1. Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery Mark B. Landon, M.D., John C. Hauth, M.D., Kenneth J. Leveno, M.D., et al. For the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network* דר' ישי לוין, בי"ח ליס ליולדות

2. background The proportion of women who attempt vaginal delivery after prior cesarean delivery has decreased largely because of concern about safety. The absolute and relative risks associated with a trial of labor in women with a history of cesarean delivery, as compared with elective repeated cesarean delivery without labor, are uncertain. דר' ישי לוין, בי"ח ליס ליולדות

3. background CS - 5 % in 1970’s to 26% in 2002. US public health goals (1990) 15% overall and 35% after previous cesarean An apparent increase in the frequency of uterine rupture and concern about maternal and perinatal morbidity have challenged the safety and appropriateness of vaginal birth after cesarean delivery Vaginal birth after cesarean goes down from 31% in 1998 to 12.7% in 2002. דר' ישי לוין, בי"ח ליס ליולדות

4. aim A multicenter observational study involving women with a prior cesarean delivery to assess the risks of uterine rupture and neonatal and maternal morbidity associated with a trial of labor as compared with repeated elective cesarean delivery. דר' ישי לוין, בי"ח ליס ליולדות

5. Methods We performed a prospective cohort study from 1999 through 2002 at 19 academic medical centers belonging to the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network This study includes all women who had a prior cesarean delivery and who had a singleton pregnancy at 20 weeks or more of gestation or whose infant had a birth weight of at least 500 g דר' ישי לוין, בי"ח ליס ליולדות

6. Methods Maternal and perinatal outcomes were compared between women who had a trial of labor and those who underwent elective repeated cesarean delivery without labor or other indications for cesarean delivery, such as a prior classical (up-and-down) or “inverted T ” incision, breech or transverse presentation, placenta previa, prior myomectomy, nonreassuring patterns in the antepartum fetal heart rate, genital herpes, or a medical condition precluding a trial of labor. Women presenting in labor with cervical dilatation of at least 4 cm, as well as those receiving oxytocin, were classified as undergoing a trial of labor. Women presenting in early labor who subsequently underwent cesarean delivery were excluded from the analysis owing to the difficulty in distinguishing between a failed trial of labor and a planned elective repeated cesarean delivery. דר' ישי לוין, בי"ח ליס ליולדות

11. Overall, our data suggest a risk of an adverse perinatal outcome at term among women with a previous cesarean delivery of approximately 1 in 2000 trials of labor (0.46 per 1000), a risk that is quantitatively small but greater than that associated with elective repeated cesarean delivery. דר' ישי לוין, בי"ח ליס ליולדות

12. Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery Shi Wu Wen, MB, PhD, I. D. Rusen, MD, MSc, Mark Walker, MD,et al. for the Maternal Health Study Group, Canadian Perinatal Surveillance System דר' ישי לוין, בי"ח ליס ליולדות

13. Methods 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. דר' ישי לוין, בי"ח ליס ליולדות

14. Results דר' ישי לוין, בי"ח ליס ליולדות

15. Results דר' ישי לוין, בי"ח ליס ליולדות

16. Discussion We found the in-hospital maternal death rate among women with cesarean delivery to be substantially higher than among women with vaginal delivery…Surgical complications during cesarean section are probable causes of some of these deaths. These findings further support the argument that trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death. דר' ישי לוין, בי"ח ליס ליולדות

17. Discussion Recent research has reported that inducing labor with a vaginal prostaglandin among women with a previous cesarean section confers the highest risk for uterine rupture. Our data source do not allow consideration of the specific method of induction. We found a higher risk of adverse outcomes associated with trial of labor in low-volume obstetric units (<500 births per year) than in high-volume units (>500 births per year). דר' ישי לוין, בי"ח ליס ליולדות

18. עמדת האיגודים האיגוד הישראלי למיילדות וגניקולוגיה ACOG דר' ישי לוין, בי"ח ליס ליולדות

19. www.obgyn.org.il מאמרים ניירות עמדה מצגות קולמצגות קול...למשללמשל ועוד. דר' ישי לוין, בי"ח ליס ליולדות