Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).
The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).
Sentilhes L
，Vayssière C
，Beucher G
，Deneux-Tharaux C
，Deruelle P
，Diemunsch P
，Gallot D
，Haumonté JB
，Heimann S
，Kayem G
，Lopez E
，Parant O
，Schmitz T
，Sellier Y
，Rozenberg P
，d'Ercole C
... -
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[Women with previous caesarean or other uterine scar: epidemiological features].
To describe the prevalence of uterine scar and the risk of associated obstetrical complications and current modes of delivery in women with a previous cesarean.
Consultation of the Medline database, and of the National Perinatal Surveys data.
Previous cesarean is the main cause of uterine scar. In France, the cesarean rate increased from 15.5% in 1995 to 20.8% in 2010; as a consequence, the prevalence of previous cesarean also increased from 8 to 11% of parturients and from 14 to 19% of multiparas, between 1995 and 2010. Previous cesarean is, in developed countries, the main risk factor for uterine rupture, whose global incidence is estimated between 0.1 and 0.5% in parturients with previous cesarean. Women with previous cesarean also are at higher risk for abnormal placenta insertion, the strength of the association increasing with the number of previous cesareans: twice higher risk of placenta praevia and greater maternal morbidity associated with placenta praevia; major risk factor for placenta accreta in particular in women combining previous cesarean and placenta praevia. Modes of delivery in women with previous cesarean vary widely between countries. According to the 2010 National Perinatal Survey, in France, 51% have a cesarean before labor; among those with a trial of labor, 75% deliver vaginally; in total, 36.5% have a vaginal delivery.
The prevalence of uterine scar is increasing, following the rise in cesarean rate. This condition is a risk factor for obstetrical complications in subsequent pregnancies. Women with multiple previous cesareans are particularly at risk.
Deneux-Tharaux C
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