Vaginal birth after caesarean (VBAC).

This review of vaginal birth after caesarean (VBAC) focuses on practical issues that will be useful for the physician in training and the obstetrician in clinical practice. Although VBAC has long been a common practice in many European nations, the same has not been true in North America. As recently as 1970 essentially all hospitals in the United States maintained a policy that women with a history of previous caesarean delivery would undergo repeat caesarean operations for any and all subsequent births. Although VBAC rates in many nations increased dramatically in the 1980s and 1990s, many aspects of trial of labour (also known as trial of scar) remain controversial at the dawn of the 21st century.

Obstetric emergencies precipitated by malignant brain tumors.

OBJECTIVE: Our goal was to present a case series of pregnancy-associated malignant brain tumors. STUDY DESIGN: A review was conducted from 1978-1998 at 5 hospitals. RESULTS: Ten women were diagnosed with a malignant brain tumor during pregnancy (n = 8) or post partum (n = 2). Patients diagnosed antenatally exhibited severe symptoms, manifest between 27 and 32 weeks' gestation. Six were emergently delivered of their infants because of maternal deterioration, and 2 were delivered electively in the early third trimester after documentation of fetal pulmonary maturity. There were 4 maternal deaths and 1 neonatal death; all of the other infants maintained viability. CONCLUSIONS: Malignant brain tumors rarely occur in pregnancy. In contrast to reports that describe an indolent course, each of the 8 antenatal patients experienced a neurologic crisis. If symptoms are amenable to pharmacologic control, we advocate delivery in the early third trimester after documentation of fetal pulmonary maturity. To minimize temporal lobe or cerebellar herniation in neurologically unstable patients, a consideration should be made for cesarean delivery with the patient under general anesthesia, followed by immediate neurosurgical decompression.

Reducing cesarean section rates safely: lessons from a "breakthrough series" collaborative.

BACKGROUND: Almost one million cesarean operations are performed each year in the United States. The objective of this project was to test the hypothesis that a structured collaborative effort can help participating health care organizations to reduce their cesarean delivery rates safely. METHODS: Experts associated with the collaborative helped participant organizations to explore several categories of change concepts and to develop action plans for safely reducing their cesarean delivery rates. Over the course of one year participants attended three two-day learning sessions. In the interval between these sessions, collaborative participants communicated by weekly conference calls and a dedicated Internet site. RESULTS: Of 28 participating organizations, 15 percent achieved cesarean delivery rate reductions of 30 percent or more during the 12-month period of active collaborative work. An additional 50 percent achieved reductions between 10 and 30 percent. CONCLUSIONS: The Healthy People 2000 goal of a cesarean delivery rate below 15 percent by the year 2000 is attainable. Clinical leadership from doctors and nurses toward the achievement of that goal is timely, ethical, and in the best interests of childbearing women in the United States.

Undetected breech presentation: impact on external version and cesarean rates.

The objective of this study was to determine the impact of undetected breech presentation on an external cephalic version program. We performed a retrospective analysis of all external cephalic versions attempted over a 1-year interval. We then analyzed all cesarean operations performed for the indication of breech presentation over the same interval. Cases involving twin gestations and premature births were excluded. We found that 21% of term breech presentations were not detected before the onset of labor and an additional 15% were not detected until after 38 weeks' gestation. Increased third-trimester screening for breech presentation could potentially decrease the need for cesarean delivery.

Vaginal birth after cesarean delivery: an admission scoring system.

OBJECTIVE: To develop a scoring system to predict the likelihood of vaginal birth in patients undergoing a trial of labor after previous cesarean delivery using factors known at the time of hospital admission. METHODS: Trial of labor was attempted in 5022 patients who were assigned randomly to score derivation and score testing groups. Multivariate logistic regression modeling was used in the score derivation group to develop a predictive scoring system for vaginal birth. The scoring system was then applied to the testing group to evaluate its predictive ability. RESULTS: Five variables significantly affected the mode of birth and were incorporated into a weighted scoring system. Rates of successful vaginal birth after cesarean ranged from 49% in patients scoring 0-2 to 95% in patients scoring 8-10. Increasing score was associated linearly with increasing probability of vaginal birth after cesarean. CONCLUSION: Increasing scores correlate with increasing probability of vaginal birth after cesarean. The admission vaginal birth after cesarean scoring system may be useful in counseling patients regarding the option of vaginal birth or repeat cesarean delivery. This information could be particularly valuable for the patient who opts for trial of labor but has second thoughts about her mode of birth when labor begins.

Once a cesarean, always a controversy.

For most of this century, "once a cesarean, always a cesarean" was the rule in the United States. In the 1980s, vaginal birth after cesarean grew in popularity and the pendulum began to swing away from routine repeat cesarean delivery. Recently, the wisdom of this transition has been questioned. As the 20th century comes to a close, the treatment of the patient with a prior cesarean delivery remains controversial.

Prostaglandin E2 for cervical ripening: a multicenter study of patients with prior cesarean delivery.

To evaluate the maternal and fetal outcomes of a large cohort of women treated with prostaglandin E2 (PGE2) gel for cervical ripening prior to trial of labor after previous cesarean delivery. Beginning in 1990 all pregnant patients with previous cesarean delivery presenting for prenatal care at 10 California hospitals were prospectively studied. We analyzed multiple parameters to compare outcomes of cases in which PGE2 gel was used to outcomes in a control group in which PGE2 was not used. Data were examined by X2 testing. During the study period 5022 patients underwent trial of labor after prior cesarean delivery. Of these 5022 patients, 453 (9%) were treated with PGE2 gel. There was no significant difference in the incidence of uterine rupture between the PGE2 group and the control group. Indicators of maternal and perinatal morbidity were not significantly higher in the prostaglandin treated group. The use of PGE2 gel for cervical ripening appears to be relatively safe in patients with prior cesarean delivery.

Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study.

OBJECTIVE: To report a prospective multicenter comparison of outcomes of patients who attempted trial of labor and those who underwent elective repeat cesarean. METHODS: During the study interval, all pregnant women with previous cesarean delivery cared for at Kaiser Permanente Hospitals in Southern California were studied regardless of whether trial of labor or elective repeat cesarean was planned. RESULTS: Of 7229 study patients, 5022 (70%) had a trial of labor and 2207 had elective repeat cesarean operations. Seventy-five percent (3746) of those opting for trial of labor went on to deliver vaginally. The rate of uterine rupture was less than 1% and there were no maternal deaths related to uterine rupture. The hospital length of stay, incidence of postpartum transfusion, and incidence of postpartum fever were all significantly higher in the elective repeat cesarean group than in the trial of labor group. CONCLUSIONS: Labor after previous cesarean delivery has a 75% success rate, with a risk of uterine rupture of less than 1%. Neither repeat cesarean delivery nor trial of labor is risk-free. With careful supervision, trial of labor eliminates the need for a large proportion of repeat cesarean operations.

External cephalic version after previous cesarean section.

Approximately 100,000 cesarean sections are performed each year in the United States because of breech presentation. Numerous studies have shown that external cephalic version can eliminate the need for many of these operations. However, because of the fear of uterine rupture, these studies have generally excluded patients who have undergone previous cesarean section. To evaluate the validity of this exclusion policy, we studied patients with one or more previous cesarean sections and breach presentations near term. Version attempts were successful in 82% of 56 patients who had undergone a previous cesarean section. Sixty-five percent of the successful version patients went on to have vaginal birth after cesarean section. There were no serious maternal or fetal complications associated with the version attempts. We conclude that external cephalic version is a reasonable option in patients with prior low transverse cesarean section.

Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study.

Cesarean delivery has become the most frequently performed major operation in the United States. Widespread use of vaginal birth after previous cesarean delivery could potentially eliminate up to one-third of cesareans. However, many physicians have been reluctant to adopt this policy without large studies conclusively demonstrating its safety. This study evaluated the maternal and perinatal outcomes of over 5000 cases of labor after previous cesarean delivery. This multicenter study began in 1984 and initially included nine California hospitals. During the first 2 years, there were 1776 trials of labor resulting in 1314 vaginal births. In January 1986 two additional hospitals joined the collaborative project. Over the next 3 years, there were 3957 trials of labor resulting in 2977 vaginal births at the 11 participating hospitals. During the entire study period, 5733 patients opted for a trial of labor and 4291 (75%) delivered vaginally. There were no maternal deaths in the trial-of-labor group, and perinatal mortality was not significantly different from that of the general obstetric population. These results support the findings of numerous smaller studies that have concluded that the policy of routine repeat cesarean delivery should be abandoned.

Vaginal birth after cesarean section: is suspected fetal macrosomia a contraindication?

The American College of Obstetricians and Gynecologists' "Guidelines for vaginal delivery after a previous cesarean birth" include a precautionary statement regarding estimated fetal weight of more than 4000 g. To evaluate the validity of this restriction, we conducted an analysis of the outcomes of 301 trials of labor with birth weights equal to or greater than 4000 g. In the birth-weight range of 4000-4499 g, 139 of 240 patients (58%) delivered vaginally. In the group with birth weights exceeding 4500 g, 26 of 61 patients (43%) delivered vaginally. When compared with 1475 trials of labor with birth weights under 4000 g, no significant differences in perinatal or maternal morbidity were found. Comparison with a control group of 301 women with no previous uterine surgery who delivered macrosomic infants also demonstrated no significant differences in perinatal or maternal morbidity. The medical literature does not support elective cesarean section for suspected fetal macrosomia in nondiabetic women, and based on our experience, there appears to be no reason for treating previous-cesarean mothers differently.