Vaginal Birth after Cesarean and Trial of Labor after Cesarean: What should we be Recommending Relative to Maternal Risk: Benefit?

Abstract

Trial of labor after cesarean (TOLAC) delivery is currently a hot obstetrical topic owing to the acute rise in the rate of cesarean deliveries, both primary and repeat. When the physician and patient are considering TOLAC, several factors should be considered: risk of uterine rupture, contraindications, minimizing risk and morbidity, choosing the appropriate candidate and whether or not to induce. Each patient has her own set of individual risk factors that may decrease her chance of successful vaginal birth after cesarean delivery or increase her risks with TOLAC. Once all things are considered, the risk:benefit of TOLAC should be weighed up before a decision is reached. Each of these factors is discussed in respect to maternal risk:benefit, with the focus on evidence presented in the current literature.

Effect of Entonox on reducing the need for Pethidine and the Relevant Fetal and Maternal Complications for Painless Labor

“…One of these methods is inhaled analgesia using Entonox gas (a mixture of 50% oxygen and 50% N2O). The benefits of Entonox are that they are fast acting, give rapid clearance from the body, there is no need for sophisticated and expensive devices, no need for highly-skilled personnel, and finally mothers have greater tolerance ( 13 – 15 ). For nearly fifty years, Entonox has been approved for pain relief, and is used especially in England.…”

Risk factors and outcomes associated with type of uterine rupture

“…When offering women ERCD several risks have to be taken into account: high risks of short-term complications such as hemorrhage, hysterectomy, thromboembolism, and neonatal complications that include respiratory distress syndrome and long-term complications such as placenta previa and accreta in future pregnancies [7-10, 26, 27]. Nevertheless, contraindications for TOLAC on the other hand such as previous uterine rupture, previous fundal incision or a present abnormally invasive placenta must be considered [28]. When analysing the intended route of delivery in our study, as expected we found that CURs were significantly more prevalent in cases with TOLAC compared to ERCD.…”

Safety and feasibility of trial of labor in pregnant women with cesarean scar diverticulum

“…Treatment is often restricted to patients with symptoms and a reduced quality of life. 12,14 Only five patients had menstrual changes in our study group, and all had mild symptoms that did not affect their quality of life. Therefore, none of the patients included in our study were recommended to undergo surgery for the diverticulum.…”

“…This is due to a higher incidence of short- and long-term complications such as uterine rupture, pathologically adherent placenta in subsequent pregnancies, and development of a cesarean scar defect (also known as an isthmocele) in patients with VBAC. 11 , 12 An isthmocele, also known as a diverticulum or niche, is defined as a reservoir-like pouch on the anterior wall of the uterine isthmus at the presumed site of the incision. 13 It develops because of poor local healing of the uterine incision and absence of myometrial layer continuity after CS.…”