Bruce L. Flamm

Elective repeat cesarean delivery versus trial of labor : A prospective multicenter study

Objective: To report a prospective multicenter comparison of outcomes of patients who attempted trial of labor and those who underwent elective repeat cesarean. Methods: During the study interval, all pregnant women with previous cesarean delivery cared for at Kaiser Permanente Hospitals in Southern California were studied regardless of whether trial of labor or elective repeat cesarean was planned. Results: Of 7229 study patients, 5022 (70%) had a trial of labor and 2207 had elective repeat cesarean operations. Seventy‐five percent (3746) of those opting for trial of labor went on to deliver vaginally. The rate of uterine rupture was less than 1% and there were no maternal deaths related to uterine rupture. The hospital length of stay, incidence of postpartum transfusion, and incidence of postpartum fever were all significantly higher in the elective repeat cesarean group than in the trial of labor group. Conclusions: Labor after previous cesarean delivery has a 75% success rate, with a risk of uterine rupture of less than 1%. Neither repeat cesarean delivery nor trial of labor is risk‐free. With careful supervision, trial of labor eliminates the need for a large proportion of repeat cesarean operations. (Obstet Gynecol 1994;83:927‐32)

Vaginal birth after cesarean delivery : results of a 5-year multicenter collaborative study

Cesarean delivery has become the most frequently performed major operation in the United States. Widespread use of vaginal birth after previous cesarean delivery could potentially eliminate up to one-third of cesareans. However, many physicians have been reluctant to adopt this policy without large studies conclusively demonstrating its safety. This study evaluated the maternal and perinatal outcomes of over 5000 cases of labor after previous cesarean delivery. This multicenter study began in 1984 and initially included nine California hospitals. During the first 2 years, there were 1776 trials of labor resulting in 1314 vaginal births. In January 1986 two additional hospitals joined the collaborative project. Over the next 3 years, there were 3957 trials of labor resulting in 2977 vaginal births at the 11 participating hospitals. During the entire study period, 5733 patients opted for a trial of labor and 4291 (75%) delivered vaginally. There were no maternal deaths in the trial-of-labor group, and perinatal mortality was not significantly different from that of the general obstetric population. These results support the findings of numerous smaller studies that have concluded that the policy of routine repeat cesarean delivery should be abandoned.

Vaginal birth after cesarean delivery: an admission scoring system.

Objective To develop a scoring system to predict the likelihood of vaginal birth in patients undergoing a trial of labor after previous cesarian delivery using factors known at the time of hospital admission. Methods Trial of labor was attempted in 5022 patients who were assigned randomly to score derivation and score testing groups. Multivariate logistic regression modeling was used in the score derivation group to develop a predictive scoring system for vaginal birth. The scoring system was then applied to the testing group to evaluate its predictive ability. Results Five variables significantly affected the mode of birth and were incorporated into a weighted scoring system. Rates of successful vaginal birth after cesarean ranged from 49% in patients scoring 0–2 to 95% in patients scoring 8–10. Increasing score was associated linearly with increasing probability of vaginal birth after cesarean. Conclusion increasing scores correlate with increasing probability of vaginal birth after cesarean. The admission vaginal birth after cesarean scoring system may be useful in counseling patients regarding the option of vaginal birth or repeat cesarean delivery. This information could be particularly valuable for the patient who opts for trial of labor but has second thoughts about her mode of birth when labor begins.

External cephalic version after previous cesarean section.

Approximately 100,000 cesarean sections are performed each year in the United States because of breech presentation. Numerous studies have shown that external cephalic version can eliminate the need for many of these operations. However, because of the fear of uterine rupture, these studies have generally excluded patients who have undergone previous cesarean section. To evaluate the validity of this exclusion policy, we studied patients with one or more previous cesarean sections and breach presentations near term. Version attempts were successful in 82% of 56 patients who had undergone a previous cesarean section. Sixty-five percent of the successful version patients went on to have vaginal birth after cesarean section. There were no serious maternal or fetal complications associated with the version attempts. We conclude that external cephalic version is a reasonable option in patients with prior low transverse cesarean section.

Results of the National Study of Vaginal Birth After Cesarean in Birth Centers

OBJECTIVE: Some women wish to avoid a repeat cesarean delivery and believe that a midwife-supported vaginal birth after cesarean (VBAC) in a nonhospital setting represents their best chance to do so; there is a small, persistent demand for out-of-hospital VBACs. We conducted a study to obtain the data necessary to formulate an evidence-based policy on this practice. METHODS. We prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000. RESULTS: A total of 1,453 of the 1,913 women presented to the birth center in labor. Twenty-four percent of them were transferred to hospitals during labor; 87% of these had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). Most fetal deaths (5/7) occurred in women who did not have uterine ruptures. Half of uterine ruptures and 57% of perinatal deaths involved the 10% of women with more than 1 previous cesarean delivery or who had reached a gestational age of 42 weeks. Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks. CONCLUSION: Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs. LEVEL OF EVIDENCE: III

Vaginal delivery following cesarean section: use of oxytocin augmentation and epidural anesthesia with internal tocodynamic and internal fetal monitoring.

The cesarean section rate continues to rise, and, as new indications for the operation continue to be proposed, a method for safely decreasing the rate is truly needed. Less than 1% of patients in the United States are allowed a trial of labor after a cesarean section, in spite of the thousands of (safe) vaginal deliveries after cesarean section now reported in the literature. Few reports in the literature mention the use of oxytocin or regional anesthesia in these patients. We present our experience with 230 trials of labor after primary low transverse cesarean section. One hundred eighty-one patients (79%) were delivered vaginally, 73 patients (32%) received epidural anesthesia, and 94 patients (41%) received oxytocin augmentation of labor. Internal tocodynamic and fetal heart monitoring was used in all patients. Our rationale for this controversial management is discussed.

Vaginal Birth After Cesarean Section

Dr. Roy Pitkin, editor of Obstetrics and Gynecology, recently stated that “without question, the most remarkable change in obstetric practice over the last decade in volves management of the woman with apriorcesarean delivery.”1 It would also prob ably be safe to say that few changes in the past decade have made obstetricians so angry. Why is this true?