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
Almost 25 percent of women with a previous cesarean delivery require early delivery because of medical indications . 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".)
LIKELIHOOD OF SUCCESSFUL INDUCTION
In women undergoing induction after a previous cesarean delivery, the chance of vaginal birth appears to be similar whether they have had one versus two prior cesareans (69 versus 65 percent in one study ).The highest chance of success is in women with a prior vaginal delivery and favorable cervix. (See "Choosing the route of delivery after cesarean birth".)
Selection of the appropriate comparator — Most studies of the outcome of labor induction in women with prior cesarean deliveries have compared those undergoing induction with those experiencing spontaneous onset of 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 .
However, contemporary investigators have opined that women in spontaneous labor are not the appropriate control group for studies of the outcome of induction. In contrast to historic comparisons, they believe the clinically relevant comparison for determining the best approach for reducing the risk of repeat cesarean is to compare women undergoing induction with a similar group of women managed expectantly. In one such study of over 12,000 women with singleton gestations ≥39 weeks and one low transverse cesarean delivery, women undergoing induction of labor at 390/7 to 3/7ths weeks without an acute obstetric medical indication were more likely to deliver vaginally than those managed expectantly (73.8 versus 61.3 percent; odds ratio 1.31, 95% CI 1.03-1.67) . These findings affirm the relatively high probability of vaginal delivery with induction after a previous cesarean delivery.
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