Vaginal birth after cesarean: a meta-analysis of morbidity and mortality

Article Abstract:

Cesarean birth involves delivery of the baby by utilizing an incision through the abdominal wall into the uterus. The rate of cesarean births has increased steadily over time, and a major reason for this is that the procedure is often repeated in the same woman with succeeding births. However, many obstetricians claim that vaginal birth after cesarean (VBAC) is as safe for the infant and mother as repeated cesarean section and should be appropriate for 39 to 89 percent of these patients, instead of the 5 to 10 percent who had VBAC in the 1980s. Information about the incidence of complications and the death rate (also referred to as morbidity and mortality data) for mothers and infants after VBAC was analyzed from 11,417 patients (in 31 different studies) to compare the relative safety of different delivery methods. The three categories of delivery method were: a successful VBAC; a failed trial of vaginal labor (leading to an unplanned cesarean); and a planned repeat cesarean. The maternal death rate was low regardless of the delivery route (fewer than three per 10,000 for both women who had planned cesareans and women who attempted vaginal birth). A mother was more likely to develop an infection (urinary tract, wound, amniotic or endometrial) after a failed trial of labor, but less likely to do so after a VBAC. The rate of uterine dehiscence (rupture of the wound) was not different after a VBAC versus a repeat cesarean, and the use of oxytocin (a hormone that stimulates uterine contractions) and the presence of an unknown uterine scar had no significant effect on dehiscence. Vaginal birth after previous cesarean section appears to be a safe method of delivery posing no increased risk to the mother or infant. Additionally, a failed attempt at VBAC followed by a cesarean section carries no increased risk either. (Consumer Summary produced by Reliance Medical Information, Inc.)

Case studies, Complications and side effects, Childbirth, Delivery (Childbirth), Obstetrics

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Vaginal birth after cesarean: a meta-analysis of indicators for success

Article Abstract:

The rate of cesarean delivery in the United States has climbed steadily since the 1970s, despite the concerns of clinicians, consumers, and insurers that it is too high. The operation is performed for four reasons: previous cesarean birth, difficult labor, fetal position that would make vaginal delivery difficult or impossible, and fetal distress. To learn more about factors present prior to delivery that best predict the outcome of a trial of labor in cases of previous cesarean, a statistical approach called meta-analysis was applied to 29 published studies. These reports had evaluated the outcome of a trial of labor in the context of pre-existing conditions. The method of meta-analysis is briefly described and evaluated. Results for 8,770 women who had trials of labor after cesarean delivery showed wide variation in the proportion of patients allowed to attempt vaginal delivery (ranging from 16 to 81 percent of patients). Women who had undergone a previous cesarean for cephalopelvic disproportion (fetal head too large for the pelvic outlet) had the lowest success rate when they attempted labor, while those who had undergone the procedure because of a breech presentation (baby positioned in the uterus with head up instead of down) had the highest rate of subsequent vaginal delivery. Chances of a successful vaginal delivery after cesarean were improved if the woman had a previous vaginal delivery. They were made worse by a history of more than one cesarean delivery, and by the use of oxytocin (a hormone that stimulates uterine contractions). However, women with the lowest rates for vaginal birth after cesarean still had a better-than-50-percent chance of success. Thus, a trial of labor can almost always be recommended for women with a previous cesarean delivery. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Labor (Obstetrics), Medical protocols

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Management of post-term pregnancy

Article Abstract:

The risk of fetal death increases significantly when a pregnancy is post-term, or lasts longer than 42 weeks. Ten percent of pregnancies are post-term, and a post-term fetus can outgrow its placenta. A post-mature fetus requires more oxygen and nutrients than its placenta can provide. It may also be poisoned by its own waste products in utero, or injure itself and its mother during delivery. Fetuses grow at different rates depending on their racial group and sex, which can also complicate management of post-term pregnancies. A research study found that fewer cesarean sections occurred because of fetal distress among women with post-term pregnancies whose labors were induced than among those whose labors were monitored. The researchers suggested that active labor management may decrease the risk of fetal death in post-term pregnancies. This suggestion may not be correct, because fetal health is difficult to assess in utero. Methods used to monitor fetal health are questionable, and intervals between assessments of fetal health are not standardized.

Care and treatment, Editorial, Pregnancy, Protracted, Post-term pregnancy

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