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DOI: 10.1111/tog.

12144 2014;16:23944
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Counselling women about the risks of caesarean delivery in


future pregnancies
a, b c
Joshua D Dahlke MD, * Hector Mendez-Figueroa MD, Katharine D Wenstrom MD
a
Fellow of Maternal-Fetal Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Warren Alpert Medical School
of Brown University, Women & Infants Hospital, Providence RI 02906, USA
b
Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UT Health,
University of Texas Medical School at Houston, Texas 77030, USA
c
Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Warren Alpert Medical School of Brown University,
Women & Infants Hospital, Providence RI 02906, USA
*Correspondence: Joshua D Dahlke. Email: joshuadahlke@gmail.com or joshua.dahlke@nmhs.org

Accepted on 7 July 2014

Key content Learning objectives


 In order to provide appropriate counselling about the risk to  To be knowledgeable about and able to provide accurate
future pregnancies imposed by caesarean delivery, providers must counselling for three important clinical situations: caesarean
be knowledgeable about and able to synthesise a multitude of delivery on maternal request; women with a history of one or two
variables such as institutional policies, the clinical implications of caesarean deliveries; and women with a history of three or more
each current delivery option for future pregnancies, patient caesarean deliveries.
understanding of maternal and neonatal risks and benefits, the
Ethical issues
womans reasons for requesting this type of delivery and the  When counselling women about the risks of caesarean delivery on
womans desired family size.
 The rate of successful vaginal birth after caesarean section ranges
future pregnancies, providers should always consider the principles
of beneficence and non-maleficence while synthesising a myriad of
5085%, with lower rates associated with both modifiable factors
scenarios and outcomes. If properly counselled on the risks,
(gestational age >40 weeks, maternal obesity, short
benefits and alternatives of a delivery decision, her autonomy
interpregnancy interval and increased birthweight) and
should be respected.
non-modifiable factors (maternal age, non-white ethnicity,
pre-eclampsia and recurrence of the indication for the initial Keywords: caesarean deliveries / counselling / delivery options /
caesarean delivery). future pregnancy
 In future pregnancies, the risk of adverse outcomes such as
haemorrhage, endometritis, operative injury, hysterectomy and
maternal death goes up with each additional caesarean section.

Please cite this paper as: Dahlke JD, Mendez-Figueroa H, Wenstrom KD. Counselling women about the risks of caesarean delivery in future pregnancies.
The Obstetrician & Gynaecologist 2014;16:23944.

Introduction for Maternal-Fetal Medicine have published statements


Caesarean delivery (CD) is the most common surgery promoting evidence-based approaches to preventing
performed in the world, and accounts for over 32% and primary CD,4,5 many women will nonetheless deliver via
over 25% of all deliveries annually in the USA and UK, CD and providers must be knowledgeable of the implications
respectively.1,2 In an analysis of over 220 000 deliveries across for the current as well as subsequent pregnancies. The aim of
19 hospitals, the Consortium on Safe Labor in the USA this article is to provide clinicians with the information
revealed that previous uterine scar was the primary indication needed to discuss the risks and benefits of various delivery
for over half of all CDs, and that 83% of women with a uterine options in future pregnancies after CD on maternal request,
scar are delivered by CD.3 In general, maternal morbidity and after one or two CDs, or after three or more CDs.
mortality among these women remains substantially higher
Counselling women desiring elective
than among those who deliver vaginally, and these risks
caesarean delivery on maternal request
increase with each subsequent CD.3,4
While national organisations such as the American College CD on maternal request (CDMR) refers to a primary
of Obstetricians and Gynecologists (ACOG) and the Society prelabour CD performed in the absence of maternal or

2014 Royal College of Obstetricians and Gynaecologists 239


Caesarean risk in future pregnancies

fetal medical indications.6 Because of a lack of specific coding  respect of patient autonomy and, when appropriate,
or designation, determining the prevalence of women seeking determination of optimal timing of CD to minimise
CDMR remains difficult, with best estimates ranging from neonatal morbidity
2% to 8% of all deliveries in the USA.3,5,7 Because there are  respect of provider autonomy by offering the woman a
no randomised controlled trials comparing CDMR with second opinion or referral to another provider for cases in
planned vaginal delivery with regard to maternal or neonatal which the provider does not agree with the decision
risks or outcomes, counselling recommendations must be for CDMR.
based largely on expert opinion.8
Because of the lack of quality trials, short-term and
Notably, ACOG, the Royal Australian and New Zealand
long-term risks associated with CDMR versus planned
College of Obstetricians and Gynaecologists (RANZCOG),
vaginal delivery can only be extrapolated. Indirect analyses
and the National Institute for Health and Care Excellence
comparing elective CD without a specified indication with
(NICE) in the UK have published consensus guidelines or
the combined outcomes of vaginal deliveries and unplanned
statements that provide an excellent reference for providers
or emergency CD are suboptimal.6 In a National Institute of
who are counselling patients about CDMR.2,6,9 Table 1
Health conference statement on CDMR in 2006,10 an expert
summarises the recommendations of these organisations.
panel reported on a systematic review of the available
These recommendations, when combined, emphasise several
literature they undertook to determine the best available
important concepts that should be included in any discussion
evidence comparing planned CD versus planned vaginal
of CDMR with patients:
delivery for term singleton gestations with vertex
 provider understanding of the reasons why the woman is
presentation. Based on moderate quality evidence,
requesting this type of delivery
outcomes that favoured planned vaginal delivery included:
 provider enquiry into the womans desired family size in
shortened maternal hospital length of stay, decreased
order to accurately discuss risks if future pregnancies
neonatal respiratory morbidity, decreased risk of
are desired
subsequent placenta praevia or accreta, and decreased risk
 womans understanding of the risks and benefits of and
of subsequent uterine rupture. The only outcome favouring
alternatives to CD versus planned vaginal delivery in the
planned CD was decreased risk of maternal haemorrhage.10
current and future pregnancy

Table 1. Summary of consensus recommendations or statements on caesarean delivery on maternal request2,6,9

Organisation Recommendations

American College of Obstetricians and In the absence of maternal or fetal medical indications for caesarean delivery, a plan for
Gynecologists (2013)6 vaginal delivery is:
 safe
 appropriate
 should be recommended

Recommendations in cases in which CDMR is planned:


 CDMR should not be performed before 39 weeks
 CDMR should not be motivated by the unavailability of effective pain management
 CDMR particularly is not recommended for women desiring several children given that
each CD increases the risk of:

placenta praevia
placenta accreta
hysterectomy

Royal Australian and New Zealand College of If, after full discussion, the patient maintains CDMR, the obstetrician may:
Obstetricians and Gynaecologists (2013)9  agree to perform CD if patient understands risks and benets of this course of action
 decline to perform CD if obstetrician believes there are signicant health concerns for mother
or baby; or patient appears to not have sufcient understanding to enable informed consent
 advise patient to seek second opinion

National Institute for Health and If a woman requests a CD:


Care Excellence (2011)2  discuss and record reasons for request
 discuss and record overall risks and benets of CD compared with vaginal birth
 discuss request with other members of obstetrics team to ensure woman has accurate information

CD=caesarean delivery; CDMR=caesarean delivery on maternal request

240 2014 Royal College of Obstetricians and Gynaecologists


Dahlke et al.

Outcomes for which there was insufficient evidence to make prior classical uterine incision, previous uterine surgery in
recommendations included fetal mortality, newborn which the uterine cavity was entered (such as myomectomy),
infection, intracranial haemorrhage, neonatal asphyxia or history of uterine rupture, history of more than two previous
encephalopathy, and birth injuries. This lack of critical data CDs, as well as contraindications to vaginal delivery in
highlights the importance of continuing research on general (for example, placenta praevia or malpresentation). A
this topic. history of a prior successful vaginal delivery is associated with
an increased probability of VBAC. Alternatively, factors that
decrease probability of success include a recurrence of the
Counselling women with a history of one previous indication for the initial CD (for example, labour
or two caesarean deliveries dystocia), gestational age greater than 40 weeks, maternal
obesity, pre-eclampsia, short interpregnancy interval,
For women with an obstetric history of one or two CDs,
increased maternal age and non-white ethnicity.11 National
discussions regarding the risks and benefits of a trial of labour
guidelines vary with regard to recommending TOLAC in
after caesarean (TOLAC) versus a repeat CD should be
various scenarios (Table 2), further highlighting the
initiated and documented, preferably before 36 weeks of
importance of obtaining and documenting a thorough
gestation. Table 2 summarises guidelines from ACOG, the
obstetrical history.
French College of Gynecologists and Obstetricians,
In a systematic review and meta-analysis of maternal
RANZCOG, the Royal College of Obstetricians and
morbidity after TOLAC compared with repeat CD, Rossi and
Gynaecologists and the Society of Obstetricians and
DAddario16 summarised four prospective and three
Gynaecologists of Canada regarding recommendations for
retrospective large cohort studies to determine outcomes
candidates who may be considering a TOLAC.1115 Notably,
such as overall maternal morbidity, uterine rupture/
all of these guidelines recommend delivery in a hospital
dehiscence, blood transfusion and hysterectomy associated
setting with immediate availability of personnel and
with four possible scenarios: overall planned TOLAC,
facilities necessary to perform an emergency CD. These
successful VBAC, failed TOLAC and repeat CD. Women
resources include an obstetrician, an anaesthesia provider,
with successful VBAC had the lowest incidence of adverse
paediatric support, operating room staff and resuscitative
outcomes while those with a failed TOLAC had the highest.
measures (such as blood products) in cases of postpartum
Table 3 summarises the estimated risks associated with
haemorrhage. It is undetermined whether immediate access
repeat CD and TOLAC. While uterine rupture is a rare
to all resources is necessary 24 hours a day, 7 days a week,
complication, it occurs more frequently in patients
and hospital policy may vary by location (rural or urban)
undergoing TOLAC than repeat CD, and although repeat
and/or country. However, every effort should be made to
CD at 3739 weeks appears to decrease the risk of stillbirth, it
transfer care to a facility that can offer these support services
is important to note that TOLAC does not increase the risk of
if it is determined that TOLAC is not contraindicated and
stillbirth above the baseline risk at any given gestational age.
desired by the woman, but cannot be safely offered at the
Alternatively, rates of blood transfusion, hysterectomy and
home hospital.
neonatal respiratory morbidity are lower in those who
When TOLAC is an option for women with a history of
undergo TOLAC. Finally, advantages of successful VBAC
one or two previous CDs, counselling and appropriate
were shown to include avoidance of major abdominal
documentation becomes paramount. Counselling
surgery, shorter time to recovery, less morbidity from
should include:
infection and avoidance of the increased risk of abnormal
 a review of the womans complete obstetric history.
placentation in future pregnancies, which is especially
 an assessment of all risks associated with both TOLAC and
important if a large family is desired.11
repeat CD.
Depending on the published source, rates of successful
 an individual assessment of the likelihood of successful
VBAC range from 50% to 85%.1115 These rates, however,
vaginal birth after caesarean (VBAC).
may vary depending on several modifiable or non-modifiable
 an enquiry into the womans understanding of risk and her
factors. Factors considered non-modifiable include maternal
desire for future pregnancies.
age, non-white ethnicity, pre-eclampsia and recurrence of the
 a specific plan for delivery including contingencies, for
indication for the initial CD, all of which decrease the
example, management if the woman presents in labour
probability of successful TOLAC. Factors considered
prior to scheduled repeat CD.
modifiable to some extent include gestational age greater
Identifying women who are appropriate candidates for than 40 weeks, maternal obesity, short inter-pregnancy
TOLAC requires obtaining a complete obstetric history interval and increased birthweight, all of which decrease the
including the timing and circumstances of all previous probability of successful TOLAC.11 While gestational age and
deliveries. In general, contraindications to TOLAC include a increasing birthweight could theoretically be modified by

2014 Royal College of Obstetricians and Gynaecologists 241


Caesarean risk in future pregnancies

Table 2. Summary of recommendations of trial of labour after caesarean by national guidelines11-15

Recommendation(s) National guidelines (level of evidence)a

Obstetric history
1 low transverse CD TOLAC recommended ACOG (A), CNFOG, RANZOG, RCOG (B)
2 low transverse CDs TOLAC may be considered ACOG, RCOG (B), CNFOG (C)
Caesarean may be considered RANZCOG
3 or more low transverse CDs Caesarean recommended ACOG, CNFOG (C), RCOG
History of uterine rupture Caesarean recommended ACOG, SOGC (B), RCOG
History of classical or uterine Caesarean recommended ACOG, CNGOF, SOGC (B)
body scar (eg T or J incision)
History of low vertical uterine incision TOLAC may be considered ACOG, CNFOG (C)
Caesarean may be considered RANZCOG
Operative note conrmation required? Not necessary, unless high suspicion ACOG, CNFOG (C), SOGC (B)
Previous uterine closure in 1 versus 2 layers TOLAC may be considered CNFOG (C)
Delivery to conception <6 months TOLAC may be considered CNFOG (C)
Caesarean may be considered RANZCOG
Current pregnancy
Twins TOLAC may be considered ACOG, SOGC (B), CNFOG, RCOG (C)
Breech External cephalic version may be considered ACOG (B), CNFOG, SOGC (C)
Maternal obesity Caesarean may be considered CNFOG (C), RANZCOG
Diabetes TOLAC may be considered CNFOG (C), SOGC (B)
Preterm birth TOLAC recommended CNFOG (C), RCOG (B)
Prolonged pregnancy (>40 weeks) TOLAC may be considered ACOG, CNFOG (C), SOGC (B)
Macrosomia TOLAC may be considered ACOG (C), SOGC (B)
Caesarean may be considered CNFOG (C)
Delivery location Hospital only, capable of timely caesarean All guidelines
Induction of labour Acceptable for maternal or fetal indications ACOG, CNGOF (C)
Not recommended if 2 previous CD CNFOG (C)
Transcervical balloon Acceptable with prudence ACOG, CNGOF (C)
Oxytocin Acceptable with prudence ACOG, CNGOF (C), RANZCOG, SOGC (B)
PGE2 Acceptable with great prudence ACOG, CNGOF (C)
Not recommended SOGC (B)
PGE1 (misoprostol) Not recommended ACOG, SOGC (A), CNGOF (C)
Intrapartum management
Continuous fetal monitoring Recommended ACOG, CNGOF (C), RCOG (B), SOGC (A)
Internal tocodynamometry Not necessary ACOG, CNGOF, RCOG (C)
Augmentation Oxytocin acceptable with prudence ACOG, CNGOF (C), SOGC (A)
Anaesthesia Acceptable for regional analgesia ACOG, RCOG (C), RANZCOG

ACOG=American College of Obstetricians and Gynecologists; CD=caesarean delivery; CNGOF=French College of Gynecologists and Obstetricians;
RANZCOG=Royal Australian and New Zealand College of Obstetricians and Gynaecologists; RCOG=Royal College of Obstetricians and
Gynaecologists; SOGC=Society of Obstetricians and Gynaecologists of Canada; TOLAC=trial of labour after caesarean.
a
Level of recommendations: A=based on good and consistent scientic evidence; B=based on limited or inconsistent scientic evidence; C=based
primarily on consensus and expert opinion.
BOLD: Denotes recommendation by specied guideline.

elective induction of labour, any potential benefit would be desire in the future, including that the risks of hysterectomy
negated by the fact that one of the most important factors in and abnormal placentation are directly related to the number
increasing probability of success is spontaneous labour. Thus, of CDs a woman undergoes. Contingency plans covering
elective labour induction is not recommended. An online early presentation in labour, variable hospital or provider
tool developed by the National Institute of Child Health and staffing, and timing of induction of labour should ideally be
Human Development Maternal-Fetal Medicine Units considered, discussed and documented to avoid confusion if
Network uses many of these variables to calculate an these situations arise.
individual womans likelihood of successful VBAC and may After appropriate counselling, some women with a
be a valuable resource for providers and women when previous CD will request a repeat CD. Whenever a woman
creating a birth plan.17,18 has been fully informed and expresses understanding of the
Finally, the womans understanding and desire for TOLAC issues, her autonomy should be respected. The recommended
should be queried and documented. This should include a gestational age for repeat CD is 3940 weeks, with delivery
discussion of the number of pregnancies the woman may prior to 39 weeks avoided unless medically indicated.

242 2014 Royal College of Obstetricians and Gynaecologists


Dahlke et al.

reports note significant adhesive disease or distortion of


Table 3. Comparison of maternal and neonatal risks between repeat
caesarean and trial of labour after caesarean12 anatomy, surgical options such as vertical skin incision may
be prudent and can be discussed at length with the woman
Repeat Trial of labour after prior to delivery. Additionally, if a difficult surgery is
caesarean (%) caesarean (%)
anticipated, preoperative consultation with anaesthesia or
Maternal risks After 1 After 2
urological services may be considered.
caesarean caesareans Risks associated with multiple repeat CDs, such as the need
Uterine rupture 0.40.5 0.70.9 0.91.8 for blood transfusion or hysterectomy, should be discussed
Hysterectomy 00.4 0.20.5 0.6 and documented. While placental location in relation to
Blood transfusion 11.4 0.71.7 3.2
Endometritis 1.52.1 2.9 3.1 the cervical os should be documented in all women with a
Operative injury 0.40.6 0.4 0.4 history of CD, it is of utmost importance in women with
Maternal death 0.020.04 0.02 0 three or more CDs, given the exponential increase in
Neonatal risks Trial of labour after maternal morbidity.
caesarean (%)
Stillbirth
3738 weeks 0.08 0.38 Conclusion
39 weeks 0.01 0.16
Neonatal death 0.05 0.08 When counselling women about the risk of CD in future
Hypoxic ischaemic 00.013 0.08 pregnancies, providers must be able to synthesise a multitude
encephalopathy of variables such as institutional policies, a womans
Respiratory morbidity 15 0.11.8
understanding of the maternal and neonatal risks and
Transient tachypnoea 6.2 3.5
Hyperbilirubinemia 5.8 2.2 benefits, and the implications of each delivery option on
future pregnancies. While national guidelines offer valuable
information with regard to these issues, variation among
recommendations exists. This article has identified and
reviewed three important areas of consideration for the
Counselling women with a history of three clinician: CDMR, women with a history of one or two CDs
or more caesarean deliveries and those with a history of three or more CDs. Given the
There is a paucity of data on TOLAC in women with three or current rate of CD and the magnitude of the effect of CD on
more CDs and quantifiable risk assessment is limited. In a millions of womens lives, additional research is needed.
prospective observational study of over 30 000 women Ultimately, the goal of thorough counselling and
undergoing elective CD, Silver et al.19 noted an increased documentation should be a mutually endorsed decision
risk of placenta accreta and hysterectomy with increasing that optimises maternal and neonatal outcomes.
number of CDs, ranging from 0.30.6% with one CD to
6.79% after six or more CDs. In the same study, women Contribution to authorship
with placenta praevia had a risk of placenta accreta in 3%, JDD, HMF and KDW all made substantial contributions to
11%, 40%, 61% and 67% for first, second, third, fourth and conception, design, drafting, critical revisions and approval
fifth or more CDs, respectively. Because of these increased of the final version of the manuscript submission.
risks, as well as the lack of data on safety, TOLAC is generally
not recommended after three or more CDs. Disclosure of interests
As noted previously, counselling and documentation The authors report no conflict of interest.
should focus on obstetric history, assessment of risk
associated with multiple repeat CD and enquiries into the
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244 2014 Royal College of Obstetricians and Gynaecologists