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GUIDELINES FORGUIDELINES FOR
VAGINAL BIRTH AFTERVAGINAL BIRTH AFTERPREVIOUSPREVIOUS
CAESAREAN BIRTHCAESAREAN BIRTHDr .Ashraf Fouda
Egypt - Damietta GeneralHospital
E. mail :
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S.O.G.C.(Society ofObstetricians &Gynecologists ofCanada)
CLINICAL PRACTICE GUIDELINESThis document with articles publishedfromJanuary 1995 to February 2004,
obtained by searching the MEDLINEdatabase using the key words
vaginal birth after C.S.
SOURCE:
July 2004
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BACKGROUND
The most frequentindications for C.S are
previous C.S., dystocia,malpresentation, and non-
reassuring fetal status.The rate of birth by C.S.
and the rate of VBAC tend
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Schell first reportedVBAC in 1923,
describing the successfulvaginal delivery of
infants in mothers withprevious Caesarean
deliveries.
BACKGROUND
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A trial of labour afterC.S. should be
considered in womenwho present for
prenatal care with ahistory of previous
BACKGROUND
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In certain situations, TOLafter C.S. will be
contraindicated and arepeat C.S. will advised,
But in most cases,successful vaginal birth can
be achieved safely for both
BACKGROUND
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Women and their
health-care providerswill need to discuss
the risks and benefitsof VBAC when
planning the birth.
BACKGROUND
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The data obtained is limited by 3
important factors:
First, there are no randomized trials ofTOL versus elective repeat C.S. (ERCS);
Second, adverse maternal or perinataloutcomes are rare and large studypopulations are necessary to observe a
significant difference in maternal andperinatal outcomes; and,
Finally, the womans choice to attempt a
TOL after C.S. is heavily influenced by
BACKGROUND
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TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
The success rate of trial oflabour after Caesarean rangesbetween 50% and85%.
In a study examining 1776women undergoing TOL after
Caesarean, the overall
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Predictors of successful VBACinclude nonrecurring
indication for Caesareanbirth, such as: Malpresentation , Gestational hypertension and
a
Previous vaginal delivery
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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When the previous C.S. was for:
2. Dystocia,
3. Failure to progress, or
4. Cephalopelvic disproportion,
Some studies found the rates ofsuccessful VBAC comparable,
while others reported or
lower-than-expected rates.
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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In 1996, McMahon et al. published areport ofmaternal morbidity in TOLcompared to ERCS from 1986 to 1992.
In an examination of3249 womenundergoingTOL and 2889 womenwho delivered by ERCS, the risk of
major complications (hysterectomy,uterine rupture, and operative injury)was almost doubled in the TOL group
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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Complications like puerperalfever, transfusion and abdominalwound infection were
comparable.When comparing those who had
a successful TOL to those whorequired a repeat Caesareansection after failed TOL, the risks
were greater of operative injury
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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In 1999, Rageth et al. reviewed 17613TOL and 11 433 ERCS deliveries.
The rates ofhysterectomy ,febrile
morbidity and thromboemboliccomplications were less in the TOLgroup than in the ERCS group.
There is less blood loss with asuccessful VBAC and a shorterhospital stay with more rapid
recovery and return to full activity.
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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Rosen et al. also reported that therisk of febrile morbidity is lower in
women who attempt a TOL afterCaesarean and is lowest in thosewho succeed ,compared to ERCS,
But is increased in those whoattempt a TOL and ultimatelydeliver by Caesarean section.
TRIAL OF LABOUR VERSUS
ELECTIVE REPEAT CAESAREAN
SECTION
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An examination of 16 938women who had undergone aCaesarean delivery found
that previous C.S. isassociated with an increasedrisk of:
Ectopic pregnancy, Placenta previa , and
Abruptio placenta
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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A repeat Caesarean
section has beenassociated with anincreased risk of :
Placenta previa and Placenta accreta
in subse uent
TRIAL OF LABOUR VERSUS
ELECTIVE REPEAT CAESAREAN
SECTION
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A meta-analysis
published in 2000demonstrated that the
overall risk ofperinataldeath is increased in
those attempting a TOL .
TRIAL OF LABOUR VERSUS
ELECTIVE REPEAT CAESAREAN
SECTION
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The risks of perinatalmortality and severe
morbidity are directly relatedto uterine rupture .
If uterine rupture occurs,the risk of perinatal mortality
and severe morbidity are
TRIAL OF LABOUR VERSUS ELECTIVE
REPEAT CAESAREAN SECTION
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The risk of suspectedneonatal sepsis is greater
in those attempting a TOLbut appears to be confined
to the group of TOL whofail and require a repeat
Caesarean section .
TRIAL OF LABOUR VERSUS
ELECTIVE REPEAT CAESAREAN
SECTION
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If an ERCS is chosen,
the risk ofrespiratoryproblems in the newbornis increased comparedto those who have a
successful VBAC.
TRIAL OF LABOUR VERSUS
ELECTIVE REPEAT CAESAREAN
SECTION
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CONTRAINDICATIONS TO VAGINAL
BIRTH AFTER CAESAREAN SECTION
1. Previous classical or invertedT uterine scar.
2. Previous hysterotomy ormyomectomy entering theuterine cavity.
3. Previous uterine rupture.
4. The presence of a
contraindication to labour, such
PLANNING A TRIAL OF LABOUR
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PLANNING A TRIAL OF LABOUR
AFTER
CAESAREAN SECTION
The woman and her
health-care provider mustdecide together whetheran appropriate situationexists for considering aTOL after Caesarean.
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DOCUMENTATION OF PREVIOUS
UTERINE INCISION
Documentation of the
location and type ofuterine incision
used during theprevious C.S. is ideal.
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In most cases, this informationcan be obtained by reviewing theoperative record from theprevious surgery.
Other information in this record,
such as the indication for theCaesarean section and theopinion of the previous surgeon,
DOCUMENTATION OF PREVIOUS
UTERINE INCISION
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The fact that the record has beenreviewed and that no
contraindications to a TOL afterCaesarean are present should bedocumented clearly on the
prenatal record.If the record is not available, the
scar is considered unknown.
DOCUMENTATION OF PREVIOUS
UTERINE INCISION
FACILITIES AND
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FACILITIES AND
RESOURCES
A trial of labour after Caesareanis always associated with a risk ofuterine rupture, however small.
For this reason, a TOL afterCaesarean should only be
considered in a hospital whereprovisions for performing animmediate Caesarean section are
available.
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Facilities providing VBACshould have a policy in
place to manage suchladies so that all resources
are mobilized promptly ifan intrapartum emergencyoccurs.
FACILITIES AND
RESOURCES
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Women who live in areaswhere local hospitals cannot
offer immediate C.S. shouldbe offered the opportunity for
transfer to a facility where
this service is available, inorder to permit a TOL after
Caesarean.
FACILITIES AND
RESOURCES
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The members of the teamwho could be called urgently
in the case of an intrapartumcomplication (anaesthesia,
pediatric, and obstetric
services) should be notifiedthat the woman is in hospital
and in labour and their
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MATERNAL MONITORING
The woman planning a TOL afterCaesarean should have appropriatemonitoring in labour.
Progress of labour should beassessed frequently as there is someevidence that prolonged labour isassociated with an increased risk offailure and uterine rupture.
Epidural analgesia is not
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FETAL MONITORING
Continuous electronic fetalmonitoring in labour isrecommended for all womenattempting a TOL after Caesarean.
The most reliable first sign of uterine
rupture is a non-reassuring fetalheart tracing.
This may be sudden in onset and
may not be related to contractions.
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POSTPARTUM
EVALUATION
Routine digital
exploration of theCaesarean section scarpostpartum is notnecessary, except when
signs or symptoms
su est uterine ru ture
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UTERINE RUPTURE
Defined as completeseparation of the
myometrium with or withoutextrusion of the fetal parts
into the maternal peritoneal
cavity requiring emergencyCaesarean delivery or
postpartum laparotomy.
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It is an uncommoncomplication of VBAC,
but is associated withsignificant maternal and
perinatal morbidity andmortality.
UTERINE RUPTURE
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The most common
sign or symptom ofuterine rupture is
non-reassuring fetal heart
rate monitoring
UTERINE RUPTURE
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Other clinical signs include :
2. Cessation of contractions,
3. Loss of the presenting part onvaginal examination,
4. Abdominal pain,
5. Vaginal bleeding,6. Hematuria, or
7. Maternal cardiovascular
instability.
UTERINE RUPTURE
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The type and
location of theprevious uterineincision helps to
determine the risk ofuterine rupture.
UTERINE RUPTURE
UTERINE RUPTURE INCIDENCE
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0.2% to 1.5% in a woman whoattempts labour after a transverselower-uterine-segment incision and
1% to 1.6% after a vertical incisionin the lower uterine segment.
4% to 9% with a classical or T
incision; and for this reason, a TOLafter Caesarean is contraindicatedin these situations.
UTERINE RUPTURE INCIDENCE
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The relative risk of: uterine rupture, maternal morbidity, and perinatal mortality or severe
morbidity
is increased in thoseundergoing a TOL afterCaesarean compared to ERCS,
but that the absolute risk
UTERINE RUPTURE
UTERINE RUPTURE
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The treatment ofsuspected uterine ruptureis immediate laparotomy
after maternal stabilizationand anaesthesia.
Once the fetus isdelivered, maternal
hemorrhage must be
UTERINE RUPTURE
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In 1996, Rozenberg et al.examined
ultrasonographicmeasurement of the lower
uterine segmentsmyometrial thickness 36to 38 weeks gestation as
a predictor of uterine
UTERINE RUPTURE
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If the lower segmentthickness was less than 3.5
mm, the risk of uterinerupture or dehiscence was
11.8%; and themeasurement was greaterthan 3.5 mm, the risk of
UTERINE RUPTURE
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In a follow-up open study,Rozenberg et al. found
that the use of the lower-uterine-segment
measurement helpedclinicians select women fora TOL after Caesarean.
UTERINE RUPTURE
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OXYTOCICS AND
TRIAL OF LABOUR AFTERCAESAREAN SECTION
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Zelop et al. supported
the same conclusionabout the risk of uterinerupture with
augmentation in a 1999study .
AUGMENTATION
AUGMENTATION
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Goetzl et al. examined therelationship between the dose ofoxytocin used and the risk of
uterine rupture in womenundergoing a TOL afterCaesarean.
No significant association wasdetected between exposure to
oxytocin and the risk of uterine
AUGMENTATION
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Careful surveillance of the womanfor progress of labour is required,especially when the diagnosis ofdystocia is being considered.
There are insufficient studies
examining the use of other agents toaugment labour, such asprostaglandins, and their safety in a
TOL after Caesarean.
AUGMENTATION
INDUCTION
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INDUCTION
In 2000, Ravasia et al. reviewed the risk
of uterine rupture in women undergoingan induction TOL after Caesarean.
In 575 women with a previous
Caesarean section, labour was inducedwith:
3. Prostaglandin E2 gel ,
4. Intracervical foley catheter , or5. Amniotomy and/or oxytocin .
Outcomes were compared to those
women undergoing a TOL with
INDUCTION
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The risk of uterine rupture wasnot increased in those who
underwent either
amniotomy/oxytocin or foleycatheter induction,
but was significantly increasedin those who underwent aprostaglandin E2 induction .
INDUCTION
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INDUCTION
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In 2003, Delaney and Young reported
the examination of3746 women with aprior Caesarean delivery who underwenteither induced or spontaneous labour.
They found that induced labour wasassociated with a greater risk of :
Early postpartum hemorrhage(7.3% vs. 5.0%),
Caesarean delivery(37.5% vs. 24.2%), and
Admission to a neonatal intensive care
unit (13.3% vs. 9.4%).
INDUCTION
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There was a trendtowards a higher rate ofuterine rupture, but this
was not statistically
significant (0.7% vs.0.3%).
INDUCTION
INDUCTION
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In another retrospective studyof560 women, the rate ofuterine rupture in women
whose labour was inducedwith :
Oxytocin was 2%,with
Prostaglandin was 2 9%
INDUCTION
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Up to 2001, there was conflictingdata on the risk of induction of
labour with prostaglandin E2.Several other smaller studies
reported that it appeared to besafe, effective, and notassociated with an increased risk
of uterine rupture.
INDUCTION
INDUCTION
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In the largest study published todate, conducted by Lydon-Rochelle et al., the incidence ofuterine rupture was reviewed
retrospectively in 20 095women with a previous C.S. andreported as follows:
Elective repeat C.S. (no labour)0.16%;
Spontaneous labour 0.52% ; Labour induced without
INDUCTION
INDUCTION
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The possibility that the use of oxytocinand/or prostaglandin for induction oflabour in women considering a TOL afterCaesarean may be associated with an
increased risk of uterine rupture and itssequelae must be discussed with thepatient.
The absolute risks of uterine rupture arelow, but the relative risks (especially withthe use of prostaglandin E2 compared to
spontaneous labour) are greater.
INDUCTION
MISOPROSTOL
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MISOPROSTOL
Misoprostol has been proposed as an
effective and economical agent forcervical ripening and induction.
In 1998, Sciscione et al. reported a case
of uterine rupture in a woman with 2previous Caesarean sections aftermisoprostol was administered as a
cervical ripening agent.A number of small series reported a risk
of uterine rupture from 0% to 11.7% withmisoprostol in women undergoing a TOL
MISOPROSTOL
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Blanchette et al. compared
prostaglandin E2 to misoprostol inwomen undergoing induction TOLafter Caesarean and found them tobe equally effective,
But misoprostol was associated with
a higher incidence of uterine rupture(18.8% compared to no ruptures inthe prostaglandin E2 group).
The numbers in all of these studies
MISOPROSTOL
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Until further randomizedstudies are completed,
misoprostol should bediscouraged as a method
of induction or cervicalripening in women withprevious Caesarean
MISOPROSTOL
CERVICAL PREPARATION
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CERVICAL PREPARATION
In situations where delivery is indicated
and the cervix is unfavourable, a TOLafter Caesarean can be considered.
In a cohort study published in 2002,
Ben-Aroya et al. compared womenundergoing a trial of labour afterCaesarean section in 3 situations:
Spontaneous labour (n=1432), Prostaglandin cervical ripening (n=55),
and
Cervical ripening by foley catheter
CERVICAL PREPARATION
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There was a significantly higherrate of dystocia (30.4% vs.11.6%) and repeat Caesarean
sectionin the second stage(49.1% vs. 35.2%) in the foleycatheter group compared to the
control group.There was no difference in the
rate of uterine rupture fetal
CERVICAL PREPARATION
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In a Canadian study published in2004, Bujold et al. compared therate of uterine rupture in 1807women who presented inspontaneous labour,
417 induced with amniotomy withor without oxytocin, and
255 induced with transcervical
foley catheter.
CERVICAL PREPARATION
CERVICAL PREPARATION
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The rate of successful vaginal birthwas :
78% in the spontaneous group,
77.9% in the amniotomy group, and 55.7% in the transcervical foley
group .
However, the rates of uterinerupture did not differ significantly:
1.1%, 1.2%, and 1.6%,
CERVICAL PREPARATION
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These data support theuse of the foley catheter
for cervical ripening ofan unfavourable cervix
in women undergoing aTOL after Caesarean.
CERVICAL PREPARATION
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SPECIAL
CIRCUMSTANCES
MORE THAN ONE PREVIOUS LOW
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.TRANSVERSE C.S
Several authors have assessedthe rate ofsuccessful VBAC andrisk ofuterine rupture in women
with more than one previous lowtransverse Caesarean section.
All indicated success ratesbetween 62% and 89%, anduterine rupture rates between
MORE THAN ONE PREVIOUS LOW
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Unfortunately, the use ofprostaglandins or oxytocin forinduction or augmentation was not
considered.Caughey et al. reported a uterine
rupture rate of 3.7% versus 0.8% in aretrospective review of 134 womenundergoing labour after 2 previous
Caesarean sections.
MORE THAN ONE PREVIOUS LOW
.TRANSVERSE C.S
MORE THAN ONE PREVIOUS LOW
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In the largest study, Miller et al.demonstrated :
A VBAC success rate of 75.3% in1827 women with 2 or moreprevious low transverse
Caesarean sections withA uterine rupture rate of 1.7%
vs. 0.6% in the ERCS group.
TRANSVERSE
CAESAREAN SECTION
MULTIPLE PREGNANCY
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MULTIPLE PREGNANCY
Seven studies have examined atotal of 233 women attemptingVBAC in multiple pregnancy.
All support a trial of VBAC inmultiple pregnancy as being safeand effective,
With success rates of69% to84%, and without increased
maternal or fetal morbidity or
MULTIPLE PREGNANCY
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In one study, uterine dehiscence wasnoted in 1 woman on manualexploration after successful vaginaldelivery of both twins, and notreatment was required.
Each of these studies examined a
small number of women, however;and greater numbers would berequired to detect rare outcomes
such as uterine rupture and maternal
MULTIPLE PREGNANCY
BREECH PRESENTATION
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BREECH PRESENTATION
A large multicentre trial by Hannahet al. demonstrated that a plannedCaesarean birth is associated withbetter perinatal and neonataloutcomes in breech presentation atterm.
This recommendation has beenadopted by the SOGC and wouldtherefore preclude a planned TOL
after Caesarean in women
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External cephalic
version is notcontraindicated in a
woman with aprevious Caesarean
BREECH PRESENTATION
DIABETES MELLITUS
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Coleman et al. examined 156women with GDM and planned
TOL after Caesarean and
compared them to non-GDMwomen attempting TOL afterCaesarean.
They reported that the successrate for VBAC of 64.1% in women
with GDM was lower than the
DIABETES MELLITUS
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A retrospective study of TOL afterCaesarean in women with pre-gestational or gestationaldiabetes found similar results.
Based on these studies,
diabetes mellitus should not beconsidered a contraindication toTOL after Caesarean.
DIABETES MELLITUS
MACROSOMIA
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In a study examining the
outcome of365 women whounderwent a TOL after
Caesarean, giving birth toneonates weighing more than4000 g, Zelop et al.
demonstrated asuccess rate of 60%, withno increase in maternal or fetal
MACROSOMIA
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In 2003, Elkousy et al. reported an
examination of9960 women with aprevious C.S. planning a trial oflabour further stratified by neonatalbirth weights and birth history.
His results indicate that the
likelihood of successful VBACdecreases with increasing birthweight and is lowest in those who
have never had a successful vaginal
MACROSOMIA
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Based on these results,suspected macrosomia is
not a contraindication to aTOL after Caesarean,although it may be
associated with a lowerchance of success.
MACROSOMIA
INTERDELIVERY INTERVAL
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INTERDELIVERY INTERVAL
Four studies haveexamined the
relationship betweenthe inter-delivery
interval and the rate ofsuccessful VBAC and
uterine rupture
INTERDELIVERY INTERVAL
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Esposito et al. examined 23 cases ofuterine rupture and compared themto 127 controls.
There was an increased risk ofuterine rupture with a shortinterpregnancy interval
(
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Shipp et al. reviewed 311 womenwho underwent a TOL afterCaesarean less than 18 months after
their Caesarean section andcompared them to 2098 women whounderwent a TOL after Caesarean
after more than 18 months.The shorter interval was associated
with a 3-fold increase in the
risk of uterine rupture (2 25% vs
INTERDELIVERY INTERVAL
INTERDELIVERY INTERVAL
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In 2002, Bujold et al.reported an observational
study of 1527 womenundergoing a planned TOL
after Caesarean atdifferent intervals from the
index Caesarean delivery
INTERDELIVERY INTERVAL
INTERDELIVERY INTERVAL
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The rates of uterine rupturewere as follows:
36 months, 1%.
INTERDELIVERY INTERVAL
POSTDATISM
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OS S
Three studies have examinedpostdatism and TOL afterCaesarean.
Success rates for VBACafter 40 weeks were
reported from 65% to 73%and were comparable to
success rates for women
POSTDATISM
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Zelop et al. reported that therisk of uterine rupture in a
TOL after Caesarean after 40
weeks was not significantlyincreased when compared to
those who delivered before 40weeks, whether inspontaneous labour or after
ONE- VERSUS TWO-LAYER CLOSUREOF LOW TRANSVERSE
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OF LOW TRANSVERSE
CAESAREAN SECTION
In 1992, Hauth et al. published datacomparing :
Operative time, Endometritis,Transfusion, and Placement of extra hemostatic
sutures in women undergoinguterine closure in 1 layer comparedto 2 layers.
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The only significant difference was inoperative time:
44 minutes with 1-layer
compared to 48minutes with 2-layer closure.
Similar findings were published byOhel et al. in 1996.
The trend shifted in many centres
towards single-layer closure
OF LOW TRANSVERSE
CAESAREAN SECTION
ONE- VERSUS TWO-LAYER CLOSURE OFLOW
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In 1997, Chapman et al. publisheda review of 145 women whounderwent a TOL after Caesarean
after being randomized to either 1-layer or 2-layer closure in theprevious Caesarean section.
They reported no significantdifference in the outcome of the
next pregnancy
LOW
TRANSVERSE CAESAREAN SECTION
- -LOW
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In a 2002 review of 2142 womenwho underwent a TOL afterCaesarean, Bujold et al. noted that
a 1-layer interlocking closure wasassociated with an increased risk ofuterine rupture when compared to a
2-layer closure (3.1% vs.0.5%).
Further study in this area is
TRANSVERSE CAESAREAN SECTION
UNKNOWN SCAR
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All records available or obtainable
describing the womans previous C.S.should be reviewed.
If unavailable, information about thecircumstances of the C.S. will helpdetermine the likelihood of a verticaluterine incision.
The majority of unknown scars willbe lower transverse incisions (92%)
and therefore at low risk for uterine
UNKNOWN SCAR
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If the history suggests a reasonablelikelihood of a classical incision, itwould be prudent to recommend arepeat C.S. ,
But in settings where the history
indicates a high likelihood of lowertransverse uterine incision and thewoman wishes to proceed after
counselling a TOL after
UNKNOWN SCAR
OTHER FACTORS
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Factors such as :
2. Maternal obesity,
3. The presence of postpartum fever afterCaesarean section,
4. Type of suture material,
5. Mllerian duct anomalies, and
6. Maternal age andTheir relationship to the risk of uterine
rupture have been examined in small
studies, but definitive conclusions
:Recommendations:Recommendations
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:Recommendations
Provided there are noProvided there are nocontraindications, a womancontraindications, a woman
with one previous transversewith one previous transverse
L.S.C.S. should be offered aL.S.C.S. should be offered a
trial of labour after C.S. withtrial of labour after C.S. with
appropriate discussion ofappropriate discussion ofmaternal and perinatal risksmaternal and perinatal risks
and benefitsand benefits.)II-2B()II-2B(
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:Recommendations:Recommendations
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The intention of a womanThe intention of a woman
undergoing a TOL after C.S.undergoing a TOL after C.S.
should be clearly stated andshould be clearly stated anddocumentation of the previousdocumentation of the previous
uterine scar should be clearlyuterine scar should be clearly
marked on the prenatalmarked on the prenatalrecord.record.
:Recommendations:Recommendations
)II-2B()II-2B(
:Recommendations:Recommendations
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For a safe labour afterFor a safe labour after
C.S. , the woman shouldC.S. , the woman should
deliver in a hospitaldeliver in a hospitalwhere an immediatewhere an immediate C.S.C.S.
is available.is available.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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The woman and her health-The woman and her health-care provider must be awarecare provider must be aware
of the hospital resources andof the hospital resources andthe availability of obstetric,the availability of obstetric,
anaesthesia, pediatric, andanaesthesia, pediatric, and
operating-room staff.operating-room staff.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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Each hospital should have aEach hospital should have awritten policy in placewritten policy in place
regarding the notificationregarding the notificationand/or consultation for theand/or consultation for the
physicians responsible for aphysicians responsible for a
possible immediatepossible immediate C.S.C.S.
:Recommendations:Recommendations
)III B()III B(
:Recommendations:Recommendations
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Continuous electronicContinuous electronic
fetal monitoring offetal monitoring of
women attempting awomen attempting aTOL afterTOL after C.S.C.S. isis
recommended.recommended.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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Suspected uterine ruptureSuspected uterine rupturerequires urgent attentionrequires urgent attention
and expedited laparotomyand expedited laparotomyin order to attempt toin order to attempt to
decrease maternal anddecrease maternal and
perinatal morbidity andperinatal morbidity and
mortality.mortality.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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OxytocinOxytocinaugmentation is notaugmentation is not
contraindicated incontraindicated inwomen undergoing awomen undergoing a
TOL afterTOL after C.S.C.S.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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Medical induction of labourMedical induction of labourwith oxytocin may bewith oxytocin may be
associated with anassociated with anincreased risk of uterineincreased risk of uterine
rupture and should be usedrupture and should be used
carefully after appropriatecarefully after appropriate
counselling.counselling.
:Recommendations:Recommendations
)II-2B()II-2B(
:Recommendations:Recommendations
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Medical induction of labourMedical induction of labourwith prostaglandin E2with prostaglandin E2
(dinoprostone) is associated(dinoprostone) is associatedwith an increased risk ofwith an increased risk of
uterine rupture and should notuterine rupture and should not
be used except in rarebe used except in rarecircumstances aftercircumstances after
appropriate counselling.appropriate counselling.
:Recommendations:Recommendations
)II-2B()II-2B(
:Recommendations:Recommendations
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Prostaglandin E1Prostaglandin E1(misoprostol) is associated(misoprostol) is associated
with a high risk of uterinewith a high risk of uterinerupture and should not berupture and should not be
used as part of a TOL afterused as part of a TOL after
C.S.C.S.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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A foleys catheterA foleys cathetermay be used safely tomay be used safely to
ripen the cervix in aripen the cervix in awoman planning awoman planning a
TOL afterTOL after C.S.C.S.
:Recommendations:Recommendations
)II-2A()II-2A(
:Recommendations:Recommendations
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The available data suggestThe available data suggestthat a trial of labour inthat a trial of labour in
women with more than onewomen with more than oneprevious C.S.previous C.S.is likely to beis likely to besuccessful but is associatedsuccessful but is associated
with a higher risk of uterinewith a higher risk of uterinerupture.rupture.
:Recommendations:Recommendations
)II-2B()II-2B(
:Recommendations:Recommendations
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Multiple gestation isMultiple gestation is
not a contraindicationnot a contraindicationto a TOL afterto a TOL after
Caesarean.Caesarean.
:Recommendations:Recommendations
)II-2B()II-2B(
:Recommendations:Recommendations
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Diabetes mellitusDiabetes mellitusis not ais not a
contraindication tocontraindication toTOL after C.S.TOL after C.S.
:Recommendations:Recommendations
(II-2B)(II-2B)
:Recommendations:Recommendations
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Suspected fetalSuspected fetal
macrosomia is not amacrosomia is not a
contraindication to acontraindication to a
TOL after Caesarean.TOL after Caesarean.
:Recommendations:Recommendations
(II-2B)(II-2B)
:Recommendations:Recommendations
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Women deliveringWomen deliveringwithin 18 to 24within 18 to 24
months of a C.S. shouldmonths of a C.S. shouldbe counseled about anbe counseled about an
increased risk of uterineincreased risk of uterinerupture in labour.rupture in labour.
:Recommendations:Recommendations
(II-2B)(II-2B)
:Recommendations:Recommendations
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Postdatism is notPostdatism is not
aacontraindication tocontraindication to
a TOL aftera TOL after
CaesareanCaesarean
:Recommendations:Recommendations
(II-2B)(II-2B)
:Recommendations:Recommendations
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Every effort should beEvery effort should bemade to obtain themade to obtain the
previous Caesarean sectionprevious Caesarean sectionoperative report tooperative report to
determine the type ofdetermine the type ofuterine incision used.uterine incision used.
(II-2B)(II-2B)
:Recommendations:Recommendations
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In situations where the scar isIn situations where the scar is
unknown, informationunknown, informationconcerning the circumstances ofconcerning the circumstances of
the previous delivery is helpful inthe previous delivery is helpful indetermining the likelihood of adetermining the likelihood of a
low transverse incision.low transverse incision.
If the likelihood of a lowerIf the likelihood of a lowertransverse incision is high, TOLtransverse incision is high, TOL
after Caesarean can be offeredafter Caesarean can be offered.
(II 2B)(II 2B)
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