ReviewObstetricsMaternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis
This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.
Section snippets
Materials and methods
A search in PubMed was performed in the period 2000-2007 to find relevant articles that compared maternal morbidity in women who had a trial of labor (TOL) vs women undergoing elective repeat cesarean section (ERCS) without labor and/or analyzed risk factors for unsuccessful TOL. Key words were vaginal birth after cesarean section (VBAC), uterine rupture, uterine dehiscence, previous cesarean, caesarean section, risk factors, trial of labor, and uterine scar. Articles were included in review
Results
Articles were subgrouped in studies that assessed maternal morbidity rates in women undergoing a TOL vs women opting for ERCS and studies that investigated the risk factors for failure of a TOL.
Comment
This review shows that TOL after previous cesarean section is associated with a successful rate of 73%, and the incidence of maternal morbidity is similar in women experiencing a TOL and women choosing ERCS. Uterine injury occurs in 1.3% and 0.4% of women undergoing TOL and ERCS, respectively, and the risk of uterine lesions is 3-fold greater in patients planning VBAC, compared with those undergoing ERCS. Additional interventions, in particular blood transfusion and hysterectomy, are performed
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Cited by (106)
Timing of cesarean delivery in women with ≥2 previous cesarean deliveries
2022, American Journal of Obstetrics and GynecologyThe rate of cesarean delivery is continuously increasing with the leading indication being a previous cesarean delivery. For women with 1 previous cesarean delivery, it is generally agreed that the optimal timing of delivery by elective cesarean delivery is during the 39th week of gestation, whereas for women with ≥2 previous cesarean deliveries, the optimal delivery time remains debatable.
To assess the maternal and neonatal risks associated with elective delivery at different gestational ages ranging from 37 0/7 to 39 6/7 weeks’ gestation and to compare it with expectant management among women with at least 2 previous cesarean deliveries.
This was a retrospective, population-based cohort study of all women with at least 2 previous cesarean deliveries who delivered after 36 6/7 weeks of gestation in Ontario, Canada, between April 2012 and March 2019. Women with multifetal pregnancies or major fetal anomalies were excluded. For each completed gestational week, outcomes of women who had an elective repeat cesarean delivery at that week solely because of 2 previous cesarean deliveries were compared with the outcomes of those who were managed expectantly and delivered at a later gestational age. The primary outcome was a composite of maternal outcomes including mortality and severe maternal morbidity. Secondary outcomes were adverse neonatal outcomes.
A total of 26,522 women met the inclusion criteria. The maternal risk was similar for elective delivery at 37 0/7 to 38 6/7 weeks of gestation compared with expectant management. However, elective delivery at 39 0/7 to 39 6/7 weeks’ gestation was associated with a decreased risk for adverse outcomes when compared with expectant management (adjusted risk ratio, 0.51; 95% confidence interval, 0.29–0.91). For the neonate, elective delivery during the 37th week of gestation significantly increased the incidence of the composite adverse outcome than in an ongoing pregnancy (adjusted risk ratio, 1.68; 95% confidence interval, 1.39–2.01), but was comparable for elective delivery at 38 0/7 to 39 6/7 weeks’ gestation and expectant management. The risk for an unplanned cesarean delivery increased from 6.5% before 38 weeks’ gestation to 21.7% before 39 weeks’ gestation and to 32.6% before 40 weeks’ gestation.
For women with ≥2 cesarean deliveries, elective delivery at 38 0/7 to 38 6/7 weeks’ gestation likely represents the optimal balance between neonatal and maternal risk while decreasing the likelihood of an unplanned cesarean delivery.
The Association between Hospital Frequency of Labor after Cesarean and Outcomes in California
2020, Women's Health IssuesLabor after cesarean (LAC) is an alternative to planned repeat cesarean delivery. The effect of hospital-level factors on LAC frequency and vaginal birth after cesarean (VBAC) has been relatively understudied. It was our goal to determine if hospital frequency of LAC (number of women undergoing LAC/number of women with previous uterine scars) is associated with increased VBAC and associated outcomes among women undergoing LAC.
We analyzed 43,331 term, singleton births to women who experienced LAC in California from 2007 to 2010. We conducted multivariable logistic regressions of infant and maternal outcomes for women at hospitals with high LAC frequency (≥median) compared with low LAC frequency (<median), adjusting for maternal and hospital characteristics. We stratified analyses by overall hospital birth volume (categories 1, low; 2, medium; 3, high).
We did not observe an association between high LAC frequency and VBAC in any category of hospital birth volume in regression models. We found that women in hospitals with high LAC frequency had higher odds of infection in category 1 (low) and 2 (medium) hospitals (category 1 hospitals adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04–2.48; category 2 hospitals, aOR, 2.12; 95% CI, 1.34–3.35) and postpartum hemorrhage in category 2 and 3 hospitals (category 2 hospitals: aOR, 2.49; 95% CI, 1.57–3.94; category 3 hospitals: aOR, 1.83; 95% CI, 1.24–2.70). We observed that high LAC frequency was associated with more adverse outcomes (e.g., infection, severe perineal lacerations, decreased Apgar scores) in category 2 than in category 1 and 3 hospitals.
We did not find that high LAC frequency was associated with more VBAC, nor with many perinatal complications in category 1 and 3 hospitals. The associations between high LAC frequency and both infection and postpartum hemorrhage are concerning and require further investigation. There may be a sensitive balance between increasing LAC access and determining appropriate LAC candidate selection.
Repeated Caesarean Section delivery in India
2020, Children and Youth Services ReviewDespite various health complications associated with Caesarean Section (CS) delivery, there are sizeable population in India opting for Caesarean Section in subsequent delivery. Therefore, the present study attempts to find out the different factors affecting repeated caesarean delivery and place of such delivery in India.
The unit level data from the fourth round of Indian National Family Health Survey is used. Bivariate and multivariate analyses are used to explore the factors affecting repeated Caesarean Section delivery in India.
It is found that women with better economic condition, urban residence, higher caste are reported higher proportion of repeated CS delivery as compared to their counterparts.
Although repeated CS is associated with various ailments but the study revealed that substantial proportion of women undergoes CS in subsequent deliveries in India. With the growing rate of caesarean delivery, women should be counselled that repeat CS are bound with surgical difficulties and complications.
Cesarean sections in the Centre-Val de Loire region: Practices and indications—the Robson Classification
2020, Revue d'Epidemiologie et de Sante PubliqueÉtudier les pratiques de césarienne en région Centre-Val de Loire : incidence de césarienne programmée et variations entre maternités, incidence des césariennes potentiellement évitables.
Les données ont été extraites du registre informatisé des naissances régional 2016, permettant de répartir les césariennes programmées selon le risque pré-existant de césarienne (bas ou haut) défini selon la classification de Robson. Afin de compléter les données avec les indications de césarienne, non présentes dans le registre, une enquête a été menée de septembre 2016 à février 2017 dans toutes les maternités en Centre-Val de Loire.
En 2016, près de 26 000 femmes ont accouché en Centre-Val de Loire. Le taux de césarienne était de 19,2 % (césariennes programmées 7,0 %). Le taux de césarienne programmée était plus élevé en cas de présentation par le siège et sur utérus cicatriciel, avec un gradient décroissant selon le type de maternité : type I (faibles effectifs) 41 % - type II 35 % - type III 32 %. Pour le recueil des indications, 1 979 césariennes ont été étudiées sur la période (18,6 % des accouchements), dont 762 programmées (7,1 % des accouchements). Parmi elles, 246 (32 %) étaient potentiellement évitables : principalement indication isolée sur utérus uni-cicatriciel ou présentation par le siège, ainsi que 17 césariennes réalisées pour radiopelvimétrie défavorable chez des primipares.
Des leviers d’action ont été identifiés : utilisation ciblée de la radiopelvimétrie, utérus uni-cicatriciel et siège avec précaution selon les recommandations de la Haute Autorité de santé. La classification de Robson doit être diffusée pour l’évaluation et l’amélioration des pratiques, notamment par comparaison inter-établissements avec toutefois une interprétation prudente.
To study the cesarean section (c-section) practices in the French Centre-Val de Loire region: incidence of planned c-section and rate variations between maternities, incidence of potentially avoidable cesarean sections.
The data were extracted from the 2016 regional birth register, which permitted classification of each planned c-section according to the pre-existing risk of c-section (high or low) as defined by the Robson classification. To enhance the data, especially the indications for c-section, which are not included in the register, a survey was conducted from September 2016 to February 2017 in all of the 20 maternities in the region.
In 2016, nearly 26,000 women gave birth in the CVL region, of whom 19.2% by c-section (7.0% planned c-sections). The planned c-section rate was higher for breech presentation and scarred uterus, and decreased according to level of the maternity (I 41% - II 35% - III 32%). Concerning the c-section indications, 1,979 c-sections were studied during the period (18.6% of births), including 762 planned c-sections (7.1% of births). Among them, 246 (32%) were potentially avoidable, mainly isolated indications of scarred uterus with only one previous c-section or breech presentation, and 17 due to unfavorable radiologic pelvimetry in nulliparous women.
Specific actions were identified: targeted use of radiologic pelvimetry, targeted c-section on scarred uterus with only one previous cesarean section or breech presentation, as recommended by the national guidelines. The Robson classification should be widely used to evaluate and enhance practices,
inparticularly through painstakingly interpreted inter-maternity comparisons.N<sup>o</sup> 382 – Épreuve de travail après césarienne
2019, Journal of Obstetrics and Gynaecology CanadaOffrir une directive clinique factuelle en ce qui concerne l'essai de travail (EDT) chez les femmes ayant déjà subi une césarienne.
La morbidité et la mortalité fœtales et maternelles liées à l'accouchement vaginal après une césarienne et à la césarienne itérative.
Des recherches ont été effectuées dans la base de données MEDLINE pour trouver des articles publiés entre le 1er janvier 1995 et le 31 octobre 2017 en utilisant le mot-clé suivant : vaginal birth after Caesarean (Cesarean) section. La qualité des données probantes indiquées s'appuie sur les critères d’évaluation des données décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs.
La présente directive a été approuvée par le comité de pratique clinique – obstétrique et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada.
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Dans la mesure où elles ne présentent aucune contre-indication, il convient d'offrir l’épreuve de travail après césarienne à toutes les femmes qui ont subi une césarienne transversale basse en prenant soin de les informer adéquatement des risques et avantages maternels et périnataux par une discussion et une documentation adéquates. Il y a lieu de documenter cette discussion (II-2B).
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L’épreuve de travail après césarienne est recommandée chez les femmes qui ne présentent aucune contre-indication au travail, qui ont déjà accouché par voie vaginale ou pour qui le travail s'amorce spontanément, car elles sont de bonnes candidates à l’épreuve de travail après césarienne et présentent un taux élevé d'accouchement vaginal après césarienne (II-2B).
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Il est possible d'offrir l’épreuve de travail aux femmes qui présentent des facteurs réduisant la probabilité d'un accouchement vaginal après césarienne. Il convient toutefois de les informer du fait que leurs chances d'accouchement vaginal après césarienne sont moindres et qu'elles présentent un risque accru de complications et de césarienne itérative (II-2A).
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Les femmes doivent être informées du fait que le risque relatif de mort maternelle pour la césarienne itérative planifiée est plus élevé que pour l’épreuve de travail après césarienne, laquelle présente un risque plus élevé de rupture utérine et de morbidités maternelles graves combinées, mais aussi du fait que le risque absolu de ces issues est faible (II-2B).
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Les femmes qui ont subi une césarienne transversale basse doivent être informées que le risque de base de rupture utérine pour l’épreuve de travail après césarienne est de 0,47 % (II-2A).
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Il y a lieu d'informer les femmes du fait que la plupart des autres complications maternelles ne sont pas particulièrement différentes entre la césarienne itérative et l’épreuve de travail après césarienne (II-2B).
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Le déclenchement artificiel du travail n'est pas contre-indiqué chez les femmes qui se soumettent à une épreuve de travail après césarienne (II-2A).
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Les femmes doivent être informées du fait que le déclenchement artificiel du travail est lié à un taux moindre d'accouchement vaginal après césarienne et augmente le risque de rupture utérine et qu'il convient d'y avoir recours avec précaution après un accompagnement adéquat de la patiente. Le risque de rupture utérine durant l’épreuve de travail est le plus élevé après 40 semaines de gestation (II-2A).
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Une sonde de Foley peut être utilisée aux fins de maturation du col utérin chez les femmes qui envisagent une épreuve de travail après césarienne (II-2B).
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L'administration d'ocytocine pour le déclenchement artificiel ou l'augmentation du travail n'est pas contre-indiquée chez les femmes qui se soumettent à une épreuve de travail après césarienne. L'utilisation d'ocytocine est toutefois liée à un risque accru de rupture utérine et il convient d'y avoir recours avec précaution après un accompagnement de la patiente adéquat (II-2B).
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Le déclenchement médical du travail au moyen de prostaglandine E2 (dinoprostone) est lié à une augmentation du risque de rupture utérine et il n'est pas recommandé d'y avoir recours dans le cadre de l’épreuve de travail après césarienne après un accompagnement de la patiente adéquat (II-2B).
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La prostaglandine E1 (misoprostol) est liée à un risque élevé de rupture utérine et ne devrait pas être utilisée dans le cadre d'un essai de travail après césarienne d'une grossesse à terme (II-2A).
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Les femmes qui ont 2 césariennes préexistantes semblent avoir un taux d'accouchement vaginal après césarienne comparable à celui des femmes qui n'en ont subi qu'une seule. Les femmes doivent être informées du risque accru de rupture utérine dans le cadre de l’épreuve de travail après césarienne chez celles qui ont subi plus d'une césarienne (II-2B).
- 14
Le nombre d’études qui font état des issues chez les femmes qui ont subi plus de 2 césariennes est limité (I).
- 15
L’épreuve de travail après césarienne ne constitue pas une contre-indication absolue en cas de présentation du siège. Cependant, il convient d'informer les femmes du fait que les données sont insuffisantes pour évaluer les risques de l’épreuve de travail après césarienne en cas de présentation du siège (III-B).
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La grossesse multiple ne constitue pas une contre-indication à l'essai de travail après césarienne (II-2B).
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Les femmes dont l'intervalle entre les accouchements est de moins de 18 mois doivent être informées du risque accru de rupture utérine de l’épreuve de travail après césarienne (II-2A).
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Bien qu'il y ait un lien entre l'amincissement du segment inférieur de la paroi utérine et le risque de rupture utérine, il n'existe pas de limite absolue entre une épreuve de travail après césarienne sécuritaire ou risquée. Ainsi, pour le moment, il ne convient pas d'utiliser les mesures échographiques du segment inférieur de la paroi utérine pour conseiller les femmes de se soumettre ou non à une épreuve de travail après césarienne en toute confiance (II-2B).
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Les femmes qui ont subi une césarienne avec incision classique ou en T ne devraient pas se soumettre à une épreuve de travail après césarienne (II-2A).
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Les femmes qui ont subi une césarienne basse au cours de laquelle la fermeture de l'utérus a été effectuée en un seul plan et qui souhaitent tenter une épreuve de travail après césarienne doivent être informées du fait qu'elles présentent possiblement un risque accru de rupture utérine (II-2A).
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Aucun effort ne doit être ménagé pour obtenir le rapport opératoire de la césarienne préexistante afin de déterminer le type d'incision utérine utilisé. Dans les situations où le type de la cicatrice est inconnu, les renseignements relatifs aux circonstances de l'accouchement précédent s'avèrent utiles pour déterminer la probabilité d'une incision transversale basse. Si la probabilité de ce type d'incision est élevée, un essai de travail après césarienne peut être offert à la patiente (II-2B).
- 22
Les femmes qui envisagent une épreuve de travail après césarienne doivent être informées du fait que le risque relatif de mortalité périnatale et de morbidité grave est plus élevé pour l’épreuve de travail après césarienne que pour la césarienne itérative planifiée, mais que le risque absolu est faible (II-2B).
- 23
Il convient d'informer les femmes que le risque de placenta prævia et de placenta accreta augmente en fonction du nombre de césariennes subies (II-2A).
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Le processus et la documentation du consentement éclairé avec une discussion adéquate sur les risques et avantages maternels et périnataux de l’épreuve de travail après césarienne et de la césarienne itérative planifiée doivent faire partie du plan de soins chez les femmes qui ont déjà subi une césarienne (III-A).
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La volonté d'une femme de se soumettre à un essai de travail après césarienne ou de subir une césarienne itérative planifiée doit être clairement énoncée et la documentation sur la cicatrice utérine existante doit être clairement indiquée au dossier prénatal (III-A).
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Toute l’équipe doit être informée lorsqu'une épreuve de travail après césarienne est en cours à l'unité des naissances (III-A).
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La surveillance électronique fœtale continue est nécessaire chez les femmes qui se soumettent à une épreuve de travail après césarienne, car les changements au tracé de fréquence cardiaque fœtale constituent un des principaux signes de rupture utérine (II-2A).
- 28
Toute suspicion de rupture utérine nécessite une attention immédiate et une laparotomie afin de réduire les risques de morbidité et de mortalité maternelles et périnatales (III-B).
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Pour optimiser les issues maternelles et néonatales, toute femme qui se soumet à une épreuve de travail après césarienne devrait recevoir des soins dans un hôpital doté des ressources nécessaires pour procéder à une césarienne d'urgence (III-B).
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La femme et son fournisseur de soins de santé doivent être au courant de la disponibilité du personnel d'obstétrique, d'anesthésie, de pédiatrie et de salle d'opération dans le milieu où elle a choisi de donner naissance (III-A).
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No. 382-Trial of Labour After Caesarean
2019, Journal of Obstetrics and Gynaecology CanadaTo provide evidence-based guidelines for the provision of a trial of labour after Caesarean section.
Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean and repeat Caesarean section.
MEDLINE database was searched for articles published from January 1, 1995, to October 31, 2017 using the key words “vaginal birth after Caesarean (Cesarean) section.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.
These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.
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Provided there are no contraindications, a trial of labour after Caesarean should be offered to all women with 1 previous low-segment transverse Caesarean section after appropriate discussion and documentation of maternal and perinatal risks and benefits. The discussion should be documented (II-2B).
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Trial of labour after Caesarean is recommended in women without contraindications to labour, with a previous vaginal birth, and/or those who present in spontaneous labour as they are good candidates for a trial of labour after Caesarean and have a higher vaginal birth after Caesarean rate (II-2B).
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Women with factors negatively affecting their likelihood of vaginal birth after Caesarean can be offered a trial of labour after Caesarean. However, they should be informed that they have a lower chance of vaginal birth after Caesarean and have an increased risk of complications and repeat Caesarean birth (II-2A).
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Women should be informed that the relative risk of maternal death is higher for elective repeat Caesarean section and the risk of uterine rupture and composite serious maternal morbidity is higher for trial of labour after Caesarean, but the absolute risks of these outcomes are low (II-2B).
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Women with 1 prior low transverse Caesarean section should be informed that the baseline risk of uterine rupture with a trial of labour after Caesarean is 0.47% (II-2A).
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Women should be informed that most other maternal complications are not significantly different between elective repeat Caesarean section and trial of labour after Caesarean (II-2B).
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Induction of labour is not contraindicated in women undergoing a trial of labour after Caesarean (II-2A).
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Women should be informed that induction of labour is associated with a lower vaginal birth after Caesarean rate and an increased risk of uterine rupture and should be used carefully after appropriate counselling. The risk of uterine rupture with induction of labour appears to be highest in women over 40 weeks gestation (II-2A).
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A Foley catheter may be used to ripen the cervix in a woman planning a trial of labour after Caesarean (II-2B).
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Use of oxytocin for induction or augmentation is not contraindicated in women undergoing a trial of labour after Caesarean. However, use of oxytocin is associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B).
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Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and its use is not recommended in trial of labour after Caesarean, after appropriate counselling (II-2B).
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Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used in trial of labour after Caesarean at term (II-2A).
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Women with 2 prior Caesarean sections appear to have similar vaginal birth after Caesarean rates as those with 1 prior Caesarean section. Women should be informed of a higher risk of uterine rupture in trial of labour after Caesarean with more than 1 Caesarean section (II-2B).
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There are limited studies reporting on outcomes of women with more than 2 prior Caesarean sections (I).
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It is not an absolute contraindication for women with a breech presentation to undergo a trial of labour after Caesarean. However, women should be advised that there is insufficient information to assess risks of trial of labour after Caesarean with a breech presentation (III-B).
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Multiple pregnancy is not a contraindication to a trial of labour after Caesarean (II-2B).
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Women delivering with <18-month interdelivery interval should be informed about an increased risk of uterine rupture with trial of labour after Caesarean (II-2A).
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Although there is relationship between lower uterine thickness and risk of uterine rupture, the absolute cut-off between safe and unsafe trial of labour after Caesarean does not exist. Therefore, at this time, we cannot use ultrasonographic measurements of the lower uterine segment to counsel women to either have or not have a trial of labour after Caesarean with confidence (II-2B).
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Women with a classical Caesarean section or T incision should not have a trial of labour after Caesarean (II-2A).
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Women with a previous Low Segment Cesarean Section in which the uterus was closed in a single layer and who wish to attempt trial of labour after Caesarean should be aware that the risk of uterine rupture may be increased (II-2A).
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Every effort should be made to obtain the previous Caesarean operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, trial of labour after Caesarean can be offered (II-2B).
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Women planning a trial of labour after Caesarean should be advised that the relative risk of perinatal mortality and serious morbidity is higher with trial of labour after Caesarean compared to elective repeat Caesarean section, but the absolute risk is low (II-2B).
- 23
Women should be informed that the risk of placenta previa and placenta accreta increases with increasing number of Caesarean sections (II-2A).
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The process and documentation of informed consent with appropriate discussion of the maternal and perinatal risks and benefits of trial of labour after Caesarean and elective repeat Caesarean section should be a part of the care plan in a woman with a previous Caesarean section (III-A).
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The intention of a woman undergoing a trial of labour after Caesarean or elective repeat Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (III-A).
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The entire team should be made aware of the presence of a woman undergoing a trial of labour after Caesarean labouring in the birthing unit (III-A).
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Continuous electronic fetal monitoring of women having a trial of labour after Caesarean is necessary, as changes to the fetal heart rate tracing are one of the key indicators of the presence of a uterine rupture (II-2A).
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Suspected uterine rupture requires immediate attention and laparotomy in order to attempt to decrease maternal and perinatal morbidity and mortality (III-B).
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To optimize maternal and neonatal outcomes, a woman having a trial of labour after Caesarean should be cared for in a hospital that has resources to perform an emergency Caesarean section (III-B).
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The woman and her health care provider must be aware of the availability of obstetric, anaesthetic, pediatric, and operating room staff in the setting where she chooses to give birth (III-A).
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