**6. VBAC and the number of repeat cesarean section**

Clinical decision-making for women following multiple prior cesarean deliveries is influenced by limited evidence and the expectations of the mother. Vaginal birth after multiple cesarean deliveries can be an option if women are eligible. In order to provide the currently best available evidence, we extracted and regrouped information from four trials (**Table 3**).

A meta-analysis of 20 studies compared the success rate—and the associated adverse maternal and fetal outcomes of vaginal birth—after one and two cesarean sections (VBAC-1/VBAC-2) with a further repeat multiple cesarean section [30]. Women requesting a trial of labor following two cesarean sections should be informed of a success rate for vaginal delivery of 71.7%, a uterine rupture rate of 1.36%, and of a similar maternal morbidity in both groups. Maternal morbidity of VBAC-2 is comparable to that of multiple cesarean sections. The neonatal morbidity data were too limited to draw valid conclusions [30].

Another trial pointed out that women with three or more prior cesareans who attempt VBAC have similar success rates and maternal morbidity as those with only one prior cesarean, as well as those delivered by elective repeat cesarean [31].

There are also two systematic Cochrane reviews showing no statistically significant differences between a planned repeat cesarean birth and a planned vaginal birth after a cesarean section [32, 33].


#### **Table 3.**

*Maternal outcome of vaginal birth following multiple cesarean section for VBAC versus a setting of increasing higher multiple repeat cesarean sections.*

In conclusion, there was no difference in the maternal morbidity of women with multiple prior cesareans for the mode of delivery in these studies. A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation (**Table 3**). However, when looking at uterine rupture alone, the risks increase with each cesarean section (>2 CS: 3.71% and >3 CS: 4.34%).

In conclusion, vaginal birth after multiple cesarean deliveries remains an option for eligible women.

#### **7. Timing of elective repeat cesarean section**

In clinical practice obstetricians have to decide when best to perform an elective repeat cesarean delivery. For the decision-making, it is interesting to have knowledge on the gestation with the best neonatal and maternal outcomes. We found five studies in total to be analyzed.

Three retrospective studies with a total of 48,757 women were identified comparing the neonatal risks at repeat cesarean delivery before and after 39 weeks of gestation [34–36]. In general elective repeat cesarean sections between 37 and 39 weeks are associated with a higher neonatal morbidity. Especially the rates of adverse respiratory outcomes and mechanical ventilation were increased. Neonates born before 39 weeks of gestation have significant more respiratory distress syndromes. Additionally the risks of newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization are also higher in the group with a repeat cesarean section before 39 weeks [36].

**45**

*Maternal and Fetal Risks in Higher Multiple Cesarean Deliveries*

essary increased risk of respiratory distress syndromes.

yielding both the best neonatal and maternal outcome.

Another study demonstrated increased costs through increasing adverse neonatal outcomes because of elective repeat cesarean deliveries at 37 or 38 weeks [37]. On the opposite side, the elective cesarean delivery at 39 weeks seems to be associated with better neonatal outcome in comparison to a later timing of delivery [34]. Altogether our findings suggest that from the neonatal point of view, there are benefits to waiting until 39 weeks of gestation to perform an elective repeat cesar-

To achieve the prolongation of the pregnancy until 39 weeks for the neonatal benefit, it is important to know if an elective repeat cesarean section at this time is also of benefit for the maternal outcome. The results of three studies with a total of 37.938 women show that an elective repeat cesarean delivery at 37 or 38 weeks is not associated with decreased maternal morbidity [34, 35, 38]. In comparison to the group of elective delivery at 39 weeks, there was no significant difference in uterine scar rupture, estimated blood loss, hysterectomy, or other maternal complications. Additionally one study pointed out that elective cesarean delivery at 37 weeks had

significantly higher risks of a prolonged (>5 days) maternal hospitalization [38]. Although a cesarean section before 39 weeks has a similar rate of risks for women with multiple repeated cesarean sections as the delivery after 39 weeks, the elective repeat cesarean section at 37 or 38 weeks exposes the neonate to an unnec-

In conclusion, if there are no other medical indications for an earlier delivery, 39 weeks of gestation is apparently the optimal timing for repeat cesarean delivery

• The risks of rare but potentially serious maternal morbidities such as visceral injury, hemorrhage, abnormal placentation, hysterectomy, or severe adhesions importantly increased with the number of multiple repeat cesarean sections.

• Adverse neonatal outcome depends more on the mode and the timing of

• There is no clear absolute threshold for a safe number of previous cesarean sections, but a total of four or more cesarean deliveries was identified as the critical level for most of the major complications to be substantially increased.

• Repeat cesarean delivery is done best at 39 weeks yielding the best outcome for

• Vaginal birth after multiple cesarean deliveries remains an option for eligible

delivery than on the numbers of repeat cesarean sections.

*DOI: http://dx.doi.org/10.5772/intechopen.86334*

ean delivery.

**8. Summary**

both the mother and baby.

women.

Another study demonstrated increased costs through increasing adverse neonatal outcomes because of elective repeat cesarean deliveries at 37 or 38 weeks [37].

On the opposite side, the elective cesarean delivery at 39 weeks seems to be associated with better neonatal outcome in comparison to a later timing of delivery [34].

Altogether our findings suggest that from the neonatal point of view, there are benefits to waiting until 39 weeks of gestation to perform an elective repeat cesarean delivery.

To achieve the prolongation of the pregnancy until 39 weeks for the neonatal benefit, it is important to know if an elective repeat cesarean section at this time is also of benefit for the maternal outcome. The results of three studies with a total of 37.938 women show that an elective repeat cesarean delivery at 37 or 38 weeks is not associated with decreased maternal morbidity [34, 35, 38]. In comparison to the group of elective delivery at 39 weeks, there was no significant difference in uterine scar rupture, estimated blood loss, hysterectomy, or other maternal complications.

Additionally one study pointed out that elective cesarean delivery at 37 weeks had significantly higher risks of a prolonged (>5 days) maternal hospitalization [38].

Although a cesarean section before 39 weeks has a similar rate of risks for women with multiple repeated cesarean sections as the delivery after 39 weeks, the elective repeat cesarean section at 37 or 38 weeks exposes the neonate to an unnecessary increased risk of respiratory distress syndromes.

In conclusion, if there are no other medical indications for an earlier delivery, 39 weeks of gestation is apparently the optimal timing for repeat cesarean delivery yielding both the best neonatal and maternal outcome.

## **8. Summary**

*Recent Advances in Cesarean Delivery*

VBAC 1 76.50%

VBAC 2 71.70%

VBAC > 2 79.77%

*higher multiple repeat cesarean sections.*

Second CS

n = 38,814/50,685 [30]

n = 4064/5666 [30]

Third CS – 3.71%

n = 71/89 [31]

≥4 CS – 4.34%

*VBAC1/VBAC2 = vaginal birth after one/two cesarean sections; CS = cesarean section*

In conclusion, there was no difference in the maternal morbidity of women with

*Maternal outcome of vaginal birth following multiple cesarean section for VBAC versus a setting of increasing* 

**Delivery VBAC successes Uterine rupture Hysterectomy Transfusion**

0.72% n = 372/50,685 [30]

> n = 52/8542 [3, 8, 12]

> 1.36% n = 74/5421 [30]

n = 29/782 [3, 8]

0.00% n = 0/89 [31]

n = 41/945 [3, 4, 8, 13]

– 0.61%

0.19% n = 42/50,685 [30]

0.43% n = 75/17,378 [3, 8, 10, 11]

0.56% n = 14/2512 [30]

0.91% n = 65/7106 [3, 8, 10, 11]

2.49% n = 66/2652 [3, 8, 10, 11, 13]

1.21% n = 358/50,685 [30]

1.58% n = 273/17,280 [3, 5, 10, 11]

2.01% n = 39/5666 [30]

2.23% n = 157/7050 [3, 5, 10, 11]

> n = 2/89 [31]

5.35% n = 142/2652 [3, 5, 10, 11, 13, 14]

n.k. 2.20%

multiple prior cesareans for the mode of delivery in these studies. A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a

single prior operation (**Table 3**). However, when looking at uterine rupture alone, the risks increase with each cesarean section (>2 CS: 3.71% and >3 CS: 4.34%).

In conclusion, vaginal birth after multiple cesarean deliveries remains an option

In clinical practice obstetricians have to decide when best to perform an elective repeat cesarean delivery. For the decision-making, it is interesting to have knowledge on the gestation with the best neonatal and maternal outcomes. We found five

Three retrospective studies with a total of 48,757 women were identified comparing the neonatal risks at repeat cesarean delivery before and after 39 weeks of gestation [34–36]. In general elective repeat cesarean sections between 37 and 39 weeks are associated with a higher neonatal morbidity. Especially the rates of adverse respiratory outcomes and mechanical ventilation were increased. Neonates born before 39 weeks of gestation have significant more respiratory distress syndromes. Additionally the risks of newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization are also higher in the group with a repeat cesarean

**44**

for eligible women.

**Table 3.**

studies in total to be analyzed.

section before 39 weeks [36].

**7. Timing of elective repeat cesarean section**


*Recent Advances in Cesarean Delivery*
