To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries (vbaMc) vs the risk of a vaginal birth attempt after one cesarean delivery (vba1c).
- VBAC = vaginal birth after cesarean
- VBA1C = vaginal birth after 1 cesarean
- VBAMC = vaginal birth after multiple (2 or more) cesareans
- Uterine Rupture (UR) = disruption of the uterine muscle and visceral peritoneum or a uterine muscle separation.
- TOL = trial of labor
- ERCS = elective repeat cesarean section
- Results obtain from 19 academic medical centers
- 45,988 women with cesarean history and single gestations included:
- 17,898 (39%) underwent TOL
- 15,801 (34%) had elective cesareans
- 9,013 (20%) had indications for repeat cesarean
- 3,276 (7%) presented in early labor; intentions unknown
- 16,915 (95%) had 1 prior cesarean
- 975 (5%) had more than 1 cesarean:
- 871 (89%) had 2 cesareans
- 84 (9%) had 3 cesareans
- 20 (2%) with 4 cesareans
Uterine Rupture rate:
- 0.7% VBA1C (115/16,915)
- 0.9% VBAMC (9/975)
- Successful VBACS
- 74% VBA1C (12,490/16,915)
- 66% VBAMC (648/975)
- Increased rate of endometriosis, hysterectomy, NICU admission and transfusion multiple cesarean group
This study was large enough to detect a 3 fold increase in rupture rates
between the 2 groups
There is no statistical difference in the rate of uterine rupture between groups
In the VBA1C group (n=16,915), with 115 uterine ruptures, there were 12 term neonatal deaths (0.08%).
In the VBAMC group (n=975) with 9 uterine ruptures, there was 1 term neonatal death. (0.1%)
In the ERCS group (n=6,035), there was 1 term neonatal death (0.02%)
It is not clear whether uterine rupture was the reason for death in the VBA1C and VBAMC group.
RISK FACTORS FOR UTERINE RUPTURE
- Oxytocin augmentation
- 25% mutiple grp
- 32% single grp
- Labor induction
- 24% multiple grp
- 26% single grp
- Less than 2 years from previous cesarean
- 27% multiple grp
- 25% single grp
WHAT SHOULD THE EFFECTS OF THIS STUDY BE?
- American College of Obstetrics and Gynecology (ACOG) should update VBAC recommendations.
- VBAMC should be allowed
- Women should be counseled about their birthing options with accurate information on risks/benefits of VBAC and ERCS
- VBAMC recommendation/allowance not likely to happen due to ingrained “perceived” high risk
- Poorly designed previous studies
- Malpractice suits, etc
- Study needs to separate out:
- single and double layer suturing
Obstetrics & Gynecology 2006;108:12-20
© 2006 by The American College of Obstetricians and Gynecologists
Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery
Mark B. Landon, MD1, Catherine Y. Spong, MD20, Elizabeth Thom, PhD21, John C. Hauth, MD2, Steven L. Bloom, MD3, Michael W. Varner, MD4, Atef H. Moawad, MD5, Steve N. Caritis, MD6, Margaret Harper, MD, MS7, Ronald J. Wapner, MD8, Yoram Sorokin, MD9, Menachem Miodovnik, MD10, Marshall Carpenter, MD11, Alan M. Peaceman, MD12, Mary J. O’Sullivan, MD13, Baha M. Sibai, MD14, Oded Langer, MD15, John M. Thorp, MD16, Susan M. Ramin, MD17, Brian M. Mercer, MD18, Steven G. Gabbe, MD for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network19 *
From the Departments of Obstetrics and Gynecology at the 1Ohio State University, Columbus, Ohio; 2University of Alabama at Birmingham, Birmingham, Alabama; 3University of Texas Southwestern Medical Center, Dallas, Texas; 4University of Utah, Salt Lake City, Utah; 5University of Chicago, Chicago, Illinois; 6University of Pittsburgh, Pittsburgh, Pennsylvania; 7Wake Forest University, Winston-Salem, North Carolina; 8Thomas Jefferson University, Philadelphia, Pennsylvania; 9Wayne State University, Detroit, Michigan; 10University of Cincinnati, Cincinnati, Ohio, and Columbia University, New York, New York; 11Brown University, Providence, Rhode Island; 12Northwestern University, Chicago, Illinois; 13University of Miami, Miami, Florida; 14University of Tennessee, Memphis, Tennessee; 15University of Texas Health Science Center at San Antonio, San Antonio, Texas; 16University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 17University of Texas Health Science Center at Houston, Houston, Texas; 18Case Western Reserve University, Cleveland, Ohio; 19Vanderbilt University, Nashville, Tennessee; and 20the National Institute of Child Health and Human Development, Bethesda, Maryland; and 21the George Washington University Biostatistics Center, Washington, DC.