Table 2.
Results of studies comparing trial of labour and emergency repeat caesarean delivery
|
Sample size
|
Uterine exploration
|
No (%) of uterine ruptures
|
|||||
|---|---|---|---|---|---|---|---|
| Study | Characteristics of population | TOL | ERCD | Symptomatic | Asymptomatic | Reported associated major morbidity | |
| Cowan 199413 | All vertical scars excluded; unclassified scars and more than 1 previous caesarean allowed | 593 | Not reported | TOL - 5 (0.8) | Not reported | 1 fetus with severe neurological sequelae | |
| Flamm 199416 | All vertical scars excluded; unclassified scars allowed | 5022 | 2207 | Discretion | TOL - 39 (0.8) | Not reported | 0 maternal and neonatal deaths, 3/39 hysterectomies |
| Duff 198814 | One prior LTCD and unclassified scar not allowed | 227* | Yes | TOL - 1 (0.4) | Not reported | 0 maternal or perinatal deaths | |
| Flamm 198815 | LTCD, unclassified scar and more than 1 previous caesarean allowed | 1776† | Yes (discretion?) | TOL - 3 (0.2) | TOL - 11 (0.6) | Symptomatic UR: TOL - 0 maternal and neonatal deaths, 1 hysterectomy | |
| Flamm 199017 | LTCD, unclassified scars and more than 1 previous caesarean allowed | 3957 | Majority no longer did | TOL - 7 (0.2) | Not reported | 0 maternal deaths; 1 hysterectomy with infant born vaginally, Apgar 9; 3 infants with Apgar <7 (one cerebral palsy at 15 months); 1 perinatal death related to rupture | |
| Phelan 198722 | Low vertical scars, unclassified scars, LTCD during 2nd year and more than 1 previous caesarean allowed | 1796 | 314 | Yes | TOL - 5 (0.3) | TOL - 34 (1.9) ERCD - 7 (2.2) | Symptomatic UR: TOL - 1 neonatal death, post rupture, scar intact, fetal bradycardia (sign), 4600g Apgar 0,0,3; none in transverse scar |
| Stoval 198723 | More than 1 LTCD or LVCD allowed; not clear what was done with unclassified scars | 272 | Yes | TOL - 1 (0.4) | TOL - 6 (2.2) | Symptomatic UR: TOL - 0 maternal or fetal deaths | |
| Paul 198521 | Not more than 1 previous caesarean allowed; low vertical scars, unclassified scars and LTCD allowed | 751 | 157 | Yes | TOL - 5 (0.7)‡ | TOL - 11 (1.5)‡ ERCD - 4 (2.5)‡ | Symptomatic UR: TOL - 0 maternal deaths, 2 fetal deaths (classical incision 3 prior CD, fundal incision), 0 hysterectomies |
| Martin 198318 | 1 or more LTCD or LVCD allowed, no rupture occurred in the 76 with prior vertical scars | 162 | 555 | Yes | TOL - 1 failed (0.6) ERCD - 2 (0.4) | TOL - 1 successful, 3 failed (2.5) ERCD - 4 (0.7) | Symptomatic UR: TOL - 0 maternal or fetal deaths ERCD - 0 maternal or perinatal deaths, 0 hysterectomies |
| Meier 198220 | 1 or more LTCD allowed, no “obvious CPD” allowed | 207 | 62 | Not reported | Not reported | TOL - 1 (0.48) ERCD −1 (1.6) | Symptomatic UR: TOL - 0 maternal and fetal deaths |
| McMahon 19962 | 1 LTCD allowed; not clear what was done with unclassified scars | 3249 | 2889 | Not reported | TOL - 10 (0.3) ERCD - 1 (0.03) | Not reported | TOL - 0 maternal deaths, 2 perinatal deaths, 2 hysterectomies; ERCD - 0 maternal or perinatal deaths, 0 hysterectomies |
CPD=cephalopelvic disproportion; ERCD=elective repeat caesarean delivery; LTCD=low transverse caesarean delivery; LVCD=low vertical caesarean delivery; TOL=trial of labour; UR=uterine rupture.
*
Called dehiscence but symptomatic.
†
One third still had thin layer of peritoneum over scar.
‡
Included in Phelan 198722