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S
imões
R
et
al
.
196
R
ev
A
ssoc
M
ed
B
ras
2015; 61(3):196-202
GUIDELINES IN FOCUS
Birth route in case of cesarean section in a previous pregnancy
V
ia
de
parto
em
caso
de
cesariana
em
gestação
anterior
Authorship:
Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo) and
Associação Médica Brasileira (AMB)
Participants:
Ricardo Simões
1,2
, Wanderley M. Bernardo
2
, Antônio J. Salomão
1
, Edmund C. Baracat
1
Conflict of interest:
no conflict of interest declared
1
Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo)
2
Programa Diretrizes da AMB
http://dx.doi.org/10.1590/1806-9282.61.03.196The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standard-
ize procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, de-
pending on the conditions and the clinical status of each patient.
I
ntroduction
Over the past decades, the increase in cesarean section rates
worldwide, especially in developed countries, has been ev-
ident. Nearly a third of all births in the US occur by cesar-
ean section and the proportion of both, first cesarean and
repeat cesarean, is still increasing every year (
A
)
1
(
D
).
3
Cesarean delivery is a relatively simple procedure, but
with inherent risks to its indication that predispose to var-
ious complications such as puerperal infection, ectopic preg-
nancy and thromboembolic events, especially when repeat-
ed. The risk of maternal death is increased, as much as the
occurrence of infection, hemorrhage and anesthetic com-
plications, which also increases maternal morbidity com-
pared to vaginal delivery. Late complications, especially poor
placental implantation in the subsequent pregnancy (pla-
centa with low insertion and varying degrees of placenta
ac-
creta
), are directly related to a history of cesarean section (
B
).
2
Maternal morbidity increases in response to each addition-
al cesarean section, especially for women with three or more
cesarean sections who have a high risk of low insertion pla-
centa, placenta
accreta
and hysterectomy (
A
).
1
With regard to the fetus, although cesarean section
can save lives if indicated due to cord prolapse, placenta
previa
, cephalopelvic disproportion and fetal distress, for
example, it can also lead to increased risk of iatrogenic
prematurity and neonatal respiratory distress when per-
formed without a precise indication (
B
).
2
Nevertheless, even though the complications related
to trial of labor (TOL) in pregnant women with previous
cesarean section are minimal, they are not ruled out and
must, thus, be taken into consideration.
O
bjective
The objective of this review is to provide the best evidence
available today on maternal morbidity and mortality re-
garding birth route (vaginal delivery or cesarean section)
in case of cesarean section in a previous pregnancy.
M
aterial
and methods
Evidence used to analyze maternal morbidity and mortal-
ity regarding birth route chosen in case of cesarean section
in a previous pregnancy was obtained as follows: prepara-
tion of a clinical question, structuring of the question,
search of evidence, critical appraisal and evidence selection.
Clinical question
Is performance of elective cesarean section in case of ce-
sarean delivery in a previous pregnancy related with less
maternal morbidity and mortality compared with vagi-
nal delivery?
Structured question
The clinical question is structured according to the P.I.C.O.
components
(P [Patient]; I [Intervention]; C [Compari-
son]; O [Outcome]).
•
•
P:
C-section in previous pregnancy
•
•
I:
C-section
•
•
C:
Vaginal delivery
•
•
O:
Maternal morbidity and mortality
Scientific databases consulted
The scientific databases consulted were: PubMed-Med-
line and Cochrane. Manual search based on reviewed ref-
erences (narrative or systematic) was also performed.
Strategies for search of evidence
PubMed-Medline
Strategy:
(cesarean section, repeat OR repeat cesarean
section OR cesarean sections, repeat OR repeat cesarean