Vaginal delivery in Nigerian women after a previous cesarean section

A total of 154 consecutive Nigerian women at term pregnancy who had undergone one previous cesarean delivery were prospectively studied during the year March 1987 to February 1988. A repeat elective cesarean section was performed in 52 (33.8%) patients. Vaginal delivery was achieved in 73 (71.6%) of the 102 subjects who were allowed into labor, and in over 90% of the comparison group. High vaginal delivery rates occurred among the women within the selection criteria irrespective of the indication for the previous cesarean section. A repeat emergency cesarean section was performed in 29 (24.5%) women. Rupture of the uterine scar occurred in 5 (4.9%) instances with the loss of 2 babies; there was no maternal loss. Excluding the high incidence of fetal asphyxia and uterine rupture which occurred among women in the study group, maternal morbidity and perinatal mortality and morbidity were similar to those of the comparison group. There was a statistically significant difference between the study and comparison group. There was a statistically significant difference between the study and comparison groups with regard to the mode of delivery. Among the study group, a significant correlation existed between the vaginal delivery rate of the patients and the indication for the primary cesarean section. There was however, no significant difference between the mean parities of the women who were delivered by cesarean section and those who delivered vaginally. Similarly, no significant difference existed in the mean birthweights of the babies delivered vaginally and those who were delivered abdominally during labor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Vaginal birth after cesarean delivery in the twin gestation

The pregnancy outcomes of 56 women with a twin gestation and a prior cesarean birth were analyzed to determine whether a trial of labor was a reasonable consideration. Of these patients, 31 (55%) underwent an elective repeat cesarean delivery and 25 (45%) attempted vaginal delivery. Of those who attempted vaginal delivery, 18 (72%) were vaginally delivered of both infants. The dehiscence rate among women with twin pregnancies who attempted a trial of labor was 4% compared with 2% in women with singleton pregnancies. There were no significant differences in maternal or neonatal morbidity or mortality rates in trial of labor versus no trial of labor groups. We conclude in this limited population that a trial of labor in a twin gestation after a previous cesarean delivery appears to be a reasonable consideration. The usual safeguards for attempted vaginal delivery in the twin gestation should be followed.     

Trial labor following previous cesarean section

Elective repeat cesarean section continues to remain the standard of care in the United States. This paper is a study of 242 patients with previous cesarean section who requested and were allowed a trial of labor. One hundred sixty-six (69%) achieved successful vaginal delivery with no maternal or fetal mortality or significant morbidity. Review of the English literature indicates similar results in other independent studies. Continued accumulation of cases showing the efficacy of post-cesarean section trial of labor should encourage a reassessment of the continuing practice of elective repeat cesarean section.     

Obstetric outcome of patients with more than one previous cesarean section

Records of patients with more than one previous cesarean section were reviewed for a 1-year period. Of 69 such pregnancies, 36 underwent trial of labor in concurrence with an ongoing departmental cesarean section reduction initiative; 80% culminated in vaginal delivery. Twenty of these 69 patients had three or more previous cesarean sections; 9 underwent trial of labor, with 8 subsequent vaginal deliveries. The vaginal delivery rate after more than one previous cesarean section was no different from that of patients with only one previous cesarean section. We conclude that trial of labor in patients with more than one previous cesarean section did not result in a deleterious outcome. Our findings suggest that a trial of labor after more than one previous cesarean section delivery can safely be allowed. Guidelines can be identical to those already established for patients with only one previous cesarean section.     

Previous cesarean section: the risks and benefits of oxytocin usage in a trial of labor

Permitting a trial of labor in patients with a previous cesarean birth is rapidly becoming an accepted alternative to routine elective repeat cesarean section. As interest in this approach has grown and the risks associated with a trial of labor have been better defined, the use of oxytocin in these patients emerges as a pertinent issue. Our retrospective experience of oxytocin use in patients undergoing a trial of labor suggested no increased maternal or fetal risk compared to patients who did not receive oxytocin. On the basis of our prior experience, we set out to investigate prospectively the role of oxytocin in 732 patients with prior cesarean section who underwent a trial of labor. During the study period, 289 (40%) patients received oxytocin for either induction (32, 11%) or augmentation (257, 89%) of labor and 443 patients did not receive oxytocin. Successful vaginal delivery was achieved in 200 patients (69%) as opposed to 395 (89%) of the patients who did not receive oxytocin. The incidences of dehiscence in the oxytocin and no oxytocin groups were 3% and 2%, respectively. Further analysis of vaginal and cesarean delivery complications for the two groups were contrasted and no significant differences were found with respect to the incidence of hemorrhage, uterine atony, hysterectomy, or the requirement of transfusions. Neonatal outcome was also comparable for both groups. On the basis of our prospective experience, it appears that the use of oxytocin, when carefully monitored, is a safe and reasonable consideration in the patient undergoing a trial of labor.     

Vaginal birth after cesarean

Allowing a woman with a previous cesarean birth a trial of labor rather than performing an elective repeat cesarean section continues to be a controversial area in obstetrics today. In an effort to evaluate the risks associated with a trial of labor, a prospective investigation was undertaken from July 1, 1982, through June 30, 1984. During the first year of the study, patients with a known vertical scar or more than one prior cesarean birth were excluded from an attempted trial of labor. Beginning July 1, 1983, patients with two prior cesarean births were no longer excluded and were studied prospectively. During this 2-year period, 32,854 patients were delivered of their infants at the Los Angeles County/University of Southern California Medical Center. Of these patients, 2708 (8.2%) had undergone a prior cesarean birth, and 1796 women (66%) underwent a trial of labor. A total of 1465 (81%) of them achieved a vaginal delivery. Successful vaginal delivery by the number of prior cesarean sections was as follows: one, 82%; two, 72%; three, 90%. When contrasted with the group without a trial of labor, the group with a trial of labor had significantly less maternal morbidity. In a comparison of the groups with and without a trial of labor, the incidence of uterine dehiscence (1.9% versus 1.9%) and rupture (0.3% versus 0.5%) was similar. With the application of attempted vaginal delivery in our patients with a previous cesarean birth, we were able to reduce our cesarean delivery rate for this population alone by 54%. In summary, the benefits associated with a trial of labor in the patient with a prior cesarean birth far outweigh the risks. The policy of "once a cesarean section, always a cesarean section" should be abandoned.     

Trial of labor in the patient with a prior cesarean birth

The increasing incidence of cesarean birth has become quite controversial. The practice of delivering virtually all women with a prior cesarean section by repeat cesarean section is open to debate. In a large institutional practice, with rapid availability of all support services, selective attempts to deliver women vaginally, after a prior cesarean section, is appealing. A prospective 1-year study on all patients with a prior cesarean delivery commenced July 1, 1982. There were 1209 patients, of whom 751 (62%) underwent a trial of labor and 614 (82%) achieved vaginal delivery. There was no maternal mortality or perinatal mortality attributed to the trial of labor process. Oxytocin usage occurred in 38% of this population. The incidence of uterine rupture and scar dehiscence was similar in the various study subgroups. The overall group of women undergoing a trial of labor had significantly fewer postpartum complications and shorter hospital stays.     

Breech presentation after cesarean section: always a section?

A retrospective review of 71 breech deliveries after previous cesarean was done to determine the need for repeat cesarean section. Twenty-four (33.8%) women were allocated to the elective repeat cesarean section group and forty-seven (66.2%) patients were allocated to a trial of labor group. Thirty-seven (78.7%) were delivered of their infants vaginally. A total of 37 of the 71 women (52.1%) had successful vaginal deliveries. Neonatal morbidity did not differ for women who were delivered vaginally or by cesarean section. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (p less than 0.001). On the basis of these data, a trial of labor seems reasonable in carefully selected cases of breech presentation after a previous cesarean section.     

Factors associated with successful vaginal delivery after cesarean section

To assess obstetric parameters that would predict successful vaginal delivery in patients with prior cesarean sections, the perinatal records of 579 such patients were reviewed. Sixty-six percent of the patients (385) had elective repeat cesarean sections. Of the 194 patients who attempted vaginal delivery, three-fourths (148) had success. Perinatal parameters that were statistically significant indicators of success included: nonrecurrent indication for cesarean section, vaginal delivery either prior or subsequent to cesarean section, duration of labor less than 24 hours prior to cesarean section, infant's birth weight less than 4,000 gm and cervical dilatation greater than 4 cm on admission for attempted vaginal delivery.     

Vaginal birth after caesarean delivery in twin gestation: is trial of labor allowed?

OBJECTIVE: To determine if a trial of labor in twin pregnancy with previous cesarean section is an acceptable alternative to systematic cesarean section. PATIENTS AND METHODS: Based on a retrospective and comparative study from 1st January 1996 to 30th June 2003 in Maternite Jeanne-de-Flandre (Lille) and Pavillon Paul-Gelle (Roubaix), 35 trials of labor in twin pregnancies with previous cesarean section have been compared with 35 twin gestations attempting vaginal delivery without a prior cesarean. This comparative study has been led by sorting out the patients according to their gestational age, parity and maternity. RESULTS: Twenty-seven women (77%) delivered vaginally and eight (23%) by elective caesarean section. Postpartum hemorrhage was more frequent for caesarean section (75%). No scare dehiscence or rupture occurred. There was not any haemostasis hysterectomy or embolisation related to postpartum haemorrhage. Neonatal outcome was similar in both groups. DISCUSSION AND CONCLUSION: Twin trial of labor after a previous cesarean section seems to be a safe alternative to routine repeat cesarean delivery as maternal and fetal morbidity and mortality are safe.     

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital.

OBJECTIVE: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar. STUDY DESIGN: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother-neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother-neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery. RESULTS: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother-neonatal dyads with a failed trial of labor sustained the greatest risk of complications. CONCLUSION: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.     

Intrapartum influences on cesarean delivery in multiple gestation

OBJECTIVE: To evaluate which intrapartum factors influence the method of delivery in a group of twin pregnancies eligible for vaginal delivery. STUDY DESIGN: Over a 10-year period, 967 consecutive twin pregnancies at gestational age >/=32 weeks with twin A presenting as a vertex and eligible for vaginal delivery were reviewed. Excluded were 40 (4.1%) patients who underwent a repeat and elective cesarean section. All patients who underwent a cesarean section were placed into one of two groups according to the method of delivery of both twins: group 1, cesarean section/cesarean section delivery; and group 2, vaginal/cesarean section delivery. The impact of the following intrapartum factors on the type of delivery were assessed: (1) presentation of the 2nd twin: vertex vs. breech vs. other; (2) experience of the obstetrician: 10 years in practice; (3) multiparity: nulliparous vs. multiparous; (4) incidence of epidural usage; (5) induction vs. spontaneous labor; and (6) difference in fetal weight between twin B and twin A: /= 25% difference. The chi-square statistic was used to compare differences in the incidence of cesarean section between the groups. RESULTS: Total incidence of cesarean section was 266/927 (28.7%). Risk of delivering by a combined vaginal delivery and cesarean section was reduced if the presentation of twin B was vertex or breech (RR: 0.114; 95% confidence interval: 0.049-0.266) or if an epidural was used (RR: 0.380; 95% confidence interval: 0.163-0.883). In twin gestations eligible for vaginal delivery the risk of requiring delivery by cesarean section for both twins is reduced if the presentation of twin B was vertex (RR: 0.782; 95% confidence interval; 0.631-0.968), if an epidural was used (RR: 0.461; 95% confidence interval: 0.375-0.566), or if the birthweight discrepancy was 相似文献   

Twice a cesarean, always a cesarean?

The cesarean delivery rate has quadrupled during the past two decades, resulting in considerable attention focused on alternatives to cesarean birth. One option, vaginal birth after one previous cesarean, has come to be recognized as an acceptable alternative to routine elective repeat cesarean delivery. The purpose of this report was to evaluate whether women with two previous cesareans can safely undergo a trial of labor. Between July 1, 1982 and June 30, 1986, data were collected prospectively on all women with previous cesareans. Those with a known classical incision or a medical or obstetric contraindication to a trial of labor were excluded from an attempted vaginal delivery. During this period, 67,784 patients were delivered, of whom 6250 (9.2%) had had a previous cesarean. Of the 6250 previous-cesarean patients, 1088 (17.4%) had had two previous cesareans; of these, 501 (46%) underwent a trial of labor and 346 (69%) delivered vaginally. Whereas the overall rate of uterine dehiscence was 3%, the rate in those women who attempted a vaginal delivery was 1.8%, versus 4.6% in those who did not. Overall, oxytocin was used in 284 (57%) and was associated with a dehiscence rate of 2.1%, versus 1.4% in the no-oxytocin group. Successful vaginal delivery was related significantly to the use of oxytocin and to a previous vaginal delivery. Trial of labor in patients with two previous cesareans appears to be a reasonable consideration.     

Vaginal birth after cesarean section: results of a multicenter study

Cesarean section is now the most frequently performed major operation in the United States. Nearly one out of every four American babies is delivered by this operation. "Elective repeat" has become the most common indication for cesarean section. Although the safety of vaginal birth after cesarean section has been documented in several recent publications, automatic repeat cesarean section remains the rule in this country. We present one of the largest series of trial of labor ever reported. Of 57,553 live births, 4929 (8.6%) were of women with prior cesarean sections. Among 1776 patients who underwent a trial of labor, 1314 (74%) delivered vaginally. There was no maternal or perinatal mortality related to uterine scar rupture. Thus during the study period 1314 major operations were avoided. We conclude that, for the vast majority of women, allowing a trial of labor is a safe alternative to automatic elective repeat cesarean section.     

Obstetric outcomes after cervical ripening by multiple doses of vaginal prostaglandin E2

AIM: The study was designed to investigate the delivery outcome in women who required vaginal prostaglandin E2 for cervical priming prior to labor induction. MATERIALS AND METHODS: This retrospective cohort study included all singleton term deliveries that required labor induction over a 3-year period. Incidence and indications of obstetric interventions were compared among women who required different doses of vaginal prostaglandin E2 for cervical priming and who had induction by amniotomy and oxytocin infusion. RESULTS: Of 706 deliveries, 411 had favorable Bishop's scores and no vaginal prostaglandin E2 for cervical priming was required (group A); 268 required one or two doses of vaginal prostaglandin E2 for cervical priming (group B); and 27 required three or more doses (group C). The incidence of cesarean section was significantly higher in group C (48.1%) than in group A (19.0%) and group B (16.4%). The difference remained statistically significant when primiparous and multiparous women were analyzed separately. The risk of obstetric intervention was particularly high in primiparous women in group C (58.8% required emergency cesarean section and 23.5% had instrumental delivery). There was an increased frequency of all major indications for cesarean section in group C. CONCLUSION: The risk of emergency cesarean section was higher in women who required more than two doses of vaginal prostaglandin E2 for cervical priming compared to induction by one or two doses of vaginal prostaglandin E2 or by amniotomy and oxytocin infusion. These women should be informed regarding the high risk of intrapartum cesarean section, and the option of alternative methods of induction or elective cesarean section should be made available.     

Failed vaginal birth after a cesarean section: How risky is it?: I. Maternal morbidity

OBJECTIVE: Our purpose was to determine the maternal risks associated with failed attempt at vaginal birth after cesarean compared with elective repeat cesarean delivery or successful vaginal birth after cesarean. STUDY DESIGN: From 1989 to 1998 all patients attempting vaginal birth after cesarean and all patients undergoing repeat cesarean deliveries were reviewed. Data were extracted from a computerized obstetric database and from medical charts. The following three groups were defined: women who had successful vaginal birth after cesarean, women who had failed vaginal birth after cesarean, and women who underwent elective repeat cesarean. Criteria for the elective repeat cesarean group included no more than two previous low transverse or vertical incisions, fetus in cephalic or breech presentation, no previous uterine surgery, no active herpes, and adequate pelvis. Predictor variables included age, parity, type and number of previous incisions, reasons for repeat cesarean delivery, gestational age, and infant weight. Outcome variables included uterine rupture or dehiscence, hemorrhage >1000 mL, hemorrhage >2000 mL, need for transfusion, chorioamnionitis, endometritis, and length of hospital stay. The Student t test and the chi(2) test were used to compare categoric variables and means; maternal complications and factors associated with successful vaginal birth after cesarean were analyzed with multivariate logistic regression, allowing odds ratios, adjusted odds ratios, 95% confidence intervals, and P values to be calculated. RESULTS: A total of 29,255 patients were delivered during the study period, with 2450 having previously had cesarean delivery. Repeat cesarean deliveries were performed in 1461 women (5.0%), and 989 successful vaginal births after cesarean delivery occurred (3.4%). Charts were reviewed for 97.6% of all women who underwent repeat cesarean delivery and for 93% of all women who had vaginal birth after cesarean. Vaginal birth after cesarean was attempted by 1344 patients or 75% of all appropriate candidates. Vaginal birth after cesarean was successful in 921 women (69%) and unsuccessful in 424 women. Four hundred fifty-one patients undergoing cesarean delivery were deemed appropriate for vaginal birth after cesarean. Multiple gestations were excluded from analysis. Final groups included 431 repeat cesarean deliveries and 1324 attempted vaginal births after cesarean; in the latter group 908 were successful and 416 failed. The overall rate of uterine disruption was 1.1% of all women attempting labor; the rate of true rupture was 0.8%; and the rate of hysterectomy was 0.5%. Blood loss was lower (odds ratio, 0.5%; 95% confidence interval, 0.3-0.9) and chorioamnionitis was higher (odds ratio, 3.8%; 95% confidence interval, 2.3-6.4) in women who attempted vaginal births after cesarean. Compared with women who had successful vaginal births after cesarean, women who experienced failed vaginal births after cesarean had a rate of uterine rupture that was 8.9% (95% confidence interval, 1.9-42) higher, a rate of transfusion that was 3.9% (95% confidence interval, 1.1-13.3) higher, a rate of chorioamnionitis that was 1.5% (95% confidence interval, 1.1-2.1) higher, and a rate of endometritis that was 6.4% (95% confidence interval, 4.1-9.8) higher. CONCLUSION: Patients who experience failed vaginal birth after cesarean have higher risks of uterine disruption and infectious morbidity compared with patients who have successful vaginal birth after cesarean or elective repeat cesarean delivery. Because actual numbers of morbid events are small, caution should be exercised in interpreting results and counseling patients. More accurate prediction for safe, successful vaginal birth after cesarean delivery is needed.     

Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital

Objective: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar.

Study design: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother–neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother–neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery.

Results: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p?<?0.05). Mother–neonatal dyads with a failed trial of labor sustained the greatest risk of complications.

Conclusion: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.     

Management trend and safety of vaginal delivery for term breech fetuses in a tertiary care hospital of Karachi, Pakistan.

AIM: To investigate the safety of vaginal delivery for term breech fetuses in a tertiary-care hospital of Pakistan. METHODS: We reviewed the medical records of all live singleton breech deliveries at or beyond 37 weeks of gestation, at the Aga Khan University Hospital, Karachi, from January 1988 to December 1995. RESULTS: Rate of cesarean section increased from 48% (1988) to 74% (1995). Out of 287 subjects, 158 underwent elective cesarean section while 129 received a trial of labor, 77% of which delivered vaginally. There was no neonatal or maternal death. Compared to babies delivered by emergency or elective cesarean section, those delivered vaginally had significantly more neonatal intensive-care unit admissions (none and 5% versus 13%) and higher rates of birth trauma (none and 0.6% versus 7%). However, there was no significant difference in the Apgar score at 5 minutes and the risk of maternal complications by delivery mode. CONCLUSION: Allowing trial of labor to carefully selected mothers can result in vaginal delivery in 77% of the cases. However, the risk of trauma and neonatal intensive-care unit admissions, among vaginal births may favor the decision of elective cesarean section, unless rigorous pre-delivery assessment and conduct of delivery by adequately trained obstetricians is performed.     

Vaginal delivery following previous cesarean section in 1983

In 1983 the question whether or not to perform vaginal delivery following previous cesarean section is again presented to the obstetrical community. Data are presented on 778 patients managed during the decade January 1, 1973 to December 31, 1982. Four hundred seventy-six had scheduled repeat cesarean section on an elective basis. One hundred sixty-five experienced normal vaginal delivery. One hundred thirty-seven failed the attempt and were delivered by cesarean section. The group that delivered vaginally and scheduled elective cesarean section did well. However, in the failed attempt the problems were awesome regardless of indication or number of previous cesarean sections.     

A comparison of the effect of epidural, general, and no anesthesia on funic acid-base values by stage of labor and type of delivery

The effect of epidural anesthesia on neonatal acid-base status, before, during, and after labor, was determined by review of funic blood-gas values from 142 women with normal term pregnancies and normal fetal heart rate patterns. Funic acid-base parameters were compared by type of anesthesia when stratified by mode of delivery (vaginal, cesarean section in the active phase of labor, or elective cesarean section). Use of epidural analgesia for vaginal delivery was associated with significantly longer labor, lower umbilical arterial pH, higher arterial PCO2 and arterial bicarbonate values. In women who had cesarean section in the active phase of labor, use of epidural anesthesia was associated with significantly lower arterial and venous PO2 values when compared with women who received general anesthesia. Patients who had elective cesarean section with epidural anesthesia had funic acid-base values similar to women who had general anesthesia. Epidural analgesia-anesthesia offers no clear advantage to the uncompromised term fetus.