DOI: 10.1111/j.1471-0528.2009.02351.

x
www.bjog.org Systematic review

Vaginal birth after two caesarean sections
(VBAC-2)—a systematic review with
meta-analysis of success rate and adverse
outcomes of VBAC-2 versus VBAC-1 and
repeat (third) caesarean sections
a b
S Tahseen, M Griffiths
a
Leeds University Hospitals NHS Trust, Leeds, UK b Luton & Dunstable Hospital NHS Foundation Trust, Luton UK
Correspondence: Dr S Tahseen, 20 Malthouse Green, Luton LU2 8SN, UK. Email stjavaid@yahoo.co.uk

Accepted 19 July 2009. Published Online 14 September 2009.

Background Trial of vaginal birth after Caesarean (VBAC) is RevMan-5 to compare VBAC-1 versus VBAC-2 and VBAC-2
considered acceptable after one caesarean section (CS), however, versus RCS.
women wishing to have trial after two CS are generally not
Main results VBAC-2 success rate was 71.1%, uterine rupture rate
allowed or counselled appropriately of efficacy and
complications. 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal
unit admission rate 7.78% and perinatal asphyxial injury/death
Objective To perform a systematic review of literature on success 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666
rate of vaginal birth after two caesarean sections (VBAC-2) and (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated
associated adverse maternal and fetal outcomes; and compare with uterine rupture rate 1.59% versus 0.72% (P < 0.001) and
commonly accepted VBAC-1 and the alternative option of repeat hysterectomy rates were 0.56% versus 0.19% (P = 0.001)
third CS (RCS). respectively. Comparing VBAC-2 versus RCS, the hysterectomy
rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus
Search strategy We searched MEDLINE, EMBASE, CINAHL,
1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%,
Cochrane Library, Current Controlled Trials, HMIC Database,
respectively (P = 0.27). Maternal morbidity of VBAC-2 was
Grey Literature Databases (SIGLE, Biomed Central), using search
comparable to RCS. Neonatal morbidity data were too limited to
terms Caesarean section, caesarian, C*rean, C*rian, and MeSH
draw valid conclusions, however, no significant differences were
headings ‘Vaginal birth after caesarean section’, combined with
indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission
second search string two, twice, second, multiple.
rates and asphyxial injury/neonatal death rates (Mantel–Haenszel).
Selection criteria No randomised studies were available, case
Conclusions Women requesting for a trial of vaginal delivery after
series or cohort studies were assessed for quality (STROBE), 20/23
available studies included. two caesarean sections should be counselled appropriately
considering available data of success rate 71.1%, uterine rupture
Data collection and analysis Two independent reviewers selected rate 1.36% and of a comparative maternal morbidity with repeat
studies and abstracted and tabulated data and pooled estimates CS option.
were obtained on success rate, uterine rupture and other adverse
Keywords Complications, uterine rupture, vaginal birth after two
maternal and fetal outcomes. Meta-analyses were performed using
caesarean sections.

Please cite this paper as: Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)—a systematic review with meta-analysis of success rate
and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010;117:5–19.

reasons for the rise in caesarean rates, together with fetal
Background
distress, dystocia and breech presentation.1,2 In UK, CS rate
Caesarean section (CS) rates have risen worldwide. Perfor- in women with a previous caesarean is 67% as compared
mance of elective repeat caesarean is one of the main to 24% in primigravid women according to the results of

ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 5
Gynaecology

Tahseen, Griffiths

The National Sentinel Caesarean Section Audit.1 Multiple tute for Clinical Excellence (NICE), Royal College of
caesarean sections are associated with placental adherence Obstetricians & Gynaecologist (RCOG), American College
to scar (placenta increta/praevia)3 which is a potential sur- of Obstetrician & Gynaecologist (ACOG), Society of Obste-
gical challenge and a cause of maternal morbidity and mor- tricians & Gynaecologists of Canada (SOGC), Cochrane
tality. A trial of labour after previous caesarean delivery has Library Issue 3 2006 and National Electronic Library for
been accepted as a way to reduce the overall caesarean rate Health (NeLH).
and also to allow women choice for mode of delivery. The search terms comprised first search string including;
Many studies have supported the efficacy and safety of vag- Caesarean section, caesarean, caesarian, C*rean and C*rian,
inal birth after caesarean (VBAC) after one caesarean sec- combined with a second search string which included; two,
tion and reliable figures of success rate and complications twice, second, multiple. Searches were applied, in turn,
are available for counselling women for VBAC after one restricting to key words, title and then abstract. This search
caesarean section.4–6 While clinicians [supported by guide- strategy yielded a large number of non-relevant articles.
7
lines (Society of Obstetricians & Gynaecologists of Canada Use of the MeSH heading ‘Vaginal birth after caesarean
and American College of Obstetricians & Gynaecologists)8] section’ was then applied combined with the second string
generally recommend or offer a trial of vaginal birth after search words (not restricted to title or abstract) which
one caesarean section, a trial of labour is generally not yielded relevant papers Relevance of articles was further
offered after two CS. determined by the titles and/or abstracts. There were no
Although outcomes of trial of vaginal delivery after two language restrictions on the searches. Electronic searching
caesarean sections9–31 have been published over last two was supplemented by hand searching of the reference lists.
decades, the subject of VBAC-2 has not received its due We attempted to contact authors where additional infor-
consideration among obstetricians. Women requesting for mation was needed.
such trials are generally not allowed or counselled appro-
priately and may receive conflicting advice, an issue likely Study selection
to be of considerable importance for many women. Suc-
cessful VBAC-2 may also reduce overall caesarean section There were no controlled trials available on the subject. Pub-
rate and associated complications of multiple caesareans. lications were either case reports, small case series or major
cohorts. Individual case reports, duplicate publications and
publications commenting on other papers were excluded. In
Objectives case of publications reflecting the same cohort, only the
To assess the success rate and associated major complica- study with most up-dated, complete and relevant data was
tions of trial of vaginal birth after two caesarean sections used. Four foreign language papers were identified, after
by means of systematic review; and to provide the relevant translation two were confirmed to be case reports,10,33 the
figures for patient counselling for such trials. third was a duplicate publication19,20 which was included
and the last21 study was considered but excluded due to
poor methodology. We used the appraisal tools from
Search strategy
STROBE34 to assess methodological quality of identified
The peer-reviewed protocol for this review was prepared studies (study selection process and targeted searching for
a priori, detailing specific objectives, criteria for study guidelines is shown in Figure 1). Characteristics of each
selec- tion and approach to assessing quality, outcomes study are summarised in Table 1 (20 studies). All but the
and sta- tistical methods. The article was prepared in three studies14,21,23 were deemed to be of reasonable quality
accordance with the Meta-analysis of Observational Studies by STROBE criteria to be included. Jamelle23 described expe-
in Epide- miology (MOOSE) Statement.32 We used rience of unplanned VBAC in unbooked women (ten cases),
published deiden- tified data and thus the present study largely or entirely labouring unsupervised, presenting to a
was exempt from Local Research & Ethics Committee tertiary centre usually in advanced labour or already with
14
(LREC) approval. complications. Similarly, Emembolu described women
Searches were performed on the following electronic bib- presenting in advanced labour with unplanned VBAC (139
liographic databases; Medline (from 1966), Cumulative cases), these scenarios do not reflect planned trial of labour
Index to Nursing and Allied Health Literature CINAHL and would introduce bias to the results. Guettier21 reported
(from 1982), The Cochrane Library (2008: Issue 3), Cur- 17 women with two previous uterine scars, one of which
rent Controlled Trials, HMIC database, National research may be a previous myomectomy/hysterotomy scar. Nine
register, Research Findings Electronic Register (ReFER). women (53%) delivered vaginally including two women
Additionally Grey Literature databases searched were fully dilated on admission and one home delivery. These
SIGLE (from 1980) and Biomed Central. Targeted internet three studies were not included in the analysis.
search- ing of key organisation websites included;
National Insti-

6 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

Success rate & adverse outcomes of vaginal birth after two caesarean sections Study selection flow chart 273 potentially relevant articles identified and screened Targeted searching for guidelines -Society of Obstetricians & Gynecologists of Canada ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 7 Gynaecology .

Copenaghen. including 5666 subjects undergoing labour (mostly as 35 ity. 17 studies included Figure 1. Cate. low Apgar scores. number of eli- gible women with previous two caesarean sections). Success rate & adverse outcomes of vaginal birth after two caesarean sections 243 articles excluded on -American College of basis of title or abstract Obstetricians & Gynecologists -Royal College of Obstetricians & 26 studies. Four publications reflected perinatal asphyxial injury/death attributable to mode of the same cohort25. In two recent large studies.42 the most comprehensive publications The comparator groups [VBAC-1 or non-trial repeat relevant to our subject were chosen from each cohort. Interstudies heterogene.05. in VBAC-2 group). The follow. The Cochrane Collaboration. same cohort17–20. Seventeen Meta-analysis was performed following the guidelines studies were included in data abstraction and analysis 32 proposed by the MOOSE Group. 25 data were available for tergroup comparisons were considered statistically signifi. version 5 for Windows. The Data were abstracted independently by the two authors and Nordic Cochrane Centre. blood transfu. 3 studies excluded due to poor methodology. if CIs did were carried out because of its wide acceptability among ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 7 Gynaecology .36 and review articles.37. success Results rate. 3 case reports and Gynecologists-UK one review article were -NICE (National Institute potentially relevant of Clinical Excellence) UK -Cochrane Library 6 studies reflected same cohort and 3 case reports and one review article were not considered further 20 studies were appraised for quality. Six studies reported outcomes using a comparator rather than chance (I2). After exclusion of case reports33.38 sion. elective).0. The (third) caesarean section] characteristics were noted if 20 studies considered in detail are summarised in Table 1. any discrepancies were resolved by discussion. proportion of women undergoing trial (i. odds ratios (ORs) with 95% confidence intervals (CI). hysterectomy rate. Study selection process for the systematic review of success rates and complications of trial of vaginal birth after two caesarean sections.24. was tested with chi-square test for group of VBAC-1 (50 685 subjects in VABC-1 versus 4565 heterogeneity at a significance level of P = 0. ing data items were collected if available from each paper. Meta-analysis was performed with Data collection and analysis RevMan (Revision Manager. the subjects included in this subset were 2829 in gorical variables were examined with calculations of pooled VBAC-2 versus 10 897 in repeat (third) caesarean sections. uterine rupture rate. defined according to Higgins et al.e. In. Eight studies used a comparator group dom effect model was generated whenever the I2 statistics of repeat third caesarean sections (RCS) (nonlabour and/or were >25% using Mantel–Haenszel analysis method. available.10 and a ran. Three studies were excluded due to poor quality. both the comparator groups. Comparison with VBAC-1 cant at an alpha level of two-tailed P < 0. not encompass 1. Denmark 2008). neonatal unit admission rate and 26 studies were assessed further.39–41 and two publications each reflected delivery (judicious review of text to extrapolate this figure).24. as the percentage planned trial of labour) after two or more caesarean sec- of total variation across studies because of heterogeneity tions.

Details of studies included in the systematic review of success rate and complications of VBAC-2 Study Study Methods Labour Success rate Maternal Neonatal reference population management outcome outcome .Table 1.

1% CS) vs 16 915 VBAC1 and prior vaginal transfusion 3.7% in VBAC-1 Term intrapartum stillbirth comparing VBAC-2 three previous trial. Blood transfusion 1% score >7 at of labour. vs 0.6% 0. 25 8 Macones 1082 VBAC-2 27% of subjects with VBAC-2 vs VBAC-1 74. minor maternal morbidity comparable in VBAC and RCS 11 Bretelle (France) 96 cases were VBAC-2 (52%) and Clinical/X-ray pelvimetry Success 65. and registry/delivery hysterectomy 1/59 records (1.18% VBAC-2 with VBAC-1 CS excluded 34% vs 34% prior vaginal in RCS.6% VBAC-2 Uterine rupture Birthweight 3347 Tahseen.2% vs 1. Griffiths (North America) 2888 RCS and previous two CS IOL 30% vs 29% success vs 1.9% vs 3349 g Cohort study. and RCS delivery were Fever 12.7%).08%. 84 cases with two CS had a Syntocinon group with multiple CS.8% in VBAC-2 to undergo trial 24 Landon 975 cases VBAC-2 14% of subjects VBAC-2 vs VBAC-1 66% (648/975) Uterine rupture 0.7%).6% Uterine rupture 0% 72 infants had Apgar Case series allowed a trial elective CS (48%) for allowing TOL. and VBAC-2 vs RCS four previous Epidural 58% vs 71% Women with vs 0.68% and 1. Transfusion 0. 12.15% vs 0. previous two CS) morbidity provided were provided Only previous low transverse uterine scars included 31 Spaans 59 cases VBAC-2 26% of women with IOL 24% 83% (49/59) had a Transfusion 4/59 (6. 84 had syntocinon augmentation Hysterectomy first minute elective repeat CS 76%.535 VBAC-1 had a trial Syntocinon 75. no data for although no data emergency CS. term HIE 0% vs 0.6% 6035 RCS after delivery were Maternal morbidity two CS Previous more likely comparable with RCS classical CS excluded to undergo trial 18 Garg (Saudi Arabia) 100 cases in VBAC-2 100 cases had No IOL or 66% success No uterine rupture or No difference in fetal Case series trial vs 71 trial (48% augmentation hysterectomy in either outcome reported elective CS and 34 non-trial of women with group.2% respectively. term NND Gynaecology ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and vs VBAC-1 CS and 20 with 25% vs 32% in VBAC-1 group Hysterectomy 0.92% comparing Previous classical and 73% repeat CS augmentation Women with vs 0.01%. no low transverse morbidity data for uterine scars included RCS group available .8% vs 0.9% Term NICU admission (North America) (including with previous IOL 23% vs 26% success in (9/975) in VBAC-2 11% vs 9% Prospective cohort study.7%) Apgar <7 at 5 min 7% (The Netherlands) vs 187 RCS previous two vaginal birth vs 19/187 (10%) in NICU admission Cohort data Data on previous scar CS had trial Similar success rate with labour uterine rupture 34% from caesarean type not available history of vaginal delivery 1/59 (1.5% VBAC-1. IOL12%.7% RCS vs more likely 8. pidural 76% secondary Only previous to atony 1%. 86% RCS augmentation 74% (12490/16915) (115/16 915) 0% vs 0.

(Continued) .Table 1.

09% 13 Chattopadhyay 115 cases VBAC-2 Compared VBAC-2 Prostaglandin IOL Success 103/115 (90%) Scar dehiscence Peri-natal mortality 2. hysterectomy failed VBAC-1 9. deaths not Case series Only previous elective CS (90%). Study Study Methods Labour Success rate Maternal Neonatal reference population management outcome outcome Gynaecology ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 12 Caughey 134 cases VBAC-2 Comparative study.4% vs 0.6%.7% vs Uterine rupture 3.7%VBAC1 in others included rupture).8% (prior vaginal vs 3506 g Caesarean registry data with 3757 VBAC-1 and VBAC-1 (proportion of 38% vs 36%. 77% 3/302 (1%) vs 5/1110 failed VBAC-2 9. trial unknown) of uterine Hysterectomy 1/134 vs 9. Case series Previous low vertical and 69% after two CS and augmentation and in VBAC-1 (0.74%) vs (0.1% unknown uterine 92% after 1CS had trial.2% vs 8.74%) vs 7/3757 uterine rupture 1/134 (0. Hysterectomy (0. one neonatal Success rate & adverse outcomes of vaginal birth after two caesarean sections unplanned vaginal delivery) admitted postdelivery No syntocinon death caused by No information on augmentation prematurity/septicaemia previous scar 9 Asakura 302 cases VBAC-2.8% (prior vs 0. Compared VBAC-2 Unrestricted use of 64% success Uterine rupture 1 min Apgar <3 in (North America) 1110 VBAC-1 with VBAC-1 IOL. low Apgar score controls (? matched) CS No information trial unknown 2. syntocinon VBAC-2.33% vs 0. epidural.18%) group only} 7/3757 (0.7%) and considered directly low transverse Only 115/230 32/115(28%) hysterectomy related to mode uterine scars included requesting for a trial (0.9% syntocinon 62% in control death (not directly <7 18% vs 17% on previous type of scar augmentation attributable) rate 7.8% vs 1. <7.33% vs 0% Asphyxial injury caused scars included to those with an by uterine unscarred uterus. one vaginal examination.6% Maternal 12%. denominator Syntocinon Ventouse delivery 4/26 rupture or dehiscence 5-min Apgar scores = 7–9 Case series 3/26 had three previous-CS data not given augmentation 54% Hospital stay No NICU admissions Only previous Epidural 80% average 3 days low transverse uterine scars included 9 .60%VBAC-2 scar excluded.7% Birthweight 3530 g (North America) compared between VBAC-2 Syntocinon augmentation 0. Oxytocin augmentation history of vaginal delivery 0.18%) 14 Emembolu Nigeria 139 cases with Proportion of women Women presented in 33% (46/139) achieved Uterine rupture Peri-natal death 12% vs Case series and previous two undergoing labour (usually advanced) vaginal delivery vs 1. (Israel) 26 controls RCS elective CS. rupture 0. identical 0. IOL 20% vs 22% Uterine rupture 3.8% vs vs 1%.45%).9/1000.6% (Saudi Arabia) 1006 cases RCS (10%) and 37/115 (32%) Similar success rate with (0.4%) of delivery were permitted comparable 20 Granovsky-Grisaru 26 cases VBAC-2 Control group from Only spontaneous labour 19/26 (73%) success No uterine scar Baby weight 2800–4600 g. all labour.2/1000 vs 5. transfusion 35% vs 14% 23 Jamelle (Pakistan) 10 cases with previous 9/10 presented Apparent disproportion All patients 1/10 scar rupture One (1/10) stillbirth Case series of 10 low segment in advanced was excluded by delivered vaginally required laparotomy associated with scar CS (9/10 unbooked. 1/10 septicaemia rupture. vaginal delivery delivery was protective {5-min Apgar score Previous classical women undergoing epidural 72% vs 70% was protective of uterine rupture).

Table 1. (Continued) .

delivery. Uterine rupture 0% vs No perinatal deaths (North America) and 587 elective CS (46%) and elective induction (3. Previous ‡2 CS had previous 1CS vs 0.4% in Elective CS 27 Novas 36 cases having VBAC-2 Compared VBAC-2 36(52%) Oxytocin 47% Success 80% (29/36) Uterine rupture 1/ Apgar scores (North America) (nine had previous and non-trial CS.2% vs 5 min Apgar <7 2. 241 with VBAC-1.8% (vs 0. Case series Previous unknown CS (54%) augmentation 53% history of Hysterectomy 0. 3/9 actually morbidity in 17 cases. 135 cases vaginal delivery Transfusion 1/35 (2.1%) in Low transverse scars without trial CS 28 Phelan 501 cases VBAC-2 Compared VBAC-2 Oxytocin used for Success 69%. no figures Case series three CS) CSs revealed at provided.8%) non-trial CS vs 11/135 (8. 2 pt fully delivery. No Oxytocin Higher success rate and hysterectomy none in the two Case series three CS. 1/35 135 cases without trial CS augmentation with history of in trial group groups pre.4 CS. 0% uterine rupture 5 min Apgar score <5.2% in elective CS in VBAC-2 and 1.018% vs trials from caesarean previous one CS. previous CS) no separate for whole group previous classical scars denominator data for excluded but Pre two CS available unknown scars included! 22 Hansell 35 cases VBAC-2 21% of women with ‡2 Only spontaneous labour Success 77% (27/35). Study Study Methods Labour Success rate Maternal Neonatal 10 Tahseen.05% registry/delivery classical scars excluded but trial vs 80% records unknown scars included! previous 1CS 21 Guettier (France) 17/41 women with two A case series of 17 Included one home 9/17 (53%) vaginal No relevant No neonatal morbidity Case series previous uterine scars. 33 (48%) 36–2.7%(H/O classical comparable.6% peri-natal death Cohort data previous ‡3 CS).2% on elective CS attributable to trial. including trial of labor (38% of for VBAC-2 for VBAC-2.6%) Higher success rate with 0.6% scars included vaginal delivery 1. available previous two 1. but three ncluding myomectomy/ dilated on admission had two CS major congenital Gynaecology ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and hysterotomy abnormality 16 Flamm 5733 trial of labour All women undergoing No separate figures 69% success (168/245) No separate No separate figures (North America) after CS. ERCS 33 laparotomy) vs 0/33 PND unrelated to trial Previous unknown Hysterectomy 0/36 uterine scars included vs 2/33 . (North America) 2/35 had previous previous CS had trial. 75% figures for VBAC-2 f or VBAC-2 Case series 245cases VBAC-2. Griffiths reference population management outcome outcome 26 Miller 1827 previous two CS Compared VBAC-2 No information Success 75% Uterine rupture Rupture related (North America) (1586 previous two CS. 10 880 54% previous CS vs 83% .

wher- Only spontaneous labour Only spontaneous labour Only spontaneous labour ever available. reported trial of scar data after single morbidity at 5 min and multiple previous caesarean sections. again only the paired outcomes are listed.Only low transverse uterine scars. Table 2 shows the outcomes in Table 1. Bretelle reported the neonatal morbidity of their study as ‘72/96 newborns had Apgar scores superior to 7 at unknown uterine scars included first minute’. Other maternal morbidities as operative Oxytocin augmentation injury or ITU admissions were variably classified24. a pooled analysis was not obtained. only a combined uterine rupture rate of 0. hospital stay was mentioned only in few. repeat (third) caesarean section. denominator 57 cases VBAC-2 (18 had three natal outcomes in their study.8%) Asymptomatic scar dehiscence found incidentally at caesar- vaginal del. (10/5733) for the whole study population was given. RCS. Hys- terectomy and blood transfusion rates were assessed. If studies used different definitions of outcomes. Miller26 reported (44/57) 17 322 cases of trial of scar from a 10-year period and Flamm16 reported 5733 trial of scar cases over 5 year. Only low population HIE/perinatal death and neonatal unit admission rates. The calculation of percentages were based only on the data from the papers reporting the relevant outcomes. No booking). Febrile morbidity was reported mainly in comparison to caesarean sections in several studies. previous CS). 55% Oxytocin 19% epidural Few studies have considered the neonatal outcomes. Different maternal mor- No scar rupture bidity indicators were reported in studies.3/55 (5. and although success rates for single and multiple caesarean sections were specified. We considered Apgar scores data not available Previous 21 cases. a report (indigent population. some studies reported neonatal morbidity only in cases of uterine rupture not the whole study population12. Apgar scores considered in few studies Self-selected motivated Methods describing VBAC-2 controls (64) ERCS comparator group comparator group were variably reported as 1-minute score or 1-. Moreover.20 Phelan28 and Pruett30).26 included this data would skew the adverse neonatal effects therefore only studies spontaneous labour (? matched) describing neonatal outcomes for all subjects were included (Table 2).6%) hysterectomies. vaginal birth after caesarean.4%) endometritis. Study data not available where reported were pooled to assess neonatal outcome. this statement was un-informative to assess neo- denominator data not available 55 cases VBAC-2. denominator to be too diverse for aggregate comparison. Table 3 shows comparison of VBAC-1 (North America) (North America) (North America) versus VBAC-2 reported in the same cohorts (six studies) Farmakides15 and only the paired available outcomes are tabulated.and/or VBAC. Asphyxial injury/ transverse uterine scars. Case series reference Case series Case series Porreco29 Pruett30 Table 4 shows comparison of VBAC-2 with non-trial repeat Study (third) caesarean section within same cohorts (eight stud- ies). Uterine rupture rates were given in all 16 studies except one. 1-minute Apgar score below 39 and 5-minute Apgar score 22 11 below 5. (Continued) all included studies. no Spaan.18. No perinatal outcomes were reported by Porreco29 Selected sample. 5. Labour augmentation 33% Oxytocin. one uterine rupture (two had Transfusion 1/55 (1. 5-min Apgar scores below 7 (reported by patients.31 Gravnovsky-Grisarau. none in placenta accrete) and ean section was disregarded and only symptomatic scar 10/30 failed trial had Maternal outcome No uterine rupture ruptures were included in analysis. limit- 5/57 (8%) ing the availability of neonatal data.17% 2/55 (3. Success rate & adverse outcomes of vaginal birth after two caesarean sections patients and clinicians and to compare the level of risk No significant peri-natal No neonatal morbidity associated with VBAC-1 versus VBAC-2. 10-minute scores. previous vertical scar. late in spontaneous labour and Chattopadhyay13. ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 11 Gynaecology .15. Success rates of trial of labour were available in all All Apgar scors >7 Neonatal outcome included studies.20 No maternal morbidity data except uterine rup- ture were available in some studies reporting on large Success 77% Success rate 45% success 81% success cohorts from birth/caesarean registries.25 and management were too diverse for the purpose of pooled analysis. pre2 CS Selected sample.

0) 0 0 Spaan31 59 49 (83) 1 (1. Tahseen.05) 1321 (9) Values in parenthesis are expressed in percentage.19) 1 (0.7) 1 (0.75) 0 (0.0) 26 Miller 1827 1376 (75) 32 (1.0) 0 (0.33) 13 Chattopadhyay 115 103 (89) 1 (0. 12 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology .7) 1 (0.7) 1 (1.2) 14 (0.99) 8 (0.89) 20 Granovsky-Grisarau 26 19 (73) 0 (0. prematurity related) were not included.9) Bretelle11 96 63 (65.7) 273 (1.0) 0 (0.0) 0 30 Pruett 55 25 (45) 3* (5.09) 90/1156 (7.6) 20 (1.05) VBAC-1 10 880 9063 (83) 63 (0.g.2) VBAC-1 16 915 12 490 (74) 115 (0.9) 31 (3.59) 41 (1.6) 1 (0.2) 6 (0.6) 2 (0.0) 28 Phelan 501 346 (69) 0 1 (0.45) 0 (0.8) 4 (6.6) 35 (0.4) 1 (1.0) VBAC-1 3757 2818 (75) 31 (0.02) 9 Asakura VBAC-2 302 194 (71) 3 (1.1) 1 (1.5) 327 (0.56) 3 (0.0) 2 (2.0) 0 29 Porreco 21 17 (81) 0 (0.0) 12 Caughey 134 83 (62) 5 (3.36) 49/2428 (2.0) 1 (0. Table 3.33) 1 (0.7) 1 (0.2) 27 Novas 36 29 (80) (0. prematurity related) were not included. Griffiths Table 2.92) 24 Landon 975 648 (66) 9 (0.7) 74/5421 (1.6) 0 (0.33) 1 (0.8) 0 (0.0) 0 0 (0.92) VBAC-1 12 535 9464 (75.2) VBAC-1 50 685 38 814 (76.7) 69 (1.21) 42 (0. *Prelabour stillbirths and postnatal deaths unrelated to mode of delivery (e.09) 26 Miller VBAC-2 1827 1376 (75) 32 (1.01) 14/2512 (0.2) Garg18 100 66 (66) 0 (0.75) 9 Asakura 302 194 (71) 3 (1) 1 (0.9) 85 (0.8) 7 (0.7) 0 (0. *2/3 uterine ruptures diagnosed by palpation after successful vaginal delivery.9) 31 (3.0) 1 (2.8) 2 (3.04) 0 (0.2) 6 (0.018) 16 Flamm VBAC-2 245 168 (69) VBAC-1 5488 4123 (75) Total VBAC-2 4565 3276 (71.33) VBAC-1 1110 856 (64) 5 (0.72) 358 (1.55) 3/3285 (0.15) 75 (11. Outcome of VBAC-2 for all included studies Study reference Numbers VBAC Uterine Transfusion Hysterectomy Asphyxial NNU VBAC-2 success Rupture injury/PND** 25 Macones 1082 807 (74.8) 10 (0.09) 75 (11.78) Values in parenthesis are expressed in percentage.5) 113 (0.6) 1 (0.0) 15 (34.8) 10 (0.15) 75 (11.09) 1321 (9) 12 Caughey VBAC-2 134 83 (62) 5 (3.6) 20 (1.05) 16 Flamm 245 168 (69%) NA 22 Hansell 35 27 (77) 0 (0.6) 15 Farmakides 57 44 (77) 0 (0.19) 17 (0.0) 0 (0.68) 24 Landon VBAC-2 975 648 (66) 9 (0.04) 1 (0.0) 0 Total 5666 4064 (71.8) 1 (0. **Prelabour stillbirths and postnatal deaths unrelated to mode of delivery (e.8) 1 (0.g. Outcome of VBAC-2 versus VBAC-1: only outcomes with paired data available are included Study reference Group Number Success Uterine rupture Transfusion Hysterectomy PND/Asphyxial injury* NNU 25 Macones VBAC-2 1082 807 (74.

The pooled s uterine rupture rate of Successful vaginal delivery was achieved in 4064/5666 (71.0001. P < 0.23–1.78 e (Figure 2. The comparable rate in VBAC-1 group was higher 38 814/50 685 (76.48 of higher E success rate in VBAC-1 f group versus f VBAC-2.18). t i Adverse maternal v outcomes e Uterine rupture rate after n VBAC-2 was reported in e all stud. ranging in studies from 45% to 89%. meta-analysis showed a significant difference between the two groups with ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 13 Gynaecology .5%— Table 4). Success rate & adverse outcomes of vaginal birth after two caesarean sections OR = 1. CI 1. Z = c 4.ies except by s Flamm16.1%) as shown in Table 2.

11) 172 (1.39) 1 (0.1) 1 (0.2) 6 (0.17) 7 (1. 14 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology .09) 90 (8. Outcome of studies comparing VBAC-2 versus Repeat (third) Caesarean Section (RCS) Study reference No.8) CS 2888 1 (0. cases Uterine rupture Transfusion Hysterectomy Fever Peri-natal death NNU admission 25 Macones VBAC-2 1082 19 (1.67) 51 (0.92) 96 (8.8) 1 (0.03) 34 (1.02) 514 (9.68) 9 (0.7) 24 Landon VBAC-2 975 9 (0.63) 630 (6.7) 0 (0) 0 (0) CS 26 0 (0) 0 (0) 0 (0) 5 (19) 0 (0) 0 (0) 22 Hansell VBAC-2 35 0 (0) 1 (2.85) Values in parenthesis are expressed in percentage.03) 1 (0.6) 30 (3.4) 15 (1. Tahseen.5) 27 (0.8) CS 1006 7 (0.18) 366 (12.76) 10 (0.9) 31 (3.8) 1 (0.01) 553 (8.8) 0 (0) 4 (11.7) 1 (1.1) 1 (0.09) 47 (1.2) CS 6035 0 (0%) 93 (1.7) 0 (0) CS 33 0 (0) 2 (6) Total VBAC-2 2829 31 (1.4) CS 135 1 (0.2) 74 (12) 27 Novas VBAC-2 36 1 (2.4) 20 Granovsky-Grisarau VBAC-2 26 0 (0) 0 (0) 0 (0) 2 (7.7) 4 (6. Griffiths Table 4.49) CS 10 897 12 (0.06) 19 (10) 0 (0) 17 (9) 39 (23) Chattopadhyay13 VBAC-2 115 1 (0.4) 129 (2.40) 192 (6.1) 75 (11.2) 55 (11) CS 587 1 (0.4) 15 (35) CS 187 2 (1.7) 5 (8.1) 31 Spaan VBAC-2 59 1 (1.7) 15 (1.7) 11 (8) 0 (0) 39 (28) 28 Phelan VBAC-2 501 0 (0) 1 (0.

meta-analysis showed (Table 3). the rates were 0.22. ranging VBAC.13–0.48). showed OR = 0. Success rate & adverse outcomes of vaginal birth after two caesarean sections 16 studies was 1.55% in VBAC-2 group.63%. Success rate of VBAC-2 versus VBAC-1.75 of hysterectomy in VBAC-2 to 2. respectively.29–0. CI 0. ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and 15 Gynaecology . ranging 0–5. 0. with and without a group versus RCS.0001.72% in figures in the comparison of VBAC-2 and VBAC-1 VBAC-1 versus 1. the hysterectomy istry cohort reported a uterine rupture rate of 1. CI 0. within studies.40% and 0. In the subset of data com- inal delivery was indicated. (P = 0.4% The rate of hysterectomy was reported in eight studies. Subgroup comparative analysis with pooled average was 0.4% rupture noted.61 A lower risk of uterine rupture with history of prior vag.42 of a uterine rupture in VBAC-1 group sis of three studies reporting hysterectomy rates comparing versus VBAC-2. respectively. within studies 0–3.65).60 (Figure 3.19%.63. tomy in VBAC-1 versus VBAC-2 groups. Similarly Caughey12 reported Z = 0.43 (Figure 5.59% in VBAC -2.5% compared come showed OR = 0. paring VBAC-2 with repeat CS (Table 4). previous vaginal delivery.001. CI 0. Figure 2. VBAC-1 versus VBAC-2.23–2. meta-analy- pooled OR = 0. P = 0. VBAC-2 versus 0.8% in rates were similar. Figure 4). Macones25 in a large birth reg. Z = 3.56% versus 0. Previous vaginal delivery meta-analysis of seven studies reporting the paired out- appeared protective for uterine rupture as 0.36% (74/5421) (Table 2). revealed rupture rates 0. Rate of major haemorrhage was not specified in subjects with previous vaginal delivery were one-fourth as any of the papers but numbers needing blood transfusion likely to have a uterine rupture as those without.9% in VBAC-1.6% (Table 2). Considering hysterectomy 1 in five studies (Table 3). P < 0.29 of hysterec- Z = 4.

Figure 4. Hysterectomy rates in VABC-2 versus VBAC-1 groups.Figure 3. Uterine rupture rates in VABC-2 versus VBAC-1 groups. .

Meta-anal. meta. P = 0. .were given in eight studies.94 of having a blood transfusion in VBAC-2 versus (Table 2).96 (Figure 7. Z = 3.55–1.18 (Figure 8.68% respectively Table 4). CI 0.03% in in VBAC-1 versus VBAC-2.77 (Figure 6. Transfusion rates were lower in the VBAC-1 RCS.56 of having a blood transfusion son with repeat caesarean sections in six studies.0004. group 1.39% in RCS group Table 4. Febrile morbidity was reported particularly in compari- analysis showed OR = 0.11). OR = 0.99% in VBAC-2 (Table 3).17). Z = 0.81 of febrile morbidity in VBAC-2 versus RCS.52) and similar in repeat CS and VBAC-2 of six studies reporting the paired outcome showed groups (1. Hysterectomy rates in VBAC-2 versus RCS.67% and 1. average 2.45–1.7% OR = 0. P = 0. Figure 5.27.01% range 0–6. Z = 1. Meta-analysis 0.21% versus 1.40–0. CI 0. P = VBAC-2 and 6. CI ysis of six studies reporting paired transfusion rates showed 0. 6.86.

Figure 6. Blood transfusion rates in VBAC-2 versus VBAC-1 groups. .

09% morbidity were given in some studies as ‘no maternal (range 0–0.17 (P = 0.64 [0.06.04.33%). 1.0% 0. 0. 4. Pooled NNU admis- population’.35.97] Total (95% CI) 2292 10277 100. 2.33 [0. (0.01 0. VBAC-2 RCS Odds ratio Odds ratio Study or subgroup Events Total Events Total Weight M-H. 2. Mantel–Haens- able reporting within studies. 3. Table 2. VBAC-2 RCS Odds ratio Odds ratio Study or subgroup Events Total Events Total Weight M-H.43] Granovsky-Grisarau 1994 0 26 0 26 Not estimable Hansall 1990 1 35 11 135 9.7% (range 0–34. χ² = 11. random. Non-specific reassuring statements regarding maternal death attributed to mode of delivery occurred in 0.27 sion rate was 7.17] Macones 2005 10 1082 34 2888 27.39.21.11 (P = 0. 95% CI M-H.10 [1. 95% CI M-H. I ² = 64% 0. Neonatal unit admission rates 29 30 compli. Blood transfusion rates in VBAC-2 versus Repeat (third) CS (RCS) groups.93 [0.9% 0.11. 1. Asphyxial injury or perinatal .63] Total (95% CI) 2678 9858 100. Table 2.18] Macones 2005 96 1082 366 2888 28. random.35 [0.85] Phelan 1989 55 501 74 587 24.2% 0.7% 0. 95% CI Chattopadhyay 1994 1 115 15 1006 9.0% 0.59] Spann 2003 4 59 19 187 20.53.86) Blood transfusion VBAC-2Blood transfusion RCS Figure 7.09%) versus VBAC-1 (0.12.18] Total events 192 630 Heterogeneity: τ² = 0.08.94 [0.7% 0.1 1 10 100 Test for overall effect: Z = 0. ‘no febrile morbidity noted’.03). χ² = 14. df = 4 (P = 0. I ² = 65% 0.32 [0.58 [0.81 [0.9%).66] Landon 2006 31 975 93 6035 33.38.55.85 [0.9% 1.3% 2. only were reported in some studies as an index of neonatal ‘outcomes were similar to hospital’s general obstetric morbidity rather than Apgar scores.59.38.67 [0.05.24] Spann 2003 5 59 17 187 9.9% 0.27) Fever VABC-2 Fever RCS Figure 8. 2.97. random. df = 5 (P = 0. 0. 95% CI Granovsky-Grisarau 1994 2 26 5 26 4.1 1 10 100 Test for overall effect: Z = 1. Febrile morbidity rates in VBAC-2 versus Repeat(third) CS (RCS) groups.39.4% 0. 1.05%) (P = 0.7% 0.33.96] Total events 47 172 Heterogeneity: τ² = 0.cations occurred’. The neonatal outcome of five studies comparing VBAC-1 and VBAC-2 had similar rates for neonatal asphyxial injury/perinatal Adverse neonatal outcomes death (attributable to mode of delivery) after VBAC-2 Neonatal Apgar scores are not analysed further due to vari.78 [0. 2. random.0% 0.01 0.96] Landon 2006 30 975 129 6035 23.00] Hansall 1990 4 35 39 135 8.01).45. 1.5% 0. 1.45 [0.

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8%25).ture. does not indicate a in the subgroup in Table Non-specific reassuring significant difference 4 (with data from more statements regarding (assessed by neonatal recent years). with similar disruption of muscle and systematic review included versus hysterectomy (P = 0. 1.zel). the available data indicated 0. (third) caesarean and peritoneum—or heavy weight in the 0.7% . All included studies pattern (rupture rate admission rates were (71.09% as neonatal morbidity were death/asphyxial injury and compared to a rate of given in some studies. as previous a higher scar rupture rate difference in fetal multiple operations would was reported. Earlier studies revealed rates of perinatal comparable to repeat ruption of uterine muscle which con. rupture possibility of unknown 0. ‘Signs and proportion of lower although the difference The adverse maternal symptoms of intra.89. Mantel–Haenszel). may be a reason for D The reluctance to offer lower scar rup. s caesarean sec.ture rates i a trial after two in more recent studies.7%). Novas27 ‘no Although our comparison contributed a higher signifi.14. Mantel– Haenszel). The NNU a reasonable success rate 2).19%). The but the absolute rates are immediately preceded by 2. Table 3 where earlier significant perinatal RCS or VBAC-1.come prob.01% with repeat blood transfusion (P = broad ligament’ in uterine scars (with caesarean sections (P = 0. rate risk of scar rupture is (8.27 NNU admission rates small.57.8%26). comparison of maternal and full thickness uterine ture related perinatal morbidity of VBAC-2 is wall defects repaired.63). a . alternative choice to together with a known women who already had lower segment uterine scar two CS is a RCS.27) rates.63%. rate rare event and individual after RCS (0. clinically different.tions of rupture performed for acute fetal VBAC-2 versus repeat vaginal delivery after two have been used in distress (rupture rate (third) caesarean sections previous caesareans are different studies as ‘dis. 1. A lower were similar as well outcome data are limited. The neonatal non-reassuring fetal heart 5.26. pooled data higher surgical risks This review shows that analysis provides more associated with previ. Apgar scores and pragmatic and rational was routinely performed birthweights and no rup. Landon24 (2006.cence 0.36% (Table praevia. which o risk a difficult out.55%. extension to bladder or patients with unknown 0.tions is Overall hysterectomy c likely to stem from rate was 0. disruption of uterine scar rupture rates (3. data (subjects26) morbidity’. Neonatal Unit admission 1. bidity (P = 0.tributed a death/asphyxial injury.cant differences was carried out with proportion.49% P = however. Garg18 ‘no with RCS. Where manual were observed between the VBAC-1 group because of scar exploration after a two groups in gestational its wide acceptance. ‘….ous trial of vaginal delivery reliable figures. Mantel–Haenszel). The multiple caesarean sections after two caesarean rupture rate in the pooled including placenta accrete/ sections is associated with analysis was 1. although lower provided figures for scar 1. The adverse maternal but clinically meaningful found at caesarean section Subgroup analysis of outcomes of a trial of defini. Noteworthy. 1. A lower u concerns regarding scar rate noted after VBAC-1 s rup.9%). vertical/classical scars) and does not reach statistical outcomes rates of VBAC-2 peritoneal bleeding—or reported higher uterine significance but may be are higher than VBAC-1. Scar rupture is a (0.ably reflects the n to assess. slightly varying thickness dehis.6%12. Table s studies are limited by size 4) was similar within i making uterine rupture subgroup analysis. rupture. no neonatal have a higher background exploration is now rarely data were extracted from risk43and the available carried out and this these studies.09% with VBAC-2 sections. however.and full also comparable (P = than VBAC-1 (76. rate 0. Manual scar outcome’.86) and febrile mor.8%26).30 death’.5%).59% in subgroup in Farmakides15 ‘there was no rates) between VBAC-2.85 versus 8.4%30. successful vaginal delivery age.

68% versus of current practice given 1.05% in because of women’s desire VBAC-1 group (P = 0. Neonatal morbidity with VBAC-2 assessed by neonatal unit admissions was comparable to the RCS group (Table 4).6%) was = 0.bidity.2% by Landon24 to 69% by 9 Asakura .34). 19. from 9. for tubal ligation.09% in . as well as febrile considerable advances in morbidity (6. A more selective approach may be associated with higher success and/or lower uterine rupture rate. the pooled rates were 0.2%20) reported in earlier studies has significantly reduced after advent of broad spectrum antibiotics and concern regarding postoperative infectious morbidity is not a major issue in selecting mode of delivery. hence the The blood transfusion neonatal morbidity figures rates were similar as with may not be representative RCS (1. Higher febrile years.67%).lower threshold for VBAC-2 as compared hysterectomy in Pruett’s 0. the morbidity after a failed trial of labour and in repeat caesarean sections (33%30. moreover.jects). facilities.01% in RCS group (P paper30 (3.24 but a clear pattern does not emerge. when The publications involved scar defects were detected a time period of one or on manual scar palpation two decades ago with after successful vaginal less-advanced neonatal delivery. The more important measure of neonatal mor. hypoxic neonatal brain injury/death attributable to mode of delivery was reported in six studies (3285 sub. The proportion of women undergoing a trial after two caesarean sections is variable between studies which may indicates variable selection criteria.39%).14) and 0.03% versus neonatal care in recent 6. 28%22.

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cating have had two prior control the effect of V favourable outcome with a caesareans may choose to confounding variables.cacy and . postpartum fever and same group further The risks involved should need for blood 41 commented40 that the be considered in per- transfusions.25 improve pros.25 aiming to women with two prior risk of abnormal report on all women with a caesarean deliveries.24. rupture and of major compared with women it would seem reasonable Ideally. a trial of interventions as labour overall mater.sarean section. trial should be counselled a decreased rate of major However. a and augmentation) do not with policy of repeat similar trend of higher lend themselves to elective caesarean sections. Landon 24 i successful vaginal delivery. secondary analysis by the monitored trial of labour. induction risks/morbidity associated prior caesarean sections. B prior vaginal delivery.e.ticularly target should be within cases with a VBAC attempt than VBAC attempts in this eligible to have a trial with repeat third birth.available data does not two studies are much population.41 and for the subset lower risk group (i. and Gynecol. interpretation of results.centa n previous multiple CS those with a prior vaginal praevia/increta) increase receiving trial or d delivery should be with further surgery on otherwise. evidence presented. the comparison complications is higher without a prior vaginal to par. A successful concordant results. showing considered candidates for uterus. the substantial A note is the American birth or elect to have body of accumulated C College of Obstetricians another caesarean section. success and lower uterine prediction of scar rupture. .pects of evidence of effi. Of have a trial of vaginal However. exclude such patients from addition to one prior either induced or Heterogeneous a trial is an arbitrary caesarean delivery are augmented and in those populations in included decision.nal birth. rupture rates are hence clinicians will be indicated in women who L justified in offering a trial have had a prior to wider group. elective repeat caesarean augmentation to reduce Patients keen to have a delivery is associated with the risk of rupture. sarean for women with a t deliveries to be previous vagi. rupture and adverse bearing in mind the latter The included studies span outcomes in this . Macones et al. concluded that as the future pregnancies in risks of trial of vaginal majority terms of future success birth after two CS. a planned to pursue a carefully maternal morbidities. Phelan28 and conclusion that a i Hansell22 noted better requirement of prior t prospects for successful vaginal delivery with a VBAC-2 (as for VBAC-1) multiple cae. to completely a prior vaginal birth in women whose labour was caesareans.8 VBAC-2 attempt would provides more reliable C S Moreover. only placentation (pla. as although the more likely to have a who had not had a studies merit judicious relative risk of uterine successful VBAC attempt previous vaginal delivery. considered candidates for i interestingly o trial of labour seems Chattopadhay13 and unwarranted given the n 31 Spaan found no low risk of uterine s advantage to this group. those and then assignment to caesarean delivery the of women with prior with a previous vaginal either elective CS or a abso. nal of labour as opposed to an induction or morbidity is comparable. R a trial of labour. ogist’s such a choice may impact especially large cohort 2 recommendation that for her future pregnancies as studies12. In our associations (lack of prior spective keeping in mind analysis considering two vaginal delivery.lute risk of such vaginal birth as well as a delivery) and avoidance trial of labour policy complications is small and cae. reached the same m Macones25. (prospective randomised indicate a significant smaller as compared to the Women who already controlled studies) to difference in studies indi. In our It has been identified that women who have had of ruptures occurred in and need for further view.

such analyses rates of trial of labour present reasonable after caesarean. some studies included patients with unknown uter. however.over time period of more vational studies. Thus. Method of prior uterine incision has also not been described. were variable as well.prising that there may be differences seen in C the studies by different o time periods that may n reflect not that the old c studies had inappropriately l high rates.1% with is variable from 9% to associated risk 69% among studies which may indicate heter- ogeneous selection. The control groups. but that the u current studies represent s biased populations in that i only good/self motivated o candidates are encouraged to consider a trial of labour n after caesarean. rate has fallen. There is possibility of over-representation of favourable results within published literature. caesarean sections is Proportion of women associated with success having a trial after two CS rate of 71. than two decades. although the numbers were small. if chosen. in late in the absence of 1980s and early 1990s in randomised trials on the the US were times of high subject. VBAC efficacy and risks. it is not sur. some studies compared with VBAC-1 group and others with women having non- trial CS. Moreover. an inherent limitation of meta-analysis of obser- . This pooled data analysis patients may have been indicates that a trial of managed differently in labour by women with a labour for varying history of previous two amounts of time. which led to the sub-group analyses.ine scars (lower vertical/classical) which might have led to higher complications risk. Women having more than two CS were included in some studies. In the available evidence of current decade.

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Landon MB. A to them. t r Success rate is higher for r o R women with a prior i v e history of vaginal delivery. Spong c CY. No funding from any appropriately considering s Brocklehurst P. . This o s information is important F 1 Thomas J.107:1226–32. The sources is involved in available evidence. Dickinson JC. Br J Obstet should have the option of i manuscript. o r 5 McMahon M.sarean n Section Audit Report.nal delivery available MG conceived the idea 3 Silver RM. should be counselled r 2 Thomas J. Walker J. Vaginal birth o d after caesar. Gynaecol 2000. Women request- t Effectiveness Support Unit. et al. Olshan AF. the available data ethical approval was c does not indicate required.36%. b a f More importantly. reviewed studies Obstet Gynecol for quality.script preparation. o t 7 i 7 f N l : o 4 s i n 6 e 5 n – o t 7 f t 0 e . l tabulated and analysed data as well as preparation of e Westhoff CL. 9 r l 9 e 6 C . and h National Senti. e e Bowes W. and conducted literature Rouse DJ. two caesarean sections o g London: RCOG Press. c l 4 Rosen MG.ean: a meta- manuscript. Both MG and k Maternal morbidity D ST were involved in n associated with multiple i designing the study o repeat caesarean deliveries. w 2006. Paranjothy S. Callwood A. 2001. Luther E. for women and healthcare u Royal College of a providers who are making n Obstetricians and Gynae- u cologists Clinical choices about the type of d delivery. i data were used in e Although neonatal o preparation of this morbidity information is manuscript. searches.107:579– a carefully monitored p 80. s g analysis of morbidity and mortality. e t excessive risk. N No financial disclosures or i l Engl J Med funding was involved in c 1 a a manu. i ing to have a trial after h National Sentinel Cae.of scar rupture 1. s questions. abstracted.nel Caesarean preparation of this Section Audit. the u l e maternal morbidity is t Published de-identified r comparable with RCS. hence no n n limited. Leveno KJ. o a 3 3 n p j 5 p : . Obstet Gynecol u e D 1 r m 9 e e e 9 t 1 a n . t d Comparison of a trial of s h e labour with an elective t c second caesarean section. Thom EA. vagi.

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