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12144 2014;16:23944
The Obstetrician & Gynaecologist
Review
http://onlinetog.org
Please cite this paper as: Dahlke JD, Mendez-Figueroa H, Wenstrom KD. Counselling women about the risks of caesarean delivery in future pregnancies.
The Obstetrician & Gynaecologist 2014;16:23944.
fetal medical indications.6 Because of a lack of specific coding respect of patient autonomy and, when appropriate,
or designation, determining the prevalence of women seeking determination of optimal timing of CD to minimise
CDMR remains difficult, with best estimates ranging from neonatal morbidity
2% to 8% of all deliveries in the USA.3,5,7 Because there are respect of provider autonomy by offering the woman a
no randomised controlled trials comparing CDMR with second opinion or referral to another provider for cases in
planned vaginal delivery with regard to maternal or neonatal which the provider does not agree with the decision
risks or outcomes, counselling recommendations must be for CDMR.
based largely on expert opinion.8
Because of the lack of quality trials, short-term and
Notably, ACOG, the Royal Australian and New Zealand
long-term risks associated with CDMR versus planned
College of Obstetricians and Gynaecologists (RANZCOG),
vaginal delivery can only be extrapolated. Indirect analyses
and the National Institute for Health and Care Excellence
comparing elective CD without a specified indication with
(NICE) in the UK have published consensus guidelines or
the combined outcomes of vaginal deliveries and unplanned
statements that provide an excellent reference for providers
or emergency CD are suboptimal.6 In a National Institute of
who are counselling patients about CDMR.2,6,9 Table 1
Health conference statement on CDMR in 2006,10 an expert
summarises the recommendations of these organisations.
panel reported on a systematic review of the available
These recommendations, when combined, emphasise several
literature they undertook to determine the best available
important concepts that should be included in any discussion
evidence comparing planned CD versus planned vaginal
of CDMR with patients:
delivery for term singleton gestations with vertex
provider understanding of the reasons why the woman is
presentation. Based on moderate quality evidence,
requesting this type of delivery
outcomes that favoured planned vaginal delivery included:
provider enquiry into the womans desired family size in
shortened maternal hospital length of stay, decreased
order to accurately discuss risks if future pregnancies
neonatal respiratory morbidity, decreased risk of
are desired
subsequent placenta praevia or accreta, and decreased risk
womans understanding of the risks and benefits of and
of subsequent uterine rupture. The only outcome favouring
alternatives to CD versus planned vaginal delivery in the
planned CD was decreased risk of maternal haemorrhage.10
current and future pregnancy
Organisation Recommendations
American College of Obstetricians and In the absence of maternal or fetal medical indications for caesarean delivery, a plan for
Gynecologists (2013)6 vaginal delivery is:
safe
appropriate
should be recommended
placenta praevia
placenta accreta
hysterectomy
Royal Australian and New Zealand College of If, after full discussion, the patient maintains CDMR, the obstetrician may:
Obstetricians and Gynaecologists (2013)9 agree to perform CD if patient understands risks and benets of this course of action
decline to perform CD if obstetrician believes there are signicant health concerns for mother
or baby; or patient appears to not have sufcient understanding to enable informed consent
advise patient to seek second opinion
Outcomes for which there was insufficient evidence to make prior classical uterine incision, previous uterine surgery in
recommendations included fetal mortality, newborn which the uterine cavity was entered (such as myomectomy),
infection, intracranial haemorrhage, neonatal asphyxia or history of uterine rupture, history of more than two previous
encephalopathy, and birth injuries. This lack of critical data CDs, as well as contraindications to vaginal delivery in
highlights the importance of continuing research on general (for example, placenta praevia or malpresentation). A
this topic. history of a prior successful vaginal delivery is associated with
an increased probability of VBAC. Alternatively, factors that
decrease probability of success include a recurrence of the
Counselling women with a history of one previous indication for the initial CD (for example, labour
or two caesarean deliveries dystocia), gestational age greater than 40 weeks, maternal
obesity, pre-eclampsia, short interpregnancy interval,
For women with an obstetric history of one or two CDs,
increased maternal age and non-white ethnicity.11 National
discussions regarding the risks and benefits of a trial of labour
guidelines vary with regard to recommending TOLAC in
after caesarean (TOLAC) versus a repeat CD should be
various scenarios (Table 2), further highlighting the
initiated and documented, preferably before 36 weeks of
importance of obtaining and documenting a thorough
gestation. Table 2 summarises guidelines from ACOG, the
obstetrical history.
French College of Gynecologists and Obstetricians,
In a systematic review and meta-analysis of maternal
RANZCOG, the Royal College of Obstetricians and
morbidity after TOLAC compared with repeat CD, Rossi and
Gynaecologists and the Society of Obstetricians and
DAddario16 summarised four prospective and three
Gynaecologists of Canada regarding recommendations for
retrospective large cohort studies to determine outcomes
candidates who may be considering a TOLAC.1115 Notably,
such as overall maternal morbidity, uterine rupture/
all of these guidelines recommend delivery in a hospital
dehiscence, blood transfusion and hysterectomy associated
setting with immediate availability of personnel and
with four possible scenarios: overall planned TOLAC,
facilities necessary to perform an emergency CD. These
successful VBAC, failed TOLAC and repeat CD. Women
resources include an obstetrician, an anaesthesia provider,
with successful VBAC had the lowest incidence of adverse
paediatric support, operating room staff and resuscitative
outcomes while those with a failed TOLAC had the highest.
measures (such as blood products) in cases of postpartum
Table 3 summarises the estimated risks associated with
haemorrhage. It is undetermined whether immediate access
repeat CD and TOLAC. While uterine rupture is a rare
to all resources is necessary 24 hours a day, 7 days a week,
complication, it occurs more frequently in patients
and hospital policy may vary by location (rural or urban)
undergoing TOLAC than repeat CD, and although repeat
and/or country. However, every effort should be made to
CD at 3739 weeks appears to decrease the risk of stillbirth, it
transfer care to a facility that can offer these support services
is important to note that TOLAC does not increase the risk of
if it is determined that TOLAC is not contraindicated and
stillbirth above the baseline risk at any given gestational age.
desired by the woman, but cannot be safely offered at the
Alternatively, rates of blood transfusion, hysterectomy and
home hospital.
neonatal respiratory morbidity are lower in those who
When TOLAC is an option for women with a history of
undergo TOLAC. Finally, advantages of successful VBAC
one or two previous CDs, counselling and appropriate
were shown to include avoidance of major abdominal
documentation becomes paramount. Counselling
surgery, shorter time to recovery, less morbidity from
should include:
infection and avoidance of the increased risk of abnormal
a review of the womans complete obstetric history.
placentation in future pregnancies, which is especially
an assessment of all risks associated with both TOLAC and
important if a large family is desired.11
repeat CD.
Depending on the published source, rates of successful
an individual assessment of the likelihood of successful
VBAC range from 50% to 85%.1115 These rates, however,
vaginal birth after caesarean (VBAC).
may vary depending on several modifiable or non-modifiable
an enquiry into the womans understanding of risk and her
factors. Factors considered non-modifiable include maternal
desire for future pregnancies.
age, non-white ethnicity, pre-eclampsia and recurrence of the
a specific plan for delivery including contingencies, for
indication for the initial CD, all of which decrease the
example, management if the woman presents in labour
probability of successful TOLAC. Factors considered
prior to scheduled repeat CD.
modifiable to some extent include gestational age greater
Identifying women who are appropriate candidates for than 40 weeks, maternal obesity, short inter-pregnancy
TOLAC requires obtaining a complete obstetric history interval and increased birthweight, all of which decrease the
including the timing and circumstances of all previous probability of successful TOLAC.11 While gestational age and
deliveries. In general, contraindications to TOLAC include a increasing birthweight could theoretically be modified by
Obstetric history
1 low transverse CD TOLAC recommended ACOG (A), CNFOG, RANZOG, RCOG (B)
2 low transverse CDs TOLAC may be considered ACOG, RCOG (B), CNFOG (C)
Caesarean may be considered RANZCOG
3 or more low transverse CDs Caesarean recommended ACOG, CNFOG (C), RCOG
History of uterine rupture Caesarean recommended ACOG, SOGC (B), RCOG
History of classical or uterine Caesarean recommended ACOG, CNGOF, SOGC (B)
body scar (eg T or J incision)
History of low vertical uterine incision TOLAC may be considered ACOG, CNFOG (C)
Caesarean may be considered RANZCOG
Operative note conrmation required? Not necessary, unless high suspicion ACOG, CNFOG (C), SOGC (B)
Previous uterine closure in 1 versus 2 layers TOLAC may be considered CNFOG (C)
Delivery to conception <6 months TOLAC may be considered CNFOG (C)
Caesarean may be considered RANZCOG
Current pregnancy
Twins TOLAC may be considered ACOG, SOGC (B), CNFOG, RCOG (C)
Breech External cephalic version may be considered ACOG (B), CNFOG, SOGC (C)
Maternal obesity Caesarean may be considered CNFOG (C), RANZCOG
Diabetes TOLAC may be considered CNFOG (C), SOGC (B)
Preterm birth TOLAC recommended CNFOG (C), RCOG (B)
Prolonged pregnancy (>40 weeks) TOLAC may be considered ACOG, CNFOG (C), SOGC (B)
Macrosomia TOLAC may be considered ACOG (C), SOGC (B)
Caesarean may be considered CNFOG (C)
Delivery location Hospital only, capable of timely caesarean All guidelines
Induction of labour Acceptable for maternal or fetal indications ACOG, CNGOF (C)
Not recommended if 2 previous CD CNFOG (C)
Transcervical balloon Acceptable with prudence ACOG, CNGOF (C)
Oxytocin Acceptable with prudence ACOG, CNGOF (C), RANZCOG, SOGC (B)
PGE2 Acceptable with great prudence ACOG, CNGOF (C)
Not recommended SOGC (B)
PGE1 (misoprostol) Not recommended ACOG, SOGC (A), CNGOF (C)
Intrapartum management
Continuous fetal monitoring Recommended ACOG, CNGOF (C), RCOG (B), SOGC (A)
Internal tocodynamometry Not necessary ACOG, CNGOF, RCOG (C)
Augmentation Oxytocin acceptable with prudence ACOG, CNGOF (C), SOGC (A)
Anaesthesia Acceptable for regional analgesia ACOG, RCOG (C), RANZCOG
ACOG=American College of Obstetricians and Gynecologists; CD=caesarean delivery; CNGOF=French College of Gynecologists and Obstetricians;
RANZCOG=Royal Australian and New Zealand College of Obstetricians and Gynaecologists; RCOG=Royal College of Obstetricians and
Gynaecologists; SOGC=Society of Obstetricians and Gynaecologists of Canada; TOLAC=trial of labour after caesarean.
a
Level of recommendations: A=based on good and consistent scientic evidence; B=based on limited or inconsistent scientic evidence; C=based
primarily on consensus and expert opinion.
BOLD: Denotes recommendation by specied guideline.
elective induction of labour, any potential benefit would be desire in the future, including that the risks of hysterectomy
negated by the fact that one of the most important factors in and abnormal placentation are directly related to the number
increasing probability of success is spontaneous labour. Thus, of CDs a woman undergoes. Contingency plans covering
elective labour induction is not recommended. An online early presentation in labour, variable hospital or provider
tool developed by the National Institute of Child Health and staffing, and timing of induction of labour should ideally be
Human Development Maternal-Fetal Medicine Units considered, discussed and documented to avoid confusion if
Network uses many of these variables to calculate an these situations arise.
individual womans likelihood of successful VBAC and may After appropriate counselling, some women with a
be a valuable resource for providers and women when previous CD will request a repeat CD. Whenever a woman
creating a birth plan.17,18 has been fully informed and expresses understanding of the
Finally, the womans understanding and desire for TOLAC issues, her autonomy should be respected. The recommended
should be queried and documented. This should include a gestational age for repeat CD is 3940 weeks, with delivery
discussion of the number of pregnancies the woman may prior to 39 weeks avoided unless medically indicated.
National Institute of Child Health and Human Development, Society for 13 The Royal Australian and New Zealand College of Obstetricians and
Maternal-Fetal Medicine, and American College of Obstetricians and Gynaecologists. Planned Vaginal Birth after Caesarean Section (Trial of
Gynecologists Workshop. Obstet Gynecol 2012;120:118193. Labour). C-Obs 38. Melbourne VIC: RANZCOG; 2010.
6 American College of Obstetricians and Gynecologists. ACOG committee [www.ranzcog.edu.au/college-statements-guidelines.html].
opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol 14 Royal College of Obstetricians and Gynaecologists. Birth after Previous
2013;121:9047. Caesarean Birth. Green-top Guideline No. 45. London: RCOG; 2007.
7 Ecker J. Elective cesarean delivery on maternal request. JAMA [www.rcog.org.uk/womens-health/clinical-guidance/
2013;309:19306. birth-after-previous-caesarean-birth-green-top-45].
8 Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM. Caesarean section 15 The Society of Obstetricians and Gynaecologists of Canada. Guidelines for
for non-medical reasons at term. Cochrane Database Syst Rev 2012;(3): Vaginal Birth after Previous Caesarean Birth. No 155. Ottawa ON: SOGC;
CD004660. 2005. [http://sogc.org/guidelines/guidelines-for-vaginal-birth-after-
9 The Royal Australian and New Zealand College of Obstetricians and previous-caesarean-birth-replaces-147-july-2004/].
Gynaecologists. Caesarean Delivery on Maternal Request (CDMR). C-Obs 16 Rossi AC, DAddario V. Maternal morbidity following a trial of labor after
39. Melbourne VIC: RANZCOG; 2013. [www.ranzcog.edu.au/ cesarean section vs elective repeat cesarean delivery: a systematic review
college-statements-guidelines.html]. with metaanalysis. Am J Obstet Gynecol 2008;199:22431.
10 State-of-the-Science NIH. Conference Statement on cesarean delivery on 17 Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, et al.
maternal request. NIH Consens State Sci Statements 2006;23:129. Development of a nomogram for prediction of vaginal birth after cesarean
11 American College of Obstetricians and Gynecologists. ACOG Practice delivery. Obstet Gynecol 2007;109:80612.
bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet 18 Vaginal birth after cesarean calculator: [http://mfmu.bsc.gwu.edu/
Gynecol 2010;116(2 Pt 1)45063. PublicBSC/MFMU/VGBirthCalc/vagbirth.html].
12 Sentilhes L, Vayssiere C, Beucher G, Deneux-Tharaux C, Deruelle P, Diemunsch 19 Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al.
P, et al. Delivery for women with a previous cesarean: guidelines for clinical Maternal morbidity associated with multiple repeat cesarean deliveries.
practice from the French College of Gynecologists and Obstetricians (CNGOF). Obstet Gynecol 2006;107:122632.
Eur J Obstet Gynecol Reprod Biol 2013;170:2532.