Cervical ripening and induction of labor in women with a prior cesarean delivery
- Deborah A Wing, MD, MBA
Deborah A Wing, MD, MBA
- Professor of Obstetrics and Gynecology
- University of California, Irvine School of Medicine
The risk of failed induction and the possibility of uterine rupture are major concerns of clinicians caring for women undergoing a trial of labor after a previous cesarean delivery (TOLAC). The best method, efficacy, and safety of cervical ripening and/or labor induction in this population have not been established . Available evidence is inconclusive because no randomized trials have compared the outcome of induction of labor in women with prior cesareans with elective repeat cesarean delivery (ERCD); data are mostly limited to findings from retrospective studies of fair to poor quality. These data are insufficient for many reasons, including inconsistent definitions of uterine rupture and dehiscence, wide variation in induction protocols (eg, timing and dosage of prostaglandins and/or oxytocin administration), heterogeneity in patient populations, and inconsistency in primary outcome measures .
Cervical ripening and induction of labor in women attempting TOLAC will be reviewed here. Other issues relating to TOLAC are discussed separately. (See "Choosing the route of delivery after cesarean birth".)
Women who are induced after a previous cesarean delivery have a longer latent phase, but a similar active phase, compared with women who experience spontaneous labor after a cesarean delivery . When making the diagnosis of a protraction or arrest disorder in women who undergo induction of labor after cesarean delivery, it is reasonable for clinicians to apply the same criteria as in women without a previous cesarean delivery. (See "Overview of normal labor and protraction and arrest disorders".)
LIKELIHOOD OF SUCCESSFUL INDUCTION
At least 50 percent of inductions in women with a prior cesarean delivery are successful, with the highest chance of success in women with a prior vaginal delivery and favorable cervix. Calculators are available that estimate the likelihood of successful induction in women with a prior cesarean delivery. (See "Use of calculators and models for predicting vaginal birth after a previous cesarean delivery".)
Most studies of the outcome of labor induction in women with a prior cesarean delivery have compared those undergoing induction with those undergoing spontaneous labor. The body of evidence from these studies indicates that induction results in a lower vaginal delivery rate than spontaneous labor (mean vaginal delivery rate 68 versus 80 percent ). Two factors significantly increase the chance of successful vaginal birth: (1) a previous history of vaginal delivery and (2) favorable cervical status (modified Bishop score ≥6). In one large study, successful induction occurred in 91 percent of women with a prior vaginal delivery and a favorable cervix, 77 percent of women with a prior vaginal delivery but an unfavorable cervix, 69 percent of women with no prior vaginal delivery but a favorable cervix, and 45 percent of women with no prior vaginal delivery and an unfavorable cervix .
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