Association between prior vaginal birth after cesarean and subsequent labor outcome

Objective: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean.

Methods: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007–2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes.

Results: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p?=?.036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p?p?=?.04).

Conclusions: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.     

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Abstract

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.

Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.

Results: Overall, 33?925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.

Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.     

Does vaginal preparation with povidone–iodine prior to caesarean delivery reduce the risk of endometritis? A randomized controlled trial

Objective: The purpose of the present study was to determine whether the vaginal preparation with povidone–iodine prior to caesarean delivery decreased the incidence of postpartum endometritis. Methods: The present study was a prospective randomized controlled trial in which subjects received a vaginal preparation with povidone–iodine solution immediately prior to caesarean delivery or received no vaginal preparation. The primary outcome measure was the rate of postpartum endometritis. Results: A significant decrease in post-caesarean endometritis was noted in the group that received the povidone–iodine vaginal preparation (n = 334) compared with the control group (n = 336) [6.9 vs. 11.6%; RR = 1.69; 95% CI = 1.03–2.76]. No statistically significant differences in the incidence of endometritis were noted between the experimental and control groups among women who were not in labor at the time of the caesarean delivery [9.2 vs. 8.6%; RR = 1.05; 95% CI = 0.58–1.90], and no differences were found between groups when women with ruptured membranes were excluded from the analysis [9.6 vs. 6.7%; RR = 1.39; 95% CI = 0.78–2.47]. Conclusions: Vaginal preparation with povidone–iodine solution immediately prior to a caesarean delivery reduces the risk of post-operative endometritis. This preemptive measure was only found to be beneficial in women whose membranes had ruptured and those who were in labor prior to caesarean surgery.     

Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands

OBJECTIVE: To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. MATERIALS AND METHODS: During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. RESULTS: There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2-14.3, OR 4.8, 95% CI 1.6-14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04-5.0). CONCLUSION: The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin.     

Induction of labour after a previous caesarean section: a retrospective study in a district general hospital.

A retrospective study was undertaken in a district general hospital to identify factors associated with vaginal delivery, as opposed to caesarean section, in women undergoing induction of labour after a previous caesarean section. The study was undertaken over 9 years (April 1994 - May 2003) and included patients in their second or subsequent pregnancy who had previously had one lower segment caesarean delivery and in whom labour had been induced. Records were extracted from a database and anonymised. Vaginal delivery after induction of labour was attempted in 81 patients of whom 64 (79.0%) subsequently delivered vaginally. There were few complications and no cases of uterine rupture. Two factors had a statistical significant relationship with vaginal birth after induction of labour; occipito-anterior position (OR 10.18, 95% CI 1.42 - 112.7, Yates corrected chi2; p = 0.001) and more than one previous birth (OR 4.76, 95% CI 1.28 - 21.67, p = 0.017). Other associations were explored but were not statistically significant. This paper contributes to the literature on factors associated with vaginal delivery after induction of labour and previous caesarean section, which may inform the selection of cases, and consequent success rates for vaginal delivery.     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Is gestational age an independent variable affecting uterine scar rupture rates?

OBJECTIVE: To evaluate the influence of gestational age on uterine scar rupture. METHODS: This was a population-based study of data from Cardiff Births Survey over a 10-year (1990-1999) period. Women with only one previous lower segment caesarean section with singleton uncomplicated pregnancy of 37 or more week's gestation, undergoing trial of vaginal delivery were included. SPSS version 10 was used for statistical analysis. Mann-Whitney, Fisher's exact test and Chi-square tests were used wherever appropriate. Odds ratio (OR) with confidence intervals (CI) was used to quantify the risk. Potential confounding by other factors was controlled using logistic regression and corrected odds ratios with 95% confidence intervals were calculated. The data was analysed separately for induced and spontaneous labours. Primary outcome measure assessed was uterine scar rupture rate. Secondary outcome measures were repeat caesarean section rates, maternal and perinatal mortality and morbidity. RESULTS: Total sample number was 1620. Eighty percent (n = 1301) of the population went into spontaneous labour and 20% (n = 319) were induced. Successful trial of vaginal birth was accomplished in 60% and trial of scar after estimated date of delivery did not alter this outcome significantly (39.1% versus 43.6%, p > 0.05). We noted an overall scar rupture rate of 0.9% (n = 14) and caesarean section rate of 40.4% (n = 654). Scar rupture rates significantly increased in women who underwent trial of labour after estimated date of delivery (p < 0.001, OR 6.3, CI 1.9-20.2) without a corresponding increase in caesarean section, maternal and perinatal morbidity figures. The influence of gestational age on scar rupture persisted even after controlling for other confounding factors such as birth weight, induction of labour and BMI (corrected OR 1.9, CI 1.1-3.5). CONCLUSIONS: The overall incidence of scar rupture and success of trial of scar after previous caesarean section in our population was similar to that quoted in the literature. Previous evidence has suggested that it is safe for these women to exceed 40 weeks gestation but our data do not support this.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Outcome of subsequent delivery after a previous early preterm cesarean section.

OBJECTIVE: To determine the vaginal birth after cesarean section (VBAC) rate and risk of uterine rupture in women with a previous early preterm cesarean section. METHODS: Women who delivered their first child by cesarean section between 26 and 34 weeks of gestation were included in a retrospective cohort study. Medical charts were reviewed for characteristics of the index pregnancy and delivery. Information of the subsequent delivery was obtained from the medical charts or from information of the attending gynecologist if the delivery was elsewhere. RESULTS: Two hundred and forty-six women were included: 131 (53.3%) women had a subsequent pregnancy, 64 (26.0%) had no subsequent pregnancy, and from 51 (20.7%) women no information could be obtained. Of the 131 women with a subsequent pregnancy, 93 (71.0%) underwent a trial of labor (TOL) and 80 (86.0%) achieved a vaginal delivery, resulting in a VBAC rate of 61.1%. One uterine rupture occurred with favorable neonatal outcome. The uterine rupture rate for the whole cohort was 0.8% (95% CI 0.02-4.0) and for the group of women undergoing a TOL 1.1% (95% CI 0.03-5.8). CONCLUSION: In this small series of women with a previous early preterm cesarean section the VBAC rate was high (61.1%) and the uterine rupture rate was 1.1%.     

Introducing routine trial of labour after caesarean section in a second level hospital setting

Objective: We analysed the impact on caesarean section (CS) rate of introducing a routine trial of labour (TOL) for patients with a previous CS. Study design: During 2007 and 2008, we offered a TOL to all women with one previous CS planning to give birth in our hospital. The adherence to the procedure, success of vaginal delivery, overall CS rate, incidence of symptomatic uterine rupture and other complications were evaluated. Labour induction was allowed only using castor oil or Amniotomy. Results: One hundred and ninety-four women were considered eligible for TOL. A total of 87.6% of them agreed to undergo the procedure (78.7% in the first year versus 95.2% in the second year, p?<?0.05). Of these, 63.5% delivered successfully (42.3% in the first year versus 78.8% in the second year, p?<?0.05); 10.6% underwent a primary CS because of failed spontaneous labour or failed labour induction and 25.9% a secondary CS during labour. The CS rate decreased significantly from 19.6% (in 2003–2006) to 14.9% (iN 2007–2008) (p?<?0.05). One case of symptomatic uterine rupture occurred, while no difference for other complications was observed. Conclusions: The CS rate decreased dramatically through introducing a TOL programme for patients with one previous CS. The possibility of symptomatic uterine rupture should be however considered and patients adequately informed.     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

Risk factors for emergency caesarean section in planned vaginal breech delivery

Purpose

To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term.

Methods

Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared.

Results

Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09–3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87–4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04–1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003–2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58–83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort.

Conclusions

Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.

     

Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor

OBJECTIVE: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery. STUDY DESIGN: The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had > or =1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. RESULTS: Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. CONCLUSION: Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.     

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.     

Pregnancy outcome of patients following deep venous thrombosis

Objective. To investigate pregnancy outcome of patients with a history of deep vein thrombosis (DVT).

Methods. A population-based study comparing all pregnancies of patients with and without a history of DVT was conducted. Deliveries occurred during the years 1988–2007 at a tertiary Medical Center. Stratified analyses were performed using multivariable logistic regression models and the Mantel-Haenszel technique.

Results. During the study there were 212,086 deliveries, of which 122 (0.06%) occurred in patients with a history of DVT. Using a multivariate analysis, with backward elimination, the following conditions were significantly associated with DVT: advanced maternal age (OR, 1.1; 95% CI, 1.02–1.1; p = 0.004), chronic hypertension (OR, 2.9; 95% CI, 1.4–6.0; p = 0.005) and previous caesarean delivery (OR, 2.8; 95% CI, 1.9–4.1; p < 0.001). Patients with a history of DVT were more likely to have caesarean deliveries (OR, 2.6; 95% CI, 1.8–3.8; p < 0.001) than non-DVT patients. After controlling for possible confounders, such as maternal age, hypertensive disorders, pregestational diabetes and multiple gestations, by using another multivariate analysis with preterm delivery (<37 weeks' gestation) as the outcome variable, DVT was found to be an independent risk factor for preterm birth (OR, 1.8; 95% CI, 1.1–2.9; p = 0.033). This association remained significant after controlling for labor induction, using the Mantel-Haenszel technique (OR, 1.8; 95% CI, 1.1–3.0; p = 0.011). No significant differences were noted between the groups regarding perinatal outcomes such as low Apgar scores, congenital malformations or perinatal mortality.

Conclusions. A history of DVT is an independent risk factor for spontaneous preterm delivery. Nevertheless, in our population it is not associated with adverse perinatal outcome.     

Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

BACKGROUND: The issues related to safety of induction of labour in women with previous caesarean section remain controversial. The main adverse outcome fuelling this debate is a "small" risk of uterine rupture that is potentially devastating for both the mother and the fetus. OBJECTIVE: To estimate the risk of uterine rupture or dehiscence in women who require induction of labour with previous caesarean sections. DESIGN: Five year retrospective review of computerised hospital records and case note review of index cases. SETTING: Large inner city teaching hospital. POPULATION: Two hundred and five women who had their labour induced with history of one lower segment caesarean section. METHODS: This study was conducted at Liverpool Women's Hospital, a tertiary referral centre, with approximately 6000 births per annum. We searched the hospital's computerised records of deliveries from June 1997 to June 2002 and reviewed all indications and outcomes of induction of labour in women with one previous caesarean section. Women with singleton pregnancy and cephalic presentation were then divided into three groups: those with one previous caesarean section and no previous vaginal deliveries, those whose last delivery was a caesarean section but had delivered vaginally before and those whose last delivery was by vaginal route, but had had one caesarean section in the past. MAIN OUTCOME MEASURES: Uterine rupture or dehiscence, adverse neonatal outcome. RESULTS: Two hundred and five women were included. There were four cases of uterine rupture and one dehiscence (2.4%, 95% CI 0.8-5.6%). Two babies were profoundly acidotic at birth, but all five neonates were healthy when discharged from hospital with no long term morbidity. All five cases occurred in the group of women with no previous vaginal deliveries. The intrauterine pressure catheter recordings had contributed to the diagnosis of uterine rupture/dehiscence in three out of five cases. CONCLUSION: In women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.     

Induction of labor in women with a uterine scar

Objective: To evaluate the frequency of uterine rupture following induction of labor in women with a previous cesarean section. Misoprostol was compared to other methods of induction.

Methods: A retrospective cohort study of 208 women attempting induction of labor after one previous cesarean section. Delivery data were collected retrospectively and compared. Group 1(2009–2010) was compared with Group 2 (2012–2013). In Group 1, the main method of induction was vaginal PGE₂ (prostaglandin-E₂), amniotomy, oxytocin or a balloon catheter. In Group 2, the dominant method of induction was an oral solution of misoprostol. Main outcome measures: frequency of uterine rupture in the two groups.

Results: Nine cases (4.3%) of uterine rupture occurred. There was no significant difference in the frequency of uterine rupture following the change of method of induction from PGE₂, amniotomy, oxytocin or mechanical dilatation with a balloon catheter to orally administered misoprostol (4.1 versus 4.6%, p?=?0.9). All ruptures occurred in women with no prior vaginal delivery.

Conclusion: The shift to oral misoprostol as the primary method of induction in women with a previous cesarean section did not increase the frequency of uterine rupture in the cohort studied.     

Elective cervical ripening in women beyond the 290th day of pregnancy: a randomized trial comparing 2 dinoprostone preparations

OBJECTIVE: To determine the better performer among cervical ripening agents for the elective induction of labor. STUDY DESIGN: An open-label, randomized study was done in consecutive patients undergoing elective induction of labor at the 41st week and beyond. Inclusion criteria were: singleton pregnancy, gestational age ascertained through first-trimester ultrasound, Bishop score <4 and nulliparity. Exclusion criteria were: oligohydramnios, maternal/fetal disorder or pregnancy complication, previous uterine surgery, rupture of membranes and presence of uterine activity. Patients received either slow-release dinoprostone vaginal insert (VI) or 0.5-mg dinoprostone intracervical (IC) gel, twice, 6 hours apart. RESULTS: Women receiving VI showed increased risk of entering labor without further stimulation (OR = 6.48, 95% CI 2.06-21.67, p < 0.001) and delivering vaginally within 24 hours (OR = 2.71, 95% CI 1.19-6.21, p = 0.01) in comparison to those receiving IC gel. A stay in the hospital (> 4 days) was more prevalent in women treated with IC gel in comparison to those treated with VI (OR = 2.35, 95% CI 1.04-5.37). CONCLUSION: Preinduction cervical ripening with the dinoprostone slow-release vaginal insert is associated with a hight rate of women undergoing vaginal delivery within 24 hours, with a shorter stay. Considering its good performance, the dinoprostone slow-release vaginal insert is the first choice for elective induction of labor in postdate pregnancy.     

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.     

Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden

Objective  Uterine rupture is a rare but a catastrophic event. The aim of the present study was to explore the risk factors for uterine rupture and associated neonatal morbidity and mortality among a cohort of Swedish women attempting vaginal birth in their second delivery.
Design  Population-based cohort study.
Setting  Sweden.
Population  A total of 300 200 Swedish women delivering two single consecutive births between 1983 and 2001.
Methods  Swedish population-based registers were used to obtain information concerning demographics, pregnancy and birth characteristics, and neonatal outcomes. Logistic regression was used to analyse potential risk factors for uterine rupture and risk of neonatal mortality associated with uterine rupture. Odds ratios were used to estimate relative risks using 95% CI.
Main outcome measure  Uterine rupture and neonatal mortality in the second pregnancy.
Results  Compared with women who delivered vaginally in their first birth, women who underwent a caesarean delivery were, during their second delivery, at increased risk of uterine rupture (adjusted OR 41.79; 95% CI 29.73–57.00). Induction of labour, high (≥4000 g) birthweight, postterm (≥42 weeks) births, high (≥35 years) maternal age, and short (≤164 cm) maternal stature were also associated with increased risk of uterine rupture. Uterine rupture was associated with a substantially increased risk in neonatal mortality (adjusted OR 65.62; 95% CI 32.60–132.08).
Conclusion  The risk of uterine rupture in subsequent deliveries is not only markedly increased among women with a previous caesarean delivery but also influenced by induction of labour, birthweight, gestational age, and maternal characteristics.