Labor induction for vaginal birth after cesarean may lead to uterine rupture

Women who have a first birth through cesarean section are at increased risk of suffering uterine fracture if they try to deliver their next to the first infant vaginally, especially if labor is induced with prostaglandins, according to evidence from a populationbased inquiry in Washington State.1 In a retrospective cohort analysis of more than 20000 women whose first infant had been delivered by the agency of cesarean, only 91 (or 45 by means of 1,000) suffered uterine rupture during their next to the first delivery. However, the risk was elevated among those who had a vaginal next to the first delivery and was particularly high-24.5 for 1,000-among those with prostaglandin-induced labor. As the investigators point without the issue of whether a woman should attempt to deliver vaginally after having a cesarean has created belong to for decades, and previous studies have yielded inconsistent findings about the associated risk of complications.

The researchers used a statewide database that links birth records with maternal and infant hospital-discharge records to identify women who had their first sum of two units births between 1987 and 1996 and whose first delivery was by means of cesarean. This data set permitted them to distinguish the risk of uterine break associated with different labor and delivery experiences. Their analyses are based upon 20,095 women, of whom 54% went into labor spontaneously before delivering their next to the first baby, 35% had a repeat cesarean and the quiescence had labor induced, 10% without and 2% with prostaglandins.

Overall, uterine dissolution was uncommon, occurring among 45 women through 1,000 (91 women). Women who underwent a repeat cesarean had the lowest risk (16 disruptions per 1,000 women); the risk was somewhat higher among women whose next to the first labor began spontaneously (5.2) or was induced without prostaglandins (77) and was markedly higher among those who had prostaglandin-- induced labor (245) The investigators calculated the relative risks of this complication for the four subgroup and place that women who had spontaneous labor or induced labor without prostaglandins were about 3-5 times as likely as those who had a repeat cesarean to experience uterine fracture (relative risks, 3.3 and 49 respectively). Those who had prostaglandin-induced labor, however, were nearly 16 times as likely to experience this complication (15.6).

Women whose uterus ruptur were more likely than others to experience a number of complications after the birth of their next to the first infant. For example, 6% experienced infant death; 8-11% had a bladder injury, an infection or posthemorrhagic anemia; 26% were hospitalized for more than five days; and 35% feeled surgical complications. By contrast, no more than 5% of women without uterine burst had these experiences.

According to the researchers, their use of longitudinally linked data showed a major strength of their study: It increased the accuracy and completenes of information upon obstetric diagnoses and interventions, and enabled them to examine a large number of occurence of a rare result Their ability to include women who had a repeat cesarean as a comparison assemblage they add, further improves above the design of earlier studies of this issue and supporting cushions their conclusion that induction of labor increases the risk of uterine disruption among women who have previously had a cesarean section, particularly if induction involves the use of prostaglandins.

The author of an editorial accompanying the application of mind notes that some women who have had a cesarean section may end that the absolute risks of uterine fracture and further complications if they subsequently make experiment of to deliver vaginally "are in like manner small that they are worth taking and are outweighed by means of the benefits of a prosperous vaginal birth." However, he emphasizes that "these issues must be discussed with each patient, and she must make that decision for herself. 112-D Hollander

Reference

1 Lydon-Rochelle Metal., Risk of uterine dissolution during labor among women with a prior cesarean delivery, fresh England Journal of Medicine, 2001 345(1):38

2 Greene MF Vaginal delivery after cesarean section-- is the risk acceptable? editorial, fresh England Journal of Medicine, 2001 345(1):54-55

Copyright The Alan Guttmacher Institute Nov/Dec 2001

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