Risk of Uterine Rupture With a Trial of Labor
in Women With Multiple and Single Prior
Cesarean Delivery
Mark B. Landon, MD, Catherine Y. Spong, MD, Elizabeth Thom, PhD, John C. Hauth, MD,
Steven L. Bloom, MD, Michael W. Varner, MD, Atef H. Moawad, MD, Steve N. Caritis, MD,
Margaret Harper, MD, MS, Ronald J. Wapner, MD, Yoram Sorokin, MD, Menachem Miodovnik, MD,
Marshall Carpenter, MD, Alan M. Peaceman, MD, Mary J. O’Sullivan, MD, Baha M. Sibai, MD,
Oded Langer, MD, John M. Thorp, MD, Susan M. Ramin, MD, Brian M. Mercer, MD,
and Steven G. Gabbe, MD, for the National Institute of Child Health and
Human Development Maternal-Fetal Medicine Units Network*
OBJECTIVE: To determine whether the risk for uterine
rupture is increased in women attempting vaginal birth
after multiple cesarean deliveries.
METHODS: We conducted a prospective multicenter
observational study of women with prior cesarean delivery
undergoing trial of labor and elective repeat operation.
Maternal and perinatal outcomes were compared
among women attempting vaginal birth after multiple
cesarean deliveries and those with a single prior cesarean
delivery. We also compared outcomes for women with
multiple prior cesarean deliveries undergoing trial of
labor with those electing repeat cesarean delivery.
RESULTS: Uterine rupture occurred in 9 of 975 (0.9%)
women with multiple prior cesarean compared with 115
of 16,915 (0.7%) women with a single prior operation (P
.37). Multivariable analysis confirmed that multiple
prior cesarean delivery was not associated with an increased
risk for uterine rupture. The rates of hysterectomy
(0.6% versus 0.2%, P .023) and transfusion (3.2%
versus 1.6%, P < .001) were increased in women with
multiple prior cesarean deliveries compared with women
with a single prior cesarean delivery attempting trial of
labor. Similarly, a composite of maternal morbidity was
increased in women with multiple prior cesarean deliveries
undergoing trial of labor compared with those
having elective repeat cesarean delivery (odds ratio 1.41,
95% confidence interval 1.02–1.93).
CONCLUSION: A history of multiple cesarean deliveries
is not associated with an increased rate of uterine rupture
in women attempting vaginal birth compared with those
with a single prior operation. Maternal morbidity is
increased with trial of labor after multiple cesarean
deliveries, compared with elective repeat cesarean delivery,
but the absolute risk for complications is small.
Vaginal birth after multiple cesarean deliveries should
remain an option for eligible women.
(Obstet Gynecol 2006;108:12–20)
LEVEL OF EVIDENCE: II-2
See related editorial on page 2.
* For members of the NICHD Maternal-fetal Medicine Units Network, see the
Appendix.
From the Departments of Obstetrics and Gynecology at the Ohio State University,
Columbus, Ohio; University of Alabama at Birmingham, Birmingham, Alabama;
University of Texas Southwestern Medical Center, Dallas, Texas; University of
Utah, Salt Lake City, Utah; University of Chicago, Chicago, Illinois; University of
Pittsburgh, Pittsburgh, Pennsylvania; Wake Forest University, Winston-Salem,
North Carolina; Thomas Jefferson University, Philadelphia, Pennsylvania; Wayne
State University, Detroit, Michigan; University of Cincinnati, Cincinnati, Ohio, and
Columbia University, New York, New York; Brown University, Providence, Rhode
Island; Northwestern University, Chicago, Illinois; University of Miami, Miami,
Florida; University of Tennessee, Memphis, Tennessee; University of Texas Health
Science Center at San Antonio, San Antonio, Texas; University of North Carolina
at Chapel Hill, Chapel Hill, North Carolina; University of Texas Health Science
Center at Houston, Houston, Texas; Case Western Reserve University, Cleveland,
Ohio; Vanderbilt University, Nashville, Tennessee; and the National Institute of
Child Health and Human Development, Bethesda, Maryland; and the George
Washington University Biostatistics Center, Washington, DC.
Supported by grants From the National Institute of Child Health and Human
Development (HD21410, HD21414, HD27860, HD27861, HD27869,
HD27905, HD27915, HD27917, HD34116, HD34122, HD34136,
HD34208, HD34210, HD40500, HD40485, HD40544, HD40545,
HD40560, HD40512, and HD36801).
The following core committee members participated in protocol/data management
and statistical analysis: Sharon Gilbert, MS; and protocol development
and coordination between clinical research centers: Frances Johnson, RN, and
Julia McCampbell, RN.
Corresponding author: Mark B. Landon, MD, the Ohio State University College
of Medicine and Public Health, 1654 Upham Drive, Means Hall 5th Floor,
Columbus, OH 43210-1228; e-mail: landon.1@osu.edu.
© 2006 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/06
12 VOL. 108, NO. 1, JULY 2006 OBSTETRICS & GYNECOLOGY
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
http://www.cbc.ca/health/story/2008/09/04/c-sections.html?ref=rss
Mothers who push to give birth may be more responsive to the cry of their babies than those mothers who elect to have a cesarean birth, a brain-scanning study suggests.
When U.S. researchers looked at functional MRI brain scans taken up to a month after mothers gave birth and heard their own babies' cries, they found more activity in areas linked to motivation and emotion among the six who had vaginal deliveries compared with six who had cesarean sections.
"We wondered which brain areas would be less active in parents who delivered by cesarean section, given that this mode of delivery has been associated with decreased maternal behaviours in animal models, and a trend for increased postpartum depression in humans," said the study's lead author, Dr. James Swain of the Child Study Centre at Yale University in Connecticut.
"Our results support the theory that variations in delivery conditions such as with cesarean section, which alters the neurohormonal experiences of childbirth, might decrease the responsiveness of the human maternal brain in the early postpartum."
The differences in brain activity were found in regions that seem to affect how a mother responds to her child and regulate her mood.
Postpartum depression risk
In natural birth, contractions help trigger the release of the hormone oxytocin, which is thought to shape a mother's behaviour. Hormones are not released in the same way during a cesarean section.
Obstetricians have long known that women who have a cesarean section sometimes have problems bonding with their baby.
That's why doctors and nurses on maternity wards commonly advise women to cuddle newborns against their skin right after birth to establish a bond, and offer support for feeding and care for the baby.
It is possible that the clinical reasons that lead women to have C-sections may play a role. To rule that out, researchers studied six mothers who opted to have C-sections, rather than cases where the procedure was medically necessary.
The study appears in the October issue of the Journal of Child Psychology and Psychiatry.
The number of women giving birth by C-section in Canada rose to 26 per cent in 2005-06 from 23 per cent in 2001-02, according to a report by the Canadian Institute for Health Information.
"As more women opt to wait until they are older to have children, and by association be more likely to have a cesarean section delivery, these results are important, because they could provide better understanding of the basic neurophysiology and psychology of parent-infant attachment," said Swain.
"This work could lead to early detection of families at risk for postpartum depression and attachment problems and form a model for testing interventions."
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"The risk of a baby dying because of uterine rupture appears to be less than one in one thousand. To put these numbers in perspective, remember that in the United States the [overall] perinatal mortality rate is around 1.1 percent."7 In contrast, mortality and morbidity rates associated with cesarean section are higher than these average rates. In addition, rupture can also occur in an unscarred uterus, and these ruptures tend to be much more catastrophic than those in VBACs.8 In fact, in one study of 93 reported cases of uterine rupture over a five-year period, 61 were in unscarred uteri and 32 in scarred. Nine maternal deaths occurred, and all were women who had not had cesarean sections.9 It may be these catastrophic ruptures in unscarred uteri that cause the misguided fear of cesarean scars rupturing.
from Bruce Flamm's book, Birth After Cesarean 1990
~Blessings~
in Women With Multiple and Single Prior
Cesarean Delivery
Mark B. Landon, MD, Catherine Y. Spong, MD, Elizabeth Thom, PhD, John C. Hauth, MD,
Steven L. Bloom, MD, Michael W. Varner, MD, Atef H. Moawad, MD, Steve N. Caritis, MD,
Margaret Harper, MD, MS, Ronald J. Wapner, MD, Yoram Sorokin, MD, Menachem Miodovnik, MD,
Marshall Carpenter, MD, Alan M. Peaceman, MD, Mary J. O’Sullivan, MD, Baha M. Sibai, MD,
Oded Langer, MD, John M. Thorp, MD, Susan M. Ramin, MD, Brian M. Mercer, MD,
and Steven G. Gabbe, MD, for the National Institute of Child Health and
Human Development Maternal-Fetal Medicine Units Network*
OBJECTIVE: To determine whether the risk for uterine
rupture is increased in women attempting vaginal birth
after multiple cesarean deliveries.
METHODS: We conducted a prospective multicenter
observational study of women with prior cesarean delivery
undergoing trial of labor and elective repeat operation.
Maternal and perinatal outcomes were compared
among women attempting vaginal birth after multiple
cesarean deliveries and those with a single prior cesarean
delivery. We also compared outcomes for women with
multiple prior cesarean deliveries undergoing trial of
labor with those electing repeat cesarean delivery.
RESULTS: Uterine rupture occurred in 9 of 975 (0.9%)
women with multiple prior cesarean compared with 115
of 16,915 (0.7%) women with a single prior operation (P
.37). Multivariable analysis confirmed that multiple
prior cesarean delivery was not associated with an increased
risk for uterine rupture. The rates of hysterectomy
(0.6% versus 0.2%, P .023) and transfusion (3.2%
versus 1.6%, P < .001) were increased in women with
multiple prior cesarean deliveries compared with women
with a single prior cesarean delivery attempting trial of
labor. Similarly, a composite of maternal morbidity was
increased in women with multiple prior cesarean deliveries
undergoing trial of labor compared with those
having elective repeat cesarean delivery (odds ratio 1.41,
95% confidence interval 1.02–1.93).
CONCLUSION: A history of multiple cesarean deliveries
is not associated with an increased rate of uterine rupture
in women attempting vaginal birth compared with those
with a single prior operation. Maternal morbidity is
increased with trial of labor after multiple cesarean
deliveries, compared with elective repeat cesarean delivery,
but the absolute risk for complications is small.
Vaginal birth after multiple cesarean deliveries should
remain an option for eligible women.
(Obstet Gynecol 2006;108:12–20)
LEVEL OF EVIDENCE: II-2
See related editorial on page 2.
* For members of the NICHD Maternal-fetal Medicine Units Network, see the
Appendix.
From the Departments of Obstetrics and Gynecology at the Ohio State University,
Columbus, Ohio; University of Alabama at Birmingham, Birmingham, Alabama;
University of Texas Southwestern Medical Center, Dallas, Texas; University of
Utah, Salt Lake City, Utah; University of Chicago, Chicago, Illinois; University of
Pittsburgh, Pittsburgh, Pennsylvania; Wake Forest University, Winston-Salem,
North Carolina; Thomas Jefferson University, Philadelphia, Pennsylvania; Wayne
State University, Detroit, Michigan; University of Cincinnati, Cincinnati, Ohio, and
Columbia University, New York, New York; Brown University, Providence, Rhode
Island; Northwestern University, Chicago, Illinois; University of Miami, Miami,
Florida; University of Tennessee, Memphis, Tennessee; University of Texas Health
Science Center at San Antonio, San Antonio, Texas; University of North Carolina
at Chapel Hill, Chapel Hill, North Carolina; University of Texas Health Science
Center at Houston, Houston, Texas; Case Western Reserve University, Cleveland,
Ohio; Vanderbilt University, Nashville, Tennessee; and the National Institute of
Child Health and Human Development, Bethesda, Maryland; and the George
Washington University Biostatistics Center, Washington, DC.
Supported by grants From the National Institute of Child Health and Human
Development (HD21410, HD21414, HD27860, HD27861, HD27869,
HD27905, HD27915, HD27917, HD34116, HD34122, HD34136,
HD34208, HD34210, HD40500, HD40485, HD40544, HD40545,
HD40560, HD40512, and HD36801).
The following core committee members participated in protocol/data management
and statistical analysis: Sharon Gilbert, MS; and protocol development
and coordination between clinical research centers: Frances Johnson, RN, and
Julia McCampbell, RN.
Corresponding author: Mark B. Landon, MD, the Ohio State University College
of Medicine and Public Health, 1654 Upham Drive, Means Hall 5th Floor,
Columbus, OH 43210-1228; e-mail: landon.1@osu.edu.
© 2006 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/06
12 VOL. 108, NO. 1, JULY 2006 OBSTETRICS & GYNECOLOGY
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
http://www.cbc.ca/health/story/2008/09/04/c-sections.html?ref=rss
Mothers who push to give birth may be more responsive to the cry of their babies than those mothers who elect to have a cesarean birth, a brain-scanning study suggests.
When U.S. researchers looked at functional MRI brain scans taken up to a month after mothers gave birth and heard their own babies' cries, they found more activity in areas linked to motivation and emotion among the six who had vaginal deliveries compared with six who had cesarean sections.
"We wondered which brain areas would be less active in parents who delivered by cesarean section, given that this mode of delivery has been associated with decreased maternal behaviours in animal models, and a trend for increased postpartum depression in humans," said the study's lead author, Dr. James Swain of the Child Study Centre at Yale University in Connecticut.
"Our results support the theory that variations in delivery conditions such as with cesarean section, which alters the neurohormonal experiences of childbirth, might decrease the responsiveness of the human maternal brain in the early postpartum."
The differences in brain activity were found in regions that seem to affect how a mother responds to her child and regulate her mood.
Postpartum depression risk
In natural birth, contractions help trigger the release of the hormone oxytocin, which is thought to shape a mother's behaviour. Hormones are not released in the same way during a cesarean section.
Obstetricians have long known that women who have a cesarean section sometimes have problems bonding with their baby.
That's why doctors and nurses on maternity wards commonly advise women to cuddle newborns against their skin right after birth to establish a bond, and offer support for feeding and care for the baby.
It is possible that the clinical reasons that lead women to have C-sections may play a role. To rule that out, researchers studied six mothers who opted to have C-sections, rather than cases where the procedure was medically necessary.
The study appears in the October issue of the Journal of Child Psychology and Psychiatry.
The number of women giving birth by C-section in Canada rose to 26 per cent in 2005-06 from 23 per cent in 2001-02, according to a report by the Canadian Institute for Health Information.
"As more women opt to wait until they are older to have children, and by association be more likely to have a cesarean section delivery, these results are important, because they could provide better understanding of the basic neurophysiology and psychology of parent-infant attachment," said Swain.
"This work could lead to early detection of families at risk for postpartum depression and attachment problems and form a model for testing interventions."
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"The risk of a baby dying because of uterine rupture appears to be less than one in one thousand. To put these numbers in perspective, remember that in the United States the [overall] perinatal mortality rate is around 1.1 percent."7 In contrast, mortality and morbidity rates associated with cesarean section are higher than these average rates. In addition, rupture can also occur in an unscarred uterus, and these ruptures tend to be much more catastrophic than those in VBACs.8 In fact, in one study of 93 reported cases of uterine rupture over a five-year period, 61 were in unscarred uteri and 32 in scarred. Nine maternal deaths occurred, and all were women who had not had cesarean sections.9 It may be these catastrophic ruptures in unscarred uteri that cause the misguided fear of cesarean scars rupturing.
from Bruce Flamm's book, Birth After Cesarean 1990
~Blessings~
| | |
| | |
No comments:
Post a Comment