ACOG
Opinion
Committee on
Obstetric Practice
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Induction of labor for vaginal birth
after cesarean delivery. ACOG
Committee Opinion No. 342.
American College of Obstetricians
and Gynecologists. Obstet Gynecol
2006;108:465–67.
VOL. 108, NO. 2, AUGUST 2006
Committee
Number 342, August 2006 (Replaces No. 271, April 2002)
Induction of Labor for Vaginal Birth
After Cesarean Delivery
ABSTRACT: Induction of labor in women who have had cesarean deliveries
may be necessary because of fetal or maternal indications. The potentially
increased risk of uterine rupture should be discussed with the patient and
documented in the medical record. Selecting women most likely to give birth
vaginally and avoiding the sequential use of prostaglandins and oxytocin
appear to offer the lowest risks. Misoprostol should not be used in patients
who have had cesarean deliveries or major uterine surgery.
An ongoing controversy surrounds whether induction of labor with or with-
out prostaglandins (specifically, the prostaglandin E2 series) significantly
increases the baseline risk of uterine rupture during labor. Induction with
misoprostol (prostaglandin E1) in women who have had cesarean deliveries
has been shown, in a randomized trial, to be associated with a significant risk
of uterine rupture, with two cases of uterine rupture out of 17 women treat-
ed with 25-mcg doses of misoprostol (1). This trial was stopped because of
the increased rupture rate, and the Committee on Obstetric Practice contin-
ues to recommend that misoprostol not be used for induction of labor in
women who have had cesarean deliveries or major uterine surgery (2–4).
Since the last Committee on Obstetric Practice Opinion on induction of labor
for vaginal birth after cesarean delivery was published, additional studies
have addressed the issue of induction of labor with or without prostaglandins
in women who have had cesarean deliveries.
Several studies noted an increased risk of uterine rupture from induction
of labor in women who have had cesarean deliveries (5–7). A population-
based, retrospective cohort study of the relationship of uterine rupture to
vaginal birth after cesarean delivery using vital records and abstracted hos-
pital discharge International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM) code diagnoses reviewed 20,095 women
with histories of cesarean deliveries for their first delivery (5). The risk of
uterine rupture was compared between patients who had repeat cesarean
deliveries, patients giving birth after spontaneous onset of labor, and patients
who had labor induced with or without the use of prostaglandins. There were
91 cases of uterine rupture with rates of 1.6 per 1,000 (0.16%) for repeat
ACOG Committee Opinion Induction of Labor for VBAC 465
cesarean delivery, 5.2 per 1,000 (0.52%) for sponta-
neous labor, 7.7 per 1,000 (0.77%) for labor induced
without prostaglandins, and 24.5 per 1,000 (2.4%)
for prostaglandin-induced labor. Compared with
women who gave birth by elective repeat cesarean
delivery, the relative risk (RR) of uterine rupture was
significantly higher among women who had sponta-
neous labor (RR, 3.3; 95% confidence interval [CI],
1.8–6), induction of labor without prostaglandins
(RR, 4.9; 95% CI, 2.4–9.7), and induction of labor
with prostaglandins (RR, 15.6; 95% CI, 8.1–30).
There was no difference in the risks of uterine rup-
ture between spontaneous labor and labor induced
without prostaglandins. The authors acknowledged
that they did not confirm the diagnoses of uterine
rupture by examining medical records. Furthermore,
their use of ICD-9-CM codes may have resulted in
an overstatement of the actual incidence of uterine
rupture because a single code is used for both uter-
ine incision extension and uterine rupture (5). In
another study, only 40% of ICD-9-CM-coded uter-
ine ruptures were actually found to be uterine rup-
tures when the charts were reviewed, which raises a
concern about the reliability of these findings (8).
In a larger, more recent, prospective, multicenter
study, 33,699 women who had cesarean deliveries
(17,898 and 15,801 with trial of labor or elective
repeat cesarean deliveries, respectively) were stud-
ied (9). Charts were reviewed to document uterine
rupture. There was no difference in the incidence of
hysterectomy, thromboembolic disease, or maternal
death between these two groups. Augmentation or
induction of labor was associated with an increased
risk of uterine rupture compared with spontaneous
labor. There were 124 cases of uterine rupture, and
the rate of uterine rupture in the trial of labor group
was 0.4% for spontaneous labor, 0.9% for augmen-
tation of labor, and 1% for induction of labor. In
the group of women in whom labor was induced,
the rate of uterine rupture was 1.1% when only oxy-
tocin was used and 1.4% when any prostaglandins
were used in combination with oxytocin; this result
was not significantly different. There were no cases
of uterine rupture in the group of women in whom
labor was induced who received only prostaglan-
dins. The prostaglandins used in this group included
misoprostol, dinoprostone, and prostaglandin E2 gel.
This absence of uterine rupture likely represents
women who went into labor “easily,” requiring no
oxytocin after prostaglandin administration. In
466 ACOG Committee Opinion Induction of Labor for VBAC
another large study evaluating 25,005 women,
induction or augmentation of labor was associated
with an increased risk of uterine rupture (10). There
was no significantly increased association between
oxytocin or prostaglandins not used in combination
with uterine rupture compared with women who
went into spontaneous labor (10). The risk of uterine
rupture was significantly increased with sequential
use of prostaglandins and oxytocin (odds ratio, 4.54;
95% CI, 1.66–12.42) (10). Uterine rupture was con-
firmed with chart reviews in this study.
The rate of uterine rupture was significantly
higher in women who had failed trials of labor
(2.3%) compared with successful trials of labor
(0.1%) (9). These results are similar to a study that
reported nearly identical rates of uterine rupture (2%
versus 0.1% in failed versus successful trials of
labor) (11). Together, these studies (5, 9–11) suggest
that rates of uterine rupture are likely increased by
induction of labor more than by spontaneous labor,
but the magnitude of risk is still low (1–2.4%).
Additionally, sequential use of prostaglandins and
oxytocin may further increase risk. Consistently, the
highest rates of uterine rupture are associated with
failed trials of labor (2–2.3% versus 0.1% for suc-
cessful trials of labor). These more recent data do
not confirm a specific increase in uterine rupture
with the use of prostaglandins alone. The three
largest studies vary in the quality of data, and data
quality should be incorporated into any decision to
use these data. Two of the three studies were
prospective and confirmed uterine rupture with chart
reviews (9–10). These two studies reported lower
rates of uterine rupture with induction and prosta-
glandin induction of labor (1–1.4%). The third study
was smaller, retrospective, and did not confirm uter-
ine rupture with chart reviews, and it reported the
highest rate of uterine rupture with the use of
prostaglandins (2.4%) (5).
Induction of labor may be necessary for women
who have had cesarean deliveries, for a maternal or
fetal indication. Induction of labor remains a rea-
sonable option, but the potentially increased risk of
uterine rupture associated with any induction should
be discussed with the patient and documented in the
medical record. Selecting women most likely to
give birth vaginally and avoiding sequential use of
prostaglandins and oxytocin appear to offer the low-
est risks of uterine rupture. Misoprostol should not
be used in patients who have had cesarean deliveries
or major uterine surgery.
OBSTETRICS & GYNECOLOGY
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