Vaginal Birth After Cesarean Section
(VBAC) Bibliography


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compiled primarily by: Philip J. Rosenow, M.D. < philip "at" netpath "dot" net >

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Primary sort by: Date of Publication, Secondary sort by: Author, Last Search: 6/2005

Disclaimer: This bibliography has been made publicly accessible in order to faciltate research by medical professionals. No claim is made for accuracy of the contents, nor is any guarantee made to update it over time, although we have updated it quarterly since 1996. Use at your own discretion.

Author Title Journal vol page yr Abstract
A case report: change in fetal heart rate pattern on spontaneous uterine rupture at 35 weeks gestation after laparoscopically assisted myomectomy J Nippon Med Sch 71 69 2004 Case report of a uterine rupture following myomectomy. Early signs of rupture included sudden onset of severe abdominal pain, frequent uterine contractions despite reassuring FHT tracing. Variable decelerations were not observed until 7.5 hours after onset.
Uterine rupture associated with misoprostol labor induction in women with previous cesarean delivery Eur JOG Rep Bio 113 45 2004 Retro, chart review of women undergoing misoprostol induction with Hx of prior cesarean versus those without Hx of PCS. Uterine rupture occurred in 4 of 41 patients (9.7%) in women with PCS who underwent misoprostol induction versus none in the no previous CS group.
(U of Minnesota)
VBAC: a pilot study of outcomes in women receiving midwifery care J Midwifery Womens Health 49 113 2004 Retro evaluation of the nurse midwife's role in VBAC. Conclusion: a larger prospective study is needed to provide evidence for determining the continuation of VBAC as part of midwifery care.
(St. Michael's Hosp)
Outcome of subsequent pregnancy 3 years after previous operative delivery in the second stage of labour: cohort Study BMJ 328 311 2004 Retro, cohort of 393 patients who required operative delivery either forceps of CS at full dilation.32% wished to avoid a further pregnancy, women with instrumental vaginal delivery more likely to opt for vaginal delivery than if they had CS. There was a high rate of success for those who attempted a vaginal delivery after CS — 94%.
Trial ol labor in patients with a previous cesarean section: does maternal age influence the outcome? AJOG 190 1113 2004 Cohort study, 3 age groups, <30, 30-34 and 35 and older undergoing a trial of labor after a previous CS. Of the 2493 patients who met the criteria, 1750 did not have a prior vaginal delivery. Found that the group 35 and older had a lower rate of successful TOL in both the history of previous vaginal delivery group and no previous vaginal delivery.
(U de Montreal)
Cervical ripening with transcervical Foley catheter and the risk of uterine rupture OG 103 18 2004 Retro of all pts. attempting VBAC. Compared those in spontaneous labor versus labor induction with amniotomy and/or oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter.. There were 2479 patients, 1807 had spontaneous labor, 417 had labor induced by amniotomy-etc and 255 had labor induced by transcervical catheter. The rate of successful VBAC was significantly different among the groups (78% versus 77.9% versus 55.7%) but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%)
(Universite de Montreal)
Modified Bishop's score and induction of labor in patients with a CPS. AJOG 191 1644 2004 Retro, all records of 685 patients who had induction of labor with Hx of PCS. There were 4 groups by Bishop score: 0-2, 3-5, 6-8 and 9-12. Group 0-2 had 187 patients with a successful VBAC rate of 57.5%. Group 3-5 had 276 patients with success of 64.5%. Group 6-8 had 189 patients with success of 82.5% and Group 9-12 had 33 patients with success of 97%. Statistically, the rate of uterine rupture was not significant (2.1%/1.8%/0.5% and 0% respectively)
Delivery related rupture of the gravid uterus: imaging findings Abdom Imaging 29 120 2004 Case report of uterine rupture in VBAC Dx by means of ultrasound and computed tomography
(Leicester Royal Infirm)
Risk of uterine rupture following induction of labour in women with a PCS in a large UK teaching hospital JOG 24 264 2004 Retro, all cases of labor inductions. There were 43,175 deliveries, 8761 induction of which 5047 were by prostaglandin. 138 had Hx of PCS. There were no uterine ruptures, and a 39% CS. Conclusion: prostaglandins are safe for inducing labor in women with previous CS but should be administered with caution.
(Orlando Reg. S. Seminole)
VBAC: safety for the patient and the nurse JOG Neonat Nurs 33 105 2004 Brief view of VBAC Hx. VBAC should be performed in hospitals equipped to care for women at high risk. Nurses caring for patients undergoing VBAC should be able to recognize and respond to the signs and symptoms of uterine rupture, including the most common symptom, which is a non-reassuring fetal monitor tracing. Nurses should be aware of the necessity for 24 hour blood banking, electronic fetal monitoring, on-site anesthesia coverage and continuous presence of a surgeon.
(Med. Col. VA)
Predicting failed trial of labor after primary cesarean delivery OG 103 282 2004 "A better system to predict the success or failure of trial of labor is needed.
(Case Western)
The impact of maternal obesity and weight gain on VBAC success AJOG 191 954 2004 Study of impact of maternal obesity on success of TOL for VBAC. BMI classified as underweight <19.8 kg/M2, normal BMI 19.8-24.9, overweight as 25-29.9 kg/M2 and obese as > 30kg/M2) Results of 510 patients attempting VBAC, 66% successful overall, obese had success of 54.6%, overweight had success of 65.5% and normal 70.5%
(Case Western)
VBAC: predicting success, risks of failure J Mat Fet Neonatal Med 15 388 2004 Retro chart review of patients with one PCS who delivered at their institution. 768 patients studied, 522 attempted VBAC with 66% success. Uterine rupture occurred in 0.8% of VBAC group. Women with successful VBAC had more spontaneous labor and less oxytocin use. There were no differences in outcome between the groups except more frequent low Apgar and increased endometritis in the failed VBAC group.
Childbirth preferences after cesarean birth: a review of the evidence Birth 31 49 2004 Cochran, MEDLINE, Earthstar, Psych INFO and CINAHL databases search patient data on preference for route of delivery. Found that those who has experienced a vaginal delivery were more likely to select trial of labor than women who did not have one.
Ruptured uterus in South Western Nigeria: a reappraisal Singapore Med J 45 113 2004 10-year retro, 61 cases of ruptured uterus only 25% with uterine scar.
(Good Samaritan)
The magnetic resonance imaging-based fetal-pelvic index: a pilot study in the community hospital. AJOG 190 1679 2004 Pt's who were planning VBAC were recruited for MRI pelvimetry and fetal ultrasonography at 37-38 weeks. A fetal-pelvic index was calculated, pregnancies were managed routinely. 13 patients attempted VBAC, the most favorable index 5/6 were successful, the two patients in the unfavorable index had failed attempt. Conclusion:
The use of comparative MRI pelvimetry and fetal ultrasonography is feasible in a community hospital and appears to have potential in enhancing the management of VBAC candidates.
(Saudi Arabia)
VBAC following 2 PCS — are the risks exaggerated? Ann Saudi Med 24 276 2004 Prior to 1996 all patients with Hx of 2 PCS had repeat CS, after 1996 appropriate patients were allowed to attempt VBAC. Labor was neither induced nor augmented. There were 205 patients in the study, 66 delivered vaginally, 68 had emergency CS, and 71 had elective CS. There were no scar dehiscence nor was hysterectomy required in either group. There rate of complications was lower in the vaginal group (4.5%) than in the CS group (19.4%)
Variables associated with successful VBAC after one CS: a proposed VBAC score. Am J Perin 21 447 2004 Retro, 475 patients with Hx of PCS, 136 had elective CS and 339 underwent a TOL of whom 82% were successful. Attempted to develop a scoring system based on 5 factors significantly associated with successful VBAC, each factor had 0-3 score. (Abnormal presentation as indication for first CS, previous VBAC, cervical dilation, gestational age <41 weeks and lower gestational age at the time of the first CS.) The proposed score may help obstetricians when counseling patients.
Induction of labor after one prior cesarean: predictors of vaginal delivery OG 103 534 2004 Statistical study of 429 women with Hx of PCS attempting VBAC, 77.9% successfully. Found only Hx of prior vaginal delivery associated with a successful outcome, odds ratio 3.75. Decreased likelihood of success as associated with prior CS for dystocia, induction at or past due date, need for cervical ripening and maternal gestational or preexisting diabetes. Level of evidence: II-2
Systematic review of the incidence and consequences of uterine rupture in women with PCS BMJ 329 19 2004 Medline, Cochran and Health STAR search, 568 full text articles, identifying 78 potential eligible studies, 21 rated at least fair in quality. Found that trial of labor increased risk of uterine rupture 2.7/1000 cases. For attempting trial of labor, the additional risk of perinatal death from uterine rupture was 1.4/10,000 and additional risk of hysterectomy was 3.4/10,000.
Conclusion: Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective cesarean sections would need to be performed to prevent one symptomatic uterine rupture.
(Oregon Health)
Safety of VBAC: a systematic review OG 103 420 2004 Meta-analysis from various sources
(Mt. Sinai, NY)
Increased success of TOL after previous VBAC OG 104 715 2004 Retro, 1,216 cases of attempted VBAC, 336 of which had hx of one or more successful VBAC. They had a 94.6% rate of success versus those without a Hx of previous VBAC success of 70.5%. Those with a previous normal vaginal delivery the rate of successful VBAC was 87.8%.
Conc: A Hx of a previous successful VBAC increases the likelihood for success with future attempts.
(Wayne State)
The effect of gestational age on TOL after PCS J Mat Fet Neonat Med 15 202 2004 Cohort study divided into 3 groups: 24-36 weeks gestational age, 37-40 weeks gestational age and >41 weeks. The rate of uterine rupture was sig. Greater in the advanced gestational age (0% versus 1% versus 2.7%) and the rate of successful VBAC was progressively lower (83% versus 75.9% versus 62.6%)
Predicting VBAC: a review of prognostic factors and screening tools AJOG 190 547 2004 Medline search, 13 of 100 studies applicable, "further research is needed"
(Oregon Health ans Science U)
Predicting VBAC: a review of prognostic factors and screening tills. AJOG 190 547 2004 Literature review, 13 of 100 eligible studies provided fair to good quality evidence for the predictive nature of 12 factors. Conclusion: there is little high-quality data to guide clinical decisions regarding which women are likely to have a successful TOL. Conducting high-quality research should be a national priority.
(U of Montreal)
Effect of prior vaginal delivery or prior VBAC on OB outcomes in women undergoing trial of labor. OG 104 273 2004 Observational, Pts. with only a PCS were compared to those with a PCS and either a previous vaginal birth or successful VBAC. 1,685 had PCS and no vaginal delivery, 198 had a vaginal delivery before the PCS and 321 had a VBAC. The rate of successful trial of labor was 70.1%, 81.8% and 93.1% respectively. Uterine rupture rate was 1.5%, 0.5% and 0.3% respectively. Patients with a prior VBAC had, in addition, a higher rate of uterine scar dehiscence (21.8%) compared with patients with a PCS (5.3%).
Conclusion: a prior vagina delivery and particularly, a prior VBAC are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery. In addition, prior VBAC is associated with an increased rate of uterine scar dehiscence. Level of evidence II-2
Uterine rupture in patients with a PCS: the impact of cervical ripening Amer J Peri 21 217 2004 Retro, examine factors associated with uterine rupture in patients attempting VBAC. 28 symptomatic ruptures in 972 attempts at VBAC (2.88%) The use of preinduction cervical ripening agents was significantly associated with an increased risk of symptomatic uterine rupture (odds ration 3.92) Conclusion: preinduction cervical ripening is associated with an increased risk of uterine rupture.
Vesicouterine fistula in pregnancy: a case report JOGCan 26 657 2004 Case report of a patient with hx of PCS presented at 23 weeks with Hx c/w SROM. Cystoscopy 3 days after admission demonstrated a ballooning of amnion into the bladder. Several days later she had a precipitous vaginal delivery. Two months late had a successful repair
(Oregon Ha SU)
The relationship of health care delivery system characteristics and legal factors to mode of delivery in women with PCS: a systematic review Womens Health Issues 14 94 2004 MEDLINE and healthSTAR search on the relationship of health care delivery system characteristics and legal factors to mode of delivery in women with PCS.
Conclusion: studies have focused primarily on rates of delivery modes rather than patient safety or health outcomes.
(Ohio State)
Maternal and perinatal outcomes associated with a trial of labor after prior CS NEJM 351 2581 2004 Prospective 4 years observational study of all women with singleton gestation and hx of PCS. Maternal and perinatal outcomes were compared between women who underwent TOL and those who had ERCS.
Results: VBAC was attempted by 17,898 patients and ERCS was performed on 15,801 patients. Symptomatic rupture occurred in 124 women undergoing TOL (0.7%). Hypoxic-ischemic encephalopathy occurred in no infants whose mothers had ERCS and in 12 infants in TOL group. 7 of these cases of HIE followed uterine rupture, including 2 neonatal deaths. The rate of endometritis was higher in the TOL group as was the rate of blood transfusions. The rate of hysterectomy and maternal death did not differ sig. Between the two groups.
Effect of peer review and TOL on lowering CS rates J Chin Med Assoc. 67 281 2004
(Brigham and Women's)
Results of a national study of VBAC in birth centers OG 104 933 2004 Prospective collection of pregnancy outcomes in 1,913 women attempting VBAC in 41 participating birth centers from 1990 to 2000. A total of 1,453 of the 1,913 presented to the birthing centers in labor, 24% were transferred to hospitals during labor, and 87% of these had VBAC. There were 6 uterine ruptures (O.4%), one hysterectomy, 15 infants with 5 minute Apgar scores <7 and 7 fetal/neonatal deaths. Most fetal deaths occurred in women without uterine ruptures. Half of the uterine rupture and 57% of the perinatal deaths involved the 10% of women with more than one PCS or who had reached a gestational age of 42. Conc: Birth centers should refer women who have had PCS to hospital for delivery
Risk of uterine rupture in labor induction of patients with prior CS: an inner city hospital experience AJOG 190 1476 2004 Retro, pts. who delivered with Hx of one or more prior CS, 3355 patients. They were divided into 4 groups: Oxytocin induction (n=430), misoprostol induction (n=142, spontaneous labor (n=2523) and repeat CS without labor (=438). Found that the rate of rupture was increased in all induction compared with spon. labor group. Among one previous CS groups, the rate of rupture in misoprostol was 0.8% and in the Pitocin group rupture rate was 1.1%.
(St. Francis
Maternal and neonatal morbidity after ERCS versus TOL after PCS in a community teaching hospital J Mat Fet Neonat Med 15 243 2004 Retro, all patients who delivered at term with Hx of PCS and no contraindication to VBAC were studied.1408 deliveries, 749/927 (81%) had a successful VBAC. There were no difference in rates of uterine rupture, transfusion, infection and operative injury. Neonates delivered by ERCS had higher rates of respiratory complications. Mother-neonatal dyads with a failed TOL sustained the greatest risk of complications.
(U of Penn.)
Diet-controlled gestational diabetes mellitus does not influence the success rates for VBAC AJOG 190 790 2004 Retro, 25,079 patients with Hx of PCS, 13,396 attempted VBAC 1995-1999 at 16 hospitals. Analysis was limited to 9437 without diabetes and 423 with diet controlled diabetes who attempted VBAC. The success for VBAC was 70% with those with gestational diabetes and 74% for non-gestational diabetes group.
Guidelines for VBAC J OG Can 26 660 2004 Medline search with the following guidelines:
  1. Patients with one PCS should be offered TOL with informed consent (IIB)
  2. The plan should be clearly documented in the patient's record (II-2B)
  3. Delivery should be where emergency CS is immediately available (II-2A)
  4. Each hospital should have a written policy regarding notification, etc.
  5. Suspected uterine rupture requires urgent attention
  6. Fetal monitoring is recommended
  7. Oxytocin is not contraindicated
  8. Medical induction of labor with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counseling
  9. Medical induction of labor with prostaglandin is associated with an increased risk of uterine rupture and should not be used except in rare circumstances
  10. Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used.
  11. A Foley catheter may be safely used to ripen the cervix
  12. Data suggest s that TOL after more than one PCS is likely to be successful but is associated with a higher risk of uterine rupture
  13. Multiple gestation is not a contraindication to TOL.
  14. Diabetes is not a contraindication to TOL
  15. Suspected macrosomia is not a contraindication to TOL
  16. Women delivering within 18-24 months after PCS should be counseled about the increased risk of uterine rupture
  17. Postdatism is not a contraindication to TOL
  18. Every effort should be made to obtain previous operative note

These guidelines were approved by the Clinical Practice Obstetrics and Executive Committee of the Society of Obstetricians and Gynecologists of Canada

Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester JOG Res 30 34 2004 Case report of a patient with Hx of emergency cesarean, low transverse incision, Transvaginal US showed a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall
(U of Penn)
Conservative management of vesicouterine fistula after uterine rupture Int Uro J Pelvic Floor Dysfunct 15 434 2004 Case report of vesicouterine fistulas after a uterine rupture followed an attempted VBAC. The base of the bladder was involved in the uterine rupture, this was repaired. On day 14 a cystogram revealed a vesicouterine fistula Rx with Foley.
Uterine rupture: differences between a scarred and an unscarred uterus AJOG 191 425 2004 Retro, 53 cases of uterine rupture, 26 in a scarred uterus and 27 without a uterine scar. Conclusion: Other than an increased involvement of cervix in the scarred uterus, there were no significant differences in maternal or perinatal morbidity noted.
(Maine Med. Center)
VBAC are declining rapidly in the rural state of Maine J Mat Fetal Neonatal Med 16 37 2004 Since institution of ACOG guidelines for VBAC in Oct. 1998 and July 1999 VBAC rate have declined over 50% from 30.1% to 13.1% and total CS rate has climbed from 19.4% to 24%.
(U of Washington)
Fetal heart rate changes associated with uterine rupture OG 103 506 2004 Case control study of uterine ruptures, there were 48 ruptures, 36 met inclusion criteria (operative confirmation, gestational age > 24 weeks, presence of one or more low transverse incisions and availability of fetal tracings) Fetal bradycardia in first and second stage of labor were the only criteria significantly increased with uterine rupture. There were no sig. differences with mild or severe variable decelerations, late decelerations, prolonged decelerations, fetal tachycardia or loss of uterine tone.
Changes in fetal heart rate and uterine patterns associated with uterine rupture JRM 49 373 2004 FHT and uterine patters of 50 women with uterine rupture were compared with 601 tracings of controls without scarred uteri. Interobserver and intraobserver agreements of FHT and uterine tracings in the uterine rupture group were excellent. Found much higher rates of severe fetal bradycardia, fetal tachycardia, reduced baseline variability, uterine tachysystole and disappearance of contractions in the uterine rupture group during the first stage. Found in the second stage of labor that the uterine rupture group had a much higher rate of reduced baseline variability, severe variable decelerations, uterine tachysystole and disappearance of contractions.
Making choices for childbirth: development and testing of a decision-aid for women who have experienced previous CS. Patient Educ Couns 52 307 2004 Description of development of an educational booklet about VBAC.
An audit on trends of vaginal delivery after one CS JOG 24 135 2004 Retro, 197 patients with Hx. of one PCS over a one year time frame, TOL was attempted in 51.3% of whom 65.3% were successful for an overall success of 33.5% of all patients with Hx. Of PCS.
An audit on trends of VBAC JOG 24 135 2004 Audit of 197 patients with one PCS over a 1-year period was undertaken. 35% overall attempted and were successful. Maternal request was the most common indication for ERCS.
Factors predisposing to perinatal death related to uterine rupture during attempted VBAC: retrospective cohort study BMJ 329 375 2004 Population based, retrospective cohort of all women with one PCS who attempted VBAC at term. There was a 74.2% success and a uterine rupture rate of 0.35%. The incidence of uterine rupture was higher in women who had not had a previous vaginal birth and those whose labor was induced with prostaglandins. The risk of perinatal death was increased in hospitals with less than 3000 births per year.
Spontaneous uterine rupture at an unusual site due to placenta percreta in a 21-week pregnancy with PCS. Clin Ex OG 31 239 2004 Case report of uterine rupture with a large transverse rupture at the posterior isthmus wall with a placenta percreta.
Unplanned VBAC after 2 PCS Niger J Med 13 410 2004 Case report of multigravid with 2 PCS having an unplanned VBAC successfully.
(Saudi Arabia)
VBAC in grand multiparous women Arch Gyn Ob 270 21 2004 Retro, 405 grandmultips with Hx of PCS. The outcome of 217 VBAC compared to the outcome of 217 multips. Found no statistical difference in outcomes of the groups. Multips required more labor augmentation.
Van Bogaert
(South Africa)
Mode of delivery after one PCS Int J GO 87 9 2004 Retro audit of 202 VBAC and 382 repeat CS. There were 108 ERCS and 274 emergency CS after unsuccessful TOL. Conc: dysfunctional labor accounted for most primary and repeat emergency CS, but not as a recurrent condition in the same parturients.
Comparison of maternal mortality and morbidity between TOL and elective CS among women with PCS. AJOG 191 1263 2004 Retro cohort of 308,755 Canadian women with PCS between 1988 and 2000. The rates of uterine rupture (0.65%), transfusions (0.19%), and hysterectomy (o.1%) were higher in the TOL group. Maternal in-hospital death rate was lower in the TOL group (1.6/100,000 deliveries) versus the elective CS group (5.6/100,000)

Author Title Journal vol pg yr Abstract
Ruptured uterus: a 7 year review of cases from Accra, Ghana J OG Can 25 225 2003 Retro, 193 uterine ruptures out of 82061 deliveries for an incid of 2.4/1,000 deliveries. Of the UR, 24.6% had a Hx of PCS, the most frequently associated factor was prolonged labor (33.6%) The perinatal mortality rate was 74.3%
Two vaginal deliveries after a classical cesarean section—case reports Niger Postgrad Med 10 110 2003 Case report of a patient with previous classical CS refusing repeat CS for both subsequent pregnancies and delivered at another hospital. "Suggests a more liberal attitude to allowing attempt a VBAC in a well-equipped facility"
Management of previous cesarean section Curr Opin OG 15 123 2003 Review. The absolute risk of VBAC remains small. The maternal and neonatal morbidity risk increases when VBAC fails which emphasizes the importance of careful selection.
The management of VBAC at term: a survey of Canadian obstetricians J OG Can 25 300 2003 Survey of 601 obstetricians who managed VBAC. Found considerable disparity in the approach of Canadian OB to the management of VBAC.
VBAC: review of antenatal predictors of success J OG Can 25 275 2003 Medline literature review
(U of Miss.)
VBAC versus elective repeat CS: weight-based outcomes A J OG 188 1516 2003 209 VBAC candidates stratified into groups by prepregnancy weight: gp I <200 pounds, gp II 200-300, gp III >300 pounds. The TOL success rates were: gp I = 81.8%, gp II 57.1% and 13.3% in gp III. Found that infectious morbidity was increased with increasing weight.
(Spartanberg, SC)
Application of learning theory to obstetric maloccurrence J Mat Fet Neon Med 13 203 2003 The avg. ObGyn performs 140 deliveries a year. The majority of brachial plexus injuries are transient and resolve within 6 months, between 8-22% last longer than 12 months. A clinician would encounter one of these every 33 years. Cerebral palsy occurs at a rate of 1-2/1,000 deliveries. One in ten is assoc. with perinatal asphyxia meaning that one case secondary to asphyxia will occur every 6667 deliveries and the avg. clinician would see one case every 48 years. Asphyxia with uterine rupture occurs in 1/2819 VBAC attempts so the avg. clinician would encounter a case every 403 years.
(Spartanburg, SC)
Maternal and perinatal complication with uterine rupture in 142,075 patients who attempted VBAC: a review of the literature A J OG 189 408 2003 MEDLINE search of 361 articles, 72 met criteria for inclusion. There were a total of 880 uterine ruptures in 142,075 trials of labor. Conclusion: Although relatively uncommon, uterine rupture is associated with several adverse outcomes.
(Dalhousie U)
Trial of labor compared to elective CS in twin gestations with a previous CS. J Ob Gyn Can 25 289 2003 Retro, 121 women with Hx of PCS and present twin gestation, 38 chose a TOL of which 28 delivered vaginally with no uterine ruptures, scar dehiscence, maternal death or increase in neonatal morbidity or morality. Women choosing repeat CS had a higher incid. of infectious morbidity. "Further research is needed as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.
(Dalhousie U)
Spontaneous versus induced labor after a previous Cesarean section OG 102 39 2003 Retro, 3745 patients with Hx of previous CS with a trial of labor, (2943 spontaneous labor, 803 induced). The induced group had more early postpartum hemorrhage, cesarean sections, and neonatal intensive care unit. There is a trend toward higher uterine rupture rates in those with induced versus spontaneous labor. (0.7% versus 0.3%) The rate of uterine rupture was higher in the prostaglandin group (1.1% versus 0.6%).
VBAC: a survey of practice in Australia and New Zealand Aust NZ J Ob Gyn 43 226 2003 Survey of practice, 67% returned. 96% agreed that VBAC should be presented as an option, varying from 90% agreed for previous breech indication, 88% for previous fetal distress indication, and 55% for FTP indication. 40% agreed that VBAC was the safest option and 44% disagreed. 2/3 would offer induction with 1/3 willing to use prostaglandin. Most respondents preferred to perform VBAC at a level 2 or 3 hospital, while 80-90% required anesthesia, neonatologist and OR crew within 30 minutes availability.
Dunsmoor-Su R
(U of Penn.)
Impact of sociodemographic and hospital factors on attempts at VBAC OG 102 1358 2003 Retro, cohort comparing all women with previous LTCS who attempted a TOL with those who elected to have a repeat CS for a total of 15,172 patients. Found that the odds of a trial of labor decreased significantly with increasing age, gravity and the number of previous CS. Medicaid patients had a higher odds of trial of labor than did privately insured patients. Patients with a nonrecurrent indication for previous CS had generally higher odds of trial of labor. Black women were more likely to have a trial of labor.
Conclusion: clinical and non clinical factors influence rates of attempted VBAC.
(U of Fla.)
Deciding on route of delivery for obese women with a prior cesarean delivery A J OG 189 385 2003 Historical cohort analysis of singleton deliveries in women with a body mass index 40or greater and one prior cesarean. There were 122, 61 in CS group and 61 in VBAC group. Results-the VBAC group had higher rates of chorioamnionitis (13.1% versus 1.6%), endometritis (6.6% versus 0) and composite puerperal infection (24.6% versus 8.2%). Mean cost of care was similar. Conclusion: compared with planned cesarean, VBAC trials in obese women are 3 times as likely to be complicated by infection and do not result in reduced costs.
(U of Penn)
The effect of birth weight on vaginal birth after cesarean delivery success rates A J OG 188 824 2003 Retro, from 16 community and university hospitals, 9960 patients attempting VBAC after one previous CS. Four groups: no previous vaginal deliveries, one prev. vaginal birth B4 CS, one prev. vaginal birth after CS and vaginal births B4 and after CS. The overall success rate was 74% (65%, 94%, 83% and 93% respectively) Conc: women with a previous vaginal birth should be informed of the favorable risk. The success rate with no previous vaginal births and EFW of > 4,000 gms was <50%. The uterine rupture rate in the first group with infants > 4,000 gms was 3.6%
Fenwick Women's experiences of CS and VBAC: a birthrites initiative Int J Nurs Pract 9 10 2003 Psychological statement from a small pilot study of 59 women survived by mail
(Winthrop U Hosp)
Posterior uterine rupture in a woman with a previous CS J Mat Fet Neo Med 14 130 2003 Case report of 33 yo G2, Hx. of previous CS, underwent labor induction at 41 weeks with dinoprostone vaginal insert. Labor was eleven hours, when the patient was fully dilated she developed repetitive late decelerations followed by fetal bradycardia. A posterior uterine wall rupture extending from the fundus to the vagina was repaired. Neonate expired on the 7th day of life.
Neonatal outcome after trial of labor compared with elective repeat CS Birth 30 83 2003 Compared low-risk, 1-2 previous CS from December 1994 to July 1995 were identified. 136 patients with ERCS were compared with 313 women who delivered after a TOL. Found that TOL group had an increased rate of infant diagnostic tests and therapeutic interventions but that was from a smaller sub-group who had an epidural.
Placenta Percreta: report of two cases and review of the literature Clin Exp OG 30 70 2003 Case report of two placenta percretas, one of which had 2 previous CS.
(RWJ MedSchool)
Physician CS rates and risk-adjusted perinatal outcomes OG 101 1204 2003 Population based study, divided physicians into 3 groups low (CS rate < 18%), medium (18-27%) and high rate (>27%) Found that low rate physicians had fewer uterine ruptures but a higher rate in intracranial hemorrhages.
VBAC: Trial of labor or repeat Cesarean section? A decision analysis A J OG 189 714 2003 Model using a decision tree. The model favors a trial of labor if it has a chance of success of 50% or above and if the wish for additional pregnancies after a cesarean section is estimated at near 10-20% or above because the delayed risks from a repeated cesarean section are greater than its immediate benefit.
(U of Wash)
Uterine rupture during VBAC trial of labor: risk factors and fetal response J Midwifery Womens Heatlh 48 249 2003 Review of risk factors for uterine rupture during VBAC-TOL.
(Baystate Med. Cntr)
Vernixuria: another sign of UR J Perinatol 23 351 2003 UR complicates approx. 1% of TOL. Classical signs are loss of station, cessation of labor, vaginal bleeding, fetal distress and abdominal pain. Case report of UR indicated by vernix and blood in Foley catheter.
(Uof Penn)
Current concepts regarding VBAC Curr Opin OG 15 479 2003 Review of current literature.
Uterine rupture: risk factors and pregnancy outcome A J OG 189 1042 2003 Population based study comparing all singleton deliveries with and without uterine rupture between 1968 and 1999. There were 117,685 deliveries and 42 uterine ruptures (0.035%) There were three risk factors found for uterine rupture: previous cesarean section, malpresentation and dystocia during the second stage.
VBAC: clinical and legal perspectives OG Cand 25 846 2003 Discussion, the common practice of attempting VBAC warrants some reconsideration in light of recent clinical data on the risks associated with VBAC. It is incumbent upon clinicians to ensure that women under their care are fully aware of these risks. Indeed, in some circumstances, an attempt at VBAC may be perceived by the courts to represent a negligent standard of care.
(Saudi Arabia)
Uterine rupture incidence, risk factors and outcome. Saudi Med J 24 37 2003 Retro review of 23245 deliveries with 23 women with Dx of uterine rupture. 15 (65%) occurred in women with PCS and 8 (34.8%) had no previous uterine surgery. In the previous CS group, 2 women sustained bladder injury, one subsequently developed a vesico-vaginal fistula. In the unscarred uterus, one person died, one developed renal failure, 3 fetal deaths, 4 patient required hysterectomy. Conc: In our circumstances, uterine rupture is not rare and consequences can be life threatening. The outcome is worse in women with unscarred uterus.
(U of Montreal)
Twin delivery after a PCS: a 12 year experience J OG Can 25 294 2003 Observational study of patients with twins and a Hx of PCS. 26 women in TOL group and 71 in the repeat CS group. Found that the only difference was that the TOL group had a shorter hospital stay.
Extrusion of fetus into the abdominal cavity following complete rupture of uterus: a case report Eur J Ob Gyn Repro Biol 109 110 2003 Case report of G10P9, one previous CS, 4 successful VBACs after CS, presented at term complaining of abdominal pain. Severe bradycardia was observed and emergency CS was performed with the findings of a complete uterine rupture, the fetus in intact membranes and placenta was found in the abdominal cavity.
Post-cesarean delivery fever and uterine rupture in a subsequent trial of labor. OG 101 136 2003 Nested, case-control study in a cohort of all women undergoing TOL after CS in a 12-year period. 21 cases of uterine rupture, the rate of fever after previous delivery was 38% in the uterine rupture group and 15% of the controls. Conc: postpartum fever after CS is associated with an increased risk of uterine rupture during a subsequent trial of labor.
(Winthrop U Hosp. NY)
Uterine rupture associated with castor oil ingestion J Mat Fet Neo Med 13 133 2003 Patient 39 weeks gestation and Hx of prior cesarean section ingested 5 cc castor oil. 45 minutes later, repetitive variable decelerations prompted a CS. At surgery, a portion of the umbilical cord was protruding from a 3 cm. Rupture of the lower transverse scar.
(Northwestern U)
VBAC—is it worth the risk Semin Perinatol 27 105 2003 Enthusiasm for VBAC has waned. As a result, the CS rate is again on the rise. As a medical community and society we must decide whether the most appropriate question is "what is safest for my baby" or "is the risk associated with VBAC acceptable?" There are risks assoc. with VBAC but in a hospital setting with appropriate resources these risks are low and would still seem to be acceptable.
Success rate of VBAC at Maharaj Nakorn Chiang Mai Hospital J Med Assoc Thai 86 829 2003 Prospective study of 177 pregnant patients with one or two prior CS. Non-directive counseling concerning VBAC and repeat CS were given. Of the 177 patients, 118 chose VBAC, 33 were excluded leaving 98 in the VBAC group and 46 in the repeat CS group. 19 of the planned VBAC had CS because of obstetrical indications or changed their mind leaving 79 trial of labors. 43 of the 79 were successful, 36 underwent CS for obstetrical indications, The success rate for VBAC after trial of labor was 54%.
VBAC in a small rural community with a solo practice Am J Perinatol 20 63 2003 Retro review of all deliveries over an 11-year period by a single practitioner in a rural community. 74% of patients with Hx of PCS (413) attempted VBAC and 75% of those were successful. There were no incidents of maternal or neonatal death and no uterine rupture.
(Hong Kong)
Use of fetal-pelvic index in the prediction of VBAC J OG Res 29 104 2003 170 women with one PCS attempting a TOL enrolled. US was performed at 38-39 weeks to measure fetal head and abdominal circumference and a fetal-pelvic index was derived. Did not find it useful in clinical practice.

Author Title Journal vol pg yr Abstract
ACOG Committee Opinion Induction of labor for VBAC OG 99 679 2002 Committee opinion: review of current literature. Conclusion: Rate of uterine rupture with spontaneous labor in VBAC is 5.2/1000, labor induced with Pitocin is 7.7/1000 and prostaglandin 24.5/1000. Committee concludes that the risk of uterine rupture during VBAC attempts is substantially increased with the use of various prostaglandin cervical ripening agents for the induction of labor and their use for this purpose is discouraged.
(Saudi Arabia)
Obstetric and perinatal outcome of women para J Ob Gyn Res 28 163 2002 Retro., of all women (238) whose parity was > 5 and in whom there was one previous CS. Found an increased incid of fetal malpresentation, uterine rupture and scar dehiscence. There was no increase in perinatal or maternal mortality.
(Saudi Arabia)
Placenta percreta with painless uterine rupture at the 2nd trimester Saudi Med J 23 857 2002 Case report uterine rupture in case of placenta percreta
Ripening of the uterine cervix in a post-cesarean parturient: prostaglandin E2 versus Foley catheter. Jmat Fet Neo Med 12 42 2002 Retro, cohort of 161 patients with PCS undergoing cervical ripening with Foley versus 55 with PGE2 and control gp of 1432 PCS patients without induction. Conclusions: PGE2 was found to be superior to Foley for ripening of the uterine cervix as demonstrated by a lowered repeated CS delivery rate.
Interdelivery interval and uterine rupture AJOG 187 1199 2002 Observational cohort, 1527 patients attempting VBAC after one PCS. Uterine rupture rate was 4.8% for interdelivery interval of < 1 year, 2.7% for interval of 13-24 months and 0.9% for > 24 weeks. Conclusion: an interdelivery interval of < 24 months was associated with a 2-3 fold increase in the risk of uterine rupture.
Neonatal Morbidity associated with uterine rupture: what are the risk factors? AJOG 186 311 2002 Retro., 2233 TOL had 23 cases of uterine rupture after a previous LTCS. Nine infants (39.1%) had severe acidosis (pH <7.0), among these, 3 neonates had severe hypoxic-ischemic encephalopathy and another neonate died. Placental or fetal extrusion or both were associated with severe metabolic acidosis but not with other factors (birth weight, induction of labor, use of oxytocin, epidurals and cervical dilatation). Two newborns with severe acidosis had impaired motor development even with an intervention time less than 18 minutes from the onset of prolonged deceleration to delivery. Conclusion: When uterine rupture occurs, placental or fetal extrusion was the most important factor associated with severe metabolic acidosis; Prompt intervention did not always prevent severe metabolic acidosis and neonatal morbidity.
(U of Washington)
VBAC: a national survey of US midwifery practice J Midw Womens Health 47 347 2002 Survey of 325 midwifery practices about VBAC practices with a 62% return rate. Found that criteria for VBAC were stricter and consent forms more extensive.
Pregnancy after classic CS OG 100 946 2002 Retro, 37,863 deliveries in 10 years, 157 had classic incision. In the next pregnancy, there was 1 rupture with 9% dehiscence. There were no sig differences in the dehiscence and control group. Conclusion: among patients with prior classical incision, uterine rupture and dehiscence are neither predictable nor preventable. One in four patients will experience some form of maternal morbidity. Uterine rupture, although infrequent, can be fatal to the fetus.
Reduction of occurrence of uterine rupture in Central India JObGyn 22 39 2002 Retro, 12 cases of uterine rupture with incidence of 0.62/1000 births. 4 were with patients with a PCS, 5 were with malpresentations, 4 lack of progress, 2 abnormal placentation, and 1 with case of hydrocephalus. Perinatal mortality was 77% and there was one maternal mortality.
What are the implications for the next delivery in primigravidae who have an elective cesarean section for breech presentation BJOG 109 624 2002 194 patients who had an elective CS for breech as primigravidas. 9.8% had another breech compared with only 1.7% of control group. The overall CS rate was 43.8% in the group with previous CS for breech although 84% of those allowed to labor were successful.
Diaz Riverside
(Regional Medical Center, VA)
Uterine rupture and dehiscence: ten-year review and case-control study. Southern Medical J 95 431 2002 Retro., 25,718 deliveries at Riverside Regional Medical Center from 1990 to 2000 were reviewed. RESULTS: Eleven uterine ruptures and 10 dehiscences occurred during this period (0.08%). In this group of rupture/dehiscence there was one maternal death (5%) and three neonatal deaths (14%). Other complications included intrapartum non reassuring fetal status (67%), 5-minute Apgar score < 7 (52%), maternal blood transfusion (24%), neonatal hypoxic injury (14%), hysterectomy (14%), and endometritis (10%). Uterine rupture/dehiscence was independently associated with fetal weight > or = 4,000 g, non reassuring fetal status, use of oxytocin, and previous cesarean delivery; internal fetal monitoring reduced the risk of uterine rupture/dehiscence. CONCLUSIONS: To reduce the risk of uterine rupture/dehiscence, a delivery plan should include assessment of cesarean history and fetal macrosomia, judicious use of oxytocin, and intrapartum monitoring for non reassuring fetal pattern.
(U of Fla)
VBAC: a historic and cohort cost analysis AJOG 186 890 2002 Historic cohort analysis of 204 mother infant pairs, 139 in the TOL group and 65 in the ERCS group in 1999 with the primary outcome variable being mean cost. The mean cost of TOL for mother/baby pairs was $5949 for ERCS and $4863 for the TOL group.Conclusion: In women with a single PCS, a TOL is more cost-effective than an ERCS.
VBAC: what's new in the new millennium? Curr Opio Obsete Gynecol 14 595 2002 Review of trends in the last 2 years. Summary: the recent trend has been towards a more cautious approach to VBAC. Some are concerned that this trend may limit childbirth options for those women who wish to avoid repeat CS.
(Riverside Regional Medical Cntr)
VBAC: Current Status JAMA 287 2627 2002 Review article, The rise and fall of VBAC exemplifies fundamental shifts in medical care in the past 20 years. Previously, physicians made most medical decisions, control then shifted to managed care dictates. Increasing pressure by both physicians and the public is now shifting decisional authority back to physicians and their patients. However physicians are serving more in a consultative and advisory role. The current guidelines and dynamic tensions between physician and patient will drive the national VBAC rate dramatically down.
(Queen's Medical Center)
Prediction of vaginal delivery following CS for failure to progress based on the initial aberrant labor pattern Eur J Ob Gyn Repro Bio 101 121 2002 Retro, chart review of 171 patients with Hx of PCS for FTP and subsequently delivered at their hospital. Cervicograms were categorized into one of the four patterns. Conc: categorization did not predict subsequent successful VBAC.
(U of C, Irvine)
Interdelivery interval and the success of VBAC OG 99 41 2002 Retro, cohort study from 1997-2000 of pts with PCS attempting VBAC. A total of 1516 pts attempting VBAC were found in 24,162 deliveries. The success rate was 79% with an interdelivery interval of less than 19 months compared with a success of 85.5% if interval was greater than 19 months (not sig) They did find that if the labor was induced there was less success in the interval < 19 months group.
(Delhousie U Nova Scotia)
A 10-year population-based study of uterine rupture OG 100 749 2002 Population-based review of 114,933 deliveries with 39 cases of uterine rupture, 18 complete rupture and 21 incomplete (uterine dehiscence). 36 of the 38 had a history of a PCS (33 LTCS, 2 classical and 1 low vertical). 11,585 deliveries were in patients with a PCS. UR was 2.4/1,000 deliveries and UD was 2.4/1,000 deliveries. There were no maternal deaths. Uterine rupture was associated with sig. More maternal blood transfusion and neonatal asphyxia.
(Northeastern Ohio U)
A state-wide assessment of the obstetric, anesthesia and operative team personnel who are available to manage the labors and deliveries and to treat the complications of women who attempt vaginal birth after cesarean delivery AJOG 187 611 2002 All obstetrical units in Ohio surveyed about immediate availability of OR crew, anesthesiologist and obstetrician for patient attempting VBAC. 94% of Level I units allowed VBAC attempt while level II and III all allowed attempted VBAC. An obstetrician was immediately available 27.3%, 62.9% and 100% of level I, II, III respectively. Anesthesia was available 39%, 100% and 100%. A surgical team was immediately available 35.1%, 97.1% and 100%. Two hospitals had stopped offering VBAC and an additional ten were considering stopping.
Martin Births: final data for 2001 Natl Vital Stat Rep 51 1 2002 The CS delivery rate rose for the fifth consecutive year to 24.4%, the primary CS rate was up 5% and the rate of VBAC fell 20%.
(Jackson State U)
Reducing CS rates in managed care organizations Am J Manag Care 8 730 2002 Review of methods to encourage a decrease of CS rate from present 22% to 10-15% as proposed by WHO. "The Medical Care Organization objective would be to lower CS rates without alienating physicians or attempting to impose a regimented approach that would offend and be counterproductive for consumers".
Management of VBAC J Ob Gyn Res 28 240 2002 468 patients with PCS, 365 gave consent for study protocol which was basically awaiting labor, using breathing to avoid straining until vacuum assisted delivery could be accomplished to avoid straining, controlling the intrauterine pressure. Of 322 TOL, 88.2% were successful. There were 2 cases of uterine rupture and one fetal death.
MMW VBAC - California 1996-2000 MMWR 51 996 2002 VBAC rate in California decreased 35% from 23% to 15%
MMWR VBAC   California 1996-2000 MMWR Center for Disease Control and Prevention 51 996 2002 General discussion of CS rates and CS/VBAC rates in California from 1996-2000. In 2000 the overall CS rate was 23%, 37% of which were repeat CS. A national objective is to reduce primary CS rate to 15% and 63% in those who have had a PCS. A key strategy to reduce repeat CS rate is to promote VBAC as an alternative to ERCS. During 1989-1999 the VBAC rates increased from 19% in 1989 to 28% in 1996 and then decreased to 23% in 1999. California VBAC rate has decreased from 35% in 1996 to 15% in 2000.
(U of Mich.)
VBAC Safer than you think ObG Management 14 56 2002 Article discussing some of the literature on VBAC, pros and cons, management with a favorable tilt towards VBAC.
Epidemiological features of uterine rupture in West Africa (MOMA Study) Paed Perinatl Epidemiol 16 108 2002 Cohort study identifying 25 cases of clinically symptomatic uterine rupture in a population of 20,326 deliveries. Five variables were significantly associated with uterine rupture: PCS, malpresentation, limping, CPD and high parity.
(Nassau U Med Cent, NY)
"Endoview" project of intrapartum endoscopy JSLS 6 175 2002 28 patients with unknown or poorly documented scar were subjected to intrauterine endoscopy after ROM. Were able to visualize all scars.
The association of maternal age and symptomatic uterine rupture during a trial of labor after prior Cesarean Delivery OG 99 585 2002 Retro., evaluated charts on all patients attempting TOL over a 12 year span, one prior CS, no prior vaginal deliveries. Overall, 32 (1.1%) uterine ruptures occurred among 3015 patients. Of women < 30 years old. The risk of rupture was 0.5% and for those > 30 the risk of rupture was 1.4%. After controlling for birth weight, induction, augmentation and inter-delivery interval, the odds ratio for symptomatic uterine rupture for women > 30 yo was 3.2 (95% confidence interval 1.2, 8.4)
(Cambridge U)
Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies JAMA 287 2684 2002 Population based, retro, cohort. 313,238 singleton, cephalic term births. There were 15,515 attempted TOL with an overall delivery related perinatal death rate of 12.9/10,000 deliveries. This was approximately 11 times greater than the risk of planned cesarean section and more than double the risk with multiparous women in labor and similar to the risk among nulliparous women in labor.Conclusion: The absolute risk of perinatal death associated with TOL following previous CS is low. However, in our study, the risk was significantly higher than that associated with planned repeat cesarean delivery and there was a marked excess of deaths due to uterine rupture compared with other women in labor.
(Saudi Arabia)
Induction of labor with prostaglandin E2 vaginal tablets in parous and grand multiparous patients with PCS. IJOG 78 19 2002 Prospective study of 113 patients with one PCS of low parity and high parity and induction of labor with prostaglandin tablets. Found no statistical difference in complications. There was one uterine rupture in each group.
(The Netherlands)
Risk factors at cesarean section and failure of subsequent trial of labor Eur J O G Reprod Biol 100 163 2002 Retro. of hospital records 1988-1999 of index pregnancy compared to subsequent pregnancy for successful outcome VBAC. Conclusion: Women who attempt VBAC may be informed that a labor pattern of their index pregnancy characterized by oxytocin use, contractions of more than 12 hours and slow dilatation is associated with a reduced chance of success.
Delivery strategies for women with a previous classic cesarean delivery: a decision analysis AJOG 187 1203 2002 Hypothetical cohort analysis, predicted that a 36 weeks delivery may be preferable providing a lower risk of severe adverse outcomes and higher maternal quality of life.
(St. Alexius, Illinois)
Uterine rupture with the use of PGE2 vaginal inserts for labor induction in women with previous CS. JRM 47 549 2002 Retro., 58 patients with Hx of PCS undergoing induction of labor with PGE2. 10% of these experienced a uterine rupture. Conc: the risk of UR is significantly increased when a PBE2 vaginal insert for CX ripening/induction is used.
Uterine rupture: what family physicians need to know Am Fam Phys 66 823 2002 Review article
Uterine Rupture Best Pract Res Clin O G 16 69 2002 Chapter examines the incidence, etiology, clinical presentation, complications and prevention of uterine rupture. The key factor in the cause of rupture is whether or not the uterus is scarred and usually occurs after a TOL in a patient with a PCS.
Strategies to address global CS rates: a review of the evidence Birth 29 28 2002 Discussion of interventions that have been used to attempt to reduce Cesarean sections.
(Shangi, China)
Effect of early pregnancy on a previous lower segment CS scar Int J Gyn Ob 77 201 2002 Retro of 15 cases of early pregnancy implanting on uterine scar from previous CS

Author Title Journal vol pg yr Abstract
Fetal survival despite unrecognized uterine rupture resulting from previous unknown corporeal scar. Arch Gyn Ob 265 89 2001 Case report of uterine rupture
(Salmaniya Medical)
Risk factors of uterine rupture Saudi Med J 22 702 2001 45 uterine ruptures for an incid of 1 in 2213 deliveries. Risk factors for uterine rupture include: previous cesarean, prior CS for CPD, malpresentation, induction and augmentation. Conclusion: Careful monitoring needed. Use of Oxytocin or prostaglandin should be used judiciously to prevent catastrophic uterine rupture.
(U. Mich.)
Characteristics of fetal heart rate tracings prior to uterine rupture Int J Gyn Ob 74 235 2001 Retro eval of FHT for 2-hour period before uterine rupture (dehiscence excluded) 11 patients had uterine rupture, 7 of the 11 had operative or post-operative complications. There were no maternal deaths. 8 tracings were available for review, 7/8 (87.5%) had recurrent late decelerations and 4/8 with terminal bradycardia. All 4 infants with fetal bradycardia were preceded by recurrent late decelerations. Conclusions: The most common FHT pattern occurring before uterine rupture was recurrent late decelerations and bradycardia.
VBAC in a population with a low overall CS rate. Eur J Ob Gyn Reprod Biol 96 158 2001 Prospective, population based study. Dutch overall CS rate of 6.5%. Study of 252 patients with previous CS. The TOL rate was 73%, success rate was 77%. The reason for the first CS influenced success rate. Complications, morbidity and mortality were not different between ERCS, TOL and emergency CS groups except for a higher incidence of hemorrhage in the elective CS group.
VBAC: the European experience Clin OG 44 594 2001 Review of the European experience with VBAC.
(Metro West Medical)
Is VBAC safe? Experience at a community hospital AJOG 184 1478 2001 4-year prospective, cohort in a community hospital. Total number of PCS were 1481, 727 had ERCS whereas 754 attempted VBAC. Found that the attempted VBAC rate declined significantly in the last two years. There were 2 neonatal deaths caused by uterine rupture. 12 uterine ruptures occurred for a rate of 1.6% and 11 of the 12 ruptures involved with induction or augmentation of labor. Conclusions: VBAC is safe provided that induction of labor is not used.
VBAC following 2 previous CS Eur J OG RB 94 23 2001 Retro, 180 patients with 2 previous CS, 96 had normal pelvic dimensions and were allowed a TOL. Success rate was 65.5%. There were 3 scar dehiscences, one requiring hysterectomy for hemorrhage with uterine atony
Should we allow a TOL after a PCS for dystocia in the second stage of labor? OG 98 652 2001 Retro, all attempted TOL after PCS from 1990 to 2000. There were 2002 patients, 11% (214) had CS for dystocia in the second stage of labor, 33% (654) for dystocia in the first stage of labor and 57% (1134) for other indications. The success rates were as follows: CS for second stage dystocia was 75%, dystocia in the first stage was 65.6% and for other indications the success rate was 82.5%
(Spartanburg, SC)
Mode of Delivery for the morbidly obese with prior cesarean delivery: Vaginal versus repeat cesarean section AJOG 185 349 2001 69 patients weighing > 300 pounds and had history of previous CS over a 3 year span. 39 (57%) underwent an elective repeat CS, 30 (43%) women attempted VBAC. Successful VBAC occurred in 13%, indications for CS were labor arrest (46%), fetal distress (38%), failed induction (15%) The rate of infectious morbidity and wound breakdown was higher in the trial of labor group. Conclusion: The success rate for a vaginal delivery in the morbidly obese women with a prior CS is less than 15% and more than half of the patients undergoing a trial of labor have infectious morbidity.
Choy-Hee (Emory) Misoprostol induction of labor among women with a history of cesarean delivery AJOG 184 1115 2001 Previous reports have suggested a uterine rupture rate of 6% using misoprostol. Retro of 48 patients attempting VBAC given misoprostol compared with 377 given misoprostol without that history. Women attempting VBAC had a CS rate of 56% versus 28% of those receiving misoprostol but no Hx of CS. There was no difference in overall complication rates. There were no uterine ruptures.
Cost effectiveness of a trial of labor after previous CS OG 97 932 2001 Statistical model looking at cost effectiveness of VBAC versus repeat CS. Found that if there was a 0.74 probability of success than VBAC would be cost effective.
(Beth Israel)
Brief history of VBAC Clin OG 44 604 2001 Review of the history of VBAC. With the safety of repeat CS and the known rare and catastrophic outcomes related to uterine rupture, the future of VBAC remains as uncertain today as it was during Cragin s time.
(Grady Memorial)
VBAC among women with gestational diabetes AJOG 184 1104 2001 Retro, VBAC with and without gestational diabetes. 156 gestational VBAC compared with 272 similar VBAC but no gestational diabetes. Women with gestational diabetes who attempted VBAC were significantly more likely than controls to be delivered abdominally. Those successful VBAC with gestational diabetes were more likely to have an operative delivery with forceps or vacuum.
Daviss VBAC. Study's focus on induction vs spontaneous labor neglects spontaneous deliver. BMJ 323 1307 2001  
D' Orsi
Factors associated with VBAC in a maternity hospital of Rio de Janeiro Eur J Ob Gyn Repro Biol 97 152 2001 Case control record review, 141 VBAC and 304 controls, greater probability of success associated with one previous CS, CX > 3 cm on admission, < 37 weeks gestation, Hx of one previous VBAC,
VBAC Best Presct Res Clin Ob Gyn 15 81 2001 Review of VBAC.
(U. Calif., Irvine)
VBAC: reducing medical and legal risks Clin OG 44 622 2001 Summary, One lesson is that when a poor outcome occurs, even if you have made no technical errors and even if patient rapport is wonderful, you may still be sued and you may lose. It must be emphasized that once a uterus is scarred, the risk of any and all subsequent pregnancies is increased and selecting one mode of birth instead of the other cannot eliminate this risk. Things to watch out for: 1. Previous classical or T-shaped uterine incisions. Estimates for low vertical ruptures range 1-5% and for classical 5-10%. There is no data on a T incision but generally thought to be contraindicated. 2. Unknown scar, probably OK, one of the largest studies showed a 1% rupture rate with 90% unknown scar. 3. Placenta previa/accreta, this is a major potential risk for life threatening placenta previa accreta. The risk may be as high as 30% with Hx of PCS. 4. Misoprostol, avoid, also avoid outpatient cervical ripening. 5. More than one PCS: exercise caution, risk of rupture is 1.8%. 6. Oxytocin: exercise caution, oxytocin can cause rupture in both scarred and unscarred uteri. 7. Clinical signs of uterine rupture, none are " classic" , certainly heavy vaginal bleeding is always of concern, dramatic loss of station. 8. Fetal Monitor: Prolonged deceleration of FHT to 60-70 lasting more than a few minutes requires rapid intervention, as do variable decelerations that are severe and do not respond to nursing intervention. 9. Informed Consent: Must find a middle ground between over informing or a "scorched earth" process versus not informing the patient enough. Strongly suggests a formal consent form balancing the risks of repeat CS and the risks of VBAC. 10. Response Time: There is no "17 minute rule" however since uterine rupture is the main risk of VBAC, it would be prudent for physician to remain in or very near the hospital while a patient is attempting VBAC. Practicing crash CS drills may also help as would having a minimal emergency CS tray always available to eliminate the time of counting instruments before the baby is out. If rapid response is not possible, patients should have a repeat CS or be referred to a center where physicians and facilities are immediately available.
Oxytocin dose and the risk of uterine rupture in trial of labor after cesarean OG 97 381 2001 Case control study, 24 women in 12 years received oxytocin attempting VBAC. Found no sig difference in uterine rupture. Value very limited in view of small numbers
(Mass. Gen.)
Vaginal Delivery after Cesarean Section Is the Risk Acceptable? NEJM 345 54 2001 Editorial: The 91 women in the study by Lydon-Rochelle et al. who had uterine ruptures had substantially greater rates of several postpartum complications, suggesting that these ruptures were clinically important and not merely instances of asymptomatic dehiscence. Notably, the incidence of infant death was 10 times as high among the 91 women who had uterine rupture as among the 20,004 who did not (5.5 percent vs. 0.5 percent). It is important to emphasize that this study, like all others to date, was an observational study of the results of clinical practice and not a randomized trial. The relative risk of 3.3 in the present study for uterine rupture in women with a spontaneous onset of labor, as compared with those who underwent elective repeated cesarean section, is consistent with the odds ratio of 2.1 for a similar comparison reported in a recent meta-analysis of 11 studies involving a total of 39,000 subjects. This meta-analysis also found significant increases in the risks of fetal death (odds ratio, 1.7) and of an Apgar score of less than 7 at five minutes (odds ratio, 2.2) associated with a trial of labor as compared with elective repeated cesarean delivery. These risk estimates reflect broad experience in a wide range of clinical-practice settings. There is no reason to believe that improvements in clinical care can substantially reduce the risks of uterine rupture and perinatal mortality. Given the potential risks, why might a woman choose a trial of labor? Women who successfully deliver vaginally generally have less postpartum discomfort, shorter hospital stays, and shorter periods of disability than women who undergo repeated cesarean section. A trial of labor may be associated with a lower risk of fever than elective repeated cesarean section. Women who plan future pregnancies may prefer to avoid repeated cesarean deliveries that further increase the risks of uterine rupture, placenta accreta, and morbidity related to multiple abdominal surgeries. Finally, there may be social and cultural reasons why some women prefer vaginal delivery. ...
After a thorough discussion of the risks and benefits of attempting a vaginal delivery after cesarean section, a patient might ask, "But doctor, what is the safest thing for my baby?" Given the findings of Lydon-Rochelle et al., my unequivocal answer is: elective repeat cesarean section.
Dystocia among women with symptomatic uterine rupture AJOG 184 620 2001 Case control review of 19 women with uterine ruptures.
(U. Chicago)
Failed VBAC: how risky is it? I. Maternal Morbidity AJOG 184 1365 2001 Retro, chart review, 29,255 deliveries, 2450 had previous CS. 1344 patients who were appropriate attempted VBAC or 75% of all appropriate candidates. There was a 69% success (921 with 424 unsuccessful) The overall rate of uterine rupture was 1.1% of all women attempting VBAC, the rate of true disruption was 0.8% and the rate of hysterectomy was 0.5%. Blood loss was less but chorioamnionitis was higher in the women attempting VBAC. Compared with patients who were successful in attempts at VBAC, those who ended up with CS had a uterine rupture rate of 8.9%.
Intrapartum management of VBAC Clin OG 44 588 2001 Review of candidates, induction and labor management. Conclusion: Only complete and thorough counseling between patient and physician weighing the risks and benefits of VBAC should ultimately govern who attempts a TOL. Women with PCS are at increased risk for complications whether they achieve successful VBAC, failed VBAC or opt for elective CS. Research should continue to focus on identifying those who are highest risk for complications as well as those who are most likely to succeed. Meanwhile, the only impact the individual obstetrician can have on decreasing the communal risk of VBAC is by vigilance, with respect to decreasing the rate of primary CS performed.
Johnson VBAC. Safety of single layer suturing in CS must be proved BMJ 323 1307 2001  
Risk factors for uterine rupture during a TOL after CS. Clin OG 44 609 2001 Review, MEDLINE search of risk factors for uterine rupture. Type of scar: low transverse has risk of rupture of 1%, low vertical of 1.1% and classical of 12%. Number of previous CS: wide variety of findings, because there are substantial data suggesting that even 2 CS may be associated with a substantial increased risk of rupture. Previous vaginal deliveries: data somewhat inconsistent. Interdelivery interval: short interdelivery interval was associated with a 3-fold increase in uterine rupture. Postpartum fever after CS: associated with a 3 fold increased risk of rupture. Maternal age: > 30 years old associated with a 2.7 fold increased risk of rupture. Macrosomia: not associated with a large risk of uterine rupture. Postdates: no sig. Increase. Breech and external cephalic version: data not definitive but not likely to be associated with an extremely high rate of uterine rupture. Induction/Augmentation of Labor: Data from the largest studies suggest that ocytocin is associated with an increased risk of rupture. Recent studies have raised concerns that misoprostol may be associated with an unacceptably high risk of uterine rupture.
(U. Washington)
Risk of uterine rupture during labor among women with a prior cesarean delivery NEJM 345 3 2001 Population based, retrospective cohort analysis of all women who gave birth via CS with their first child and then delivered a second child in Washington state from 1987 to 1996. (total of 20,095 patients) Risk of uterine rupture was evaluated for repeat CS, spontaneous labor, induced labor. Results: Uterine rupture occurred in 1.6/1000 with repeat CS (no labor) Uterine rupture occurred 5.2/1000 with spontaneous onset labor. Uterine rupture occurred 7.7/1000 in those whose labor was induced without prostaglandins. Uterine rupture occurred 24.5/1000 in those with prostaglandin induction. Relative risk of uterine rupture: 3.3 with spontaneous labor, 4.9 relative risk with induced labor (not prostaglandin) and 15.6 relative risk of rupture with prostaglandins. The incidence of fetal death was 5.5 with uterine rupture
Macones Predicting outcomes of TOL in women attempting VBAC: A comparison of multivariate methods with neural networks AJOG 184 409 2001 Assess the utility and effectiveness of a neural network for predicting the likelihood of success of VBAC relative to standard multivariate predictive models. Identified 100 failed VBAC and compared with 300 successful VBAC by both multivariate predictive model and by a neural network using a back-propagation algorithm. Found that the multivariate model was better able to predict outcome.
(U. Calif., Davis)
VBAC in California OG 98 421 2001 51 hospitals selected from 267 nonfederal acute care hospitals in a stratified sample. Hospitals were then categorized as having high, medium and low risk-adjusted CS rates using a logistic regression model. 369 charts were reviewed, 312 were potentially eligible for VBAC, for evidence of counseling regarding trial of labor. Hospitals with low rates of CS documented counseling 99% of the time compared with 85% and 79% respectively for intermediate and high CS rates. Completed VBAC rates were 71%, 39% and 31% respectively. They also found that once a patient consented to attempt VBAC, the rates of success were comparable for all institutions.
(Texas Tech)
VBAC of twins J Matern Fetal Med 10 171 2001 Retro, control of all twins VBAC, 19 twin pregnancies with 57 control VBAC. The success of VBAC twins was 84.2% compared with 75.4% for controls. One uterine rupture occurred in control group and one dehiscence in the study group. The incid of PPH was 5.3% for both groups.
(Yakima Valley)
Using active management of labor and VBAC to lower CS rates: a 10 year experience AJOG 184 1535 2001 Retro, 10-year period, overall CS rate decreased from 16.6% to 10.9% with primary rate decreasing from 7.4 to 3.8%. During this time, active management of labor and encouraging VBAC statistically increased.
Cost analysis of VBAC Clin OG 44 571 2001 Review of cost analysis of all aspects of VBAC. A VBAC program will likely prove cost-effective only in select women with a previous scar who have a high likelihood of success because the greatest expenses remain with patients who experience adverse outcome that are more frequently associated with a failed TOL.
(Albert Einstein, Phila)
Safety of misoprostol as a cervical ripening agent in VBAC OG 97 (Sup) S67 2001 Retro, 3 VBAC groups compared spontaneous labor (SL), those who received oxytocin (OA) and those who received misoprostol and oxytocin (M+O) There were 100 in the M+O, 115 in SL and 167 in OA. There were no uterine ruptures and 3 uterine dehiscences none of which were in the M+O group. Success was not statistically different between the groups. Conclusion: in contrast to published reports and ACOG's Committee Opinion 228, misoprostol is not assoc. with an increased risk of uterine rupture. Misoprostol in VBAC patients is a relatively safe method for cervical ripening and appears as successful as spontaneous labor or oxytocin in vaginal delivery.
(U of C, Irvine)/td>
VBAC: 270 Degrees J Ob Gyn Res 27 169 2001  
Rabinerson VBAC? AJOG 184 780 2001  
(Beth Israel)
VBAC: a health policy perspective Clin OG 44 553 2001 Review of health policy aspects of VBAC. "A great deal of harm is being caused by advocating an ideal CS delivery rate. "
Inter delivery interval and risk of symptomatic uterine rupture OG 97 175 2001 Review of records, 12 years, limited to one previous CS and no VBAC, delivered at term with singleton. 2409 patients had TOL after one PCS and complete data. There were 29 uterine ruptures (1.2%). The rate of rupture was 2.25% with interval of <=18 months and 1.05% if interval >19 months.
Conclusion: Inter delivery intervals of up to 18 months were assoc. with 3 times increased risk of symptomatic uterine rupture compared to longer inter delivery intervals.
VBAC: to induce or not to induce AJOG 184 1122 2001 Prospective, observational analysis of 505 pts with Hex of previous CS. Three cohorts developed: repeat CS without TOL (269), spontaneous trial of labor (179) and induced trial of labor (57). VBAC successful in 77% of those in spon labor versus 57.9% of induced labor. Uterine scar separation more common in induced group (7%) than in the repeat CS group (1.5%) Conclusion: Induction of labor in women attempting VBAC is associated with a significantly reduced rate of successful vaginal delivery and an increased risk of serious maternal morbidity.
TOL after 4 CS: a case report and literature review Aus NZ J OG 41 233 2001 Case report of successful VBAC after 4 previous CS.
Maternal and neonatal outcomes after uterine rupture in labor AJOG 184 1576 2001 Retro chart review of all cases of uterine rupture 1976-1998. There were 38,027 deliveries; attempted VBAC rate was 61.3% with 65.3% successful. There were 21 cases of uterine rupture or scar dehiscence. (17 had Hx of prior CS 10 one previous CS, 3 unknown scar, 1 classical CS, 2 with 2 previous CS and one with 4 previous CS.) Of the 4 with no previous Hx of uterine surgery, one had a bicornuate uterus. 16 women had Sx of increased pain, vaginal bleeding or altered hemodynamic status. 2 patients required transfusions and 3 required hysterectomies. There were no maternal deaths. The fetal heart rate pattern in 13 cases showed bradycardia and repetitive variable or late decelerations. 2 cases of fetal or neonatal death occurred but both in markedly premature infants. The cord pH was > 7.0 in 13 infants. All live born infants were without evidence of neurologic damage at the time of discharge. Conclusion: Relative small risk of uterine rupture. In an institution that has in-house Ob, anesthesia and surgical staff in which close monitoring of fetal and maternal well-being is available, uterine rupture does not result in major maternal morbidity or mortality or in neonatal mortality
(Lenox Hill Hosp)
Trial of labor after 40 weeks' gestation in women with prior cesarean OG 97 391 2001

Review of 12 years of 2775 patients with one prior scar and no other deliveries, 1504 were del at or before 40 weeks and 1271 were delivered after 40 weeks. Spontaneous uterine rupture rate before 40 weeks was 0.5% and 1.0% after 40 weeks. For induced labor, the uterine rupture rate was 2.1% B4 40 weeks and 2.6% after 40 weeks.

Rates of CS as follows: Spon labor B4 40 weeks-25%, after 40 weeks 33.5%

Induced labor B4 40 weeks-33.8%, after 40 weeks 43%

Conclusion: The risk of uterine rupture does not increase substantially after 40 weeks but is increased with induction of labor regardless of gestational age.

(Lenox Hill Hosp)
Outcomes of TOL following previous CS among women with fetuses weighing > 4,000 grams AJOG 185 903 2001 Record review of women at term with one PCS comparing outcomes of infants > 4,000 grams with those less than 4,000 grams. There were 365 (of 2749 patients) whose infants weighed > 4,000 grams. The CS rate was 40% for the larger infants and 29% for the small group giving the larger group a 1.7 fold increase in the CS rate. There was not a statistically different rate of uterine rupture. The rate of uterine rupture was 2.4% if the infant weighed > 4250 grams. Conc: VBAC is still a reasonable consideration for the infant weighing. 4,000 grams but some caution should apply when infant weighs 4250 grams.
VBAC: a continuing controversy Clin OG 44 561 2001 Review of VBAC and ACOG s stance. Reasons for ACOG's more aggressive approach to the availability of personnel and facilities: First the risk of uterine rupture is at least 1% and among these ruptures, some possibly catastrophic, the rate of maternal and/or fetal morbidity is 10-25%. Moreover, there is concern that uterine rupture in VBAC is an underreported event, making this approximate 1% risk to be even higher. Second, based on reports from members of ACOG, uterine rupture almost always results in legal action, no matter what the clinical outcome and no matter how excellent the clinical care. "Medical positions on subjects of long term debate often demonstrate shifting, evolving or even cyclic patterns. The VBAC controversy is no exception to this premise. The concept that VBAC is a safe and effective approach for may patients is a well-established fact. This does not mean that it is appropriate for all women contemplating a pregnancy in the presence of a uterine scar. In the case of VBAC, the pendulum may have swung too far and it may be time to return closer to a middle ground. The medical community should not use VBAC as its principle tool to respond to society s economic and social concerns about the increasing CS rate rather individual patient safety and the dictates of best evidence-based medical practice should determine the standard."

Author Title Journal vol pg yr Abstract
Knowledge and attitudes about VBAC in Australian hospitals. VBAC Study group. Aust NZ J OG 40 195 2000 Survey of staff physicians, 67% response (900). 53% felt that VBAC should be actively encouraged and 47% felt it should be simply presented as an option.
VBAC: an Australian multicentre study. VBAC Study Group. [In Process Citation] Aust NZ JOG 40 87 2000 Retro, 11 hospitals, 5 years. Total deliveries of 234,015 of which 21,452 (9.2%) had one or more PCS. Within the PCS group, 5419 (25.3%) delivered vaginally. There were 62 cases of significant UR with no maternal deaths. Perinatal mortality with UR was 25% and serious maternal morbidity (usually requiring hysterectomy) was 25% with UR.
(Nippon Med School)
Prediction of uterine dehiscence by measuring lower uterine segment thickness prior to the onset of labor evaluation by TVUS. J Nippon Med Sch 67 352 2000 186 term gravidas, PCS, had the thickness of the LUS measured and its correlation with uterine dehiscence/rupture was investigated. There were no cases of rupture, there were 9 cases (4.7%) of dehiscence. The thickness of the LUS in those who developed dehiscence was sig. less than those who did not have dehiscence. Found that if the thickness was >1.6 mm the risk of dehiscence was very small.
Indications for and outcomes of emergency peripartum hysterectomy. A 5 year review JRM 45 733 2000 Retro., evaluated 39 cases of emergency peripartum hysterectomy. The overall incidence was 2.7/1,000 liver births. The relative risk was increased for PCS, cesarean and placenta previa.
Bayer - Zwirello
ACOG's 1999 VBAC guidelines: a survey of western Massachusetts ob services OG 95 sup S73 2000 Six OB services surveyed, all returned survey representing 8,000 annual deliveries, had an 18.5% CS rate. From 1994, all reported a decline in overall CS rate and an increase VBAC rate. 50% considered "immediately" available to mean CS within 30 minutes and 50% considered it to be within 15 minutes. 67% describe "physician availability" for anes as in hospital coverage and 33% as anes in L+D.
(U of Brit. Col.)
Uterine Rupture following induction of labor with PCS. AJOG 182 S137 2000 Retro review, of all cases of uterine rupture 1992-1998 in 3687 women attempting TOL (0.5%). Induction was carried out in 1097 women, 8 ruptures occurred with either oxytocin or PGE2 for a rate of 0.7%. There was no increased risk when compared with those having spontaneous labor.
VBAC in the diabetic gravida JRM 45 987 2000 Retro, of class a-r diabetics delivering at >37 weeks gestation with Hx of one PCS. 32 patients were attempting VBAC, 18 of which were successful (43.7% or a CS rate of 56.3%). This was compared with controls-127 without PCS had a CS rate of 26.3%. There were no cases of uterine rupture and no differences in the frequency of endometritis or neonatal intensive care admission. Conc: VBAC success rates appeared to be lower for diabetic gravidas. Although maternal and neonatal complication rates were low, further studies are necessary to determine the safety of VBAC in this population.
(U of Penn)
UR during a failed TOL: are there any identifiable risk factors? OG 95 S42 2000 10 year retro, found 25 cases of UR with attempted VBAC. Found no specific factors in the management of a TOL were clearly assoc. with UR.
Epidemic of CS at the general, private and university hospitals in Thailand J Ob Gyn Res 26 357 2000 Questionnaire, overall response was 88%, Mean CS rates were 24%, 48% and 22% for general, private and university hospitals respectively. CS rates had increased in the last 5 years by 78%, 50% and 66% respectively. Repeat CS was the most common indication for CS in the private hosp. (63%) and 88% in the university hospitals. ECV and VBAC were performed in only 12% of the hospitals.
(Spartanburg, SC)
Neonatal acidemia with TOL among parturients with PCS, a case control study J Mat Fet Med 9 278 2000 Prospective, compared attempted VBAC with resultant acidemic infant (cord pH < 7.15) compared with the next 4 infants of attempted VBAC without acidemia. The frequency of neonatal acidemia amongst TOL patients overall was 12%. Found that the acidemic infants significantly weighed more, had a higher failed VBAC rate and a higher uterine rupture rate.
(U of Utah)
Is VBAC less expensive than repeat CS? AJOG 182 599 2000 Compared total medical costs of VBAC with those of ERCS with both short and long term neonatal costs assoc. with such procedures taken into account. Assumed a 70% successful VBAC rate and delivery in a tertiary center with a mean UR to delivery time of 13 minutes, the net cost differential ranged from a saving of $149 to a loss ot $217, depending on morbidity assumptions. For VBAC success <70%, TOL with 2 prev. CS, and institutional factors increasing the perinatal morbidity rate by just 4%, TOL resulted in a net financial loss to the health care system regardless of all other assumptions made. Conclusion: when costs as opposed to charges are considered and the cost of long-term care for neurologically injured infants is taken into account, TOL is unlikely to be assoc. with a significant cost saving for the health care system. Factors other than cost must govern decisions regarding TOL or ERCS.
CS and VBAC rates stalled in the mid-1990s Birth 27 54 2000  
Esposito Association of interpregnancy interval with uterine scar failure in labor: a case-control study AJOG 183 1180 2000 Case-control, of uterine scar failures in TOL measuring interpregnancy interval. Found that an interpregnancy interval of < 6 months was sig more prevalent among patients with patients with scar rupture. Conc: interpregnancy interval was inversely associated with likelihood of UR during subsequent labor
(US Navy)
Bladder rupture assoc. with UR. A report of 2 cases occurring during VBAC JRM 45 240 2000 Case report, 2 pts with posterior bladder wall rupture in assoc. with rupture of low transverse incision. The potential for bladder injury should be included in the patients antepartum counseling
Fujii Successful pregnancy following antenatal closure of uterine wall defect Int J Gyn Ob 68 261 2000  
(US Navy)
Uterine Rupture associated with VBAC: a complication of intravaginal misoprostol? Gyn Ob Invest 50 212 2000 Case report of uterine rupture after a single 25 microgram dose of intravaginal misoprostol in a patient with 2 prior CS.
(Nagasaki University)
Predicting incomplete UR with vaginal sonography during the late second trimester in women with prior cesarean OG 95 596 2000 Serial TVUS of the thickness of the lower uterine segment performed on 374 controls and 348 patients with hx of PCS. Found that the thickness decreased from 6.7 mm to 3 mm in controls and 6.8 mm to 2.3 mm in pts with PCS. 11/12 patients with lower uterine segment less than the mean control minus 1 standard deviation had a very thin lower uterine segment at time of delivery. 17/23 women with LUS < 2mm had intrapartum incomplete UR. Conc: TVUS is useful for measurement of the LUS after PCS.
Grobman Cost-effectiveness of elective CS after one prior LTCS OG 95 745 2000 Decision tree model incorporating a Markov analysis was used to examine the reproductive life of a hypothetical cohort of 100,000 pregnant women whose only prior pregnancy was via CS.

Routine CS would cause an additional 117,748 CS, 5500 maternal morbid events and 179 million $. The prevention of one major adverse neonatal outcome requires 1591 CS and 2.4 million $.

Conc.: routine ECS for second delivery results in an excess of maternal morbidity and mortality and a high cost to the medical system.
(Sacred Med Center)
Use of misoprostol for cervical ripening SMJ 93 881 2000 Open label setting of 470 pts induced, 254 with misoprostol, 144 with dinoprostone. With misoprostol, mean time from beginning contractions to delivery was 7 hours, 30 minutes with 85% vaginal birth. 23 patients with previous CS got misoprostol and delivered vaginally. Conc: misoprostol was found to be a sage and effective agent for cervical ripening.
Kirkendall Catastrophic UR:maternal and fetal characteristics OG 95 (4 Sup) S74 2000 Childbirth Injury Prevention Foundation Used National Registry of Brain-injured Neonates. Of the 81 patients with UR, the number of PCS as follows: No previous CS-11% (9) rupture, One PCS-61% (49 patients) rupture, 2 PCS-27% (22 patients) rupture. Complications included 2 maternal deaths, 14 bladder injuries, 12 hysterectomies, 48 anemias, and 27 transfusions. Of the 82 fetuses, 64 were extruded into the abdomen. (27 partially and 37 completely extruded) Infant mortality within one year was 28%.
Marshak Prognostic indicators for successful VBAC OG 95 S38 2000 Retro chart review, of 444 undergoing attempted VBAC. Statistically positive predictors were Hx of previous vaginal delivery, spontaneous rather than induced labor, greater dilatation and greater effacement. Heavier women and the use of ripening agents led to a decreased success rate. In women previously having CS after arrest of descent at full dilatation, 74.5% delivered vaginally which is in marked contrast to prior literature reporting success rates of 16%.
MMWR Use of hospital discharge data to monitor uterine rupture-Massachusetts 1990-97 MMWR Morb Mort Wkly Rep 49 245 2000 During 1990-1997 the proportion of vaginal deliveries among women with previous CS increased 50% from 22.3% to 33.5%. concern about increased risk of UR can not be addressed from their data because of lack of adequate specificity for UR surveillance.
(U of Mich.)
Elective repeat CS versus TOL: a meta-analysis of the literature from 1989 to 1999 AJOG 183 1187 2000 Medline, etc meta-analysis found 52 controlled studies, 37 of which were excluded because many of controls were not eligible for TOL. 15 studies with a total of 47,682 patients were included. Uterine rupture occurred more frequently amongst patients undergoing a TOL versus elective CS. (odds ratio 2.10) The TOL group had and increase in fetal/neonatal death (odds ratio 1.71) and more 5 minute Apgar scores <5 (odds ratio 2.24). The mothers undergoing a TOL were less likely to have febrile morbidity, require transfusion or hysterectomy. Conc: a TOL may result in small increases in the UR rate and fetal/neonatal mortality rates with respect to elective CS. Maternal morbidity, including febrile morbidity, need for transfusion or hysterectomy may be reduced with a TOL.
(Texas Tech)
VBAC in the twin gestation OG 95 sup S65 2000 Retro, 19 twin pregnancies attempting VBAC along with 57 controls eval. The VBAC success rate for twins was 84.2% and 75.4% for controls. The incid of PPH was 5.3% for both groups. One UR occurred in the control gp, none in the twin group.
(U of Illinois)
Rupture of a cesarean-scarred uterus: a community hospital experience J Nat Med Assoc 92 295 2000 Retro, studied deliveries and VBAC from 1988 to 1997. During 1994 strategies were developed to reduce cs rate. Found that the total cs rate decreased from 24.3% to 17.9% whereas the primary cs rate decreased from 14.9 to 10.3%. The repeat CS rate decreased from 9.4% to 7.6%. The VBAC rate increased from 13.0 to 28.6% where as the incid of UR did not change. Conc: during the study period, the CS rate decreased while the VBAC rate safely increased. The incid of UR remained unchanged.
Uterine rupture during induced TOL among women with previous CS. AJOG 183 1176 2000 Retro, all deliveries between 1992 and 1998 studied. There were 2119 TOL, 575 of which were induced (27%). There overall uterine rupture was 0.71% but the rupture rate with induction was sig higher 1.4%. Rupture was highest when prostaglandin E2 was used. (2.9%)
(Thomas Jefferson U)
Population adjustment of the definition of the VBAC rate AJOG 183 1166 2000 Evaluated the effect of removing non-candidates for a TOL from the statistics for VBAC. All patients with hx of PCS were classified as candidates or non-candidates. Found that the maternal fetal medicine service had higher non-candidates than either the private or resident clinic. Previously, the fetal maternal medicine service had a lower VBAC success rate, when non-candidates are controlled for their success rates are similar.
Sanchez - Ramos UR associated with the use of prostaglandin E1 in patients with PCS AJOG 184 990 2000  
Shimonovitz Successful first VBAC: a predictor of reduced risk for uterine rupture in subsequent deliveries Isr Med Assoc J 2 526 2000 Retro, 26 VBAC del complicated by UR compared with 66 controls.

Conc-once the patient has been successful once the risk of UR drops significantly. Risk factors for uterine rupture include: use of Pitocin, PGE2 and instrumental deliveries.
(Mass General)
Labor after PCS: influence of prior indication and parity OG 95 913 2000

Retro, records reviewed of women undergoing TOL after PCS with nullips from 1984-1996.

    CS rate          CS rate   Nullips
    Overall             28.7%       13.5%
    Breech              13.9%
    FTP                 37.3%
    "Fetal Distress"    25.4%
    Other               24.8%

Conclusion: Overall CS rates are higher for patients attempting VBAC than for nullips. Rates of CS were related to indication for prior CS, highest for failure to progress and lowest for previous breech.

(U of Pittsburgh)
Assessing regional variation in CS and VBAC in a major metropolitan area: improving health service delivery OG 95 sup S78 2000 Looked at 285 physicians at 22 Pittsburgh hospitals doing 26, 358 consecutive deliveries. Had overall CS rate of 19% and VBAC rate of 40.5%

Conclusion: Significant variation among physicians for CS and VBAC rates suggests that decision making by physicians providing ob care is a major contributor to overall rates.
(Pop. Council)
Reduction of the CS rate in Ecuador Int JGO 69 229 2000 Described a method to reduce CS by instituting hospital policy of co-management for CS.
VBAC: a population study Paediatr Perinat Epidemiol 14 340 2000 Retro of patients who gave birth and whose previous delivery was via CS.
Women's perceptions of CS: reflections from a Turkish teaching hospital Soc Sci Med 50 1227 2000 Discussion
(Med Col Ga.)
Predicting the success of TOL with a simple scoring system JRM 45 332 2000 Retro, applied the Troyer-Parisi scoring system to predict the success in a patient undergoing a VBAC attempt. Confirmed an inverse relationship between the Troyer-Parisi scoring system and a successful TOL.
Posterior uterine wall rupture during labor Hum Repro 15 1198 2000 Case report of patient attempting VBAC at 38 weeks gestation. Labor course was smooth, no stimulation, with sudden onset of UR. UR resulted in maternal shock and ultimately neonatal death.
Wax Twin VBAC Conn Med 64 205 2000 Years 1988-98, one institution, case control, 12 sets of twins with Hx of PCS matched to 36 controls. 10/12 twin sets and 31/36 of controls delivered vaginally. The only difference was that the second twin had a longer NICU stay.
(US Army)
Uterine scar separation in patients undergoing TOL in one army hospital Mil Med 165 730 2000 General discussion, no data in abstract
(Lenox Hill Hosp)
Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor AJOG 1183 1184 2000 Retro for 12-year review of TOL with Hx of previous vaginal delivery and the risk of uterine rupture. 1021 patients with Hx of previous CS and prior vaginal delivery. The rate of UR was 1% with no previous vaginal delivery and 0.2% of those with a previous vaginal delivery.
(Mass General)
Outcomes of TOL following PCS beyond the estimated date of delivery OG 95 (4 Sup) S79 2000 Retro., reviewed outcomes for all women (2,775) with Hx of one PCS and no other deliveries who had a TOL. Analysis included rates of symptomatic UR and CS for term deliveries prior to EDD and those after the EDD while stratifying for spontaneous and induced labor. The rate of rupture before 40 weeks gestation was 0.5% whereas the rate after EDD was 1%. For induced labor before 40 weeks that rate of UR was 2.1% and 2.6% for those beyond 40 weeks.

ERCS=Elective repeat Cesarean Section, PCS=Prior Cesarean Section, TOL=Trial Of Labor, UR=Uterine Rupture, UD=Uterine Dehiscence, conc.=conclusion, ECV=External Cephalic Version, LTCS=Low Transverse Cesarean Section, LVCS=Low Vertical Cesarean Section, EFM=Electronic Fetal Monitoring, PNM=Peri-Natal Mortality, CPD=Cephalo-Pelvic Disproportion

We have honestly attempted to record everything accurately, however, please refer to original article for any major decisions pertaining to patient care.

Keywords for search:Vaginal Birth After CS, Cesarean Section, Uterine Rupture, Trial of Labor

Philip J. Rosenow, M.D.
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Burlington, NC 27215-4500
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Please send additions, corrections, problems or missing abstracts to: Ken Turkowski. turk "at" worldserver "dot" com

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