommendations included in these guidelines have been adapted from the ranking method described in the Classification of Recommendations found in the
Report of the Canadian Task Force on the Periodic Health Exam.
Rosen et al. also reported that the risk of febrile morbidity is CONTRAINDICATIONS TO VAGINAL BIRTH
lower in women who attempt a TOL after Caesarean (OR, AFTER CAESAREAN SECTION
0.5; 95% CI, 0.5–0.6) and is lowest in those who succeed The following situations are contraindications to a TOL (OR, 0.2; 95% CI, 0.2–0.2), compared with ERCS, but is increased in those who attempt a TOL and ultimatelydeliver by Caesarean (OR, 2.0; 95% CI, 1.7–2.5).28 1. previous classical or inverted "T" uterine scar3,13; 2. previous hysterotomy or myomectomy entering the uter-ine cavity3,19; An examination of 16 938 Finnish women who had under-gone a Caesarean delivery found that previous Caesarean 3. previous uterine rupture3,19; section is associated with an increased risk of ectopic preg- 4. presence of a contraindication to labour, such as placenta nancy (RR, 1.28), placenta previa (RR, 3.89), and abruptio previa or malpresentation3; placenta (RR, 2.41).29 A repeat Caesarean has been associ-ated with an increase in the risk of placenta previa (OR, 5. the woman declines a TOL after Caesarean and requestsERCS.3,19 1.59; 95% CI, 1.21–2.08)30 and placenta accreta in subse-quent pregnancies.31 1. Provided there are no contraindications, a woman with 1previous transverse low-segment Caesarean section should A meta-analysis published in 2000 demonstrated that the be offered a trial of labour after Caesarean with appropriate overall risk of perinatal death is increased in women discussion of maternal and perinatal risks and benefits. The attempting a TOL (OR, 1.71; 95% CI, 1.28–2.28).32 The process of informed consent with appropriate documenta- risks of perinatal mortality and severe morbidity are directly tion should be an important part of the birth plan in women related to uterine rupture as a sentinel event. If uterine rup- with a previous Caesarean section (II-2B).
ture occurs, the risks of perinatal mortality and severe mor-bidity are increased. The risk of suspected neonatal sepsis is PLANNING A TRIAL OF LABOUR AFTER
greater in women attempting TOL but appears to be con- fined to those who fail TOL and require a repeat Caesarean A woman and her health care provider must decide together section (OR, 4.8; 95% CI, 2.6–9.0).33 In women who whether an appropriate situation exists for considering choose ERCS, the risk of respiratory problems in the new- TOL after Caesarean. The evaluation and discussion should born is increased (6% vs. 3%), compared with women who address the issues outlined below and should be well docu- have a successful VBAC (OR, 2.3; 95% CI, 1.4–3.8).33 mented in the prenatal record or chart.
l FEBRUARY JOGC FÉVRIER 2005
Guidelines for Vaginal Birth After Previous Caesarean Birth
Documentation of Previous Uterine Incision
Labour and delivery in women who have had a previousCaesarean section should be conducted in a hospital setting Documentation of the location and type of uterine incision with facilities for a laparotomy.
used during the previous Caesarean section is ideal.3 Inmost cases, this information can be obtained by reviewing the operative record from the previous surgery. Other 3. For a safe labour after Caesarean section, the woman information in this record, such as the indication for the should deliver in a hospital where a timely Caesarean sec- Caesarean section and the opinion of the previous surgeon, tion is available. The woman and her health care provider may be helpful in counselling as well. The fact that the must be aware of the hospital resources and the availability record has been reviewed and that no contraindications to a of obstetric, anesthetic, pediatric, and operating-room staff TOL after Caesarean are present should be documented clearly on the prenatal record.34 If the operative record is 4. Each hospital should have a written policy in place not available, the scar is considered "unknown." Review of regarding the notification and (or) consultation for the phy- the operative report from previous hysterotomy or sicians responsible for a possible timely Caesarean (III-B).
myomectomy should be documented in detail.
5. In the case of a TOL after Caesarean, an approximate time frame of 30 minutes should be considered adequate inthe set-up of an urgent laparotomy (III-C).
2. The intention of a woman undergoing a TOL after Cae-sarean should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the pre- Women planning a TOL after Caesarean should have natal record (II-2B).
appropriate monitoring in labour. The presence of adevoted birth attendant is ideal. Progress of labour shouldbe assessed frequently, as there is some evidence that pro- Facilities and Resources
longed or desultory labour is associated with an increased A trial of labour after Caesarean is always associated with a risk of failure and uterine rupture.19,36,37 Epidural analgesia risk of uterine rupture, however small, and a good outcome is not contraindicated.7,19,34,38 is not guaranteed under any circumstances. Further, littleevidence exists about the exact timing of a Caesarean sec- tion following a suspected uterine rupture, which would Continuous electronic fetal monitoring in labour is recom- prevent a poor neonatal outcome. A TOL after Caesarean mended for all women attempting TOL after Caesar- can be offered to women within any hospital setting where ean.19,34,39 The most reliable first sign of uterine rupture is a there is an ability to perform a Caesarean section.13,34,35 This nonreassuring fetal heart tracing.34 This may be sudden in document does not intend to set a standard regarding onset and may not be related to contractions.40 whether staff must be "in house" or "on site" to provide safe intrapartum care and therefore makes no statements on 6. Continuous electronic fetal monitoring of women such attendance. Facilities providing TOL after Caesarean attempting TOL after Caesarean is recommended (II-2A).
should have a policy in place to manage such parturients, sothat all resources are mobilized promptly if an intrapartum emergency occurs.23 The SOGC recognizes that in suchcases of maternal fetal compromise, necessitating timely Routine digital exploration of the Caesarean scar Caesarean section, an approximate time frame of 30 min- postpartum is not necessary, except when signs or symp- utes may be required to assemble the team and commence toms suggest uterine rupture.41 laparotomy. This availability and time required for obstet- ric, anesthetic, and pediatric services to attend such anemergency should be fully discussed with the woman.
Uterine rupture, the most serious complication of a TOL Women who live in areas where local hospitals cannot pro- after Caesarean, is defined as complete separation of the vide a timely Caesarean section should be offered the myometrium with or without extrusion of the fetal parts opportunity for transfer to a facility where this service is into the maternal peritoneal cavity and requires emergency available, in order to permit a TOL after Caesarean.13 The Caesarean section or postpartum laparotomy.19,42 It is an members of the team who could be called urgently in the uncommon complication of VBAC but is associated with case of an intrapartum complication (anesthetic, pediatric, significant maternal and perinatal morbidity and mortal- and obstetric services) should be notified that the woman is ity.1,7 The most common sign or symptom of uterine rup- in hospital and in labour, and their availability should be ture is nonreassuring fetal heart rate monitoring.18,20,43 Other clinical signs include the cessation of contractions, FEBRUARY JOGC FÉVRIER 2005 l
SOGC CLINICAL PRACTICE GUIDELINES
loss of the presenting part on vaginal examination, abdomi- encephalopathy, and 1 (0.04%) died.52 The presence of pla- nal pain, vaginal bleeding, hematuria, or maternal cardio- cental or fetal part extrusion at laparotomy was associated with severe metabolic acidosis (P < 0.001).52 Other vari- The type and location of the previous uterine incision helps ables (e.g., induction, birth weight, or use of epidural) did to determine the risk of uterine rupture. The incidence of not demonstrate an association with uterine rupture. Even uterine rupture is 0.2% to 1.5% in women who attempt in situations where very rapid decision to delivery times labour after a transverse lower uterine segment inci- were recorded, some cases of perinatal acidosis could not sion14,16,18,27,45 and 1% to 1.6% in women who have had a vertical incision in the lower uterine segment.46–49 The risk Smith et al. published a large series of 15 515 women under- is 4% to 9% with a classical or "T" incision; thus TOL after going a TOL after Caesarean compared with 9014 women Caesarean is contraindicated in these situations.16,19,30 who underwent ERCS between 1992 and 1997.53 The rate Shimonovitz et al. found the risk of uterine rupture after 0, of perinatal death in the TOL group was 0.129%, 11.6 times 1, 2, and 3 VBAC deliveries to be 1.6%, 0.3%, 0.2%, and higher than that of the ERCS group (OR, 11.6; 95% CI, 0.35%, respectively, indicating that the risk of uterine rup- 1.6–86.7).53 Smith compared this to the risk of perinatal ture decreases after the first successful VBAC.50 death in other common obstetrical situations: TOL com- Since uterine rupture is a rare event, a realistic appraisal of pared with multiparous women in labour (OR, 2.2; 95% CI, potential maternal and perinatal risks is difficult to accom- 1.3–3.5) and TOL compared with nulliparous women in plish outside of large series, literature reviews, or meta- labour (OR, 1.3; 95% CI, 0.8–21).53 analyses. The most important published reports in this area In 2003 Chauhan et al. published a review of data on the are discussed below, as well as those applicable to the Cana- maternal and perinatal complications of uterine rupture in dian population.
those attempting a TOL after Caesarean.54 Examining 142 In 1991 Rosen et al. performed a meta-analysis of 10 studies 075 trials of labour revealed an overall rate of uterine rup- that examined a total of 4617 women who had a TOL after ture of 0.62%.54 The rate of maternal death was 0.002%; Caesarean compared with 3831 women who had ERCS hysterectomy, 0.09%; transfusion, 0.18%; and genitouri- births.28 The rate of uterine rupture was similar in the 2 nary tract injury, 0.08%.54 In this study, the rate of neonatal groups: TOL 0.18% and ERCS 0.19% (P = 0.5). There was acidosis was 0.15%, and the rate of perinatal death was no difference in the rate of maternal death (0.028% vs.
0.04%.54 Oxytocin was involved in 43% of the uterine rup- 0.024%) or perinatal death (0.3% vs. 0.4%) in the TOL tures in this series.54 group, compared with the ERCS group.28 The data indicate that the relative risk of uterine rupture, In 2000 Mozurkewich and Hutton published a meta- maternal morbidity, and perinatal mortality or severe mor- analysis of 15 studies that examined a total of 28 813 bidity is increased in women undergoing a TOL after Cae- women undergoing a TOL compared with ERCS between sarean, compared with ERCS, but that the absolute risk 1989 and 1999.32 There was an increased rate of uterine rup- remains very low.
ture (0.39% vs. 0.16%; OR, 2.1; 95% CI, 1.45–3.05) and The treatment of suspected uterine rupture is timely perinatal mortality (0.58% vs. 0.28%; OR, 1.71; 95% CI, laparotomy after maternal stabilization and anaesthesia.
1.28–2.28) in the TOL group. The rates of maternal mortal- Urgent intervention is mandatory to obtain the best possi- ity and low 5-minute Apgar scores were not different.32 ble outcome for both mother and fetus. Once the fetus is In 2002 Keiser et al. reviewed the incidence and conse- delivered, maternal hemorrhage must be arrested, and if the quences of uterine rupture in Nova Scotia from 1988 to uterus cannot be salvaged, hysterectomy may be required.
1997.51 Among 4516 women undergoing a TOL, 18 Although the risk of uterine rupture has been found to be (0.39%) uterine ruptures were documented over 10 years.
increased in situations of prolonged labour with augmenta- All women underwent laparotomy, and there were no tion,55 when Phelan et al. retrospectively examined the pat- maternal deaths. Of those who had a uterine rupture, 3 terns of uterine activity before uterine rupture, no associa- women underwent hysterectomy, 10 required transfusion, tion with frequency or intensity of contractions could be and 5 suffered a cystotomy. After excluding lethal anoma- lies, there was 1 perinatal death (0.02%) and 6 neonates with In 1996 Rozenberg et al. examined ultrasonographic mea- severe asphyxia (0.13%).51 surement of the lower uterine segment's myometrial thick- In 2002 Bujold et al. examined the risk factors for serious ness at 36 to 38 weeks' gestation as a predictor of uterine neonatal morbidity associated with 23 cases of uterine rup- rupture and found that if the lower segment thickness was ture among 2233 women attempting a TOL (rate 1.03%).52 less than 3.5 mm, the risk of uterine rupture or dehiscence Nine neonates (0.4%) had a pH < 7.0 (severe metabolic aci- was 11.8%; if the measurement was greater than 3.5 mm, dosis), 3 (0.13%) were diagnosed with hypoxic ischemic the risk of uterine rupture was minimal.56 However, the l FEBRUARY JOGC FÉVRIER 2005
Guidelines for Vaginal Birth After Previous Caesarean Birth
incidence of uterine rupture in this population was 2.3%, E2 for cervical ripening in women with a previous Caesar- significantly greater than the usually quoted 1%. Therefore, ean section and found it to be effective and not associated the positive predictive value of this test in clinical practice with an increased risk of uterine rupture (OR, 1.46; 95% CI, will be much lower.56 In a follow-up open study, Rozenberg 0.96–2.22), compared with spontaneous labour.62 et al. found that the use of the lower-uterine-segment mea- In 2003 Delaney and Young reported the examination of surement helped clinicians select women for a TOL after 3746 women with a prior Caesarean delivery who under- Caesarean.57 The rate of successful VBAC for those with 1 went either induced or spontaneous labour.63 They found previous Caesarean section did not change but was that induced labour was associated with a greater risk of increased in those with 2 previous Caesarean deliveries.57 early postpartum hemorrhage (7.3% vs. 5.0%: OR, 1.66; These findings will need to be confirmed in further ran- 95% CI, 1.18–2.32), Caesarean delivery (37.5% vs. 24.2%: domized studies before ultrasonography can be used to OR, 1.84; 95% CI, 1.51–2.25), and admission to a neonatal make a decision about the safety of TOL after Caesarean.
intensive care unit (13.3% vs. 9.4%: OR, 1.69; 95% CI, 1.25–2.29).63 There was a trend toward a higher rate of uter- 7. Suspected uterine rupture requires urgent attention and ine rupture, but this was not statistically significant (0.7% expedited laparotomy to attempt to decrease maternal and vs. 0.3%, P = 0.128).63 perinatal morbidity and mortality (II-2A).
In another retrospective study of 560 women, the rate ofuterine rupture in women whose labour was induced with OXYTOCICS AND TOL AFTER
oxytocin was 2%, with prostaglandin was 2.9%, and with Up to 2001, there were conflicting data on the risk of labour In 1987 Flamm et al. performed a multicentre examination induction with prostaglandin E2. Several other smaller stud- of 485 women who received oxytocin to augment their ies reported that it appeared to be safe, effective, and not spontaneous labour in a planned TOL after Caesarean.58 associated with an increased risk of uterine rupture.45,64–66 No increase in the risk of uterine rupture, maternal morbid- In the largest study published to date, conducted by ity, or perinatal morbidity or mortality was detected.58 Lydon-Rochelle et al., the incidence of uterine rupture was Zelop et al. supported the same conclusion about the risk of reviewed retrospectively in 20 095 women with a previous uterine rupture with augmentation in a 1999 study (OR, 2.3; Caesarean section and was reported as follows: ERCS (no 95% CI, 0.8–7.0).59 Goetzl et al. examined the relation labour) 0.16%; spontaneous labour 0.52% (RR, 3.3; 95% between the dose of oxytocin used and the risk of uterine CI, 1.8–6.0); labour induced without prostaglandin 0.77% rupture in women undergoing a TOL after Caesarean.60 No (RR, 4.9; 95% CI, 2.4–9.7); and labour induced with prosta- significant association was detected between exposure to glandin 2.45% (RR, 15.6; 95% CI, 8.1–30.0).67 oxytocin and the risk of uterine rupture.60 Careful surveil- As for all inductions, the indication for induction in women lance for progress of labour is required, especially when the undergoing a planned TOL after Caesarean should be com- diagnosis of dystocia is being considered.19,34 There are pelling and documented. The possibility that the use of insufficient studies examining the use of other agents to oxytocin and (or) prostaglandin for labour induction in augment labour, such as prostaglandins, and their safety in a women considering TOL after Caesarean may be associated TOL after Caesarean.
with an increased risk of uterine rupture and its sequelaemust be discussed with the parturient. The absolute risks of uterine rupture are low, but the relative risks (especially with In 2000 Ravasia et al. reviewed the risk of uterine rupture in the use of prostaglandin E2, compared with spontaneous women undergoing an induction TOL after Caesarean.61 In labour) are greater.
575 women with a previous Caesarean section, labour wasinduced with prostaglandin E2 gel (n = 172), intracervical foley catheter (n = 129), or amniotomy and (or) oxytocin Misoprostol has been proposed as an effective and eco- (n = 274).61 Outcomes were compared with women under- nomical agent for cervical ripening and induction.68 In 1998 going a TOL with spontaneous labour. The risk of uterine Sciscione et al. reported a case of uterine rupture in a woman rupture was not increased in women who underwent either with 2 previous Caesarean deliveries after misoprostol was amniotomy/oxytocin or foley catheter induction but was administered as a cervical ripening agent.69 Several small significantly increased in those who underwent a prosta- series reported a risk from 0% to 11.7% of uterine rupture glandin E2 induction (P = 0.004).61 with misoprostol in women undergoing a TOL after Cae- Also in 2000, Sanchez-Ramos et al. performed a meta- sarean 43,70–73 Blanchette et al. compared prostaglandin E2 to analysis looking at the efficacy and safety of prostaglandin misoprostol in women undergoing induction TOL after FEBRUARY JOGC FÉVRIER 2005 l
SOGC CLINICAL PRACTICE GUIDELINES
Caesarean and found them to be equally effective, but misoprostol was associated with a higher incidence of uter-ine rupture (18.8% compared to no ruptures in the prosta- More Than 1 Previous Low Transverse Caesarean
glandin E2 group).74 The numbers in all these studies are small, and it is difficult to draw meaningful conclusions.
Several authors have assessed the rate of successful VBAC and the risk of uterine rupture in women with more than 1 misoprostol should be discouraged as a method of induc- previous low transverse Caesarean section.8,78–84 All indi- tion or cervical ripening in women with previous Caesarean cated success rates between 62% and 89% and uterine rup- ture rates between 0% and 3.7%. In the largest study, Milleret al. demonstrated a VBAC success rate of 75.3% in 1827 women with 2 or more previous low transverse Caesareandeliveries, with a uterine rupture rate of 1.7% versus 0.6% In situations where delivery is indicated and the cervix is in the ERCS group (OR, 3.06; 95% CI, 1.95–4.79).8 Unfor- unfavourable, TOL after Caesarean can be considered.
tunately, the use of prostaglandins or oxytocin for induction Various methods of cervical ripening have been examined.
or augmentation was not considered. Caughey et al. In a cohort study published in 2002, Ben-Aroya et al. com- reported a uterine rupture rate of 3.7% versus 0.8% (RR, pared women undergoing a trial of labour after Caesarean 4.8; 95% CI, 1.8–13.2) in a retrospective review of 134 section in 3 situations: spontaneous labour (n = 1432), women undergoing labour after 2 previous Caesarean deliv- prostaglandin cervical ripening (n = 55), and cervical ripen- eries after correction for prostaglandin, oxytocin, and ing by foley catheter (n = 161).76 There was a significantly higher rate of dystocia (30.4% vs. 11.6%, P < 0.01) andrepeat Caesarean section in the second stage (49.1% vs.
35.2%, P < 0.01) in the foley catheter group, compared with 13. The available data suggest that a trial of labour in the control group.76 There was no difference in the rate of women with more than 1 previous Caesarean is likely to be uterine rupture, fetal distress, or Apgar scores.76 In a Cana- successful but is associated with a higher risk of uterine rup- dian study published in 2004, Bujold et al. compared the rate ture (II-2B).
of uterine rupture in 1807 women who presented in sponta-neous labour, 417 induced with amniotomy with or without oxytocin, and 255 induced with transcervical foley cathe- Seven studies have examined a total of 233 women attempt- ter.77 The rate of successful vaginal birth was 78% in the ing VBAC in multiple pregnancy.85–91 All support a trial of spontaneous group, 77.9% in the amniotomy group, and VBAC in multiple pregnancy as being safe and effective, 55.7% in the transcervical foley group (P < 0.001).77 with success rates of 69% to 84% and without increased However, the rates of uterine rupture did not differ signifi- maternal or fetal morbidity or mortality.85–91 In one study, cantly: 1.1%, 1.2%, and 1.6%, respectively (P = 0.81).77 uterine dehiscence was noted in 1 woman on manual explo- These data support the use of the foley catheter for cervical ration after successful vaginal delivery of both twins, and no ripening of an unfavourable cervix in women undergoing a treatment was required.86 Each of these studies examined a TOL after Caesarean.
small number of women, however, and greater numberswould be required to detect rare outcomes such as uterine rupture and maternal and perinatal mortality.
8. Oxytocin augmentation is not contraindicated in womenundergoing a TOL after Caesarean (II-2A).
Recommendation
14. Multiple gestation is not a contraindication to a TOL
9. Medical induction of labour with oxytocin may be associ- after Caesarean (II-2B).
ated with an increased risk of uterine rupture and should beused carefully after appropriate counselling (II-2B).
10. Medical induction of labour with prostaglandin E2 A large multicentre trial by Hannah et al. demonstrated that (dinoprostone) is associated with an increased risk of uter- a planned Caesarean birth is associated with better perinatal ine rupture and should not be used except in rare circum- and neonatal outcomes in breech presentation at term.92 stances after appropriate counselling (II-2B).
This recommendation has been adopted by the SOGC andwould therefore preclude a planned TOL after Caesarean in 11. Prostaglandin E1 (misoprostol) is associated with a high women presenting with a singleton fetus in breech presen- risk of uterine rupture and should not be used as part of a tation at term.92,93 Vaginal delivery of premature fetuses and TOL after Caesarean (II-2A).
the second twin were not addressed in the study; therefore, 12. A foley catheter may be used safely to ripen the cervix in no recommendations can be made in this regard. It would a woman planning a TOL after Caesarean (II-2A).
seem appropriate to consider these cases individually.
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External cephalic version is not contraindicated in women control subjects (17.4% vs. 4.7%, P = 0.05).102 Shipp et al. with a previous Caesarean birth.94,95 reviewed 311 women who underwent a TOL after Caesar-ean less than 18 months after their Caesarean section and compared them with 2098 women who underwent a TOL In a retrospective cohort study, Coleman et al. examined the after Caesarean after more than 18 months.103 The shorter issue of TOL after Caesarean in women with gestational interval was associated with a threefold increase in the risk diabetes mellitus (GDM).96 Coleman examined 156 women of uterine rupture (2.25% vs. 1.05%: OR, 3.0; 95% CI, with GDM and planned TOL after Caesarean and com- 1.2–7.2).103 Huang et al. reviewed 1185 women undergoing a pared them with women with no GDM and attempting TOL after Caesarean and noted no difference in the success TOL after Caesarean. They reported that the success rate of vaginal delivery in women with a shorter interval of less for VBAC of 64.1% in women with GDM was lower than than 19 months (79% vs. 85.5%, P = 0.12); however, they the 77.2% of women without GDM (P < 0.001).96 Maternal did note a significant difference in successful VBAC in and fetal morbidities were comparable.96 A retrospective women who underwent medical induction, compared with study of TOL after Caesarean in women with pregestational spontaneous labour (14.3% vs. 86.1%, P < 0.01).104 Their or gestational diabetes found similar results.97 Based on study noted no difference in the rate of uterine rupture.104 these studies, diabetes mellitus should not be considered a In 2002 Bujold et al. reported an observational study of 1527 contraindication to TOL after Caesarean.
women undergoing a planned TOL after Caesarean at dif-ferent intervals from the index Caesarean delivery.105 The rates of uterine rupture were as follows: < 12 months, 4.8%; 15. Diabetes mellitus is not a contraindication to TOL after 13 to 24 months, 2.7%; 25 to 36 months, 0.9%; and > 36 Caesarean (II-2B).
months, 0.9%.105 After adjusting for such confounders asnumber of layers in the uterine closure, induction, oxytocin, and epidural use, the odds ratio for uterine rupture in a In a study examining the outcome of 365 women who woman less than 24 months from her last delivery was 2.65 underwent a TOL after Caesarean and who were giving (95% CI, 1.08–6.46).105 birth to neonates weighing more than 4000 g, Zelop et al.
demonstrated a success rate of 60%, with no increase in maternal or fetal morbidity and no increase in the risk ofuterine rupture.98 These data support previously reported 17. Women delivering within 18 to 24 months of a Caesar- findings by Flamm (success rate 58%)99 and Phelan (success ean section should be counselled about an increased risk of rate 67%).100 In 2003 Elkousy et al. reported an examination uterine rupture in labour (II-2B).
of 9960 women with a previous Caesarean section planninga trial of labour. The study was further stratified by neonatal birth weights and birth history (primarily, whether they had Three studies have examined postdatism and TOL after a previous vaginal delivery and whether it occurred before Caesarean.106–108 In 2 of these studies, the rate of successful or after their Caesarean).101 Their results indicate that the VBAC and uterine rupture in women who delivered at less likelihood of successful VBAC decreases with increasing than 40 weeks' gestation was compared with those who birth weight and is lowest in women who have never had a delivered at more than 40 weeks.106,107 Success rates for successful vaginal birth.101 According to these results, sus- VBAC after 40 weeks were reported from 65.6%107 to pected macrosomia is not a contraindication to TOL after 73.1%106 and were comparable to success rates for women Caesarean, though it may be associated with a lower chance who delivered before 40 weeks' gestation.106,107 Zelop et al. also compared the risk of uterine rupture in women who delivered before and after 40 weeks' gestation in spontane- 16. Suspected fetal macrosomia is not a contraindication to ous labour and induced labour.108 They reported that the a TOL after Caesarean (II-2B).
risk of uterine rupture in a TOL after Caesarean after 40weeks' gestation was not significantly increased when com- pared with women who delivered before 40 weeks, whether Four studies have examined the relation between the in spontaneous labour (1.0 % vs. 0.5%, P = 0.2, adjusted interdelivery interval and the rate of successful VBAC and OR, 2.1; 95% CI, 0.7–5.7) or after induction (2.6% vs.
uterine rupture.102–105 Esposito et al. examined 23 cases of 2.1%, P = 0.7, adjusted OR, 1.1; 95% CI, 0.4–3.4).108 uterine rupture and compared them with 127 control sub- jects.102 There was an increased risk of uterine rupture witha short interpregnancy interval (< 6 months between preg- 18. Postdatism is not a contraindication to a TOL after Cae- nancies; < 15 months between deliveries), compared with sarean (II-2B).
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One- Versus 2-Layer Closure of Low Transverse
Trial of labour after Caesarean section should be considered In 1992 Hauth et al. published data comparing operative in women who have no contraindications after appropriate time, endometritis, transfusion, and placement of extra discussion. The efficacy and safety of a TOL after Caesar- hemostatic sutures in women undergoing uterine closure in ean in appropriately selected women about to give birth in a 1 layer compared with 2 layers.109 The only significant dif- hospital where timely Caesarean section facilities are avail- ference was in operative time: 44 minutes with 1-layer clo- able is well supported. Support of the woman in labour, sure, compared to 48 minutes with 2-layer closure (P < including close observation of herself and her fetus for 0.05).109 Ohel et al. published similar findings in 1996.110 signs of complications, is recommended.
The trend shifted in many centres toward single-layerclosure.
Augmentation of labour with oxytocin is safe. Induction oflabour may be provided when the indication for induction is In 1997 Chapman et al. published a review of 145 women compelling and the risks have been fully discussed. The use who underwent a TOL after Caesarean after being random- of prostaglandin E2 (dinoprostone) and prostaglandin E1 ized to either 1-layer or 2-layer closure in the previous Cae- (misoprostol) in women planning a TOL is not recom- sarean section.111 They reported no significant difference in mended. The use of a foley catheter for cervical ripening in the outcome of the next pregnancy.111 In a 2002 review of situations where the cervix is unfavourable is associated 2142 women who underwent a TOL after Caesarean, with a lower chance of success but no increased risk of uter- Bujold et al. noted that a 1-layer interlocking closure was ine rupture.
associated with an increased risk of uterine rupture whencompared with a 2-layer closure (3.1% vs. 0.5%, P < 0.001; OR, 3.95; 95% CI, 1.35–11.49).112 Further study in this area 1. McMahon MJ, Luthier ER, Bowes WA, Olshan AF. Comparison of a trial is recommended.
of labor with an elective second Cesarean section. N Engl J Med1996;335:689–95.
2. Davies GA, Hahn PM, McGrath MM. Vaginal birth after Cesarean section: physicians' perceptions and practice. J Reprod Med 1996;41:515–20.
All records available or obtainable describing the woman's 3. Society of Obstetricians and Gynaecologists of Canada. Vaginal birth after previous Caesarean section should be reviewed. If unavail- previous Caesarean birth. Clinical Practice Guideline No. 68. Ottawa (ON): able, information about the circumstances of the Caesarean SOGC; December 1997.
4. Biswass A. Management of previous Cesarean section. Curr Opin Obstet section will help determine the likelihood of a vertical uter- ine incision.113,114 Most unknown scars will be lower trans- 5. Curtin SC, Kozak LJ, Gregory KD. U.S. Cesarean and VBAC rates stalled verse incisions (92%) and therefore at low risk for uterine in the mid-1990s. Birth 2000;27:54–7.
rupture.115 If the history suggests a reasonable likelihood of 6. Health Canada. Canadian perinatal health report 2003. Ottawa (ON): Health Canada; 2003. p. 33.
a classical incision, it would be prudent to recommend a 7. Weinstein D, Benshushan A, Ezra Y, Rojansky N. Vaginal birth after Cesar- repeat Caesarean section, but in settings where the history ean section: current opinion. Int J Gynecol Obstet 1996;53:1–10.
indicates a high likelihood of lower transverse uterine inci- 8. Miller DA, Diaz FG, Paul RH. Vaginal birth after Cesarean: a 10-year expe- rience. Obstet Gynecol 1994;84:255–8.
sion and the woman wishes to proceed after counselling, 9. Schell JT. Once a Cesarean always a Cesarean? N Y Med J 1923;637.
TOL after Caesarean is acceptable.115 10. Roberts LJ, Beardsworth SA, Trew G. Labour following Caesarean section: current practice in the United Kingdom. Br J Obstet Gynaecol 19. Every effort should be made to obtain the previous 11. Norman P, Kostovcik S, Lanning A. Elective repeat Caesarean sections: how Caesarean operative report to determine the type of uterine many could be vaginal births? Can Med Assoc J 1993;149:431–5.
12. Kline J, Arias F. Analysis of factors determining the selection of repeated incision used. In situations where the scar is unknown, Cesarean section or trial of labor in patients with histories of prior Cesarean information concerning the circumstances of the previous delivery. J Reprod Med 1993;38:289–92.
delivery is helpful in determining the likelihood of a low 13. National Institutes of Health. Cesarean childbirth. Bethesda (MD): NIH; 1981. Publication No. 82-2067.
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Source: http://familymidwiferycare.ca/wp-content/uploads/2010/06/SOGC-Clinical-Guidelines.pdf