[Specific particularities of uterine scars and their impact on the risk of uterine rupture in case of trial of labor].

To assess the risk of uterine rupture in case of uterine scar in specific situations. To investigate whether ultrasonographic measurement of the lower uterine segment is predictive of the risk of uterine rupture. French and English publications were identified through PubMed and Cochrane databases. Trial of labor after cesarean (TOLAC) is possible in cases of uterine mullerian anomalies, segmental vertical or unknown uterine incision, postpartum fever, cesarean delivery before 37 weeks during the previous cesarean (professional agreement). TOLAC can be considered if obstetrical conditions are favorable even if the delay is less than 6 months between the previous cesarean delivery and the date of conception of the following pregnancy (professional agreement). TOLAC can be considered after a previous myomectomy, depending on technical conditions under which the intervention was conducted (gradeC). TOLAC is possible even after previous hysteroscopic metroplasty for uterine septa or in cases of uterine perforation with monopolar coagulation (professional agreement). The type of uterine suture during the previous cesarean should not influence the choice of the route of delivery (professional agreement). TOLAC can be considered in cases of two previous cesarean sections if obstetrical conditions are favorable (professional agreement). Planned cesarean section is recommended from history of three previous cesarean sections (professional agreement). A planned cesarean section is recommended in cases of previous corporeal incision during cesarean (gradeC). There is not enough data to recommend ultrasonographic measurement of the lower uterine segment during pregnancy to help to determine the route of delivery (professional agreement). TOLAC can be considered, depending on obstetric conditions, in all situations studied, except in cases of previous obstetric corporeal incision or previous history of at least three cesareans.

Kayem G ，Raiffort C ，Legardeur H ，Gavard L ，Mandelbrot L ，Girard G ... -  《-》

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 ... -  《-》

[Multi-centric clinical study of trial of labor after cesarean section].

Yu L ，Su CH ，Wang XY ，Gong JJ ，Chen P ，Du HM ，Quan QH ，Li LL ，Chen DJ ... -  《-》

[Delivery in women with previous cesarean section or other uterine surgery: guidelines for clinical practice - text of the guidelines (short text)].

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[Maternal benefits and risks of trial of labor versus elective repeat caesarean delivery in women with a previous caesarean delivery].

To assess maternal outcomes during trial of labor (TOL) and elective repeat caesarean delivery (ERCD) in women with a previous caesarean delivery. French and English publications were searched using PubMed and Cochrane Library. Maternal mortality remains a very rare event regardless of the planned mode of delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of complete uterine rupture significantly increases with TOL versus ERCD but it remains low at about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood transfusion, data are heterogeneous because of the nature of the populations studied. These risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous thrombo-embolic complications and infections (endometritis and maternal fever) appears to be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the additional presence of obesity (EL2). While maternal morbidity progressively increases with the number of iterative caesarean sections, maternal morbidity in TOL after a previous caesarean delivery decreases with the number of successful TOL (EL2). In patients with a previous caesarean delivery, the risks of maternal complications are rare and similar between TOL and ERCD. There is an increased risk of complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk balance in most cases and its success reduces the risk of short and long-term maternal complications (EL3).

Beucher G ，Dolley P ，Lévy-Thissier S ，Florian A ，Dreyfus M ... -  《-》