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Predicting Success and Reducing the Risks When Attempting Vaginal Birth After Cesarean

Harper, Lorie M. MD*; Macones, George A. MD, MSCE

Obstetrical & Gynecological Survey: August 2008 - Volume 63 - Issue 8 - p 538-545
doi: 10.1097/OGX.0b013e31817f1505

The goal of this manuscript is to review the contemporary evidence on issues pertinent to improving the safety profile of vaginal birth after cesarean (VBAC) attempts. Patients attempting VBAC have success rates of 60%–80%, and no reliable method of predicting VBAC failure for individual patients exists. The rate of uterine rupture in all patients ranges from 0.7% to 0.98%, but the rate of uterine rupture decreases in patients with a prior vaginal delivery. In fact, in patients with a prior vaginal delivery, VBAC appears to be safer from the maternal standpoint than repeat cesarean. Inevitably, the obstetrician today will encounter the situation of deciding whether or not to induce a patient with a uterine scar, and particular attention is paid to the success and risks of inducing labor in this patient population. Induction of labor is associated with a slightly lower successful vaginal delivery rate, although the rate remains above 50% in virtually all patient populations. The rate of uterine rupture increases slightly, but still remains around 2%–3%. Although misoprostol use is discouraged due to its association with increased risks of uterine rupture, transcervical catheters, oxytocin, and amniotomy may be used to induce labor in women attempting VBAC.

Target Audience: Obstetricians & Gynecologists, Family Physicians

Learning Objectives: After completion of this article, the reader should be able to summarize recent literature regarding vaginal birth after cesarean and list factors related to labor induction success among women with a history of cesarean delivery.

*Resident Physician, and †Mitchell and Elaine Yanow Professor and Chair, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri

Chief Editor’s Note: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA category 1 credits™ can be earned in 2008. Instructions for how CME credits can be earned appear on the last page of the Table of Contents.

Dr. Macones has disclosed that he was the recipient of grant research support from the National Institute of Child Health and Human Developement (NICHD). All other authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity.

The Faculty and Staff in a position to control the content of this CME activity have disclosed that they have no financial relation-ships with, or financial interests in, any comercial companies pertaining to this educational activity.

Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity.

Reprint requests to: Lorie M. Harper, Washington University in St. Louis, 4566 Scott Avenue, Campus Box 8064, St. Louis, MO 63110. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.