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I Waited Enough Months for Vbac but Ended Up With C Section Instead Still Again

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  • Journal List
  • Geburtshilfe Frauenheilkd
  • v.76(12); 2016 Dec
  • PMC5177557

Geburtshilfe Frauenheilkd. 2016 Dec; 76(12): 1279–1286.

Linguistic communication: English | German

Labour and Childbirth After Previous Caesarean Section

Recommendations of the Austrian Guild of Obstetrics and Gynaecology (OEGGG)

Geburt nach vorausgegangenem Kaiserschnitt

P. Reif

iUniversitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz, Graz, Austria

C. Brezinka

twoUniversitätsklinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Medizinische Universität Innsbruck, Innsbruck, Austria

T. Fischer

iiiUniversitätsklinik für Frauenheilkunde und Geburtshilfe der Paracelsus Universität Salzburg, Salzburg, Austria

P. Husslein

fourUniversitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Wien, Vienna, Austria

U. Lang

1Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz, Graz, Republic of austria

A. Ramoni

5Universitätsklinik für Gynäkologie und Geburtshilfe, Medizinische Universität Innsbruck, Innsbruck, Austria

H. Zeisler

4Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Wien, Vienna, Austria

P. Klaritsch

oneUniversitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz, Graz, Republic of austria

Abstract

The new expert recommendation from the Austrian Club of Obstetrics and Gynaecology (OEGGG) comprises an estimation and summary of guidelines from the leading specialist organisations worldwide (RCOG, ACOG, SOGC, CNGOF, WHO, NIH, Squeamish, UpToDate). In essence it outlines alternatives to the direct pathway to constituent repeat caesarean section (ERCS). In so doing it aligns with international trends, co-ordinate to which a differentiated, individualised clinical approach is recommended that considers benefits and risks to both mother and child, provides detailed counselling and takes the patientʼs wishes into account. In view of good success rates (60–85 %) for vaginal nascency after caesarean department (VBAC) the consideration of predictive factors during antenatal birth planning has become increasingly important. This publication provides a compact management recommendation for the majority of standard clinical situations. However it cannot and does not claim to cover all possible scenarios. The consideration of all relevant factors in each private instance, and thus the ultimate decision on mode of delivery, remains the discretion and responsibility of the treating obstetrician.

Central words: caesarean section, status after caesarean section, vaginal delivery, direction, recommendation, assessment

Zusammenfassung

Die neue Expertenempfehlung der Österreichischen Gesellschaft für Gynäkologie und Geburtshilfe (OEGGG) stellt eine Zusammenfassung und Interpretation der Guidelines der weltweit führenden Fachgesellschaften und Organisationen (RCOG, ACOG, SOGC, CNGOF, WHO, NIH, Overnice, UpToDate) dar. In ihrer Kernaussage zeigt die Empfehlung Alternativen zum direkten Weg zur geplanten Re-Sectio auf. Sie folgt damit dem internationalen Tendency, der stattdessen ein differenziertes, individualisiertes klinisches Management unter Abwägen mütterlicher und kindlicher Vorteile und Risiken sowie eine detaillierte Aufklärung und Miteinbeziehung der Wünsche der Schwangeren empfiehlt. Angesichts guter Erfolgsraten für eine vaginale Geburt nach Kaiserschnitt von sixty–85 % gewinnt das Einbeziehen von prädiktiven Faktoren in dice antenatale Geburtsplanung zunehmend an Wichtigkeit. Die Empfehlung versteht sich als kompakte Handlungsempfehlung für die meisten klinischen Standardsituationen, kann jedoch niemals alle potenziellen Einzelsituationen abdecken. Das individuelle Bewerten aller Faktoren und damit die Entscheidung über den tatsächlichen Entbindungsmodus bleibt letztendlich im Ermessen des behandelnden Facharzts/der behandelnden Fachärztin.

Schlüsselwörter: Kaiserschnitt, Zustand nach Kaiserschnitt, vaginale Geburt, Management, Empfehlung, Bewertung

Summary of Recommendations for Women with Previous Caesarean Section

  1. The vast majority of affected significant women fulfil weather condition for an attempted vaginal nascence after caesarean section (VBAC) and should be counselled accordingly (ACOG – Level 1). This is specially true after 1 previous caesarean and for singleton pregnancies with cephalic lie and gestational age beyond 37 completed weeks (RCOG – Form B).

  2. Women should be informed that the success rate for VBAC is between threescore–85 % (SOGC, ACOG, RCOG – Grade C).

  3. Women should exist informed that a successful vaginal nascence is associated with the everyman complication rate (RCOG-Grade B).

  4. Women should be informed that occasionally, in the outcome of unsuccessful vaginal delivery, an urgent caesarean section is necessary and this is associated with an increased complication rate (RCOG – Grade B).

  5. Women should exist informed that at that place is an approx. 0.5 % (1 in 200) risk of uterine rupture during VBAC (RCOG – Grade B).

  6. Women should be informed that the adventure of commitment-associated perinatal fetal/neonatal death is extremely low for VBAC – risk comparable with that for vaginal birth in primiparous women (RCOG – Class C). Maternal mortality is non measurable (just sporadic individual reports from industrialised countries).

  7. The perinatal bloodshed risk is extremely low for constituent echo caesarean department (ERCS). Neonatal respiratory morbidity is slightly increased peculiarly if nascency is before 39 completed weeks (RCOG – Grade C).

  8. Women should be informed that every echo caesarean further increases the adventure of abnormal placentation in futurity pregnancies and that adhesions, which may complicate hereafter intestinal surgery, can result (RCOG – Grade C).

  9. ERCS should ideally be performed subsequently 39 completed weeks of pregnancy (RCOG – Grade A).

  10. Nascency should accept place in a hospital. The infirmary should take suitably skilled staff and facilities necessary for the immediate management of potential complications (all guidelines).

  11. There should be continuous fetal monitoring (CTG) as shortly equally regular contractions are established (all guidelines).

  12. There are no restrictions to peripartum analgesia (ACOG – Level 1).

  13. A medical indication is required for induction of labour (all guidelines).

  14. Women should be informed that induction of labour carries a two- to 3-fold increased run a risk of uterine rupture (approx. 1–1.5 %) and a ane.five-fold increased chance of caesarean delivery (RCOG – Class D).

  15. A specialist obstetrician must be involved in the decision to induce labour and the choice of induction method (RCOG).

  16. Beyond term (mail-dates) when no signs of spontaneous labour are nowadays, an obstetric assessment to estimate the likelihood of successful vaginal birth should be performed at the latest after 41 completed weeks. Ideally the date for induction of labour or ERCS should be set at 41 + 3 weeks of gestation at the latest (RCOG).

  17. Oxytocin is not contraindicated for augmentation of labour after previous caesarean (SOGC – Grade B – Level 2a).

  18. Amniotomy and oxytocin for labour induction is a low-gamble method when the cervix is ripe (Bishop score ≥ half dozen) (UpToDate – Level ii, SOGC, ACOG).

  19. Mechanical methods of labour consecration (transcervical airship catheter, amniotomy) are associated with lower risk than medical methods (prostaglandins, oxytocin) (RCOG – Grade D).

  20. Misoprostol should not be used for induction of labour or cervical ripening in the tertiary trimester after previous caesarean (ACOG – Level 1, SOGC – Grade B – Level 3).

Aim of this Recommendation

This expert recommendation provides an overview and interpretation of the recommendations of the leading specialist organisations worldwide. It should be seen as a compact management guideline for the bulk of standard clinical situations, however it cannot, and does non merits to encompass all potential individual scenarios. The consideration of all relevant factors mentioned in this publication and thus the ultimate decision on fashion of delivery in each individual example, remains the discretion and responsibility of the treating specialist.

For the sake of readability detailed listing of the primary literature and comprehensive study data has mostly been avoided. Instead, the relevant guideline is mentioned in each case, and where available the level of testify/grade of recommendation stated.

Level of Testify and Grading of Recommendations

Level of prove

Level 1a: Meta-analyses or systematic reviews based on loftier-quality randomised, controlled trials; numerous high-quality randomised, controlled trials with very low chance of bias.

Level 1b: At least one high-quality RCT of sufficient size with low risk of bias.

Level 2a: Systematic reviews of non-randomised trials; at to the lowest degree one high-quality, non-randomised trial with a low take a chance of bias.

Level 2b: At least 1 high-quality study of a dissimilar blazon, such as a comparative study, correlation report or case-control trial.

Level 3: Non-belittling studies, e.g. instance reports, example serial.

Level four: Opinions and convictions of respected government (expert stance); consensus opinions of skillful commissions.

Grade of recommendation

Class A recommendation: Based on at least one randomised controlled trial, systematic review or meta-analysis of good quality and consistency overall that is not extrapolated from, but applies directly to the recommendation in question (prove level 1a and 1b).

Class B recommendation: Based on well constructed, non-randomised clinical studies straight applicable to the recommendation (evidence level 2a) or extrapolated from level 1 evidence if not straight applicable to the specific situation.

Course C recommendation: Based on well constructed, not-randomised clinical studies direct applicable to the recommendation (evidence level 2b) or extrapolated from level 2a evidence if not direct applicable to the specific situation.

Grade D recommendation: Reports from expert groups or expert opinions and/or clinical experience of recognised authorities (prove level 4), as well as findings straight from level 3, or extrapolation from level 2b, or level iii evidence when no straight relevant expert quality clinical studies are available.

Guidelines

This practiced recommendation is based on the guidelines of the leading specialist organisations worldwide, including the Royal Higher of Obstetricians & Gynaecologists (RCOG), the American College of Obstetricians & Gynecologists (ACOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), the French College of Gynecologists and Obstetricians (CNGOF), and the recommendations of the British National Found for Health and Care Excellence (NICE), the American National Institutes of Health (NIH) and the World Health System (WHO). In addition, the very current and topic-specific recommendations of www.uptodate.com were drawn on.

These guidelines include:

  • NICE Guideline. Inducing labour – Quality standard. 2014 1

  • Nice Guideline. Induction of labour. 2008 ane

  • RCOG Greentop Guideline No 45. Birth after previous Caesarean Nascence. 2015 2

  • ACOG Practise Message no. 115. Vaginal birth after caesarean delivery. 2010 3

  • ACOG Practice Bulletin no. 107. Induction of Labor. 2009 4

  • SOGC clinical practice guideline no. 155. Guidelines for vaginal birth after previous caesarean nativity. 2005 5

  • SOGC clinical practice guideline no. 296. Induction of Labour: Review. 2015 vi

  • Delivery for women with a previous caesarean: guidelines for clinical exercise from the French College of Gynecologists and Obstetricians. 2013 vii

  • NIH Consensus Development Briefing Statement: Vaginal Birth Subsequently Cesarean: New Insights. 2010 8

  • WHO recommendations for Induction of labour. 2011 ix

  • UpToDate. Choosing the road of delivery after caesarean birth. 2015 10

  • UpToDate. Cervical ripening and induction of labor in women with a prior caesarean delivery. 2015 11

  • UpToDate. Apply of calculators for predicting successful trial of labor afterwards caesarean delivery. 2015 12

The equivalent guidelines in German language are currently being revised and a validated version is not available.

Introduction and Background

The assumption "once a caesarean, always a caesarean", which prevailed in the early decades of the 20th century, has long lost its validity. Instead, a differentiated management approach has arisen that aims to assess the chances of successful vaginal birth on an individualised basis taking the risks to both mother and child into consideration. With this approach, detailed counselling and the incorporation of the meaning patientʼs wishes play an ever greater roll. This paradigm shift in planning the mode of delivery subsequently previous caesarean section has now been ratified and accepted past all relevant specialist societies and organisations and has lead to the revision of their corresponding guidelines.

And so it is that obstetricians and midwives face an e'er increasing number of situations in which birth planning after previous caesarean and decisions surrounding possible labour induction and consecration methods are required. Decisions should ever be made on an individual basis; the management recommendations presented here provide general orientation and counselling support. Guidelines are currently not able to make a valid, general recommendation for any choice over some other. Nevertheless an attempt has been made to provide an overview of the pros and cons of each individual method and to ascertain factors likely to be predictive of successful vaginal birth thus making consecration of labour both sensible and safe.

Predictors of Successful VBAC

The success rate of vaginal nascence after previous caesarean department is uniformly stated as lx–85 % (SOGC, ACOG, RCOG). The indications for previous caesareans are useful as predictive factors: abnormal fetal lie such as breach presentation (OR 1.9; 95 % CI: one.0–3.7) 13 and pregnancy induced hypertension (OR 2.iii; 95 % CI: 1.0–5.8) thirteen tin be regarded every bit favourable predictors, likewise previous normal vaginal births (OR 1.8; 95 % CI: i.1–iii.1) 13, which are associated with a success rate of 82 % 14. Opinion is divided on the prognosis following previous caesarean due to uterine dystonia, labour arrest/obstructed labour or cephalopelvic disproportion, some studies showing significantly reduced success rates.

The success rate of a VBAC falls with increasing maternal age. Available information are bereft to ascertain an age limit. Subsequent family unit planning should exist incorporated into decision-making around mode of nativity (CNGOF) in this context.

Higher multiparity increases the chances of successful vaginal birth and is associated with reduced risk of uterine rupture. Attempted VBAC can therefore be advised preferentially to higher-parity multipara (CNGOF).

Preexisting diabetes lowers the chances of successful VBAC. In the absenteeism of fetal macrosomia, gestational diabetes that is well controlled with dietary measures does not lower the chances of successful VBAC. Diabetes is not a risk factor for uterine rupture. Attempted VBAC is possible with all forms of diabetes (CNGOF, SOGC).

Maternal obesity (BMI > 40) lowers the chances of successful VBAC without influencing the hazard of uterine rupture (CNGOF – Level 3). ERCS is recommended at a BMI > 50 (CNGOF-Grade C) in view of low success rates (13 %) for VBAC (CNGOF-Grade C) and difficulty in emergency situations.

The hazard of uterine rupture rises for shorter intervals between current pregnancy and previous caesarean section. Uterine rupture rates of up to two.65 % (95 % CI: 1.08–6.46) 15 are quoted for intervals < 24 months. Nevertheless, where obstetric atmospheric condition are favourable, a trial of labour (VBAC) is possible for intervals of > 6 months (CNGOF – Form C). Women with intervals of eighteen–24 months should be informed explicitly about the increased risk of uterine rupture (SOGC – Grade B – Level 2b).

The success rate of external cephalic version does not seem to be influenced by previous caesarean department (CNGOF – Level iii, ACOG – Level 2) and it does not seem to affect the rate of uterine rupture (CNGOF – Level iv, ACOG). External cephalic version can thus exist offered to patients with previous caesarean section (CNGOF – Grade C, SOGC).

Twin pregnancies have similar rates of successful VBAC (CNGOF – Level 3) and uterine rupture (CNGOF – Level 3) compared to singleton pregnancies. VBAC tin can be offered to women with twin pregnancies without increasing maternal or fetal bloodshed or morbidity (CNGOF – Grade C, ACOG – Level 2) and has a success charge per unit of 69–84 % (SOGC).

Fetal macrosomia (birth weight > 4000 thousand) lowers the success rate of VBAC (ACOG). While the French and American guidelines assume the risk of uterine rupture is doubled (CNGOF-Level 3, ACOG), the Canadian guideline quotes a written report by Zelop et al. sixteen that institute no increased rupture risk. With a remaining success rate of > sixty % and an passably low run a risk of uterine rupture, a trial of labour is possible upward to an estimated nascence weight of 4500 g (CNGOF – Level iii). ERCS should be performed when estimated birth weight is > 4500 grand (CNGOF – Grade C).

The success rate of VBAC before 37 completed weeks of gestation is comparable to that at term. The risk of uterine rupture is lower (CNGOF – Level 3). Neonatal issue earlier 37 completed weeks is not different for ERCS compared to VBAC (CNGOF – Level 3). Therefore, when commitment is necessary before 37 weeks gestation the patient should be offered a trial of labour (in the absenteeism of other contraindications) (CNGOF – Class C).

Beyond term (post-dates) the success rate of VBAC is decreased (ACOG) without an influence on uterine rupture rate (CNGOF – Level 3). VBAC is possible beyond term (CNGOF – Grade C, SOGC – Grade B – Level 2b).

There are no clinically established scoring systems that predict successful VBAC (ACOG, CNGOF, NIH, RCOG). Nevertheless employ of a prognosis calculator tin be considered when planning style of birth (UpToDate), eastward.1000. every bit available on the Maternal-Fetal Medicine Units (MFMU) Network homepage (https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html).

Informed Consent

The treating physician has a substantial influence on a meaning womanʼs determination whether or not to attempt a vaginal delivery after previous caesarean section (SOGC 17, xviii). The practice obstetrician therefore has the job of providing accurate, non-directive counselling early in pregnancy on the pros and cons of the diverse modes of nativity. An unconsidered decision for ERCS early on in the pregnancy using the often quoted phrase "once a caesarean, always a caesarean" should exist avoided.

Building on this counselling and based on an individualised risk assessment the safest mode of birth bachelor at the birthing facility, with the greatest chances of success, that is also concordant with the patientʼs wishes tin be chosen (Fig. 1). A specialist obstetrician must ever be involved in the final decision on manner of birth in patients with previous caesarean section.

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Flow diagram determination tree.

Timing

Since potential gamble factors for VBAC are usually known early on, specific counselling tin can be provided from an early stage of pregnancy (ACOG). A concluding word should accept place at the delivery unit of measurement closer to the time of birth, early on enough however, to allow for gathering potentially outstanding data and results. ERCS should ideally exist performed after 39 completed weeks of gestation (RCOG – Level 1).

When labour is induced, depending on the chosen induction method, patients should be informed about possible off-label use of certain drugs or mechanical methods and all discussions should be documented in writing.

Risks

Patient counselling should include an individualised evaluation of the advantages and risks of both ERCS and VBAC. Adequate time should be available for the analysis of each individual clinical history, taking known predictors of success and failure of VBAC into account. It is specially important to discuss maternal short- and long-term morbidity when considering ERCS. Information on peradventure increased long-term kid morbidity are currently inconclusive. The increased risk of uterine rupture should be mentioned when a vaginal nascence is attempted; patients should be informed that the chance is slightly increased with spontaneous labour and in some cases significantly increased with induction of labour, dependant on method of induction. Counselling should include information on the potential associated consequences of uterine rupture for both female parent and child.

Documentation

Counselling nearly maternal (especially uterine rupture) and fetal risks should be documented (ACOG – Level 3). To ensure the best possible counselling, controlling and documentation the utilize of a checklist or standardised counselling form is recommended (RCOG – Grade B).

Documentation should include information on the previous caesarean department (especially indication and incision blazon). In some centres the "conjugata vera" measured at previous caesarean is taken into account when planning the nativity.

When the previous caesarean section surgical written report is not bachelor and the type of uterine incision is unknown a lower segment transverse incision can be assumed when at that place is no information to the contrary. The lack of a surgical report is non a contraindication to a trial of labour CNGOF, SOGC – Course B – Level 2b, ACOG – Level ii). Nevertheless the birthing assistant/midwife should exist aware of this, equally a previous longitudinal incision involving the uterine corpus cannot be definitely excluded.

Analgesia

The patient should be informed that there are no restrictions to analgesia options (ACOG-Level 1). Available data practice non propose that epidural amazement (PDA) has a negative affect on the success charge per unit of VBAC. Since the about common signs of uterine rupture are CTG changes, there is no reason to fear masking of possible rupture past PDA (ACOG). A sudden requirement for analgesia should however increase vigilance for possible uterine rupture (RCOG – Class D).

Plan for spontaneous onset of labour before scheduled ERCS

When ERCS has been chosen as the preferred style of delivery the possibility of spontaneous onset of labour (contractions, spontaneous rupture of membranes) earlier the scheduled caesarean engagement should be discussed. A programme of action for this eventuality should be fabricated and documented in the patient notes (RCOG).

In the effect of an unexpectedly early onset of labour, or in the absenteeism of prenatal counselling/documented plan of activeness the determination on mode of nativity should exist fabricated by an experienced obstetrician (RCOG).

Structural Requirements and Direction

Patients with previous caesarean section should give birth in a infirmary (SOGC – Grade B – Level 2a). The obstetric department should be staffed accordingly and have suitable equipment to perform an emergency caesarean and manage any possible complications (SOGC – Grade B – Level 2a, CNGOF). The Canadian guideline recommends a maximum determination-to-delivery time of 30 minutes (SOGC – Grade C – Level 3); the equivalent American organisation posits that the appropriate personnel must be "immediately available" (ACOG – Level three). The French guideline further stipulates that an obstetrician with sufficient operative expertise for emergency haemostasis be available (CNGOF). In German-speaking countries the maximum decision-to-commitment time is legally ready at xx minutes.

Patients should exist informed beforehand if the necessary personnel are usually not on site 24 hours a day (ACOG).

A standard operating procedure (SOP) should be available for the management of potential emergencies (SOGC – Grade C – Level 2).

Continuous CTG monitoring is recommended when regular contractions are established (SOGC – Grade B – Level 2a, CNGOF, ACOG) since changes in fetal centre rate are unanimously recognised every bit the first sign of possible uterine rupture (SOGC, CNGOF, ACOG).

The progress of labour should exist monitored regularly since prolonged labour or ineffective contractions increase the run a risk of uterine rupture (SOGC, CNGOF) and may themselves be important signs of actual uterine rupture.

Routine postpartum digital exploration of the uterine cavity and the previous caesarean section scar is not beneficial (CNGOF, SOGC, ACOG).

Imaging (ultrasound) to determine the thickness of the lower uterine segment may help in defining increased risk of uterine rupture; equally withal, even so, this is not established as a standard procedure. Threshold measurements have not been defined (SOGC, UpToDate 19, twenty).

Risks and Benefits, VBAC vs. ERCS

Maternal risks and benefits

All the guidelines reviewed confirm that successful VBAC carries the lowest, and secondary caesarean section afterwards an unsuccessful attempted VBAC the highest maternal mortality. Information on maternal bloodshed are however inconsistent. Whereas the Canadian guidelines report increased maternal mortality for VBAC (OR 1.71 95 % CI: 1.28–2.28) 21, the NIH guideline quotes a mortality rate of 1.9/100 000 for attempted vaginal nativity vs. nine.6/100 000 for ERCS.

The risk of uterine rupture for attempted VBAC is slightly increased and for previous depression transverse incision caesarean is quoted at 0.one to one.half dozen % (CNGOF, SOGC, NIH, ACOG). A previous vaginal birth constitutes a protective factor, reducing the chances of uterine rupture irrespective of whether information technology occurred before or after the previous caesarean. Thus the risk of uterine rupture falls with increasing number of VBACs from one.six % (first VBAC) to 0.2 % later on two successful VBACs (SOGC 22). The sometimes widely varying alleged incidence of uterine rupture can generally exist explained past the fact that there has been hardly whatever meaningful stratification of cases into either asymptomatic wound dehiscence or life-threatening, complete rupture (ACOG).

In comparison the uterine rupture rate for ERCS is quoted at 0.03 % (NIH) to 0.xix % (SOGC 23). Hysterectomy is required in 14–33 % of cases when uterine rupture occurs (NIH).

Testify of a mayhap increased hysterectomy rate for attempted VBAC is variable. The reviewed guidelines range from quoting a similar risk to that for ERCS (NIH), to maintaining a doubled charge per unit of astringent complications (1.6 % vs. 0.8; OR: 1.viii; 95 % CI: one.1–3.0; SOGC) although this same guideline quotes a study by Rageth et al. 24 that reports a reduced hysterectomy charge per unit for VBAC (relative risk 0.36; 95 % CI: 0.23–0.56).

In that location are no conclusive data on the surgical method of closure of the uterine incision (continuous vs. interrupted sutures, "locked" or "unlocked" etc.) with respect to uterine rupture take a chance in future pregnancies (CNGOF, SOGC).

Guidelines are unanimous in the view that successful VBAC is associated with less febrile morbidity, fewer thromboembolic complications, shorter infirmary stay and quicker recovery (SOGC, CNGOF, NIH).

Previous caesarean section is associated with an increased incidence of placenta praevia (RR 3.89) and placental abruption (RR 2.41) (SOGC 25). The incidence of placenta praevia increases farther to 1.7 % after a repeat caesarean section and to 3 % after a 3rd (NIH). Fifty-fifty with a normally localised placenta the gamble of placenta accreta, increta or percreta increases from 0.3 % after one caesarean to 2.4 % afterwards three or more.

Information technology is particularly important to consider the potential morbidity associated with repeated caesarean sections when discussing mode of nascency options with a patient who is planning further pregnancies (SOGC, CNGOF, NIH, ACOG). This morbidity includes disorders of placentation, increased likelihood hysterectomy, increased adventure of infection, bowel and bladder injury and need for blood transfusion (ACOG).

Paediatric risks and benefits

Whereas all-encompassing data is by and large bachelor on the maternal pros and cons of the various modes of birth, at that place is limited show on neonatal outcome.

In all the reviewed guidelines perinatal mortality (from xx completed weeks of gestation upwards to 28 days after nascence) and neonatal mortality (within the first 28 days after birth) are quoted equally depression, but higher for VBAC than for ERCS. Thus perinatal bloodshed is estimated at 0.13 vs. 0.05 % respectively (NIH), with an odds ratio of 1.71 (95 % CI: 1.28–two.28) (SOGC 21), and neonatal mortality at 0.11 vs. 0.05 % (NIH, CNGOF – Level two). The Canadian guideline explicitly points out that this increased perinatal morbidity and mortality can be regarded every bit straight related to the occurrence of uterine rupture (SOGC).

The incidence of hypoxic ischemic encephalopathy is mostly low but occurs significantly more often with VBAC. Prevalence rates of 0.5–2.iii/1000 vs. 0–1.i/1000 are quoted (CNGOF – Level two).

The run a risk of neonatal sepsis is college for VBAC (2 vs. 0 %; CNGOF – Level 2) and more often than not seems to touch cases where attempted vaginal nativity is unsuccessful and secondary caesarean is required (OR 4.eight; 95 % CI: three.six–9.0; SOGC 26). Co-ordinate to the NIH, notwithstanding, information on neonatal sepsis are insufficient.

Neonatal respiratory issues (transient tachypnoe of the newborn) seem to occur more than often after ERCS compared to successful VBAC (6 vs. iii %, OR: 2.three 95 % CI: 1.4–iii.8; CNGOF, SOGC, ACOG), although here too the NIH guideline regards the evidence level as insufficient.

The take chances of fetal hyperbilirubinemia is significantly increased after ERCS compared to VBAC (five.eight vs. 2.two %, ACOG).

The long-term consequences of caesarean section for the kid have not withal been adequately researched.

Contraindications to VBAC

Recommendations regarding type of previous uterine incision are not uniform. While the Canadian (SOGC) and French (CNGOF) specialist bodies regard all uterine scars other than the lower segment transverse incision as contraindications to a trial of vaginal nascency, according to the ACOG a lower segment vertical incision is non necessarily a contraindication. All specialist organisations notwithstanding do regard previous classical caesarean (abrupt autopsy of all layers) or T-incision every bit contraindications.

ERCS is generally recommended after a previous uterine rupture (SOGC, CNGOF, ACOG). The risk of repeated rupture is quoted at 6–32 %.

ERCS should also be the aim when contraindications to labour (e.g. placenta praevia, anomalous presentation incompatible with vaginal nativity) are present (SOGC, ACOG – Level 2).

When a patient does not consent to VBAC and has a clear desire to accept an elective repeat caesarean, this wish should be met (SOGC).

Three or more (≥ 3) previous caesarean sections is uniformly regarded every bit a contraindication to VBAC. The risk of uterine rupture is thought to be increased already afterwards 2 previous caesareans (CNGOF – Level iii), although there are some data that suggest hazard is not significantly increased 27. The risk is quoted at upwardly to 3.7 % (SOGC). VBAC tin be considered in private cases following detailed counselling when obstetric conditions are favourable (CNGOF – Grade D). Success rates are between 62–89 % (SOGC), the largest study by Miller et al. 28 showing a success rate of 75 % and a uterine rupture rate of one.7 vs. 0.6 % for ERCS. In line with this result the American guideline states a moderate increase in morbidity of 3.2 % vs. two.one % for VBAC afterwards two vs. one previous caesarean. The possibility of VBAC for these patients is best-selling (ACOG – Level ii). The decision for VBAC afterwards 2 previous caesareans must be made on a example-by-case basis and should only get ahead afterward extensive counselling by an experienced obstetrician (RCOG – Grade C).

Methods of Labour Induction

Wait and watch

The Prissy guidelines make a general recommendation to induce labour at 41 + 0 completed weeks of gestation, nonetheless it is non clear whether this tin simply be applied to the previous caesarean section population. On the ane hand, after previous caesarean section there is a 1.five- to two-fold increased risk (0.11 vs. 0.05 %) 29 of intrauterine death after 39 completed weeks. This must exist weighed up confronting a ane.5-fold increased risk of emergency caesarean and a 2- to 3-fold higher risk of uterine rupture during induction of labour, both factors which themselves influence perinatal morbidity and mortality.

Taking these data into consideration the RCOG in England recommends the following: when a pregnant adult female with previous caesarean department is beyond term (post-dates) and no signs of spontaneous labour are present she should exist examined at 41 + 0 weeks of gestation by a senior obstetrician. Autonomously from assessing fetal wellbeing, a vaginal exam should be performed and the chances of successful VBAC estimated taking all possible factors into business relationship. Furthermore, the patientʼs preferences and options (VBAC vs. ERCS) also as possible consecration methods should exist discussed with her once more. Induction or ERCS should be planned for 41 + 3 weeks at the latest, though a change of plan (from repeat caesarean to induction) may be offered if the neck becomes favourable.

Oxytocin

Oxytocin can be used for induction of labour in hospitalised patients when the cervix is ripe (SOGC – Grade B – Level 3, CNGOF – Grade C). The risk of uterine rupture is regarded every bit minimal to moderate (CNGOF – Level ii). In a study of 142 075 attempted VBACs where oxytocin was used in 43 % of cases the uterine rupture rate was 0.62 % 30. A slightly increased rupture chance is reported for the use of oxytocin for induction compared to augmentation of labour (1.1 vs. 0.eight %) (ACOG 31). An unripe cervix (Bishop score < six) significantly increases the rupture risk (ACOG). Pregnant women with a previous vaginal nascence have a significantly lower rupture risk (1.five vs. 0.8 %) (ACOG, RCOG 32). There is a dose–hazard correlation, though a maximum oxytocin dose has not been divers (ACOG 32). The utilize of prostaglandins before oxytocin assistants is associated with a higher rupture risk (one.4–2.24 %) than oxytocin alone (ACOG 31, 33).

Prostaglandin E2

Data on the utilize of prostaglandin E2 is inconsistent and recommendations are contradictory. In America, for instance, the ACOG recommends prostaglandin E2 only for women with good chances of successful VBAC, however the guideline quotes studies that report no increased uterine rupture risk 31 and studies that report uterine rupture risk is increased 33; studies are also quoted that show increased rupture risk only associated with subsequent oxytocin use 34. The French guideline is in understanding, recommending cautious employ of prostaglandin E2 after careful consideration of the chances of success and taking all relevant obstetric and maternal factors into account.

In directly contrast to this, the Canadian guideline does not allow for the utilize of prostaglandin E2 for induction of labour except in special private cases and after explicit counselling (SOGC – Class B – Level 2). The take a chance of uterine rupture is described as significantly higher than for amniotomy/oxytocin/Foley catheter 35. In England, while the 2008 Dainty guideline all the same allowed for the rather liberal use of prostaglandin E2, the current RCOG Green-superlative guideline advises cautious use with a recommendation to and limit the total prostaglandin exposure. In this regard the NICHD study 31 is referred to, which states lower risk with amniotomy/Foley catheter, nevertheless a recent Cochrane review 36 is besides quoted, which states that there is insufficient evidence to define the induction method with everyman chance. When using prostaglandin E2 for women with previous caesarean section explicit reference should be fabricated to its off-label utilize in this context.

Misoprostol

Fifty-fifty though current noesis and experience with misoprostol is based on pocket-size case numbers nearly all specialist organisations advise confronting its utilise after previous caesarean section. The RCOG makes no recommendation with respect to misoprostol. Information technology is besides unlikely in that location will be new data from large studies in futurity in view of reported rupture rates of upwards to 18.viii % 37; prospective, comparative trials have been discontinued 38 due to unacceptably high rupture rates. It is besides hard to predict whether, and to what extent, the written report of unlike dosage schemes or alternative application methods (oral) will change the available evidence.

Transcervical balloon catheter

The WHO recommends preferential utilise of induction methods associated with lower risk of uterine hyperstimulation, explicitly mentioning the balloon catheter (WHO). A more comprehensive appraisement of the subject is planned for future WHO guidelines.

The Canadian guideline considers the apply of Foley catheters adequate and safe (SOGC-Grade A – Level 2) and mentions the double-balloon catheter equally a second-line alternative (SOGC-Class B – Level 2b). The utilise of Foley catheters does not announced to be associated with an increased rate of uterine rupture (SOGC 39).

The American guideline states the rupture adventure is comparable with that of spontaneous labour and recommends the Foley catheter as beneficial (ACOG).

A low-lying placenta should exist regarded as an absolute contraindication to the utilise of transcervical balloon catheter systems. This deserves detail attention and increased vigilance since disorders of placentation (east.thousand. placenta praevia) occur more than oft following caesarean section (SOGC).

In Republic of austria only the double-airship induction catheter (Cook Med Inc, Bloomington, IN, USA) is licensed for induction of labour. Licensing studies did non include women with previous caesarean section then that this is formally a contraindication to its use. The Foley catheter is not licensed for labour consecration in Austria at all and explicit reference to its off-characterization utilise must be made.

Footnotes

Conflict of Interest The authors report no conflict of interest.

Supporting Information

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177557/

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