Hi, here's a copy of that study:
Australian and New Zealand Journal of Obstetrics and Gynaecology
Volume 43 Issue 6 Page 471 - December 2003
doi:10.1046/j.0004-8666.2003.00131.x
Case Report
Successful vaginal birth after three previous Caesarean sections with no prior labour
Lucy Bowyer 1,2 and Michael Chapman 1,2
Introduction
Vaginal birth after Caesarean section is in danger of becoming extinct. Despite the
spectre of litigation and bankruptcy we should maintain an evidence-based, rather than
a litigation fearful, practice. To this end the present case illustrates the
application of the best available evidence to a clinical challenge.
Case report
A 36-year-old woman consulted for a second opinion at 32 weeks' gestation in her
fourth pregnancy. The woman wished to have a vaginal birth, having previously had
three lower segment Caesarean sections. Her pregnancy had been uncomplicated with no
vaginal bleeding; she was fit and well with a low body mass index.
Her first baby (male 3.62 kg) was delivered in South Africa in 1994 by elective
Caesarean section with an ante-partum diagnosis of 'cephalo-pelvic disproportion'. Her
second baby (female 3.24 kg) was delivered by elective Caesarean section, again in
South Africa, in 1996 for the indication of previous Caesarean section. In 1998 she
and her family moved to the UK, she was keen to attempt vaginal birth and this was
agreed provided that she laboured spontaneously before 42 weeks' gestation. At 42
weeks she had a third elective Caesarean section (female infant, 3.24 kg), as
spontaneous labour had not occurred.
The patient was very unhappy with the conduct of her previous deliveries. On each
occasion the epidural had been difficult to insert, a spinal tap had occurred with the
first baby and she felt bereft that she was unable to hold her babies (beyond the
brief standard initial contact) and keep them with her. The consultation with her
involved a review of published reports examining births after two or more previous
Caesarean sections. It was obvious that she and her husband were already well informed
with regard to the likely success of vaginal delivery and the possible uterine rupture
rates. The opinion offered was a 60% chance of vaginal birth and a 3% risk of scar
rupture with subsequent serious consequences. It was agreed that, after 6 h of active
labour, if progress was poor then a Caesarean section would be advised. The risk of
placenta praevia and percreta was discussed, and ultrasound revealed a posterior
placenta well clear of the lower segment. As they wished to accep
t the risks involved, a vaginal birth after three previous Caesarean sections was
planned at St. George Hospital, New South Wales, Australia. It was agreed that
continuous fetal monitoring would be carried out throughout labour, if after 6 h of
active labour delivery was not imminent then Caesarean section would be advised. At
the 37-week visit the fetal lie was oblique; subsequently the lie became longitudinal
with a cephalic, but unengaged, presentation at term.
As she had been having short-lived contractions irregularly through the night and was
fearful that intervention would be suggested she did not attend for her 41-week visit.
However, she was persuaded to attend for an antenatal 42-week consultation. She had
been having contractions overnight with only mild pain and felt well. The cervix was
posterior, soft, 50% effaced and closed, the fetal vertex was 2 cm above the ischial
spines, fetal movements and heart rate were normal. The increased risk of unexpected
stillbirth as gestation prolongs was discussed, and she declined fetal ultrasound or
cardiotocography.
The following day at 42 weeks and 1 day gestation, she arrived in hospital in the
evening, having had contractions that had become more painful and more regular
throughout the day. On examination the cervix was 8 cm dilated, fully effaced and the
fetal head at the ischial spines. She proceeded to have a normal vaginal birth 90 min
later with a right medio-lateral episiotomy. A live male infant was born in excellent
condition, weighing 3.565 kg. She and her husband were delighted with the outcome and
she was discharged home on the early discharge program the following day.
Discussion
The largest reported series on birth after two or more previous Caesarean sections was
by Miller et al. 1 Miller et al.'s study was conducted over a 10-year period in
California and included 1586 women with two previous Caesarean sections undergoing a
trial of labour; 1.8% (29) of these women had a uterine rupture, with one
rupture-related perinatal death (0.63:1000). There were 241 women who had a trial of
labour with three or more previous Caesarean section scars, with a rupture rate of
1.2% (three) and no perinatal deaths. The success of trial of labour in these groups
was 75% and 79%, respectively. Within the same series the success for vaginal birth
after Caesarean section with only one scar was 83% with a 0.6% uterine rupture rate
and 0.18:1000 perinatal deaths, thus uterine rupture was more common in women with two
or more Caesarean section scars. The maternal morbidity and hysterectomy rates are not
stated in Miller et al.'s publication. There was one rupture-related
maternal death giving a rupture-related maternal mortality rate of 7.9 per 100 000
trials of labour and a 5.1% risk of perinatal asphyxia as a consequence of uterine
rupture.
The second largest series was by Phelan et al. and conducted over a 4-year period in
California. 2 Trial of labour after two previous Caesarean sections was attempted by
501 women, with a 69% successful vaginal delivery rate. The uterine dehiscence rate is
reported as 1.8% (less than the control group of repeat Caesarean sections who had a
4.6% dehiscence rate, with one uterine rupture), with no uterine ruptures and one
hysterectomy carried out for uterine atony. The perinatal mortality rates from Phelan
et al.'s series are hard to interpret as they included some very low birthweight
infants (320-1990 g), but overall the perinatal mortality rate was comparable between
women who did and who did not attempt a trial of labour. There were no maternal
deaths. Interestingly, there were 85 women who had undergone a trial of labour in both
previous pregnancies and, of these women, a trial was successful upon the third
occasion in 53% (45) of cases.
Undoubtedly a woman who has two or more previous Caesarean section scars in her uterus
is at greater risk of uterine rupture than a woman who has only one scar. Appleton et
al.'s Australian series estimates a rupture rate of 0.3% for women with one prior
scar; thus there is a sixfold likely increase in the risk of uterine rupture in a
woman with two previous scars, although the absolute figures are still only 1.8 per
100. 3
It is important to emphasise the serious consequences of rupture when counselling the
individual woman. Where there are two previous Caesarean section scars, there is an
approximate 2% risk of rupture necessitating hysterectomy and the possibility of fetal
death. However, in the published reports these figures do not differ greatly from
those women undergoing elective repeat Caesarean section, and should not exclude a
trial of labour after two or even three previous Caesarean sections if that is what
the fully informed individual woman desires. We must be aware of our limitations as
clinicians to be all-protective and offer the best available advice from the best
available evidence to our patients.
References
1 Miller DA, Diaz FG, Paul RH. Vaginal birth after cesarean: a 10-year
experience. Obstetrics Gynecol. 1994; 84: 255-258.
2 Phelan JP, Ahn MO, Diaz F, Brar HS, Rodriguez MH. Twice a cesarean, always a
cesarean? Obstetrics Gynecol. 1989; 73: 161-165.
3 Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permezel M. Vaginal
birth after Caesarean section: an Australian multicentre study. VBAC Study Group. Aust
NZ J Obstet Gynaecol. 2000; 40: 87-91.
Australian and New Zealand Journal of Obstetrics and Gynaecology
Volume 43 Issue 6 Page 471 - December 2003
Authors:
Lucy Bowyer
Michael Chapman
--------------------------------------------------------------------------------
Received 10 July 2003; accepted 19 July 2003.
Affiliations
1Department of Obstetrics and Gynaecology, St. George Hospital, Kogarah and
2University of New South Wales, New South Wales, Australia
Correspondence
Dr Lucy Bowyer, Department of Women's Health, Level 2, Prichard Wing, St. George
Hospital, Gray Street, Kogarah, New South Wales 2217, Australia. Email: [EMAIL
PROTECTED]
To cite this article
Bowyer, Lucy & Chapman, Michael (2003)
Successful vaginal birth after three previous Caesarean sections with no prior labour.
Australian and New Zealand Journal of Obstetrics and Gynaecology 43 (6), 471-472.
doi: 10.1046/
j.0004-8666.2003.00131.x
----- Original Message -----
From: Dean & Jo <[EMAIL PROTECTED]>
Date: Friday, June 18, 2004 4:12 pm
Subject: [ozmidwifery] anyone have access to Blackwell Science?
> I was just wondering if anyone can access this study? I cant
> unfortunatley!cheers
> Jo
>
>
> : Aust N Z J Obstet Gynaecol. 2003 Dec;43(6):471-2. Related
> Articles, Links
>
>
> Successful vaginal birth after three previous Caesarean sections
> with no prior labour.
>
> Bowyer L, Chapman M.
>
> Department of Obstetrics and Gynaecology, St. George Hospital,
> Kogarah, New South Wales, Australia. [EMAIL PROTECTED]
>
> Publication Types:
> a.. Case Reports
>
> PMID: 14712954 [PubMed - indexed for MEDLINE]
>
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