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Arch Gynecol Obstet (2013) 287:10751079

DOI 10.1007/s00404-012-2688-5

MATERNAL-FETAL MEDICINE

Second stage disorders in patients following a previous cesarean


section: vacuum versus repeated cesarean section
Roy Kessous Dan Tirosh Adi Y. Weintraub
Neta Benshalom-Tirosh Ruslan Sergienko
Eyal Sheiner

Received: 19 October 2012 / Accepted: 11 December 2012 / Published online: 30 December 2012
Springer-Verlag Berlin Heidelberg 2012

Abstract
Objective To investigate whether vacuum extraction due
to failure of labor to progress (dystocia) during the second
stage in a delivery following a previous cesarean section
(CS) is related to increased adverse maternal and perinatal
outcomes as compared with repeated CS.
Study design A retrospective cohort study of pregnancy
and delivery outcomes of patients in their second deliveries
attempting a vaginal birth after cesarean (VBAC) following one CS was conducted. Patients who delivered by
vacuum extraction were compared with patients who
underwent a repeated CS for failure of labor to progress
during the second stage.
Results During the study period, 319 patients with a
previous CS suffered from a prolonged second stage of
labor in their second delivery. Of these, 184 underwent
vacuum extraction and 135 patients underwent a repeated
CS. No significant differences in relevant pregnancy
complications such as perineal lacerations, uterine rupture,
and post-partum hemorrhage and perinatal outcomes were
noted between the groups. There were no cases of perinatal
mortality in our study.

R. Kessous  D. Tirosh  A. Y. Weintraub 


N. Benshalom-Tirosh  E. Sheiner (&)
Department of Obstetrics and Gynecology, Faculty of Health
Sciences, Soroka University Medical Center, Ben-Gurion
University of the Negev, POB 151, Beer-Sheva 84101, Israel
e-mail: sheiner@bgu.ac.il
R. Kessous
e-mail: kessousr@bgu.ac.il
R. Sergienko
Epidemiology and Health Services Evaluation, Ben-Gurion
University of the Negev, Beer-Sheva, Israel

Conclusion When managing second stage labor disorders, vacuum extraction does not seem to be an unsafe
procedure in patients with a previous CS.
Keywords Cesarean section  Vacuum extraction 
Prolonged second stage  Vaginal birth after cesarean

Introduction
In recent years, the number of cesarean deliveries is rising,
reaching a rate as high as 2530 % in developed countries
[1]. This increase is associated with changing trends in
obstetrical practice and with certain demographic, clinical,
and social factors including increasing maternal age,
electronic fetal heart rate monitoring, a decrease in the rate
of instrumental deliveries, an increase in the rate of primary (cesarean section) CS due to breech presentation, a
decrease in vaginal birth after cesarean (VBAC), increased
obesity, and an increase in medically indicated labor
inductions [1]. Notably, this increase in the rate of CS
results in turn in a higher rate of recurrent CS.
The rate of operative vaginal delivery has decreased in
recent years reaching 45 % of all deliveries [2]. The most
common instrumental delivery method presently utilized is
vacuum extraction (34 %), while delivery by forceps is
relatively rare (less than 1 %) [2]. Among the reasons for
the decline in instrumental deliveries are the related complications, fear of legal consequences, and lack of training
of the medical staff in such procedures [3].
The rate of VBAC has increased up to 25 % in the mid
1990s; however, troubling reports about complications [4, 5]
have resulted in a decline in the rate of VBAC to less than 10 %
in the USA in the last decade [1]. Interestingly, this decrease
did not affect other countries reviewed in the same survey,

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showing a rate of VBAC deliveries between 20 and 50 % [1].


The major complications of VBAC are uterine rupture and
perinatal morbidity and mortality. Landon et al. [6] found
higher rates of uterine rupture, stillbirth, and hypoxic ischemic
encephalopathy when comparing VBAC with a repeat CS [6].
Many women conceive achieving a natural birth as a
significant aspect of their femininity and a major life event
for a woman [7]. The opportunity to deliver vaginally is
important for women who have not yet completed their
family planning, especially in societies where multiparity
is highly regarded. A higher number of repeated CSs
increase the patients risk for morbidity and mortality due
to pathologic placentation, uterine rupture, massive
bleeding, and other complications that may result from post
operative changes such as intra-abdominal adhesions.
Scarce data exist concerning maternal and neonatal outcomes when comparing operative vaginal deliveries and CSs
for the management of second stage disorders. In 2008, the
Cochrane Collaboration addressed this issue and attempted to
compare outcomes of instrumental deliveries preformed in
the operating room with immediate CS for women with
failure of labor to progress during the second stage. No randomized controlled trials were found [8]. Contag et al. [9]
evaluated neonatal outcomes in pregnancies complicated by
failure of labor to progress during the second stage that
delivered either by operative vaginal delivery or by CS. The
study population included low-risk nulliparous women and
the results were comparable between the study groups [9].
Traditionally the surveillance and definition of any deviation in the progress of labor is being made according to the
Friedman curves [10]. The objective of the current study was
to investigate the operative management of failure of labor to
progress during the second stage arising during a VBAC,
comparing vacuum extraction with a repeat CS, with regard
to adverse maternal and perinatal outcomes.

Materials and methods


Setting
The study was conducted at the Soroka University Medical
Center, the only hospital in the Negev, the southern region
of Israel, serving the entire obstetrical population. Thus, the
study represents non-selective population-based data. The
Institutional Review Board (in accordance with the Helsinki declaration) approved the study.
Study population
The study population was composed of all patients in their
second delivery attempting a VBAC between the years
1993 and 2010.

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Arch Gynecol Obstet (2013) 287:10751079

Study design
A retrospective population-based study was conducted,
comparing all patients who delivered by vacuum extraction
with patients who underwent a repeated CS for failure of
labor to progress (dystocia) during the second stage. Failure of labor to progress during the second stage was
defined as deviations from the normal Fridmans curves
[10]. The length of the second stage of labor was limited to
2 h in nulliparous women or 3 h if epidural analgesia was
applied, and 1 h in multiparous women or 2 h if epidural
analgesia was applied [10, 11]. Women lacking prenatal
care or who had multiple gestations were excluded from
the study. Data regarding pregnancy complications and
adverse outcomes were available from the perinatal database of the center. Data were reported by an obstetrician
immediately after delivery. Skilled medical secretaries
routinely reviewed the information prior to entering it into
the database. Coding was performed after assessing the
medical prenatal care records together with the routine
hospital documents.
The following demographic and clinical characteristics
were evaluated: maternal age, ethnicity (Jewish or Bedouin), gravidity, parity, and gestational age at delivery.
Obstetrical risk factors that were examined included
hypertensive disorders (mild and severe preeclampsia,
eclampsia and chronic hypertension), diabetes mellitus,
placenta previa, placental abruption, placenta accreta, postpartum hemorrhage (PPH), uterine rupture, prolapse of
cord, non-reassuring fetal heart rate patterns, and cervical
tear. The following perinatal outcomes were assessed:
Apgar scores at 1 and 5 min \7, birth weight, fetal gender,
and perinatal mortality.
Statistical analysis
Statistical analysis was performed using the SPSS package
16 edition (SPSS Inc, Chicago, IL). Statistical significance
was calculated using the chi square test for differences in
qualitative variables and the Student t test for differences in
continuous variables. Odds ratio (OR) and their 95 %
confidence intervals (CI) were computed. A value of
P \ 0.05 was considered statistically significant.

Results
During the study period, 319 patients with a previous CS
were documented to have failure of labor to progress
during the second stage on their following VBAC attempt.
Of these, 184 patients underwent vacuum extraction and
135 patients underwent a recurrent CS.

Arch Gynecol Obstet (2013) 287:10751079

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Table 1 summarizes demographic and clinical characteristics of these two groups. No significant differences
were noted between the two groups including maternal age,
gestational age at delivery, and the number of patients who
delivered after not having an accepted prenatal surveillance.
Table 2 presents the rate of maternal pregnancy and
delivery complications in the two groups. No statistically
significant differences were found regarding maternal
co-morbidities such as diabetes mellitus and hypertensive
disorders. No significant differences were found regarding
pregnancy complications such as premature rupture of
membranes, meconium stained amniotic fluid, and nonreassuring fetal heart rate patterns. A significantly higher
rate of occipito posterior (OP) position was noted in the CS
group compared with the vacuum group (12.6 vs. 3.3 %,
respectively; OR 0.2; 95 % CI 0.10.6; P = 0.001). In
addition, the vacuum delivery group had statistically significant higher rates of revision of uterine cavity and cervix. There was no difference in the use of blood
transfusions.
Table 3 presents perinatal outcomes. No differences
were noticed between the two groups in terms of birth
weight. Apgar scores at 5 min following delivery showed
no difference between the two study groups, and no perinatal mortality was reported within the study population.

Discussion
Although the rate of instrumental deliveries is 54 % of all
deliveries in high-income countries [2], data comparing
vacuum extraction with cesarean delivery are very limited.
Table 1 Demographic and clinical characteristics of patients after
CS that underwent vacuum delivery compared with those that
underwent a repeated CS for prolonged second stage
Characteristics

Ethnicity

Jewish
Bedouin

Maternal age

\21
2135
35\

Gestational age at
delivery
Gravidity
Lack of prenatal
care

32[

Repeated
CS
(n = 135)
(%)

Vacuum
delivery
(n = 184)
(%)

P value

61.5
38.5

43.5
56.5

0.374
0.608

0.7

0.5

94.8

92.4

4.5

7.1

2.7

2.2

94.1

88

36\

3.7

9.8

24

98.5

98.9

5\

1.5

1.1

3.7

7.1

3236

0.146

0.754
0.199

Table 2 A comparison of pregnancy and delivery complications


between patients after CS that underwent vacuum delivery and
patients that underwent a repeated CS for prolonged second stage
Characteristics

Repeated
CS
(n = 135)
(%)

Vacuum
delivery
(n = 184)
(%)

OR

95 % CI

P value

Mild
preeclampsia
Severe
preeclampsia
Diabetes
mellitus
Premature
rupture of
membranes
Meconium
stained
amniotic
fluid
Nonreassuring
fetal heart
rate patterns
Occipito
posterior
Revision of
uterine
cavity and
cervix
Manual
removal of
placenta
Vaginal tear
grade 3
Post-partum
hemorrhage
Blood
transfusions
Uterine
rupture
Cervical tear

4.4

3.3

0.7

0.22.3

0.583

2.2

0.5

0.2

0.022.3

0.183

5.9

5.4

0.9

0.42.4

0.851

9.6

8.2

0.8

0.41.8

0.645

21.5

17.9

0.8

0.51.4

0.429

10.4

6.5

0.6

0.31.3

0.215

12.6

3.3

0.2

0.10.6

0.001

3.0

57.6

44

15125

0.001

2.7

0.57

0.520.63

0.054

1.6

0.57

0.520.62

0.136

0.7

3.8

5.3

0.643.6

0.084

8.1

7.1

0.9

0.42

0.717

1.5

0.5

0.3

0.14

0.391

5.9

2.7

0.4

0.11.4

0.152

The major finding of our study was that even when


attempting a VBAC, vacuum extraction for second stage
disorders is not associated with an increased risk for
adverse perinatal outcomes compared with repeated CS.
To the best of our knowledge, the only comparison
between vacuum extraction and CS (not after a previous
CS) was preformed by Contag et al. [9]. In their study, fetal
acidemia was compared in 549 nulliparous patients
undergoing vacuum extraction, forceps assisted delivery,
and cesarean delivery. They found no differences between
these three groups [9].
When considering the worldwide increasing rate of CS
and the fact that in common practice, a second CS ends the
opportunity for a future vaginal delivery, our results

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1078
Table 3 Neonatal outcomes in
patients after CS that underwent
vacuum delivery compared with
those who underwent a repeated
CS for prolonged second stage

Arch Gynecol Obstet (2013) 287:10751079

Characteristics

Gender

Repeated CS

OR

95 % CI

P value

Male

51.1

53.2

Female

48.9

46.8

\2,500

3.7

2.2

2,5004,000

91.1

94

[4,000

5.2

3.8

Apgar score 1 min \7

28.9

6.0

0.16

0.080.32

0.001

Apgar score 5 min \7


Perinatal mortality (total)

0.7
0

1.6
0

2.2

0.221

0.480

Birth weight
(Mean SD)

showing that vacuum delivery is a safe procedure even


after a previous CS are of paramount importance. The data
might be of significance in an attempt to reduce the rates of
repeated CS and preventing its associated complications.
A significantly higher rate of OP positioning of the head
was noticed in the CS compared with the vacuum group.
This diagnosis probably prompted the physicians managing
these patients to decide in favor of performing a repeated
CS. Scarce data regarding OP positioning of the head and
the risk for CS exist. Nevertheless, Ebulue et al. [12] found
the risk for instrumental delivery to be double when OP
positioning of the head was found [12].
Another significant difference in delivery characteristics
between the two groups was a higher rate of manual
revision of the uterine cavity. In the past, the practice of
performing a routine transcervical revision for every
patient following a previous CS was common in our
medical center. Later, it became evident that routine revision of a uterine scar at the time of a subsequent vaginal
delivery is usually unnecessary [13, 14]. Silberstein et al.
[13] evaluated the necessity of routine transcervical revision of uterine scar after prior CS. They concluded that the
potential benefit of routine examination of uterine scar after
VBAC is doubtful and that transcervical revision should be
performed only in symptomatic patients [13]. In recent
years, a uterine cavity revision is no longer preformed
routinely in our institution.
In this population-based study, we included all patients
in their second deliveries attempting a VBAC following
one CS; 184 underwent vacuum extraction and 135 patients
underwent a repeated CS. Although relatively small, these
numbers actually represent one of the largest series published. Power analysis revealed that a sample size of over
90 patients in each group would be required to detect
significant differences regarding these composite adverse
pregnancy complications (adding all maternal complications together) with 80 % power and an alpha equal to
0.05. Accordingly, our sample size of above 100 parturient
in each group is sufficient. However, regarding rare outcomes such as perinatal mortality and anal sphincter

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(n = 135) (%)

Vacuum
delivery
(n = 184) (%)

0.634
0.590

injuries, more cases would be needed for definitive conclusions since our study lacks the power to state no significant differences (type 2 error). Another potential
weakness, that is inherent to a retrospective cohort study, is
the potential for missing data. Nevertheless, the data were
reported by an obstetrician directly after delivery. Skilled
medical secretaries routinely reviewed the information
prior to entering it into the database. Coding was done after
assessing the medical prenatal care records together with
the routine hospital documents. This makes this potential
source of missing variables less likely.
Physicians decision regarding the mode of delivery
during VBAC in pregnancies complicated by second stage
disorders is influenced by several maternal and fetal characteristics including maternal age, maternal request, degree
of cooperation, fetal position, station of the fetal head, the
presence of scalp edema, estimated fetal weight, as well as
the physicians experience with the procedure and personal
preference. Other considerations such as availability of an
operating room might also play a role in the decision. The
findings of our study demonstrate that when managing
deliveries of patients after CS, vacuum delivery does not
seem to be an unsafe procedure for second stage disorders.
In common practice, a second CS brings to an end the
opportunity for future vaginal deliveries. When considering
the mode of delivery, the patients family plan as well as
possible surgical complications must be taken into account
when making a decision. It is our belief that reducing the
rate of CSs should have major priority in obstetrics. Further
prospective research is needed to establish the findings of
this study and to create guidelines for the management of
VBAC with prolonged second stage.
Conflict of interest

The authors report no conflict of interest.

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