Behind the myth – few women prefer caesarean section in the absence of medical or obstetrical factors

Objective

to describe the prevalence of women’s preference for caesarean section as expressed in mid pregnancy, late pregnancy and one year post partum. An additional aim was to identify associated factors and investigate reasons for the preference.

Design

mixed methods. Data were collected from 2007 to 2008 through questionnaires distributed to a Swedish regional cohort of women. The survey was part of a longitudinal study of women’s attitudes and beliefs related to childbirth. One open question regarding the reasons for the preferred mode of birth was analysed using content analysis.

Setting

three hospitals in the county of Västernorrland in the middle of Sweden.

Participants

1506 women were recruited at the routine ultrasound screening during weeks 17 to 19 of their pregnancy.

Findings

a preference for caesarean section was stated by 7.6% of women during mid pregnancy and by 7.0% in late pregnancy. One year post partum 9.8% of the women stated that they would prefer a caesarean section if they were to have another baby. This was related to their birth experience. There were more multiparous women who wished for a caesarean section. Associated factors irrespective of parity were fear of giving birth and a ‘strongly disagree’ response to the statement regarding that the preferred birth should be as natural as possible. Among multiparous women the strongest predictors were previous caesarean sections, particularly those that were elective, and a previous negative birth experience. Women’s comments on their preferred mode of birth revealed five categories: women described caesarean section as their only option relating to obstetrical and/or medical factors; several women stated ambivalent feelings and almost as many described their previous birthing experiences as a reason to prefer a caesarean birth; childbirth-related fear and caesarean section as a safe option were the remaining categories.

Key conclusions

rising caesarean section rates seem to be related to factors other than women’s preferences. Ambivalence towards a way of giving birth is common during pregnancy. This should be of concern for midwives and obstetricians during antenatal care. Information and counselling should be frequent and comprehensive when a discussion on caesarean section is initiated by the pregnant woman. A negative birth experience is related to a future preference for caesarean section and this should be considered by caregivers providing intrapartum care.     

Interventions in labour and birth and satisfaction with care: The Canadian Maternity Experiences Survey Findings

Objective: To examine whether interventions in labour and birth contributed to ratings of satisfaction with these experiences, in women giving birth vaginally or attempting a vaginal birth prior to giving birth by caesarean section. Background: Ratings of satisfaction with women’s overall experience of labour and birth have long been encouraged, yet remain challenging to assess or to interpret. Methods: Data from the Canadian Maternity Experiences Survey (MES) – a nationally representative sample of women who had a singleton live birth in 2005–2006 – were analysed. Associations between the number of and type of labour and birth interventions, and women’s satisfaction with the overall labour and birth experience and six aspects of caregiver interactions, were assessed. Results: Among women having vaginal births, fewer interventions during labour was significantly associated with higher overall satisfaction with the labour and birth experience (ranging from 75% of women having no interventions to 46.4% having eight or more interventions rating their experiences as ‘very postive’). The same pattern was observed for satisfaction with women’s perceptions of caregiver’s respect, concern for dignity, compassion shown to them, the information given to them, their involvement in decision making, and caregiver’s competence. Among women having unplanned caesarean sections following attempted vaginal birth, the number of interventions was not associated with satisfaction ratings; however, satisfaction ratings were consistently lower than among women giving birth vaginally. Conclusion: These findings provide support for demedicalising vaginal labour and birth as well as for optimising the potential for a vaginal birth rather than caesarean section.     

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1

ObjectiveTo compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation.Design and participantsA retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin.SettingThe review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017.Measurements and FindingsOxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation.Key conclusionsOxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section.Implication for practiceDue to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress.     

Skills-based childbirth preparation reduces stress for midwives

Objectiveto explore the potential benefits of skills-based childbirth preparation on the work related stress levels of midwives.Designa questionnaire was sent out to midwives who had clients participating in an RCT of an education package for childbirth preparation (The Pink Kit (PK) Method for Birthing Better®) delivered to parents.Settingmidwives were in private practice and acted as lead maternity carers to New Zealand first time mothers.Participantsone hundred and four independent midwives participated.Measurementsa brief questionnaire using a Visual Analogue Scale to portray perceptions of work-related stress and a yes/no question about expected and/or unexpected physical complications.Findingsmidwives working with clients in the intervention group experienced less work-related stress after correction for medical complications compared to the two control groups.Key conclusionsworking with mothers who have used a programme that increased their childbirth self-efficacy decreased the work-related stress experienced by midwives.Implications for practiceencouraging pregnant women to develop childbirth skills merits further investigation in an effort to reduce the work-related stress experienced by midwives.     

Inconceivable Conceptions: Psychological Aspects of Infertility and Reproductive Technology

Objective: We examined variables that may influence women’s decision to try for a Vaginal Birth After Caesarean (VBAC) or an Elective Repeat Caesarean Delivery (ERCD). Background: After a primary caesarean delivery, many women must choose between a VBAC or an ERCD. Both options involve risk to the mother and neonate, and the decision is a complex one. Methods: Data were collected from 166 pregnant women and 117 intending-to-become pregnant women with one previous caesarean section. Through an online survey, women reported their birth plans (current, past and future), risk perception, influences on their decision, and their locus of control for labour and delivery. Results: Women planning to have a VBAC perceive a caesarean as the riskier option, while women choosing an ERCD perceive a VBAC as the riskier option. Women who plan to have a VBAC are less satisfied overall with their first birth. Women who are planning a VBAC have a higher internal locus of control for labour and delivery and a lower ‘powerful others’ locus of control than woman planning an ERCD. Our data suggest that women who plan to have a VBAC are more influenced by online sources and less influenced by healthcare providers, relative to women who plan an ERCD. Conclusion: Women’s risk perception, personality, and their perception of past experience likely influence women’s decision making for trying a VBAC.     

Could a simple antenatal package combining micronutritional supplementation with presumptive treatment of infection prevent maternal deaths in sub-Saharan Africa?

Background

For women who have a caesarean section in their preceding pregnancy, two care policies for birth are considered standard: planned vaginal birth and planned elective repeat caesarean. Currently available information about the benefits and harms of both forms of care are derived from retrospective and prospective cohort studies. There have been no randomised trials, and recognising the deficiencies in the literature, there have been calls for methodologically rigorous studies to assess maternal and infant health outcomes associated with both care policies. The aims of our study are to assess in women with a previous caesarean birth, who are eligible in the subsequent pregnancy for a vaginal birth, whether a policy of planned vaginal birth after caesarean compared with a policy of planned repeat caesarean affects the risk of serious complications for the woman and her infant.

Methods/Design

Design: Multicentred patient preference study and a randomised clinical trial. Inclusion Criteria: Women with a single prior caesarean presenting in their next pregnancy with a single, live fetus in cephalic presentation, who have reached 37 weeks gestation, and who do not have a contraindication to a planned VBAC. Trial Entry & Randomisation: Eligible women will be given an information sheet during pregnancy, and will be recruited to the study from 37 weeks gestation after an obstetrician has confirmed eligibility for a planned vaginal birth. Written informed consent will be obtained. Women who consent to the patient preference study will be allocated their preference for either planned VBAC or planned, elective repeat caesarean. Women who consent to the randomised trial will be randomly allocated to either the planned vaginal birth after caesarean or planned elective repeat caesarean group. Treatment Groups: Women in the planned vaginal birth group will await spontaneous onset of labour whilst appropriate. Women in the elective repeat caesarean group will have this scheduled for between 38 and 40 weeks. Primary Study Outcome: Serious adverse infant outcome (death or serious morbidity). Sample Size: 2314 women in the patient preference study to show a difference in adverse neonatal outcome from 1.6% to 3.6% (p = 0.05, 80% power).

Clinical Trial Registration

ISCTRN5397431     

Induction of labour with prostaglandin E2 vaginal gel in women with one previous caesarean section

ObjectiveTo study the outcome of induction of labour with prostaglandin E2 (PGE2) vaginal gel in those with one previous caesarean section.DesignOne year prospective comparative study.SettingA tertiary care Armed Forces Hospital, Muscat.PopulationForty-six women with one previous caesarean section (CS) underwent PGE2 vaginal gel induction (study group). Hundred women with previous CS had gone into spontaneous onset of labour (control group).Main outcome measuresPrimary outcome measures are mode of delivery and uterine rupture. Others are neonatal outcome, indications for caesarean section, and complications like, postpartum haemorrhage and infectious morbidity.ResultsOverall rate of vaginal delivery after caesarean section (VBAC) was 65.21% and 79% in the study and control groups, respectively. There were 7 cases of neonatal intensive care unit (NICU) admissions (7%) in the control group; however, none in the study group. Caesarean section done for foetal distress was 5/16 CS in the study group (31.25%) and 10/21 CS in the control group (47.61%). There were no cases of uterine rupture in both control and study groups.ConclusionInduction of labour with prostaglandin E2 vaginal gel in women with one previous caesarean section does not significantly increase the risk of caesarean section rate or ruptured uterus and does not adversely affect immediate neonatal outcome.     

Childbirth expectations: an Australian study of young childless women

Objective: We investigate young childless Australian women’s stated preferences for future delivery mode and birth attendant and explore correlates of, and explanations for, these preferences. Background: In the context of debate about the causes of rising caesarean rates, we explore broad social assumptions about, and attitudes to, childbirth mode by focusing on the stated birthing preferences and attitudes of young childless women. Methods: A total of 334 single, childless, Australian women, aged 18–25, recruited through a university subject pool and via Facebook, responded to an online survey. Measures included their expected preferences for delivery mode (caesarean or vaginal) and for birth attendant (obstetrician or midwife), stated reasons for those preferences, and standard measures of childbirth self-efficacy, childbirth fear, general anxiety and depression, and life satisfaction. Results: Most women expected that they would prefer a vaginal birth and obstetrician-led care. Multiple regression showed preference for caesarean birth to be associated with low childbirth self-efficacy, and preference for an obstetrician with childbirth fear and general anxiety. Women referenced fear of childbirth as a reason for caesarean birth and ‘naturalness’ for vaginal birth; and technical expertise for obstetrician-led care and emotional support as a reason for midwife care. Conclusion: Young childless women already hold attitudes to childbirth, and at least some report high fear and low self-efficacy. These findings amongst women who have not experienced pregnancy or childbirth suggest that social and cultural attitudes play a major role in women’s approach to childbirth.     

Method of delivery and subjective distress: Women's emotional responses to childbirth practices

Abstract

Forty women who had given birth for the first time following full term-pregnancy participated in a study concerning distress in response to one of four obstetric procedures: spontaneous vaginal delivery; induced vaginal delivery; instrumental vaginal delivery; or, emergency caesarean section. During their sixth week post-delivery, they completed questionnaires and supplied biographical data. Those who had undergone instrumental delivery (as assisted by episiotomy) described the birth of their child as significantly more distressing, themselves as being more at risk of injury and dissatisfied with the efficacy of pain relief during labour than women in the other three obstetric groups. By comparison, those who had an emergency caesarean section retrospectively reported little psychological distress or perceived risk of serious injury and significantly greater satisfaction with pain relief. Thus, it would appear that the well-being of women who experience an instrumental delivery is in need of additional support. Further prospective research is needed with a larger study population to confirm or otherwise the observations made in this initial investigation.     

Women's Preference for a Cesarean Section: Incidence and Associated Factors

Background: Few studies have examined women's preferences for birth. The object of this study was to determine the incidence of women's preferred type of birth, and the reasons and factors associated with their preference. Methods: Three hundred and ten women between 36 and 40 weeks' gestation were recruited from the antenatal clinic of a major metropolitan teaching hospital and the consulting rooms of six private obstetricians in Brisbane, Australia. Participants completed a questionnaire asking about their preferred type of birth, reasons for their preference, preparation for childbirth, level of anxiety and concerns, and the influence of the primary caregiver. Results: Two hundred and ninety women (93.5%) preferred a spontaneous vaginal birth; 20 women (6.4%) preferred a cesarean section. Of the latter group, most had a current obstetric complication or experienced a previously complicated delivery (p <0.001); 1 woman (0.3%) preferred a cesarean section in the absence of any known current or previous obstetric complication. Women who preferred a cesarean section were more anxious, were generally poorly informed of the risks of this procedure, and/or overestimated the safety of the procedure. Conclusions: Women who preferred a cesarean section were more likely to have experienced this type of birth previously and to have negative feelings about it. To decrease women's preference for a cesarean section, practitioners should reduce the primary cesarean delivery rate and improve the quality of emotional care for women who require a cesarean section. Caregivers should engage in a sensitive discussion of the risks and benefits of various birth options, including a vaginal birth after cesarean, with women who have previously experienced a cesarean birth before they make decisions about mode of delivery in a subsequent pregnancy.     

Expectation and experiences of childbirth in primiparae with caesarean section

Objective  The aim of this study was to examine the expectations and experiences in women undergoing a caesarean section on maternal request and compare these with women undergoing caesarean section with breech presentation as the indication and women who intended to have vaginal delivery acting as a control group. A second aim was to study whether assisted delivery and emergency caesarean section in the control group affected the birth experience.
Design  A prospective group-comparison cohort study.
Setting  Danderyd Hospital, Stockholm, Sweden.
Sample  First-time mothers ( n = 496) were recruited to the study in week 37–39 of gestation and follow up was carried out 3 months after delivery. Comparisons were made between 'caesarean section on maternal request', 'caesarean section due to breech presentation' and 'controls planning a vaginal delivery'.
Methods  The instrument used was the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ).
Main outcome measures  Expectations prior to delivery and experiences at 3 months after birth.
Results  Mothers requesting a caesarean section had more negative expectations of a vaginal delivery ( P < 0.001) and 43.4% in this group showed a clinically significant fear of delivery. Mothers in the two groups expecting a vaginal delivery, but having an emergency caesarean section or an assisted vaginal delivery had more negative experiences of childbirth ( P < 0.001).
Conclusions  Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasises the importance of postnatal support.     

Term breech singletons and caesarean section: A population study, Australia 1991–2005

Objective: To describe the method of birth of term breech singletons in Australia.
Design, setting and participants:  A retrospective population-based study of women who gave birth to term breech singletons in Australia between 1 January 1991 and 31 December 2005 using data from the National Perinatal Data Collection.
Main outcome measures:  Caesarean section, vaginal breech birth.
Results:  Method of birth changed for term breech singletons from 1991 (vaginal breech birth 23.1% versus caesarean (no labour 55.6%, labour 21.2%)) to 2005 (vaginal breech birth 3.7% versus caesarean (no labour 76.6%, labour 19.7%)). Overall, the population attributable risk percentage of term breech singletons for all caesarean sections declined from 10.2% in 1991 to 6.9% in 2005.
Conclusion:  Planned caesarean section is the standard method of birth for term breech singletons in Australia. Active measures including external cephalic version should be supported to reduce the rate of caesarean section where clinically indicated. Retention of a skilled clinical workforce is essential in the provision of the latter and to assist the minority of women having vaginal breech births. Breech presentation is not a major factor in the overall rise in caesarean section experienced by Australia since 1996.     

Feelings of control,unconditional self-acceptance and maternal self-esteem in women who had delivered by caesarean

Objective: the objective of this study is to establish a greater understanding of the emotional and cognitive mechanisms associated with caesarean delivery. Method: 201 women who had given birth in the previous year (58 by caesarean) responded to 3 scales: the Labor Agentry Scale (LAS) evaluating sense of control during the delivery, the Maternal Self Report Inventory (MSRI) measuring the level of maternal self-esteem and the Unconditional Self-Acceptance Questionnaire (USAQ) assessing the degree of unconditional self-acceptance. Results: women who had undergone a planned or an emergency caesarean had a lower sense of control and reduced maternal self-esteem when compared to women who had spontaneous vaginal delivery. The sense of control at the delivery had a mediating role in the relationship between the delivery mode and the level of maternal self-esteem. No significant difference was found for unconditional self-acceptance concerning the type of delivery. Conclusions: delivery by caesarean has repercussions regarding women’s beliefs. Giving a sense of control at the birth and unconditional self-acceptance should be of central importance in improving maternal self-esteem.     

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term,a qualitative analysis in the Netherlands

Objectiveexternal cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term.Designqualitative study with semi-structured interviews.SettingDutch hospitals.Participantspregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation.Measurementson the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists).Findingsamong pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region.Conclusionwe identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands.This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.     

Diabetes Mellitus and lower genital tract tears after vaginal birth: A cohort study

IntroductionDiabetes Mellitus in pregnancy is increasing. No existing studies have examined Diabetes Mellitus as the primary exposure for lower genital tract tears after vaginal birth. The objective was to study the association between Diabetes Mellitus (all types combined), Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus and lower genital tract tears after vaginal birth.Material and methodsA register-based cohort study of women with singleton pregnancy and without a previous cesarean section at near-term (≥ 35 + 0 weeks) and term (≥ 37 + 0 weeks) gestational age, n = 31,297 at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012. The associations between Diabetes Mellitus and lower genital tract tears were analysed using a fixed multiple logistic regression analyses.ResultsApproximately 32,000 women were eligible for the study; 796 women had diabetes (2.5%) and 1318 experienced anal sphincter injury (4.3%). The overall risk of lower genital tract tears was similar among women with a diagnosis of diabetes (Type1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and Gestational Diabetes Mellitus) compared to women without diabetes, except for nulliparous women with Type1 Diabetes Mellitus who experienced a higher risk of episiotomies, crude and adjusted odds ratios (OR 2.13, 95% CI 1.14-3.97) and (OR 2.48, 95% CI 1.21-5.10), respectively.ConclusionsWomen with Diabetes Mellitus without a previous cesarean section who gave birth vaginally to a single child at term or near term did not experienced an increased risk of lower genital tract tears. However, nulliparous women with Type 1 Diabetes Mellitus experienced a higher risk of episiotomy. These results may be used to individualised counselling of women with Diabetes Mellitus regarding mode of birth and may reduce worries about genital tract tears in women with Diabetes Mellitus considering vaginal birth.     

Owning the birth experience: what factors influence women’s vaginal birth after caesarean decision?

Objective: Our quantitative analysis examined what factors influence pregnant women to choose a vaginal birth after a caesarean (VBAC).

Background: There is growing concern over the high rates of caesarean section; much of the high rate is driven by repeat caesareans. A trial of labour after a previous caesarean is an option for many women increasingly supported by medical literature.

Methods: Survey data from 173 pregnant women who had had only one birth by caesarean were analysed using a hierarchical binary logistic regression model.

Results: Desire for the experience of a vaginal birth strongly predicted choice of VBAC; however, this relationship was dampened among women with a high (versus low) powerful others (e.g. doctors and nurses) locus of control. Prior reason for a caesarean section and practical factors also play a role.

Conclusion: Women may be more likely to choose VBAC if they are encouraged to believe that they can help control the outcome, especially if their desire for a vaginal birth experience is high.     

The Importance of Mode of Birth After Previous Cesarean: Success,Satisfaction, and Postnatal Health

Introduction: The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase women's opportunities to make informed choices about VBAC. This study aimed to expand knowledge of women's experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth‐after‐cesarean study. Methods: At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10‐point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. Results: Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F= 5.33; P= .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health‐related problems and were least likely to agree that they would make the same birth choice again. Discussion: Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance women's opportunities to achieve spontaneous vaginal birth during planned VBAC.     

Vaginal birth after cesarean section: Experience from a regional hospital

ObjectiveTrial of labor after cesarean section (TOLAC) is an option for women with previous cesarean section. However, few women choose this option because of safety concerns. We evaluate the safety and risks associated with TOLAC and the success rate of vaginal birth after cesarean delivery (VBAC).Material and methodsWe reviewed all patients with a history of previous cesarean section that underwent elective repeat cesarean section (ERCS) or TOLAC in a regional teaching hospital from Nov, 2013 to May, 2018. Maternal basic clinical information, intrapartum management, postpartum complications, and neonatal outcomes were analyzed.Results199 pregnant women with a history of at least one previous cesarean section were enrolled. 156 women received ERCS and 43 women (21.6%) underwent TOLAC, with 37 (86.0%) who underwent successful VBAC. The VBAC rate was 18.6%. Higher success rate was found in women with previous vaginal birth than in women without vaginal birth (100% vs. 81.8%). One case (2.3%) in the VBAC group was complicated with uterine rupture and inevitable neonatal death during second stage of labor. The uterus was repaired without maternal complications. In another case, the newborn's condition was complicated with low APGAR score (<7) at birth due to maternal chorioamnionitis. Among indications for previous cesarean section, cephalo-pelvic disproportion (CPD) was associated with TOLAC failure and uterine rupture after VBAC.ConclusionVBAC is a feasible and safe option. Modes of delivery should be thoroughly discussed when considering TOLAC for women with history of previous cesarean section due to CPD, considering its association with TOLAC failure in second stage of labor.     

Trial of labour after two or three previous caesarean sections

OBJECTIVE: To investigate the safety of a trial of labour (TOL) after two or three previous caesarean sections. STUDY DESIGN: Retrospective analysis of medical records of women with a history of more than one previous caesarean section who gave birth during a 10-year period (1988-1997) in two large university hospitals in The Netherlands. RESULTS: Women numbering 30,132 gave birth with a hospital caesarean birth rate of 14.8%. There were 246 women with a history of more than one previous caesarean section: 187 (76%) delivered by elective repeat caesarean section (ERCS); 59 (24%) had a trial of labour, of whom 49 (83%) had a vaginal birth. Three uterine ruptures occurred after previous lower segment caesarean sections without maternal or perinatal mortality related to the uterine rupture; only one rupture was during a trial of labour. In the study group there was no maternal mortality. Maternal morbidity did not differ between women with an elective repeat caesarean or a failed trial of labour. Perinatal mortality was not related to the mode of delivery. CONCLUSION: Elective repeat caesarean section is not the only answer to a woman with two or three previous caesarean sections. A trial of labour can be a safe option for a selected group of women.