Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

doi:10.1016/j.ejogrb.2013.05.015

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 170, Issue 1, September 2013, Pages 25-32

https://doi.org/10.1016/j.ejogrb.2013.05.015 Get rights and content

Abstract

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3).

Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B).

TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C).

TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI > 50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age > 35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C).

The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus).

Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3 h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

Section snippets

Introduction and method [1–3]

The sponsor (the French College of Gynecologists and Obstetricians (CNGOF)) appointed a steering committee (Appendix A) to define the exact questions to be put to the experts, to choose the experts, follow their work and draft the synthesis of recommendations resulting from their work. The experts analyzed the scientific literature on the subject to answer the questions raised. A literature review identified the relevant articles through mid-2012 by searching the MEDLINE database and the

Uterine scars: epidemiologic aspects [11]

The primary cause of uterine scars is a previous cesarean section. In France, the cesarean rate was 20.8% in 2010 compared with 15.5% in 1995. Over the same period, the prevalence of uterine scars increased from 8% to 11% among all parturients and from 14% to 19% among multiparas. The mode of delivery of women with previous cesareans varies quite substantially from one country to another. According to the 2010 national perinatal survey in France, 51% of such women had a cesarean before labor;

The benefits and risks of trial of labor compared to elective repeat cesarean for women with a previous cesarean [12]

Maternal mortality remains a very rare event regardless of the mode of delivery in women with a previous cesarean (LE2). It may be slightly less rare in women who have a trial of labor after cesarean (TOLAC) (LE3). The risk of complete uterine rupture in TOLAC is significantly higher than in elective repeat cesarean delivery (ERCD) (LE2), but is nonetheless very low—approximately 0.2–0.8% in women with a single uterine scar (one previous cesarean). The occurrence of a surgical wound,

The neonatal benefits and risks of trial of labor compared to elective repeat cesarean in women with a previous cesarean [13]

Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans.

In utero fetal mortality is low but is higher in TOLAC (0.5/1000–2.3/1000) than in ERCD (0/1000–1.1/1000) (LE2). The absolute risk of perinatal mortality in TOLAC is small (1/1000–2.9/1000) but nonetheless significantly higher than in ERCD (0/1000–1.8/1000) (LE2). Similarly, the absolute risk of neonatal mortality is low in TOLAC (1.1/1000), but still significantly higher than in ERCD

Factors influencing the mode of delivery in TOLAC [14]

Three factors are strongly associated with the success of TOLAC: a history of vaginal birth, especially if the vaginal delivery took place after the cesarean (LP2), a favorable Bishop score or a cervix considered favorable at entry into the labor room (LP2), and spontaneous labor (LE2).

Several factors are associated with a reduced TOLAC success rate: previous cesarean for failure to progress or non-descent at full dilatation (LE3), a history of two cesareans (although the TOLAC success rate

Criteria for TOLAC according to characteristics of the uterine scar [15]

According to the current data, TOLAC can be attempted for women with uterine malformations if the incision for the preceding cesarean left a low transverse scar (professional consensus). No study of sufficient methodological quality justifies affirming the superiority of any particular type of uterine suture during a cesarean to reduce the risk of uterine rupture (professional consensus).

The level of evidence of the studies conducted to estimate the risk of rupture during pregnancy or during

Particular maternal or fetal clinical situations that influence the choice of mode of delivery for women with a previous cesarean [16]

The failure rate for TOLAC increases with maternal age (LE3). The literature does not provide enough information to determine a maternal age threshold above which ERCD is preferable to TOLAC; nonetheless, the woman's obstetric future is an element to consider in determining her mode of delivery (professional consensus).

Grand multiparity is associated with a significant reduction in TOLAC failure and in the risk of uterine rupture (LE3). Accordingly, TOLAC should be encouraged for grand

Guidelines for organization, planning and counseling TOLAC [17]

Because of the risks of TOLAC failure and of uterine rupture, a woman choosing TOLAC must not give birth either at home or in a birthing center (professional consensus). The risk of hemorrhagic complications accompanying uterine rupture or TOLAC failure also requires that the obstetrician be skilled in the surgical techniques for emergency hemostasis (professional consensus). In women with an anterior placenta covering the uterine scar, the risk of abnormal placental insertion, such as accreta,

Induction

Induction moderately increases the risk of cesarean delivery during labor, but approximately doubles the risk of uterine rupture compared with spontaneous labor in women with uterine scars (LE2). Labor should be induced in such women only for medical indications (professional consensus). Elective induction of labor for reasons of convenience must be avoided in women with prior cesareans (professional consensus). In cases of induction, a previous vaginal delivery and a favorable cervical

Uterine rupture: prediction, diagnosis, and management [19,20]

Uterine rupture occurs in 0.1–0.5% of women with uterine scars and 0.2–0.8% of women in TOLAC (LE2). It is associated with severe maternal morbidity in the order of 15% (hysterectomy, intensive care unit transfer, visceral injuries, and blood transfusions) (LE2). The morbidity observed during uterine rupture after a cesarean delivery nonetheless appears to be less severe than that observed during the rupture of an unscarred uterus (LE3). The maternal mortality associated with uterine rupture

Elements of anesthesiology management for women with a previous cesarean [21]

Effective communication between the obstetric team and the anesthesiologist-critical-care specialist is a prerequisite for the optimal management of a woman with a previous cesarean. (professional consensus).

In this circumstance marked by an increased risk of urgent obstetric interventions for which it is desirable to avoid general anesthesia (professional consensus), placement of epidural anesthesia is encouraged (professional consensus). Depending on the circumstances and the woman's wishes,

Conclusions

TOLAC and ERCD both present low risks of serious complications for mother and child. The risk-benefit ratio for the mother in both the short and long term favors TOLAC (professional consensus), but the short-term risk-benefit ratio for the child favors ERCD (professional consensus).

The expert advisory group of the French National College of Gynecologists and Obstetricians considers TOLAC the preferred option in the great majority of cases (professional consensus). Few individual clinical

Conflict of interest

There are no conflicts of interest.

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Cited by (143)

Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation
2024, Journal of Gynecology Obstetrics and Human Reproduction
Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery.
This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery).
Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04–1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10–1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00–1.37). Uterine rupture was observed in three women (1 %).
The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.
Retrospective evaluation of labor induction with scar uterus at the university hospital of Rennes
2023, Journal of Gynecology Obstetrics and Human Reproduction
The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section.
This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen.
The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25–0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08–0,35).
With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.
Middle eastern college of obstetricians and gynecologists (MCOG) practice guidelines: Role of prediction models in management of trial of labor after cesarean section. Practice guideline no. 05-O-22<sup>✰,✰✰,★,★★</sup>
2023, Journal of Gynecology Obstetrics and Human Reproduction
Cesarean delivery rates have been steadily rising since the beginning of the 21st century. The growing incidence is even more prominent in developing countries owing to lack of evidence-based guidance and audit, and the expansion of private practice. The uprise in Cesarean delivery rate has been associated with considerable financial burden and has increased the risk otherwise uncommon serious complications such as placenta accreta disorders and uterine rupture. In addition to primary prevention of Cesarean delivery, trial of labor after cesarean section is one of the most successful strategies to reduce Cesarean deliveries and minimize risks associated with higher order Cesarean deliveries. This guideline appraises patient selection strategies and use of prediction model to promote counseling and enhance safety in women considering vaginal birth after Cesarean.
Uterine rupture during medical termination of pregnancy or intrauterine death: A risk management study
2023, Gynecologie Obstetrique Fertilite et Senologie
Décrire et analyser une série de ruptures utérines (RU) survenues dans un contexte d’interruption médicale de grossesse (IMG) ou de mort fœtale in utéro (MFIU) dans une logique de gestion des risques.
Étude observationnelle descriptive rétrospective française de l’ensemble des cas de RU survenus lors d’un déclenchement pour MFIU ou IMG, déclarés entre 2011 et 2021 par Gynerisq. Les cas ont été enregistrés sur la base de déclarations volontaires à l’aide de questionnaires ciblés.
Entre le 27 novembre 2011 et le 22 aout 2021, 12 cas de RU survenus lors d’un déclenchement pour MFIU ou IMG ont été enregistrés. 50 % des patientes n’avaient jamais accouché par césarienne. Le terme d’accouchement variait de 17 SA + 3 jours à 41 SA + 2 jours. Les signes cliniques majoritairement retrouvés était la douleur (n = 6), la remontée de la présentation fœtale (n = 5) et les métrorragies (n = 4). Toutes les patientes ont été prises en charge par laparotomie, 5 ont été transfusées. Une ligature vasculaire et une hystérectomie ont été nécessaires.
La connaissance des antécédents chirurgicaux participe à la prévention de la RU. Les signes de détection sont la douleur, la remontée de la présentation et les métrorragies. La célérité de prise en charge ainsi qu’un bon fonctionnement de travail d’équipe permettent une diminution des complications maternelles. Les conclusions des revues de morbi-mortalité montrent que peuvent être établies des barrières de prévention et d’atténuation.
To describe and analyze a series of uterine ruptures (UR) that occurred in the context of medical termination of pregnancy (MTP) or intrauterine death (IUD) from a risk management perspective.
French retrospective descriptive observational study of all cases of UR occurring during induction for IUD or MTP, reported between 2011 and 2021 by Gynerisq. Cases were recorded on a basis of voluntary reports using targeted questionnaires.
Between November 27, 2011, and August 22, 2021, 12 cases of UR occurring during an induction for IUD or MTP were recorded. 50 % of the patients had never given birth by cesarean section. The term of delivery varied from 17 + 3 days to 41 + 2 days. The clinical signs found were pain (n = 6), ascending fetal presentation (n = 5) and bleeding (n = 4). All patients were managed by laparotomy, 5 were transfused. One vascular ligation and one hysterectomy were required.
Knowledge of surgical history is involved in the prevention of UR. The signs of detection are pain, ascending presentation and bleeding. The speed of management and good teamwork allow a reduction of maternal complications. The findings of the morbidity and mortality reviews show that prevention and mitigation barriers can be established.
Maternal and neonatal characteristics associated with clinical outcomes of TOLAC from 2012–20 in the USA: Evidence from a retrospective cohort study
2022, eClinicalMedicine
The risks of a few maternal and/or neonatal morbidities are higher with the trial of labour after caesarean (TOLAC) owing to unplanned caesarean delivery. Thus, it is imperative to consider the trade-off between the risk of side effects and the potential benefits before TOLAC utilisation and whether TOLAC should be provided to women with specific characteristics related to previous caesarean delivery. We aimed to investigate maternal and neonatal characteristics associated with TOLAC utilisation, compare maternal and/or neonatal morbidities in TOLAC women with women who chose planned caesarean deliveries, and assess specific characteristics related to maternal and/or neonatal morbidities in women with TOLAC utilisation.
In this retrospective cohort study, we used nationwide, linked birth and infant death data in the United States between 2012 and 2020, which covers all 50 states in the US. Poisson regression models using generalised estimating equations yielded adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) of TOLAC utilisation and unsuccessful TOLAC by maternal and neonatal characteristics. Logistic regression models using generalised estimating equations yielded adjusted odds ratios (aORs) with 95% CIs of maternal and neonatal morbidities. Statistical analysis was performed from February 2022 to July 2022.
The sample included 4,898,441 women with mean (SD) maternal age years (5.4 years; range 13–50). Several specific maternal and neonatal characteristics were significantly associated with unsuccessful TOLAC, although women with TOLAC utilisation were associated with significantly lower risks of maternal unplanned hysterectomy (aOR, 0.60; 95% CI, 0.60–0.61), admission to intensive care (aOR, 0.84; 95% CI, 0.84–0.85), and neonatal seizures (aOR, 0.80; 95% CI, 0.74–0.84). In women who attempted TOLAC, advanced maternal age, higher maternal body mass index, more than 2 previous caesarean deliveries, having maternal co-morbidities and fetal malpresentation increased the likelihood of maternal and neonatal morbidities.
When utilising TOLAC, specific maternal and neonatal characteristics in pregnant women should be considered in conjunction with the potential benefits of TOLAC in preventing maternal and neonatal morbidities.
This study is funded by the Clinical Medicine Plus X - Young Scholars Project, Peking University, the Fundamental Research Funds for the Central Universities (No: PKU2022LCXQ008).
Early childhood educational outcomes of children associated with vaginal birth after cesarean delivery
2022, American Journal of Obstetrics and Gynecology MFM
Rates of vaginal birth after cesarean delivery have decreased and cesarean delivery rates have increased in the last 2 decades. Evidence on short-term neonatal outcomes is available, but data on long-term childhood outcomes following vaginal birth after cesarean delivery are insufficient. Long-term childhood outcome data are essential in decision-making regarding mode of delivery.
This study aimed to evaluate the association between delivery mode and long-term educational outcomes of the children of pregnant individuals with a previous cesarean delivery.
This was a retrospective cohort study linking Rhode Island third-grade education data from 2014 to 2017 to birth certificate data. Data were obtained from a statewide database using Department of Education data, and were linked to Department of Health birth certificate data. Participants were children of multiparous women who were term, singleton births without congenital anomalies. Children delivered by primary cesarean delivery were excluded. The exposure was mode of delivery classified as vaginal birth after cesarean delivery, repeated cesarean delivery, or repeated vaginal birth. The primary outcome was children's third-grade reading and math proficiency. Bivariate analyses were conducted to assess differences in demographic variables. Bivariable and multivariable log-binomial regression was used to examine the association between subject proficiency and predictors including mode of delivery, maternal education, sex, child race or ethnicity, and lunch subsidy.
Of the 10,923 children who met the inclusion criteria, 2.0% were delivered by vaginal birth after cesarean delivery, 22.0% by repeated cesarean delivery, and 76.0% by repeated vaginal delivery. After adjustment for confounders, there was no difference in reading proficiency (adjusted risk ratio, 0.98; 95% confidence interval, 0.84–1.15) or math proficiency (adjusted risk ratio, 0.99; 95% confidence interval, 0.84–1.15) between those born by vaginal birth after cesarean delivery and those born by repeated cesarean delivery. There was no difference found in either proficiency between children born by repeated vaginal birth and those born by repeated cesarean delivery (reading: adjusted risk ratio, 0.97; 95% confidence interval, 0.93–1.01; math: adjusted risk ratio, 0.97; 95% confidence interval, 0.92–1.02).
In comparison with repeated cesarean delivery, both vaginal birth after cesarean delivery and repeated vaginal birth were not associated with differences in educational outcomes. This may aid in counseling about long-term safety outcomes regarding vaginal birth after cesarean delivery and may assist in shared decision-making when selecting between trial of labor after cesarean delivery and repeated cesarean delivery.

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ReviewDelivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

Abstract

Section snippets

Introduction and method [1–3]

Uterine scars: epidemiologic aspects [11]

The benefits and risks of trial of labor compared to elective repeat cesarean for women with a previous cesarean [12]

The neonatal benefits and risks of trial of labor compared to elective repeat cesarean in women with a previous cesarean [13]

Factors influencing the mode of delivery in TOLAC [14]

Criteria for TOLAC according to characteristics of the uterine scar [15]

Particular maternal or fetal clinical situations that influence the choice of mode of delivery for women with a previous cesarean [16]

Guidelines for organization, planning and counseling TOLAC [17]

Induction

Uterine rupture: prediction, diagnosis, and management [19,20]

Elements of anesthesiology management for women with a previous cesarean [21]

Conclusions

Conflict of interest

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

J Gynecol Obstet Biol Reprod

Review
Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)