Parto tras 2 cesáreas
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  • 1. DOI: 10.1111/j.1471-0528.2009.02351.x Systematic review Vaginal birth after two caesarean sections (VBAC-2)—a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections S Tahseen,a M Griffithsb a Leeds University Hospitals NHS Trust, Leeds, UK b Luton & Dunstable Hospital NHS Foundation Trust, Luton UK Correspondence: Dr S Tahseen, 20 Malthouse Green, Luton LU2 8SN, UK. Email Accepted 19 July 2009. Published Online 14 September 2009.Background Trial of vaginal birth after Caesarean (VBAC) is RevMan-5 to compare VBAC-1 versus VBAC-2 and VBAC-2considered acceptable after one caesarean section (CS), however, versus RCS.women wishing to have trial after two CS are generally not Main results VBAC-2 success rate was 71.1%, uterine rupture rateallowed or counselled appropriately of efficacy and 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatalcomplications. unit admission rate 7.78% and perinatal asphyxial injury/deathObjective To perform a systematic review of literature on success 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666rate of vaginal birth after two caesarean sections (VBAC-2) and (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associatedassociated adverse maternal and fetal outcomes; and compare with uterine rupture rate 1.59% versus 0.72% (P < 0.001) andcommonly accepted VBAC-1 and the alternative option of repeat hysterectomy rates were 0.56% versus 0.19% (P = 0.001)third CS (RCS). respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versusSearch strategy We searched MEDLINE, EMBASE, CINAHL, 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%,Cochrane Library, Current Controlled Trials, HMIC Database, respectively (P = 0.27). Maternal morbidity of VBAC-2 wasGrey Literature Databases (SIGLE, Biomed Central), using search comparable to RCS. Neonatal morbidity data were too limited toterms Caesarean section, caesarian, C*rean, C*rian, and MeSH draw valid conclusions, however, no significant differences wereheadings ‘Vaginal birth after caesarean section’, combined with indicated in VBAC-2, VBAC-1 and RCS groups in NNU admissionsecond search string two, twice, second, multiple. rates and asphyxial injury/neonatal death rates (Mantel–Haenszel).Selection criteria No randomised studies were available, case Conclusions Women requesting for a trial of vaginal delivery afterseries or cohort studies were assessed for quality (STROBE), 20/23 two caesarean sections should be counselled appropriatelyavailable studies included. considering available data of success rate 71.1%, uterine ruptureData collection and analysis Two independent reviewers selected rate 1.36% and of a comparative maternal morbidity with repeatstudies and abstracted and tabulated data and pooled estimates CS option.were obtained on success rate, uterine rupture and other adverse Keywords Complications, uterine rupture, vaginal birth after twomaternal and fetal outcomes. Meta-analyses were performed using caesarean sections.Please cite this paper as: Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)—a systematic review with meta-analysis of success rateand adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010;117:5–19. reasons for the rise in caesarean rates, together with fetalBackground distress, dystocia and breech presentation.1,2 In UK, CS rateCaesarean section (CS) rates have risen worldwide. Perfor- in women with a previous caesarean is 67% as comparedmance of elective repeat caesarean is one of the main to 24% in primigravid women according to the results ofª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 5
  • 2. Tahseen, GriffithsThe National Sentinel Caesarean Section Audit.1 Multiple tute for Clinical Excellence (NICE), Royal College ofcaesarean sections are associated with placental adherence Obstetricians & Gynaecologist (RCOG), American Collegeto scar (placenta increta/praevia)3 which is a potential sur- of Obstetrician & Gynaecologist (ACOG), Society of Obste-gical challenge and a cause of maternal morbidity and mor- tricians & Gynaecologists of Canada (SOGC), Cochranetality. A trial of labour after previous caesarean delivery has Library Issue 3 2006 and National Electronic Library forbeen accepted as a way to reduce the overall caesarean rate Health (NeLH).and also to allow women choice for mode of delivery. The search terms comprised first search string including;Many studies have supported the efficacy and safety of vag- Caesarean section, caesarean, caesarian, C*rean and C*rian,inal birth after caesarean (VBAC) after one caesarean sec- combined with a second search string which included; two,tion and reliable figures of success rate and complications twice, second, multiple. Searches were applied, in turn,are available for counselling women for VBAC after one restricting to key words, title and then abstract. This searchcaesarean section.4–6 While clinicians [supported by guide- strategy yielded a large number of non-relevant articles.lines (Society of Obstetricians & Gynaecologists of Canada7 Use of the MeSH heading ‘Vaginal birth after caesareanand American College of Obstetricians & Gynaecologists)8] section’ was then applied combined with the second stringgenerally recommend or offer a trial of vaginal birth after search words (not restricted to title or abstract) whichone caesarean section, a trial of labour is generally not yielded relevant papers Relevance of articles was furtheroffered after two CS. determined by the titles and/or abstracts. There were no Although outcomes of trial of vaginal delivery after two language restrictions on the searches. Electronic searchingcaesarean sections9–31 have been published over last two was supplemented by hand searching of the reference lists.decades, the subject of VBAC-2 has not received its due We attempted to contact authors where additional infor-consideration among obstetricians. Women requesting for mation was needed.such trials are generally not allowed or counselled appro-priately and may receive conflicting advice, an issue likely Study selectionto be of considerable importance for many women. Suc-cessful VBAC-2 may also reduce overall caesarean section There were no controlled trials available on the subject. Pub-rate and associated complications of multiple caesareans. lications were either case reports, small case series or major cohorts. Individual case reports, duplicate publications and publications commenting on other papers were excluded. InObjectives case of publications reflecting the same cohort, only theTo assess the success rate and associated major complica- study with most up-dated, complete and relevant data wastions of trial of vaginal birth after two caesarean sections used. Four foreign language papers were identified, afterby means of systematic review; and to provide the relevant translation two were confirmed to be case reports,10,33 thefigures for patient counselling for such trials. third was a duplicate publication19,20 which was included and the last21 study was considered but excluded due to poor methodology. We used the appraisal tools fromSearch strategy STROBE34 to assess methodological quality of identifiedThe peer-reviewed protocol for this review was prepared studies (study selection process and targeted searching fora priori, detailing specific objectives, criteria for study selec- guidelines is shown in Figure 1). Characteristics of eachtion and approach to assessing quality, outcomes and sta- study are summarised in Table 1 (20 studies). All but thetistical methods. The article was prepared in accordance three studies14,21,23 were deemed to be of reasonable qualitywith the Meta-analysis of Observational Studies in Epide- by STROBE criteria to be included. Jamelle23 described expe-miology (MOOSE) Statement.32 We used published deiden- rience of unplanned VBAC in unbooked women (ten cases),tified data and thus the present study was exempt from largely or entirely labouring unsupervised, presenting to aLocal Research & Ethics Committee (LREC) approval. tertiary centre usually in advanced labour or already with Searches were performed on the following electronic bib- complications. Similarly, Emembolu14 described womenliographic databases; Medline (from 1966), Cumulative presenting in advanced labour with unplanned VBAC (139Index to Nursing and Allied Health Literature CINAHL cases), these scenarios do not reflect planned trial of labour(from 1982), The Cochrane Library (2008: Issue 3), Cur- and would introduce bias to the results. Guettier21 reportedrent Controlled Trials, HMIC database, National research 17 women with two previous uterine scars, one of whichregister, Research Findings Electronic Register (ReFER). may be a previous myomectomy/hysterotomy scar. NineAdditionally Grey Literature databases searched were SIGLE women (53%) delivered vaginally including two women(from 1980) and Biomed Central. Targeted internet search- fully dilated on admission and one home delivery. Theseing of key organisation websites included; National Insti- three studies were not included in the analysis.6 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 3. Success rate & adverse outcomes of vaginal birth after two caesarean sections Study selection flow chart 273 potentially relevant articles identified and screened Targeted searching for guidelines -Society of Obstetricians & Gynecologists of Canada -American College of 243 articles excluded on Obstetricians & basis of title or abstract Gynecologists -Royal College of Obstetricians & Gynecologists-UK 26 studies, 3 case reports and -NICE (National Institute one review article were of Clinical Excellence) UK potentially relevant -Cochrane Library 6 studies reflected same cohort and 3 case reports and one review article were not considered further 20 studies were appraised for quality, 3 studies excluded due to poor methodology, 17 studies includedFigure 1. Study selection process for the systematic review of success rates and complications of trial of vaginal birth after two caesarean sections. not encompass 1.0. Meta-analysis was performed withData collection and analysis RevMan (Revision Manager, version 5 for Windows, TheData were abstracted independently by the two authors and Nordic Cochrane Centre, The Cochrane Collaboration,any discrepancies were resolved by discussion. The follow- Copenaghen, Denmark 2008).ing data items were collected if available from each paper;proportion of women undergoing trial (i.e. number of eli- Resultsgible women with previous two caesarean sections), successrate, uterine rupture rate, hysterectomy rate, blood transfu- After exclusion of case reports33,36 and review articles,37,38sion, low Apgar scores, neonatal unit admission rate and 26 studies were assessed further. Four publications reflectedperinatal asphyxial injury/death attributable to mode of the same cohort25,39–41 and two publications each reflecteddelivery (judicious review of text to extrapolate this figure). same cohort17–20,24,42 the most comprehensive publicationsThe comparator groups [VBAC-1 or non-trial repeat relevant to our subject were chosen from each cohort. The(third) caesarean section] characteristics were noted if 20 studies considered in detail are summarised in Table 1.available. Three studies were excluded due to poor quality. Seventeen Meta-analysis was performed following the guidelines studies were included in data abstraction and analysisproposed by the MOOSE Group.32 Interstudies heterogene- including 5666 subjects undergoing labour (mostly asity, defined according to Higgins et al.35 as the percentage planned trial of labour) after two or more caesarean sec-of total variation across studies because of heterogeneity tions. Six studies reported outcomes using a comparatorrather than chance (I2), was tested with chi-square test for group of VBAC-1 (50 685 subjects in VABC-1 versus 4565heterogeneity at a significance level of P = 0.10 and a ran- in VBAC-2 group). Eight studies used a comparator groupdom effect model was generated whenever the I2 statistics of repeat third caesarean sections (RCS) (nonlabour and/orwere >25% using Mantel–Haenszel analysis method. Cate- elective), the subjects included in this subset were 2829 ingorical variables were examined with calculations of pooled VBAC-2 versus 10 897 in repeat (third) caesarean sections.odds ratios (ORs) with 95% confidence intervals (CI). In- In two recent large studies,24, 25 data were available fortergroup comparisons were considered statistically signifi- both the comparator groups. Comparison with VBAC-1cant at an alpha level of two-tailed P < 0.05, if CIs did were carried out because of its wide acceptability amongª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 7
  • 4. 8 Table 1. Details of studies included in the systematic review of success rate and complications of VBAC-2 Study Study Methods Labour Success rate Maternal Neonatal reference population management outcome outcome Macones25 1082 VBAC-2 27% of subjects with VBAC-2 vs VBAC-1 74.6% VBAC-2 Uterine rupture Birthweight 3347 Tahseen, Griffiths (North America) 2888 RCS and previous two CS IOL 30% vs 29% success vs 1.8% vs 0.9% vs 3349 g Cohort study, 12,535 VBAC-1 had a trial Syntocinon 75.5% VBAC-1. Transfusion 0.92% comparing Previous classical and 73% repeat CS augmentation Women with vs 0.68% and 1.18% VBAC-2 with VBAC-1 CS excluded 34% vs 34% prior vaginal in RCS. and RCS delivery were Fever 12.7% RCS vs more likely 8.8% in VBAC-2 to undergo trial Landon24 975 cases VBAC-2 14% of subjects VBAC-2 vs VBAC-1 66% (648/975) Uterine rupture 0.9% Term NICU admission (North America) (including with previous IOL 23% vs 26% success in (9/975) in VBAC-2 11% vs 9% Prospective cohort study, 84 cases with two CS had a Syntocinon group with multiple CS, vs 0.7% in VBAC-1 Term intrapartum stillbirth comparing VBAC-2 three previous trial, 86% RCS augmentation 74% (12490/16915) (115/16 915) 0% vs 0.01%, term NND vs VBAC-1 CS and 20 with 25% vs 32% in VBAC-1 group Hysterectomy 0.6% 0.15% vs 0.08%, and VBAC-2 vs RCS four previous Epidural 58% vs 71% Women with vs 0.2% respectively, term HIE 0% vs 0.1% CS) vs 16 915 VBAC1 and prior vaginal transfusion 3.2% vs 1.6% 6035 RCS after delivery were Maternal morbidity two CS Previous more likely comparable with RCS classical CS excluded to undergo trial Garg18 (Saudi Arabia) 100 cases in VBAC-2 100 cases had No IOL or 66% success No uterine rupture or No difference in fetal Case series trial vs 71 trial (48% augmentation hysterectomy in either outcome reported elective CS and 34 non-trial of women with group, no data for although no data emergency CS. previous two CS) morbidity provided were provided Only previous low transverse uterine scars included Spaans31 59 cases VBAC-2 26% of women with IOL 24% 83% (49/59) had a Transfusion 4/59 (6.7%) Apgar <7 at 5 min 7% (The Netherlands) vs 187 RCS previous two vaginal birth vs 19/187 (10%) in NICU admission Cohort data Data on previous scar CS had trial Similar success rate with labour uterine rupture 34% from caesarean type not available history of vaginal delivery 1/59 (1.7%), and registry/delivery hysterectomy 1/59 records (1.7%), minor maternal morbidity comparable in VBAC and RCS Bretelle11 (France) 96 cases were VBAC-2 (52%) and Clinical/X-ray pelvimetry Success 65.6% Uterine rupture 0% 72 infants had Apgar Case series allowed a trial elective CS (48%) for allowing TOL. IOL12%, Blood transfusion 1% score >7 at of labour, 84 had syntocinon augmentation Hysterectomy first minute elective repeat CS 76%, pidural 76% secondary Only previous to atony 1%, no low transverse morbidity data for uterine scars included RCS group availableª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 5. Table 1. (Continued) Study Study Methods Labour Success rate Maternal Neonatal reference population management outcome outcome Caughey12 134 cases VBAC-2 Comparative study, IOL 20% vs 22% Uterine rupture 3.7% vs Uterine rupture 3.7% Birthweight 3530 g (North America) compared between VBAC-2 Syntocinon augmentation 0.8% (prior vs 0.8% (prior vaginal vs 3506 g Caesarean registry data with 3757 VBAC-1 and VBAC-1 (proportion of 38% vs 36%, vaginal delivery delivery was protective {5-min Apgar score Previous classical women undergoing epidural 72% vs 70% was protective of uterine rupture). <7.60%VBAC-2 scar excluded, trial unknown) of uterine Hysterectomy 1/134 vs 9.7%VBAC1 in others included rupture). Hysterectomy (0.74%) vs 7/3757 uterine rupture 1/134 (0.74%) vs (0.18%) group only} 7/3757 (0.18%) Emembolu14 Nigeria 139 cases with Proportion of women Women presented in 33% (46/139) achieved Uterine rupture Peri-natal death 12% Case series and previous two undergoing labour (usually advanced) vaginal delivery vs 1.4% vs 0.6% vs 12%, low Apgar controls (? matched) CS No information trial unknown 2.2% vs 8.9% syntocinon 62% in control Maternal death (not score <7 18% vs 17% on previous type of scar augmentation directly attributable) rate 7.2/1000 vs 5.9/1000, transfusion 35% vs 14% Jamelle23 (Pakistan) 10 cases with previous 9/10 presented Apparent disproportion All patients 1/10 scar rupture One (1/10) stillbirth Case series of 10 low segment in advanced was excluded by delivered vaginally required laparotomy associated with scar CS (9/10 unbooked, all labour, one vaginal examination. 1/10 septicaemia rupture, one neonatal unplanned vaginal delivery) admitted postdelivery No syntocinon death caused by No information on augmentation prematurity/septicaemia previous scar Asakura9 302 cases VBAC-2, Compared VBAC-2 Unrestricted use of 64% success Uterine rupture 1 min Apgar <3 in (North America) 1110 VBAC-1 with VBAC-1 IOL, syntocinon VBAC-2, 77% 3/302 (1%) vs 5/1110 failed VBAC-2 9.6%, Case series Previous low vertical and 69% after two CS and augmentation and in VBAC-1 (0.45%), hysterectomy failed VBAC-1 9.1% unknown uterine 92% after 1CS had trial. epidural, identical 0.33% vs 0% Asphyxial injury caused scars included to those with an by uterine unscarred uterus. rupture 0.33% vs 0.09% Chattopadhyay13 115 cases VBAC-2 Compared VBAC-2 Prostaglandin IOL Success 103/115 (90%) Scar dehiscence Peri-natal mortality 2.6% (Saudi Arabia) 1006 cases RCS (10%) and 37/115 (32%) Similar success rate with (0.8% vs vs 1%, deaths notª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology Case series Only previous elective CS (90%). Oxytocin augmentation history of vaginal delivery 0.7%) and considered directly low transverse Only 115/230 32/115(28%) hysterectomy related to mode uterine scars included requesting for a trial (0.8% vs 1.4%) of delivery were permitted comparable Granovsky-Grisaru20 26 cases VBAC-2 Control group from Only spontaneous labour 19/26 (73%) success No uterine scar Baby weight 2800–4600 g, (Israel) 26 controls RCS elective CS, denominator Syntocinon Ventouse delivery 4/26 rupture or dehiscence 5-min Apgar scores = 7–9 Case series 3/26 had three previous-CS data not given augmentation 54% Hospital stay No NICU admissions Only previous Epidural 80% average 3 days low transverse uterine scars included Success rate & adverse outcomes of vaginal birth after two caesarean sections9
  • 6. 10 Table 1. (Continued) Study Study Methods Labour Success rate Maternal Neonatal Tahseen, Griffiths reference population management outcome outcome Miller26 1827 previous two CS Compared VBAC-2 No information Success 75% Uterine rupture Rupture related (North America) (1586 previous two CS, 241 with VBAC-1; available previous two 1.8% (vs 0.6% peri-natal death Cohort data previous ‡3 CS), 10 880 54% previous CS vs 83% .018% vs trials from caesarean previous one CS. Previous ‡2 CS had previous 1CS vs 0.05% registry/delivery classical scars excluded but trial vs 80% records unknown scars included! previous 1CS Guettier21 (France) 17/41 women with two A case series of 17 Included one home 9/17 (53%) vaginal No relevant No neonatal morbidity Case series previous uterine scars, delivery, 2 pt fully delivery, 3/9 actually morbidity in 17 cases, but three ncluding myomectomy/ dilated on admission had two CS major congenital hysterotomy abnormality Flamm16 5733 trial of labour All women undergoing No separate figures 69% success (168/245) No separate No separate figures (North America) after CS, including trial of labor (38% of for VBAC-2 for VBAC-2, 75% figures for VBAC-2 f or VBAC-2 Case series 245cases VBAC-2, previous CS) no separate for whole group previous classical scars denominator data for excluded but Pre two CS available unknown scars included! Hansell22 35 cases VBAC-2 21% of women with ‡2 Only spontaneous labour Success 77% (27/35). 0% uterine rupture 5 min Apgar score <5, (North America) 2/35 had previous previous CS had trial, No Oxytocin Higher success rate and hysterectomy none in the two Case series three CS, 1/35 135 cases without trial CS augmentation with history of in trial group groups pre.4 CS. 135 cases vaginal delivery Transfusion 1/35 (2.8%) non-trial CS vs 11/135 (8.1%) in Low transverse scars without trial CS Phelan28 501 cases VBAC-2 Compared VBAC-2 Oxytocin used for Success 69%. Uterine rupture 0% vs No perinatal deaths (North America) and 587 elective CS (46%) and elective induction (3.6%) Higher success rate with 0.2% on elective CS attributable to trial, Case series Previous unknown CS (54%) augmentation 53% history of Hysterectomy 0.2% vs 5 min Apgar <7 2.6% scars included vaginal delivery 1.2% in elective CS in VBAC-2 and 1.4% in Elective CS Novas27 36 cases having VBAC-2 Compared VBAC-2 36(52%) Oxytocin 47% Success 80% (29/36) Uterine rupture 1/ Apgar scores (North America) (nine had previous and non-trial CS, 33 (48%) 36–2.7%(H/O classical comparable, no figures Case series three CS) CSs revealed at provided. ERCS 33 laparotomy) vs 0/33 PND unrelated to trial Previous unknown Hysterectomy 0/36 uterine scars included vs 2/33ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 7. Success rate & adverse outcomes of vaginal birth after two caesarean sections patients and clinicians and to compare the level of risk No significant peri-natal No neonatal morbidity associated with VBAC-1 versus VBAC-2. All Apgar scors >7 Neonatal Success rates of trial of labour were available in all outcome included studies. Uterine rupture rates were given in all studies except one;16 reported trial of scar data after single morbidity at 5 min and multiple previous caesarean sections, and although success rates for single and multiple caesarean sections were specified, only a combined uterine rupture rate of 0.17% 2/55 (3.6%) hysterectomies. previous vertical scar, one (10/5733) for the whole study population was given. uterine rupture (two had Transfusion 1/55 (1.8%) vaginal del.3/55 (5.4%) placenta accrete) and Asymptomatic scar dehiscence found incidentally at caesar- endometritis, none in 10/30 failed trial had ean section was disregarded and only symptomatic scar Maternal outcome No uterine rupture ruptures were included in analysis. Different maternal mor- No scar rupture bidity indicators were reported in studies. Febrile morbidity was reported mainly in comparison to caesarean sections in several studies, hospital stay was mentioned only in few.15,18,20 No maternal morbidity data except uterine rup- ture were available in some studies reporting on large Success rate Success 77% 45% success 81% success cohorts from birth/caesarean registries, Miller26 reported (44/57) 17 322 cases of trial of scar from a 10-year period and Flamm16 reported 5733 trial of scar cases over 5 year. Hys- terectomy and blood transfusion rates were assessed, wher- Only spontaneous labour Only spontaneous labour Only spontaneous labour ever available. Other maternal morbidities as operative Oxytocin augmentation injury or ITU admissions were variably classified24,25 and management Labour were too diverse for the purpose of pooled analysis. augmentation 33% Oxytocin, 55% Oxytocin 19% epidural Few studies have considered the neonatal outcomes, limit- 5/57 (8%) ing the availability of neonatal data. Moreover, some studies reported neonatal morbidity only in cases of uterine rupture not the whole study population12,26 included this data would skew the adverse neonatal effects therefore only studies spontaneous labour (? matched) describing neonatal outcomes for all subjects were included (Table 2). No perinatal outcomes were reported by Porreco29 Selected sample, pre2 CS Selected sample, a report (indigent population, late and Chattopadhyay13. Apgar scores considered in few studies in spontaneous labour Self-selected motivated Methods describing VBAC-2 controls (64) ERCS comparator group comparator group were variably reported as 1-minute score or 1-, 5- and/or VBAC, vaginal birth after caesarean; RCS, repeat (third) caesarean section. 10-minute scores; 5-min Apgar scores below 7 (reported by booking), no patients. No Spaan,31 Gravnovsky-Grisarau,20 Phelan28 and Pruett30), 1-minute Apgar score below 39 and 5-minute Apgar score below 5.22 Bretelle11 reported the neonatal morbidity of their study as ‘72/96 newborns had Apgar scores superior to 7 at unknown uterine scars included first minute’, this statement was un-informative to assess neo- denominator data not available 57 cases VBAC-2 (18 had three 55 cases VBAC-2, denominator natal outcomes in their study. We considered Apgar scores 21 cases.Only low transverse data not available Previous uterine scars, denominator to be too diverse for aggregate comparison. Asphyxial injury/ transverse uterine scars, previous CS). Only low population HIE/perinatal death and neonatal unit admission rates, Study data not available where reported were pooled to assess neonatal outcome. The calculation of percentages were based only on the data from the papers reporting the relevant outcomes. If studies used different definitions of outcomes, a pooled analysis was not obtained. Table 2 shows the outcomes in Table 1. (Continued) all included studies. Table 3 shows comparison of VBAC-1 (North America) (North America) (North America) versus VBAC-2 reported in the same cohorts (six studies) Farmakides15 and only the paired available outcomes are tabulated. Case series Case series Case series reference Porreco29 Pruett30 Table 4 shows comparison of VBAC-2 with non-trial repeat Study (third) caesarean section within same cohorts (eight stud- ies), again only the paired outcomes are listed.ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 11
  • 8. Tahseen, Griffiths Table 2. Outcome of VBAC-2 for all included studies Study reference Numbers VBAC Uterine Transfusion Hysterectomy Asphyxial NNU VBAC-2 success Rupture injury/PND** Macones25 1082 807 (74.6) 20 (1.8) 10 (0.92) Landon24 975 648 (66) 9 (0.9) 31 (3.2) 6 (0.6) 1 (0.15) 75 (11.2) Garg18 100 66 (66) 0 (0.0) 0 0 Spaan31 59 49 (83) 1 (1.8) 4 (6.7) 1 (1.7) 0 (0.0) 15 (34.9) Bretelle11 96 63 (65.6) 0 (0.0) 2 (2.1) 1 (1.04) 0 (0.0) 0 (0.0) Caughey12 134 83 (62) 5 (3.7) 1 (0.75) Asakura9 302 194 (71) 3 (1) 1 (0.33) 1 (0.33) Chattopadhyay13 115 103 (89) 1 (0.7) 1 (0.89) Granovsky-Grisarau20 26 19 (73) 0 (0.0) 0 0 (0.0) 0 (0.0) 0 (0.0) Miller26 1827 1376 (75) 32 (1.8) 1 (0.05) Flamm16 245 168 (69%) NA Hansell22 35 27 (77) 0 (0.0) 1 (2.8) 0 (0.0) Phelan28 501 346 (69) 0 1 (0.2) Novas27 36 29 (80) (0.0) 0 Pruett30 55 25 (45) 3* (5.4) 1 (1.8) 2 (3.6) Farmakides15 57 44 (77) 0 (0.0) 0 Porreco29 21 17 (81) 0 (0.0) 0 Total 5666 4064 (71.7) 74/5421 (1.36) 49/2428 (2.01) 14/2512 (0.55) 3/3285 (0.09) 90/1156 (7.78) Values in parenthesis are expressed in percentage. *2/3 uterine ruptures diagnosed by palpation after successful vaginal delivery. **Prelabour stillbirths and postnatal deaths unrelated to mode of delivery (e.g. prematurity related) were not included. Table 3. Outcome of VBAC-2 versus VBAC-1: only outcomes with paired data available are included Study reference Group Number Success Uterine rupture Transfusion Hysterectomy PND/Asphyxial injury* NNU Macones25 VBAC-2 1082 807 (74.6) 20 (1.8) 10 (0.92) VBAC-1 12 535 9464 (75.5) 113 (0.9) 85 (0.68) Landon24 VBAC-2 975 648 (66) 9 (0.9) 31 (3.2) 6 (0.6) 1 (0.15) 75 (11.2) VBAC-1 16 915 12 490 (74) 115 (0.7) 273 (1.6) 35 (0.2) 14 (0.09) 1321 (9) Caughey12 VBAC-2 134 83 (62) 5 (3.7) 1 (0.75) 0 (0.0) VBAC-1 3757 2818 (75) 31 (0.8) 7 (0.19) 1 (0.02) Asakura9 VBAC-2 302 194 (71) 3 (1.04) 1 (0.33) 1 (0.33) VBAC-1 1110 856 (64) 5 (0.45) 0 (0.0) 1 (0.09) Miller26 VBAC-2 1827 1376 (75) 32 (1.8) 1 (0.05) VBAC-1 10 880 9063 (83) 63 (0.6) 2 (0.018) Flamm16 VBAC-2 245 168 (69) VBAC-1 5488 4123 (75) Total VBAC-2 4565 3276 (71.7) 69 (1.59) 41 (1.99) 8 (0.56) 3 (0.09) 75 (11.2) VBAC-1 50 685 38 814 (76.5) 327 (0.72) 358 (1.21) 42 (0.19) 17 (0.05) 1321 (9) Values in parenthesis are expressed in percentage. *Prelabour stillbirths and postnatal deaths unrelated to mode of delivery (e.g. prematurity related) were not included. OR = 1.48 of higher success rate in VBAC-1 group versusEffectiveness VBAC-2, CI 1.23–1.78 (Figure 2, P < 0.0001, Z = 4.18).Successful vaginal delivery was achieved in 4064/5666(71.1%) as shown in Table 2, ranging in studies from 45% Adverse maternal outcomesto 89%. The comparable rate in VBAC-1 group was higher38 814/50 685 (76.5%—Table 4); meta-analysis showed a Uterine rupture rate after VBAC-2 was reported in all stud-significant difference between the two groups with ies except by Flamm16. The pooled uterine rupture rate of12 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 9. Success rate & adverse outcomes of vaginal birth after two caesarean sections Table 4. Outcome of studies comparing VBAC-2 versus Repeat (third) Caesarean Section (RCS) Study reference No. cases Uterine rupture Transfusion Hysterectomy Fever Peri-natal death NNU admission Macones25 VBAC-2 1082 19 (1.76) 10 (0.92) 96 (8.8) CS 2888 1 (0.03) 34 (1.18) 366 (12.7) Landon24 VBAC-2 975 9 (0.9) 31 (3.2) 6 (0.6) 30 (3.1) 1 (0.1) 75 (11.2) CS 6035 0 (0%) 93 (1.5) 27 (0.4) 129 (2.1) 1 (0.02) 514 (9.1) Spaan31 VBAC-2 59 1 (1.7) 4 (6.7) 1 (1.7) 5 (8.4) 15 (35) CS 187 2 (1.06) 19 (10) 0 (0) 17 (9) 39 (23) Chattopadhyay13 VBAC-2 115 1 (0.8) 1 (0.8) 1 (0.8) CS 1006 7 (0.7) 15 (1.4) 15 (1.4) Granovsky-Grisarau20 VBAC-2 26 0 (0) 0 (0) 0 (0) 2 (7.7) 0 (0) 0 (0) CS 26 0 (0) 0 (0) 0 (0) 5 (19) 0 (0) 0 (0) Hansell22 VBAC-2 35 0 (0) 1 (2.8) 0 (0) 4 (11.4) CS 135 1 (0.7) 11 (8) 0 (0) 39 (28) Phelan28 VBAC-2 501 0 (0) 1 (0.2) 55 (11) CS 587 1 (0.17) 7 (1.2) 74 (12) Novas27 VBAC-2 36 1 (2.7) 0 (0) CS 33 0 (0) 2 (6) Total VBAC-2 2829 31 (1.09) 47 (1.68) 9 (0.40) 192 (6.03) 1 (0.09) 90 (8.49) CS 10 897 12 (0.11) 172 (1.67) 51 (0.63) 630 (6.39) 1 (0.01) 553 (8.85) Values in parenthesis are expressed in percentage.16 studies was 1.36% (74/5421) (Table 2), ranging 0–5.4% The rate of hysterectomy was reported in eight studies,within studies. Subgroup comparative analysis with VBAC- pooled average was 0.55% in VBAC-2 group, ranging1 in five studies (Table 3), revealed rupture rates 0.72% in within studies 0–3.6% (Table 2). Considering hysterectomyVBAC-1 versus 1.59% in VBAC -2; meta-analysis showed figures in the comparison of VBAC-2 and VBAC-1pooled OR = 0.42 of a uterine rupture in VBAC-1 group (Table 3), the rates were 0.56% versus 0.19%; meta-analy-versus VBAC-2, CI 0.29–0.60 (Figure 3, P < 0.0001, sis of three studies reporting hysterectomy rates comparingZ = 4.65). VBAC-1 versus VBAC-2, showed OR = 0.29 of hysterec- A lower risk of uterine rupture with history of prior vag- tomy in VBAC-1 versus VBAC-2 groups, CI 0.13–0.61inal delivery was indicated; Macones25 in a large birth reg- (P = 0.001, Z = 3.22, Figure 4). In the subset of data com-istry cohort reported a uterine rupture rate of 1.8% in paring VBAC-2 with repeat CS (Table 4), the hysterectomyVBAC-2 versus 0.9% in VBAC-1. Previous vaginal delivery rates were similar, 0.40% and 0.63%, respectively;appeared protective for uterine rupture as 0.5% compared meta-analysis of seven studies reporting the paired out-to 2.4% rupture noted, respectively, with and without a come showed OR = 0.75 of hysterectomy in VBAC-2previous vaginal delivery. Similarly Caughey12 reported group versus RCS, CI 0.23–2.43 (Figure 5, P = 0.63,subjects with previous vaginal delivery were one-fourth as Z = 0.48). Rate of major haemorrhage was not specified inlikely to have a uterine rupture as those without. any of the papers but numbers needing blood transfusionFigure 2. Success rate of VBAC-2 versus VBAC-1.ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 13
  • 10. Tahseen, GriffithsFigure 3. Uterine rupture rates in VABC-2 versus VBAC-1 groups.Figure 4. Hysterectomy rates in VABC-2 versus VBAC-1 groups.were given in eight studies, average 2.01% range 0–6.7% OR = 0.94 of having a blood transfusion in VBAC-2 versus(Table 2). Transfusion rates were lower in the VBAC-1 RCS, CI 0.45–1.96 (Figure 7, P = 0.86, Z = 0.17).group 1.21% versus 1.99% in VBAC-2 (Table 3); meta- Febrile morbidity was reported particularly in compari-analysis showed OR = 0.56 of having a blood transfusion son with repeat caesarean sections in six studies, 6.03% inin VBAC-1 versus VBAC-2, CI 0.40–0.77 (Figure 6, P = VBAC-2 and 6.39% in RCS group Table 4. Meta-analysis0.0004, Z = 3.52) and similar in repeat CS and VBAC-2 of six studies reporting the paired outcome showedgroups (1.67% and 1.68% respectively Table 4). Meta-anal- OR = 0.81 of febrile morbidity in VBAC-2 versus RCS, CIysis of six studies reporting paired transfusion rates showed 0.55–1.18 (Figure 8, P = 0.27, Z = 1.11).Figure 5. Hysterectomy rates in VBAC-2 versus RCS.14 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 11. Success rate & adverse outcomes of vaginal birth after two caesarean sectionsFigure 6. Blood transfusion rates in VBAC-2 versus VBAC-1 groups. VBAC-2 RCS Odds ratio Odds ratio Study or subgroup Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI Chattopadhyay 1994 1 115 15 1006 9.7% 0.58 [0.08, 4.43] Granovsky-Grisarau 1994 0 26 0 26 Not estimable Hansall 1990 1 35 11 135 9.4% 0.33 [0.04, 2.66] Landon 2006 31 975 93 6035 33.3% 2.10 [1.39, 3.17] Macones 2005 10 1082 34 2888 27.7% 0.78 [0.39, 1.59] Spann 2003 4 59 19 187 20.0% 0.64 [0.21, 1.97] Total (95% CI) 2292 10277 100.0% 0.94 [0.45, 1.96] Total events 47 172 Heterogeneity: τ² = 0.38; χ² = 11.05, df = 4 (P = 0.03); I² = 64% 0.01 0.1 1 10 100 Test for overall effect: Z = 0.17 (P = 0.86) Blood transfusion VBAC-2Blood transfusion RCSFigure 7. Blood transfusion rates in VBAC-2 versus Repeat (third) CS (RCS) groups. VBAC-2 RCS Odds ratio Odds ratio Study or subgroup Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI Granovsky-Grisarau 1994 2 26 5 26 4.2% 0.35 [0.06, 2.00] Hansall 1990 4 35 39 135 8.7% 0.32 [0.11, 0.96] Landon 2006 30 975 129 6035 23.9% 1.45 [0.97, 2.18] Macones 2005 96 1082 366 2888 28.9% 0.67 [0.53, 0.85] Phelan 1989 55 501 74 587 24.9% 0.85 [0.59, 1.24] Spann 2003 5 59 17 187 9.5% 0.93 [0.33, 2.63] Total (95% CI) 2678 9858 100.0% 0.81 [0.55, 1.18] Total events 192 630 Heterogeneity: τ² = 0.12; χ² = 14.38, df = 5 (P = 0.01); I² = 65% 0.01 0.1 1 10 100 Test for overall effect: Z = 1.11 (P = 0.27) Fever VABC-2 Fever RCSFigure 8. Febrile morbidity rates in VBAC-2 versus Repeat(third) CS (RCS) groups. Non-specific reassuring statements regarding maternal death attributed to mode of delivery occurred in 0.09%morbidity were given in some studies as ‘no maternal compli- (range 0–0.33%), Table 2. Neonatal unit admission ratescations occurred’,29 ‘no febrile morbidity noted’,30 ‘outcomes only were reported in some studies as an index of neonatalwere similar to hospital’s general obstetric population’.27 morbidity rather than Apgar scores. Pooled NNU admis- sion rate was 7.7% (range 0–34.9%), Table 2. The neonatal outcome of five studies comparing VBAC-1 and VBAC-2Adverse neonatal outcomes had similar rates for neonatal asphyxial injury/perinatalNeonatal Apgar scores are not analysed further due to vari- death (attributable to mode of delivery) after VBAC-2able reporting within studies. Asphyxial injury or perinatal (0.09%) versus VBAC-1 (0.05%) (P = 0.35, Mantel–Haens-ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 15
  • 12. Tahseen, Griffithszel). The NNU admission rates were also comparable pattern (rupture rate 1.8%25); ‘….and full thickness dehis-(P = 0.89, Mantel–Haenszel). Subgroup analysis of VBAC-2 cence found at caesarean section performed for acute fetalversus repeat (third) caesarean sections revealed rates of distress (rupture rate 1.8%26). Earlier studies which con-perinatal death/asphyxial injury, 0.09% with VBAC-2 versus tributed a heavy weight in the systematic review included0.01% with repeat caesarean sections (P = 0.14, Mantel– patients with unknown uterine scars (with possibility ofHaenszel), although the difference does not reach statistical unknown proportion of lower vertical/classical scars) andsignificance but may be clinically different. The NNU reported higher uterine rupture rates (3.6%12; 2.7%27;admission rates were similar as well (8.85 versus 8.49% 5.4%30; 1.8%26). A lower risk of scar rupture is indicatedP = 0.57, Mantel–Haenszel). in the subgroup in Table 4 (with data from more recent Non-specific reassuring statements regarding neonatal years), 1.09% as compared to a rate of 1.59% in subgroupmorbidity were given in some studies; Farmakides15 ‘there in Table 3 where earlier data (subjects26) contributed awas no significant perinatal morbidity’; Novas27 ‘no signifi- higher proportion. Where manual scar exploration after acant differences were observed between the two groups in successful vaginal delivery was routinely performed and fullgestational age, Apgar scores and birthweights and no rup- thickness uterine wall defects repaired,26,30 a higher scarture related perinatal death’; Garg18 ‘no difference in fetal rupture rate was reported. Manual scar exploration is nowoutcome’; no neonatal data were extracted from these rarely carried out and this together with a known lowerstudies. segment uterine scar may be a reason for lower scar rup- ture rates in more recent studies. Overall hysterectomy rate was 0.55%. A lower rate notedDiscussion after VBAC-1 (0.19%), however, rate after RCS (0.63%,This review shows that trial of vaginal delivery after two Table 4) was similar within subgroup analysis, which prob-caesarean sections is associated with a reasonable success ably reflects the higher surgical risks associated with previ-rate (71.7%), although lower than VBAC-1 (76.5%). The ous multiple caesarean sections including placenta accrete/adverse maternal outcomes of a trial of vaginal delivery praevia. Noteworthy, a lower threshold for hysterectomy inafter two previous caesareans are comparable to repeat Pruett’s paper30 (3.6%) was because of women’s desire for(third) caesarean sections, with similar hysterectomy tubal ligation, when scar defects were detected on manual(P = 0.63), blood transfusion (P = 0.86) and febrile mor- scar palpation after successful vaginal delivery.bidity (P = 0.27) rates. The adverse maternal outcomes The blood transfusion rates were similar as with RCSrates of VBAC-2 are higher than VBAC-1, but the absolute (1.68% versus 1.67%), as well as febrile morbidity (6.03%rates are small. The neonatal outcome data are limited, versus 6.39%). Higher febrile morbidity after a failed trialhowever, the available data does not indicate a significant of labour and in repeat caesarean sections (33%30, 28%22,difference (assessed by neonatal death/asphyxial injury and 19.2%20) reported in earlier studies has significantlyNeonatal Unit admission rates) between VBAC-2, RCS or reduced after advent of broad spectrum antibiotics andVBAC-1. Although our comparison was carried out with concern regarding postoperative infectious morbidity is notVBAC-1 group because of its wide acceptance, pragmatic a major issue in selecting mode of delivery.and rational comparison of maternal morbidity of VBAC-2 The proportion of women undergoing a trial after twois with RCS, as previous multiple operations would have a caesarean sections is variable between studies which mayhigher background risk43and the available alternative choice indicates variable selection criteria; from 9.2% by Landon24to women who already had two CS is a RCS. to 69% by Asakura9. A more selective approach may be The reluctance to offer a trial after two caesarean sec- associated with higher success and/or lower uterine rupturetions is likely to stem from concerns regarding scar rup- rate,24 but a clear pattern does not emerge.ture. Scar rupture is a rare event and individual studies are Neonatal morbidity with VBAC-2 assessed by neonatallimited by size making uterine rupture risk a difficult out- unit admissions was comparable to the RCS groupcome to assess, pooled data analysis provides more reliable (Table 4). The more important measure of neonatal mor-figures. The rupture rate in the pooled analysis was 1.36% bidity, hypoxic neonatal brain injury/death attributable to(Table 2). All included studies provided figures for scar mode of delivery was reported in six studies (3285 sub-rupture, slightly varying but clinically meaningful defini- jects), the pooled rates were 0.09% in VBAC-2 as comparedtions of rupture have been used in different studies as ‘dis- 0.01% in RCS group (P = 0.14) and 0.05% in VBAC-1ruption of uterine muscle and peritoneum—or disruption group (P = 0.34). The publications involved a time periodof muscle and extension to bladder or broad ligament’ in of one or two decades ago with less-advanced neonatalLandon24 (2006, rupture rate 0.9%); ‘Signs and symptoms facilities, hence the neonatal morbidity figures may not beof intra-peritoneal bleeding—or disruption of uterine scar representative of current practice given considerableimmediately preceded by non-reassuring fetal heart rate advances in neonatal care in recent years, moreover, the16 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
  • 13. Success rate & adverse outcomes of vaginal birth after two caesarean sectionsavailable data does not indicate a significant difference in (prospective randomised controlled studies) to control theVBAC-2 and RCS. effect of confounding variables. However, the substantial It has been identified that women who have had a prior body of accumulated evidence presented, especially largevaginal birth in addition to one prior caesarean delivery are cohort studies12,24,25 aiming to report on all women withmore likely to have a successful VBAC attempt compared previous multiple CS receiving trial or otherwise, showingwith women without a prior vaginal birth,41 and for the concordant results, provides more reliable evidence of effi-subset of women with prior vaginal birth as well as a cae- cacy and risks of trial of vaginal birth after two CS. In oursarean section, a trial of labour as opposed to an elective view, to completely exclude such patients from a trial is anrepeat caesarean delivery is associated with a decreased rate arbitrary decision, as although the relative risk of uterineof major maternal morbidities, postpartum fever and need rupture and of major complications is higher with a VBACfor blood transfusions.41 In our analysis considering two attempt than with repeat third caesarean delivery the abso-prior caesarean sections, a similar trend of higher success lute risk of such complications is small and overall mater-and lower uterine rupture rates are indicated in women nal morbidity is comparable. Patients keen to have a trialwho have had a prior successful vaginal delivery; Macones25, should be counselled to pursue a carefully monitored trialPhelan28 and Hansell22 noted better prospects for successful of labour. The risks involved should be considered in per-VBAC-2 (as for VBAC-1) for women with a previous vagi- spective keeping in mind risks/morbidity associated withnal birth, interestingly Chattopadhay13 and Spaan31 found policy of repeat elective caesarean advantage to this group; bearing in mind the latter twostudies are much smaller as compared to the studies indi- Limitationscating favourable outcome with a prior vaginal delivery. Ofnote is the American College of Obstetricians and Gynecol- The included studies span over time period of more thanogist’s recommendation that for women with two prior two decades; in late 1980s and early 1990s in the US werecaesarean deliveries, only those with a prior vaginal delivery times of high rates of trial of labour after caesarean. In theshould be considered candidates for a trial of labour.8 current decade, VBAC rate has fallen. Thus, it is not sur-Moreover, Macones et al.25 concluded that as the majority prising that there may be differences seen in the studies byof ruptures occurred in women whose labour was either different time periods that may reflect not that the oldinduced or augmented and in those who had not had a studies had inappropriately high rates, but that the currentprevious vaginal delivery; it would seem reasonable to par- studies represent biased populations in that only good/selfticularly target VBAC attempts in this lower risk group (i.e. motivated candidates are encouraged to consider a trial ofthose with a previous vaginal delivery) and avoidance of labour after caesarean. Moreover, patients may have beeninterventions as labour induction or augmentation to managed differently in labour for varying amounts of time.reduce the risk of rupture. However, a planned secondary Proportion of women having a trial after two CS is variableanalysis by the same group further commented40 that the from 9% to 69% among studies which may indicate heter-associations (lack of prior vaginal delivery, induction and ogeneous selection. Women having more than two CS wereaugmentation) do not lend themselves to prediction of scar included in some studies, although the numbers wererupture; hence clinicians will be justified in offering a trial small, some studies included patients with unknown uter-to wider group. Landon24 reached the same conclusion that ine scars (lower vertical/classical) which might have led toa requirement of prior vaginal delivery with multiple cae- higher complications risk. Method of prior uterine incisionsarean deliveries to be considered candidates for trial of has also not been described. The control groups, if chosen,labour seems unwarranted given the low risk of uterine were variable as well, some studies compared with VBAC-1rupture and adverse outcomes in this population. group and others with women having non-trial CS, which Women who already have had two prior caesareans may led to the sub-group analyses. There is possibility ofchoose to have a trial of vaginal birth or elect to have over-representation of favourable results within publishedanother caesarean section; such a choice may impact her literature, an inherent limitation of meta-analysis of obser-future pregnancies as risk of abnormal placentation (pla- vational studies, however, in the absence of randomisedcenta praevia/increta) increase with further surgery on trials on the subject, such analyses present reasonableuterus. A successful VBAC-2 attempt would improve pros- available evidence of efficacy and risks.pects of future pregnancies in terms of future success andneed for further caesareans. Conclusion Heterogeneous populations in included studies meritjudicious interpretation of results. Ideally, the comparison This pooled data analysis indicates that a trial of labour byshould be within cases eligible to have a trial and then women with a history of previous two caesarean sections isassignment to either elective CS or a trial of labour policy associated with success rate of 71.1% with associated riskª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 17
  • 14. Tahseen, Griffithsof scar rupture 1.36%. Success rate is higher for women previous caesarean birth. Number 155 (Replaces guideline Numberwith a prior history of vaginal delivery. More importantly, 147) Int J Gynaecol Obstet 2005;89:319–31. 8 American College of Obstetricians & Gynaecologists – Practice Bulle-the maternal morbidity is comparable with RCS. Although tin (July 2004) Vaginal Birth After Previous Cesarean Delivery Clinicalneonatal morbidity information is limited, the available Management Guidelines for Obstetrician-Gynecologists No does not indicate excessive risk. This information is 9 Asakura H, Myers SA. More than one previous caesarean delivery: aimportant for women and healthcare providers who are 5-year experience with 435 patients. Obstet Gynecol 1995;85:924–making choices about the type of delivery. Women request- 9. 10 Boabang P, Bogesits-Aufschneider R, Hug K. [Vaginal delivery aftering to have a trial after two caesarean sections should be two previous cesarean sections]. (in German) Zentralbl Gynakolcounselled appropriately considering available evidence; 1999;121:449–53.and should have the option of a carefully monitored vagi- 11 Bretelle F, Cravello L, Shojai R, Roger V, D’ercole C, Blanc B. Vaginalnal delivery available to them. birth following two previous cesarean sections. Eur J Obstet Gynecol Reprod Biol 2001;94:23–6. 12 Caughey AB, Shipp TD, Repke JT, Zelop CM, Cohen A, Lieberman E.Disclosure of interest Rate of uterine rupture during a trial of labor in women with one orNo financial disclosures or funding was involved in manu- two prior caesarean deliveries. Am J Obstet Gynecol 1999;181:872–script preparation. 6. 13 Chattopadhyay SK, Sherbeeni MM, Anokute CC. Planned vaginalContribution to authorship delivery after two previous caesarean sections. Br J Obstet Gynaecol 1994;101:498–500.MG conceived the idea and conducted literature searches. 14 Emembolu JO. Vaginal delivery after two or more previous caesar-Both MG and ST were involved in designing the study ean sections: is trial of labour contraindicated? J Obstet Gynaecolquestions, reviewed studies for quality, abstracted, tabulated 1998;18:20–4.and analysed data as well as preparation of manuscript. 15 Farmakides G, Duvivier R, Schulman H. Vaginal birth after two or more previous caesarean sections. Am J Obstet Gynecol 1987;156:565–6.Details of ethical approval 16 Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. VaginalPublished de-identified data were used in preparation of birth after caesarean delivery: results of a 15-year multicentre study.this manuscript, hence no ethical approval was required. Obstet Gynecol 1990;76:750–4. 17 Garg VK, Ekuma-Nkama EN. Vaginal birth following two cesareanFunding deliveries – are the risks exaggerated? 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