European Journal of Obstetrics & Gynecology and Reproductive Biology
ReviewDelivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)
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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