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JOGC

No. 382-Trial of Labour After Caesarean

      Abstract

      Objective

      To provide evidence-based guidelines for the provision of a trial of labour after Caesarean section.

      Outcomes

      Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean and repeat Caesarean section.

      Evidence

      MEDLINE database was searched for articles published from January 1, 1995, to October 31, 2017 using the key words “vaginal birth after Caesarean (Cesarean) section.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

      Validation

      These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.

      Recommendations

      • 1
        Provided there are no contraindications, a trial of labour after Caesarean should be offered to all women with 1 previous low-segment transverse Caesarean section after appropriate discussion and documentation of maternal and perinatal risks and benefits. The discussion should be documented (II-2B).
      • 2
        Trial of labour after Caesarean is recommended in women without contraindications to labour, with a previous vaginal birth, and/or those who present in spontaneous labour as they are good candidates for a trial of labour after Caesarean and have a higher vaginal birth after Caesarean rate (II-2B).
      • 3
        Women with factors negatively affecting their likelihood of vaginal birth after Caesarean can be offered a trial of labour after Caesarean. However, they should be informed that they have a lower chance of vaginal birth after Caesarean and have an increased risk of complications and repeat Caesarean birth (II-2A).
      • 4
        Women should be informed that the relative risk of maternal death is higher for elective repeat Caesarean section and the risk of uterine rupture and composite serious maternal morbidity is higher for trial of labour after Caesarean, but the absolute risks of these outcomes are low (II-2B).
      • 5
        Women with 1 prior low transverse Caesarean section should be informed that the baseline risk of uterine rupture with a trial of labour after Caesarean is 0.47% (II-2A).
      • 6
        Women should be informed that most other maternal complications are not significantly different between elective repeat Caesarean section and trial of labour after Caesarean (II-2B).
      • 7
        Induction of labour is not contraindicated in women undergoing a trial of labour after Caesarean (II-2A).
      • 8
        Women should be informed that induction of labour is associated with a lower vaginal birth after Caesarean rate and an increased risk of uterine rupture and should be used carefully after appropriate counselling. The risk of uterine rupture with induction of labour appears to be highest in women over 40 weeks gestation (II-2A).
      • 9
        A Foley catheter may be used to ripen the cervix in a woman planning a trial of labour after Caesarean (II-2B).
      • 10
        Use of oxytocin for induction or augmentation is not contraindicated in women undergoing a trial of labour after Caesarean. However, use of oxytocin is associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B).
      • 11
        Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and its use is not recommended in trial of labour after Caesarean, after appropriate counselling (II-2B).
      • 12
        Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used in trial of labour after Caesarean at term (II-2A).
      • 13
        Women with 2 prior Caesarean sections appear to have similar vaginal birth after Caesarean rates as those with 1 prior Caesarean section. Women should be informed of a higher risk of uterine rupture in trial of labour after Caesarean with more than 1 Caesarean section (II-2B).
      • 14
        There are limited studies reporting on outcomes of women with more than 2 prior Caesarean sections (I).
      • 15
        It is not an absolute contraindication for women with a breech presentation to undergo a trial of labour after Caesarean. However, women should be advised that there is insufficient information to assess risks of trial of labour after Caesarean with a breech presentation (III-B).
      • 16
        Multiple pregnancy is not a contraindication to a trial of labour after Caesarean (II-2B).
      • 17
        Women delivering with <18-month interdelivery interval should be informed about an increased risk of uterine rupture with trial of labour after Caesarean (II-2A).
      • 18
        Although there is relationship between lower uterine thickness and risk of uterine rupture, the absolute cut-off between safe and unsafe trial of labour after Caesarean does not exist. Therefore, at this time, we cannot use ultrasonographic measurements of the lower uterine segment to counsel women to either have or not have a trial of labour after Caesarean with confidence (II-2B).
      • 19
        Women with a classical Caesarean section or T incision should not have a trial of labour after Caesarean (II-2A).
      • 20
        Women with a previous Low Segment Cesarean Section in which the uterus was closed in a single layer and who wish to attempt trial of labour after Caesarean should be aware that the risk of uterine rupture may be increased (II-2A).
      • 21
        Every effort should be made to obtain the previous Caesarean operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, trial of labour after Caesarean can be offered (II-2B).
      • 22
        Women planning a trial of labour after Caesarean should be advised that the relative risk of perinatal mortality and serious morbidity is higher with trial of labour after Caesarean compared to elective repeat Caesarean section, but the absolute risk is low (II-2B).
      • 23
        Women should be informed that the risk of placenta previa and placenta accreta increases with increasing number of Caesarean sections (II-2A).
      • 24
        The process and documentation of informed consent with appropriate discussion of the maternal and perinatal risks and benefits of trial of labour after Caesarean and elective repeat Caesarean section should be a part of the care plan in a woman with a previous Caesarean section (III-A).
      • 25
        The intention of a woman undergoing a trial of labour after Caesarean or elective repeat Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (III-A).
      • 26
        The entire team should be made aware of the presence of a woman undergoing a trial of labour after Caesarean labouring in the birthing unit (III-A).
      • 27
        Continuous electronic fetal monitoring of women having a trial of labour after Caesarean is necessary, as changes to the fetal heart rate tracing are one of the key indicators of the presence of a uterine rupture (II-2A).
      • 28
        Suspected uterine rupture requires immediate attention and laparotomy in order to attempt to decrease maternal and perinatal morbidity and mortality (III-B).
      • 29
        To optimize maternal and neonatal outcomes, a woman having a trial of labour after Caesarean should be cared for in a hospital that has resources to perform an emergency Caesarean section (III-B).
      • 30
        The woman and her health care provider must be aware of the availability of obstetric, anaesthetic, pediatric, and operating room staff in the setting where she chooses to give birth (III-A).

      Key Words

      ABBREVIATIONS:

      CS (Caesarean section), EFM (electronic fetal monitoring), ERCS (elective repeat Caesarean section), FHR (fetal heart rate), IOL (induction of labour), LUS (lower uterine segment), PGE2 (prostaglandin E2), SOGC (Society of Obstetricians and Gynaecologists of Canada), TOLAC (trial of labour after Caesarean), VBAC (vaginal birth after Caesarean)
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