|
Author
|
Topic: Emergency C vs planned C
|
<Tasha>
unregistered
|
posted 14 February 2006 06:37 AM
Gee I appreciate all the information given to me and comments have been priceless, thankyou. It seems that now I am also considering not just vbac versus planned C but also taking into account the damages that can be caused by emergency C as opposed to planned C. That is why I was worried when my doctor said yeterday that he thought I wouldn't dialate this birth since I didn't last time and if i was his wife he'd book in for a planned C to avoid complications of emergency C. I will continue to read up on it all, neither options are completely rosy, does anyone have a magic ball, it would be much easier to make a decission if you knew you would be able to deliver vaginally wouldn't it. AHHH, well back to learning how to teach high school kids history and english. thankyou again everybody. Sometimes people are so afraid to give info or opinions and you find yourself with no direction to launch original ideas from. It is nice for people to be upfront with ideas, opinions and plain old info and statistics to begin from.
|
|
<Tasha>
unregistered
|
posted 14 February 2006 06:43 AM
woops I meant to put that last message in the ongoing discussion of advantages of vbac but started a new topic by mistake, good one.
|
|
JenBen
Member
Member # 520
Rate Member
|
posted 14 February 2006 10:11 AM
Hi Tasha,
my understanding is that while an emergency c-section is more dangerous then a elective one a VBAC statistically has less morbidity then both. To get a handle on the statistics and a overview of the different studies I would recommned you check out the article in the Birthrites Magazine info (link on the right) called Uterine Rupture by Debra ???? (sorry memory fails me!) I found this article really enlightening because the risk of Uterine Rupture is really overstated. An example is that in many studies the 0.5 - 1% that we hear about takes into account the much more common uterine dyhescencene - I have mispelt that but basically the are small harmless holes which often do not go all the way through the uterine wall.Also women with no uterine scar at all are still at small risk of rupture, the risk for a women with a c-section scar is the same as a women who has had an abortion and many other interesting comparisons.
It comes down to statistics can be misrepresented to control people into taking the path which others want. Doctors bang on about Uterine rupture and yet never mention other complications which are statistically more common.
Regarding your other post on dilation, my understanding is that there are many factors affecting dilation rate, one of the most important is the position of the baby. If a baby is posterior (for example) they are not pressing on the part of the cervix which triggers labour. This has no bearing on what may happen next time. I really would listen to a GP about this type of stuff, it is not thier area and a lot of them have really odd and out of date ideas. An ob. or a midwife would be a better person to talk to.
cheers Jennie
Posts: 43 | From: perth | Registered: Sep 2005
|
|
JenBen
Member
Member # 520
Rate Member
|
posted 14 February 2006 10:13 AM
Sorry - I meant I really would NOT listen to a GP. Typing too fast again.... Jennie
Posts: 43 | From: perth | Registered: Sep 2005
|
|
JenBen
Member
Member # 520
Rate Member
|
posted 14 February 2006 10:29 AM
Hi Tasha,
I just checked my email and one of the c-aware email group had emailed us this new study on the compparisons between VBAC, planned c-section and emergency c-section.
cheers Jennie
Ovid Technologies, Inc. Email Service
------------------------------
Results: Obstetrics & Gynecology
(C) 2006 The American College of Obstetricians and Gynecologists
Volume 107(2, Part 1), February 2006, pp 240-245
Results of a Well-Defined Protocol for a Trial of Labor After Prior
Cesarean
Delivery
[Original Research]
Gonen, Ron MD1; Nisenblat, Victoria MD1; Barak, Shlomi MD1; Tamir, Ada
DSc2;
Ohel, Gonen MD1
>From the Departments of 1Obstetrics and Gynecology, Bnai Zion Medical
Center;
and 2Community Medicine and Epidemiology, Faculty of Medicine,
Technion,
Haifa,
Israel.
Corresponding author: Ron Gonen, MD, Deputy Chief, Department of
Obstetrics
and
Gynecology, Director of Maternal-Fetal Medicine, Bnai Zion Medical
Center,
47
Golomb Street, Haifa 31048, Israel; e-mail: rongon@bezeqint.net.
----------------------------------------------
Outline
Abstract
PATIENTS AND METHODS
RESULTS
DISCUSSION
REFERENCES
Graphics
Table 1
Table 2
Table 3
Abstract
OBJECTIVE: It has been claimed that a trial of labor after cesarean
carries
higher maternal and fetal risks than planned cesarean delivery. Because
the
management of such patients in our department differs from that
described in
some studies, and is perhaps more cautious, we hypothesized that the
outcome
may
be better.
METHODS: We identified women with 1 previous low uterine segment
cesarean
who
had delivered a cephalic singleton infant at gestational age 34 weeks
or
more
from January 2000 through May 2005. Our policy is to encourage such
women to
undergo a trial of labor unless cesarean delivery is indicated. Unless
otherwise
indicated, our policy is to wait for spontaneous labor. We do not use
prostaglandins,
and recommend cesarean delivery if the cervix is unripe.(Bishop score
RESULTS: A trial of labor was attempted by 841 women (80% successful),
and
467
underwent planned cesarean delivery. Uterine rupture was observed in 1
woman
18
hours after vaginal delivery. There was no difference in major or minor
maternal
morbidity. There was no serious neonatal morbidity. Among the planned
cesarean
patients, hospital stay was longer, and there were more admissions to
the
neonatal intensive care unit.
CONCLUSION: With our well-defined protocol, a trial of labor after
cesarean
seems to be as safe for the mother and infant as planned cesarean
delivery,
and
the hospital stay is shorter.
LEVEL OF EVIDENCE: II-2
----------------------------------------------
The overall rate of cesarean delivery in the United States has risen
dramatically,
from 5% of all deliveries in 1970 to a high of 26% in 2002.1 A similar
pattern
has been observed in Israel, with a national rate of cesarean
deliveries in
2004
of approximately 20%. A major reason for this increase in the rate of
cesarean
deliveries is the concomitant dramatic decline in the rate of vaginal
birth
after cesarean (VBAC). This decline may be attributed to several large
reports
from the United States showing an increase in the frequency of maternal
and
perinatal morbidity associated with a trial of labor after cesarean as
compared
with planned cesarean delivery. In the study by McMahon et al,2 major
maternal
complications were almost twice as likely among those whose deliveries
were
managed with a trial of labor as among those who had undergone an
elective
cesarean delivery. This was so because the rate of cesarean delivery in
the
women who attempted a trial of labor was 40%, and major complications
were
substantially more frequent than for women who had a second cesarean
delivery
without a trial of labor. Lydon-Rochelle et al,3 in a population-based,
retrospective cohort analysis in Washington State, concluded that for
women
with
1 prior cesarean delivery, the risk of uterine rupture is higher among
those
whose labor is induced with either prostaglandins or oxytocin than
among
those
with either spontaneous labor or repeated cesarean delivery without
labor.
In
the study by Landon et al,4 which reports the results of a prospective
cohort
study at 19 medical centers belonging to the National Institute of
Child
Health
and Human Development Maternal-Fetal Medicine Units Network, the most
significant
result was that a trial of labor after prior cesarean delivery is
associated
with greater perinatal risk than is elective repeated cesarean delivery
without
labor. This was so because the frequency of hypoxic-ischemic
encephalopathy
was
significantly greater among the infants of women who underwent a trial
of
labor
than among women who had elective repeated cesarean delivery.
Because we observed that the management of parturients with previous
cesarean
delivery in our department differs substantially from that described in
the
above-mentioned studies, we hypothesized that the maternal and
perinatal
outcome
may also be different, and possibly better, because our approach seems
to be
more conservative or more cautious. The aim of the present
investigation was
to
assess the risks of maternal and perinatal morbidity associated with a
trial
of
labor as compared with repeated planned cesarean delivery in our
institution.
PATIENTS AND METHODS
We performed a retrospective cohort study from January 2000 through May
2005
in
our institution, the Bnai Zion Medical Center, a level 3 university
hospital
mainly serving the urban population of the city of Haifa, Israel. The
study
was
approved by the Institutional Review Board. The annual number of
deliveries
is
approximately 4,500, and the cesarean delivery rate during the study
period
increased gradually from 17% in the year 2000 to 20.1% in 2004. In our
system,
the deliveries are conducted by certified midwives, supervised by
residents,
staff obstetricians, and maternal-fetal medicine specialists. Our
service
provides full in-house coverage of at least 3 obstetrics and gynecology
residents, with staff obstetricians and maternal-fetal medicine
specialists
either in house or on call. The operating room and neonatal intensive
care
unit
(NICU) are adjacent to the delivery rooms. We also have 24-hour,
in-house
coverage of a neonatologist, at least 2 anesthesiologists, a blood bank
service,
and an intensive care unit, as well as readily available consultants
from
the
various departments of the hospital.
Our policy is to encourage all women with a prior single, low-segment
cesarean
delivery and a singleton cephalic gestation to undergo a trial of labor
unless
repeated cesarean delivery is indicated. Women are counseled regarding
the
risks
and benefits of a trial of labor compared with elective cesarean
delivery.
We
usually quote a VBAC success rate ranging between 60-80%, the higher
figure
for
women with previous VBAC or previous vaginal delivery, the lower figure
for
women who had dystocia as the indication for the primary cesarean
delivery.5
Breech presentation, estimated fetal weight of more than 4,000 g,
(based on
clinical and ultrasonic evaluation), unknown uterine scar, low vertical
incision, inverted T incision, or any other uterine scar, as well as
the
patient's request are considered indications for repeat planned
cesarean
delivery. In the absence of maternal or fetal indication, our policy is
to
wait
for spontaneous labor or until 42 weeks. Whenever delivery is
indicated, we
consider induction only in the face of a ripe cervix (Bishop Score >
6), and
prefer amniotomy to oxytocin. However, we do not use prostaglandins or
Foley
catheter, and recommend cesarean delivery if the cervix is unripe. We
use
oxytocin to augment labor when necessary. (Starting at 1.6 mU/min, with
increments of 1.6 mU every 30 minutes until regular contractions, 3-4
per 10
minutes, are achieved or a maximal rate of 20 mU/min is reached.) At
admission,
all patients are evaluated and examined by an obstetrics and gynecology
resident, who assesses whether they comply with our requirements for a
trial
of
labor. Upon admission, 1 unit of packed blood cells is prepared at the
blood
bank, and intravenous infusion is started. Once in active labor, all
patients
are on continuous fetal monitoring. Epidural analgesia is provided upon
the
patient's request. We do not perform routine manual exploration of the
uterine
cavity after successful VBAC.
The study included all women who had had 1 prior low-segment cesarean
delivery
and with a singleton pregnancy at 34.0 gestational weeks or more. The
medical
records for each woman were reviewed by 1 of the authors (V.N.).
Demographic
data, details of the obstetric history, and information about
intrapartum
and
postpartum events were recorded. Neonatal data were collected up to
discharge on
all infants who were admitted to the NICU. Maternal and perinatal
outcomes
were
compared between women who had a trial of labor and those who underwent
planned
repeated cesarean delivery.
Uterine rupture was defined as a disruption or tear of the uterine
muscle
and
visceral peritoneum or a separation of the uterine muscle with
extension to
the
bladder or broad ligament. Uterine dehiscence was defined as a
disruption of
the
uterine muscle with intact serosa. Febrile morbidity was defined as a
temperature
of 38.0[degrees]C or more on at least 2 occasions at least 6 hours
apart,
excluding the first 24 hours after delivery. Major maternal
complication was
defined as the occurrence of 1 or more of the following: uterine
rupture,
hysterectomy, re-laparotomy, operative injury (bladder, bowel,
extension of
uterine excision to the cervix or to the broad ligament), transfusion
of 2
or
more units of blood. Minor maternal complications were defined as the
occurrence
of 1 or more of the following: maternal febrile morbidity, wound
infection,
uterine scar dehiscence, transfusion of 1 unit of blood.
All analyses were performed using the SPSS 11.5 statistical software
(SPSS
Inc.,
Chicago, IL). A [chi]2 test (Fisher exact test was used when
appropriate)
was
used to examine differences between groups in categorical variables,
and t
test
(Mann-Whitney test when appropriate) was used for continuous variables.
Logistic
regression was performed to adjust comparison of morbidity rate for
potential
confounder or modifier variables. A P value less than 0.05 was
considered
significant.
RESULTS
There were 23,705 births during the study period. Among the 1,376
(5.8%)
women
who had a singleton gestation and a history of 1 cesarean delivery, 68
were
less
than 34 weeks and were thus excluded. Of the remaining 1,308 women, 841
(64%)
underwent a trial of labor, and 467 (36%) had a planned cesarean
delivery.
Among
women undergoing a trial of labor, labor was induced with oxytocin or
amniotomy
in 60 (7.1%) parturients and augmented with oxytocin in 128 (15.2%).
The
indications for planned cesarean delivery were: unknown uterine scar in
30
women
(6.4%), postmyomectomy in 6 (1.3%), breech presentation in 76 (16.3%),
suspected
macrosomia in 89 (19.1%), need for induction with unfavorable cervix in
62
(13.3%), various obstetric indications in 19 (4.1%), maternal request
in 177
(37.9%), and other indications in 8 (1.7%). The overall success rate
for
vaginal
delivery was 79.7% (670 of 841 women, 95% confidence interval [CI]
76.9-82.4).
The demographic and perinatal characteristics of women and infants in
the 2
groups are presented in Table 1. Compared with women who underwent
planned
repeated cesarean delivery, women who underwent a trial of labor were
more
likely to be less than 35 years old, to be of higher parity, and to
have a
history of prior successful vaginal birth after cesarean. Women
undergoing
planned cesarean delivery were delivered at an earlier gestational age
and
were
more likely to have 1 or more pregnancy complication.
----------------------------------------------
Table 1. Demographic and Perinatal Characteristics of Women
Undergoing
a
Trial of Labor or Planned Cesarean Delivery After Prior Cesarean
Delivery
----------------------------------------------
Maternal complications are presented in Table 2. There was only 1 case
of
uterine rupture among 841 women who attempted vaginal delivery after
cesarean, a
rate of 1.2 (95% CI 0-6.6) per 1,000. The rupture was diagnosed 18
hours
after
successful vaginal delivery. This patient had a normal postdelivery
course
for
approximately 16 hours when she became hypotensive. Hematologic studies
showed a
fall in hematocrit and ultrasound examination revealed a large hematoma
within
the left broad ligament in addition to moderate amount of free fluid in
the
peritoneal cavity. At the laparotomy, a 4-cm-long rupture of the left
uterine
wall was diagnosed. The uterus was sutured and the patient had an
uneventful
postoperative course. One patient underwent hysterectomy after planned
cesarean
delivery due to placenta accreta. Relaparotomy was necessary in 1 woman
after
planned cesarean delivery and in 2 women after a failed trial of labor.
In
all 3
cases, the indication for laparotomy was postpartum hemorrhage
intractable
to
conservative management Overall, the rate of major complications was
1.3%
(95%
CI 0.3-2.31) among women undergoing planned cesarean delivery compared
with
1.8%
(95% CI 0.9-2.7) among women attempting vaginal delivery after cesarean
(P =
.50). In the latter group, all but 2 of the major complications
(uterine
rupture
and transfusion of > 2 units of blood), were associated with failed
VBAC.
Consequently, all of the operative injuries were diagnosed and treated
during
the operation. Likewise, the rate of minor complications was similar in
the
2
groups. The only significant difference between the 2 groups was
shorter
hospital stay among women undergoing a trial of labor after cesarean.
Nevertheless,
for minor complications, logistic regression analysis revealed
significant
interaction between the group and previous vaginal delivery.(P = .045)
Therefore, we analyzed for each subgroup separately. Only among women
without a
previous vaginal delivery, a trial of labor after a cesarean was
associated
with
a significantly higher rate of minor complications, compared with
planned
repeated cesarean delivery, 7.2% compared with 3.6% (P = .03, odds
ratio 2,
95%
CI 1.05-4.04).
----------------------------------------------
Table 2. Maternal Complications
----------------------------------------------
There were no neonatal deaths, and none of the infants suffered from
hypoxic-ischemic
encephalopathy. Admission to the NICU was slightly higher, but with
borderline
significance, among infants delivered by planned cesarean delivery
(4.3%
compared with 2.4%, P = .055).
Demographic and perinatal characteristics of women who had a successful
or
failed VBAC are presented in Table 3. Women who had a successful VBAC
were
of
higher parity, were more likely to have had prior vaginal delivery and
prior
successful VBAC, were more likely to be admitted in active labor, and
were
less
likely to need induction.
----------------------------------------------
Table 3. Demographic and Perinatal Characteristics of Women Who
Had a
Successful or Failed Vaginal Birth After Cesarean
----------------------------------------------
DISCUSSION
Our data indicate that with proper patient selection and a well-defined
management protocol, a trial of labor after a single low transverse
cesarean
delivery is associated with a very low rate of major complications and
seems
as
safe for the mother and newborn as planned cesarean delivery. Moreover,
it
is
associated with a shorter maternal hospital stay and possibly fewer
admissions
to the NICU. The main concern regarding a trial of labor after cesarean
is
related to the risk of uterine rupture and its consequences for the
mother
and
infant.6 In the study by Landon et al 4 the rate of uterine rupture was
0.72%.
Seven of the 12 cases of neonatal hypoxic-ischemic encephalopathy
followed
uterine rupture, a rate of 0.46 per 1,000 trials of labor. It is
therefore
obvious that to decrease the risk of a trial of labor after cesarean,
measures
must be taken to reduce the risk of uterine rupture. Several studies
have
shown
that the risk of uterine rupture is increased with the induction of
labor.3,4
Likewise, it has been well established that the risk of uterine rupture
increases with increasing number of previous cesarean deliveries.7-9
Yet, in
the
large multicenter study by Landon et al,4 26% of the women undergoing a
trial of
labor after cesarean were induced with prostaglandins or oxytocin or
both,
and
an additional 33.6% had labor augmented with oxytocin. Moreover, 5.4%
of the
women undergoing a trial of labor had more than 1 previous cesarean
delivery.
In the present study, there was only 1 case of uterine rupture among
841
women
who attempted vaginal delivery after cesarean, a rate of 1.2 per 1,000,
significantly lower than in Landon's study (P
The results of our study demonstrate that by limiting a trial of labor
after
cesarean to women with a singleton cephalic, nonmacrosomic fetus and a
previous
single, lower segment uterine incision, and by avoiding induction of
labor
in
women with unfavorable cervix, the risk for uterine rupture can be
markedly
reduced, rendering the option of a trial of labor after cesarean to be
a
safe
option, for both mother and infant. By waiting for the spontaneous
onset of
labor, not only is the risk for uterine rupture decreased but also the
rate
of
successful VBAC is increased (Table 3). For women who wish to have
larger
families, the advantage of a trial of labor may be even more apparent,
because
multiple cesarean deliveries are associated with a higher rate of
complications
compared with a second cesarean delivery.10-11 Moreover, we have shown
that
a
trial of labor after cesarean is associated with a significant
reduction in
maternal hospital stay. Indeed, our stringent patient selection reduces
the
number of women eligible for a trial of labor after cesarean;
nevertheless,
when
the legitimacy of a trial of labor after cesarean is at stake, a
limited
number
of trials of labor in a selected population seems to be preferable to
utterly
banning a trial of labor after cesarean to all.
We recognize that our study has 2 limitations: first, because it is a
retrospective
study, it is nonrandomized. Second, the number of patients is
relatively
small.
However, with power of about 80%, the sample size was able to detect 3-
and
2-fold increase in the rate of major and minor complications,
corresponding
with
differences of only 2.5% and 3.6%, respectively. Nevertheless, we
believe
that
our results are relevant, because they describe the outcome associated
with
the
implementation of a well-defined, strict management protocol in a
single
institution, with almost no deviation from that protocol.
In conclusion, we have shown that with our well-defined protocol, a
trial of
labor after cesarean seems to be as safe for the mother and infant as
planned
cesarean delivery and is associated with a shorter hospital stay. We
encourage
others to evaluate our approach further and hope that if larger studies
do
corroborate our results, the dictum "once a cesarean always a cesarean"
will
continue to be a thing of the past.
REFERENCES
1. Hamilton BE, Martin JA, Sutton PD, U.S. Department of Health and
Human
Services Centers for Disease Control and Prevention. Births:
preliminary
data
for 2002. Natl Vital Stat Rep 2003;51:1-20. Document Delivery
2. McMahon MJ, Luther ER, Bowes WA, Olshan AF. Comparison of a trial of
labor
with an elective second cesarean section. N Engl J Med 1996;335:689-95.
Full
Text Available From:
3. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine
rupture
during labor among women with one prior cesarean delivery. N Engl J Med
2001;345:3-8. Full Text Available From:
4. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW,
et al.
Maternal and perinatal outcomes associated with a trial of labor after
prior
cesarean delivery. N Engl J Med 2004;351:2581-9. Full Text Available
From:
5. Gonen R, Tamir A, Degani S, Ohel G. Variables associated with
successful
vaginal birth after one cesarean section: a proposed vaginal birth
after
cesarean section score. Am J Perinatol 2004;21:447-53. Document
Delivery
Library
Holdings
6. Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering
the
cesarean-delivery rate. N Engl J Med 1999;340:54-7. Full Text Available
From:
7. Asakura H, Myers SA. More than one previous cesarean delivery: a
5-year
experience with 435 patients. Obstet Gynecol 1995;85:924-9. Ovid Full
Text
Full
Text Available From:
8. Caughey AB, Shipp TD, Repke JT, Zelop CM, Cohen A, Lieberman E. Rate
of
uterine rupture during a trial of labor in women with one or two prior
cesarean
deliveries. Am J Obstet Gynecol 1999;181:872-6. Document Delivery
Library
Holdings
9. Vaginal birth after previous cesarean delivery. ACOG Practice
Bulletin
No.54.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;104:203-11.
10. Ananth CV, Smulian JC, Vintzileos AM. The association of placenta
previa
with history of cesarean delivery and abortion: a metaanalysis. Am J
Obstet
Gynecol 1997;177:1071-8. Document Delivery Library Holdings
11. Mankuta DD, Leshno MM, Menasche MM, Brezis MM. Vaginal birth after
cesarean
section: trial of labor or repeat cesarean section? A decision
analysis. Am
J
Obstet Gynecol 2003;189:714-9. Full Text Available From:
----------------------------------------------
Accession Number: 00006250-200602000-00007
_______________________________________
Posts: 43 | From: perth | Registered: Sep 2005
|
|
<tasha>
unregistered
|
posted 14 February 2006 03:12 PM
Thankyou all again, I am going to make up a little portfolio of info and read through it, will write back later. It's wonderful hearing info from people who have looked into the subjects and have had to face it themselves. Your so right about GP's, at the end of the day it is amazing the instincts that a mother has also. I am still planning a vbac, despite the fact that my husband might not make it (because we live so remote & he has to work). Thanks again everyone.
|
|
<Tasha>
unregistered
|
posted 15 February 2006 05:06 PM
PS: that article you gave me is there any way I can get on their mailing list and get them also, had a look around the site couldn't work it out from there.
|
|
JenBen
Member
Member # 520
Rate Member
|
posted 16 February 2006 12:48 PM
Hi Tasha,
I received that article from one of the members of the c-aware discussion group, which is a email discussion group run by birthrites. It is a fanatastic resource because everyone shares information and stories and as it is email you can talk about some quite private stuff without it being on the net. The link to join is on the left just under the home link. You can also ask the ladies about the ob, hospitals and services in your area to get a general idea of what others have experienced. I really recommend it, they have all helped me so much and most of the information I have comes from there.
All the best Jennie
Posts: 43 | From: perth | Registered: Sep 2005
|
|
|
UBBFriend: Email this page to someone!
Printer-friendly view of this topic