Ž . International Journal of Gynecology & Obstetrics 65 1999 251]253
Article
Induction of labor with vaginal prostaglandin-E in
2grand multiparous women with one previous cesarean
section
T.Y. Yamani, A.A. Rouzi
UDepartment of Obstetrics and Gynecology, King Abdulaziz Uni¨ersity Hospital, Jeddah, Saudi Arabia Received 30 September 1998; received in revised form 21 December 1998; accepted 5 January 1999
Abstract
Objecti¨e: To review the outcome of induction of labor with vaginal prostaglandin-E in grand multiparous women2 with one previous cesarean section. Methods: Twenty-six grand multiparous women with one previous cesarean
Ž .
section were induced with vaginal prostaglandin-E . Results: Twenty 76.9% women delivered vaginally and six2
Ž23.1% women delivered by emergency cesarean section. The mean duration of labor was 6. "3.6 h. There was no uterine rupture or dehiscence. There was one neonatal death and two stillbirths. Conclusions: Our limited study suggests that induction of labor with vaginal prostaglandin-E2 in selected grand multiparous women with one previous cesarean section may be a reasonable option. However, further studies are needed to document its safety.
Q1999 International Federation of Gynecology and Obstetrics.
Keywords: Induction; Prostaglandin-E ; Grand multipara; Previous cesarean2
1. Introduction
Induction of labor in grand multiparous women Žpara 6 or more. with one previous cesarean section is considered a contraindication. This is because of the combination of three risk factors
UCorresponding author. Tel.: q966 26772027; fax: q966 25372502.
for uterine rupture Žgrand multiparity, uterine scar, and the use of prostaglandin preparations .. However, there is no real data in the literature to support such a recommendation. Induction of labor with vaginal prostaglandin-E in grand mul-2 tiparous women without previous uterine scar
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proved to be relatively safe 1,2 . Furthermore, there is insufficient evidence against the use of vaginal prostaglandin-E2 in multiparous women
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with one previous cesarean section 3 . The aim of
0020-7292r99r$20.00Q1999 International Federation of Gynecology and Obstetrics.
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PII: S 0 0 2 0 - 7 2 9 2 9 8 0 0 0 1 5 - 6
( ) T.Y. Yamani, A.A. RouzirInternational Journal of Gynecology & Obstetrics 65 1999 251]253 252
this study is to review the outcome of induction of labor with vaginal prostaglandin-E in grand mul-2 tiparous women with one previous cesarean sec- tion.
2. Materials and method
Between 1 January 1991 and 31 July 1997, 26 grand multiparous women with one previous ce- sarean section were induced with vaginal prostaglandin-E2 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Analysis of the hospital records showed that they all: 1 hadŽ . medical or obstetrical indication for induction of labor; 2 requested vaginal birth after cesareanŽ .
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section VBAC after counseling regarding the potential risks; 3 completed 37 weeks of gesta-Ž . tion or more; and 4 had cephalic presentationŽ .
Ž .
with unripe cervix Bishop score-4 at the time of induction.
The indications for induction of labor were: 1Ž .
Ž . Ž .
post-date, 13 women 50% ; 2 mild pregnancy-
Ž . Ž .
induced hypertension, six 23% ; 3 gestational
Ž . Ž .
diabetes mellitus, four 15.3% ; and 4 intrauter-
Ž .
ine fetal death, two 7.7% ; and fetal multiple
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congenital anomalies, one 4% . Nineteen 73%
women had had one or more successful VBAC before the index pregnancy and seven women Ž27% did not have VBAC before the last deliv-. Ž ery was by cesarean section ..
The induction of labor and the intrapartum w x
monitoring were as reported before 2 . In short, vaginal prostaglandin-E ; half a tablet 1.5 mg of2 Ž Dinoprostone, Upjohn, London, UK. was in- serted in the posterior vaginal fornix during vagi- nal examination. This was repeated every 6 h up to three doses provided that the cervix was still unripe and the fetal heart monitoring was reas- suring. Intrapartum continuous fetal heart moni- toring was carried out for all women. Pain relief in labor was provided by intramuscular adminis- tration of pethidine and phenergan. Statistical analysis was performed using SPSS-PC for win- dows, version 6.1. Results are expressed as mean
"S.D. Statistical analysis was done with x2 test.
A P-value-0.05 was considered statistically sig- nificant.
3. Results
The maternal characteristics are shown in Table 1. The majority of our grand multiparous women
Ž .
were older than 30 years 84.6% . All women responded to a maximum of three doses of 1.5 mg
w Ž .
of prostaglandin-E2 18 women 69.2% received
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1.5 mg, five women 19.3% received 3.0 mg, and
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three women 11.5% received 4.5 mg . Twenty Ž76.9% multiparous women delivered vaginally.
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while six women 23.1% delivered by emergency cesarean section three for fetal distress and threeŽ for failure to progress . Seventeen women out of.
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19 89.5% who had had successful VBAC before the index pregnancy delivered vaginally. In con-
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trast, three women out of seven women 42.9%
who did not have VBAC before delivered vagi- nally. This was a statistically significant difference ŽPs0.01 . The mean duration of labor was 6. "3.6 h. There was no uterine rupture or dehiscence,
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however, two women 7.7% developed postpar- tum hemorrhage due to uterine atony and were
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given blood transfusion. Four babies 15.4% had
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Apgar score-7 at 1 min and one baby 3.8%
had Apgar score-7 at 5 min. The mean fetal weight was 3611.5"486.8 g. Twenty-four babies were delivered alive, but one died in the neonatal period due to multiple congenital anomalies which were diagnosed antenatally. There were two still- births came with history of absent fetal move-Ž
Table 1
Maternal characteristics Variable
Age 34.6"4.4
Gravidity 9.0"2.1
Parity 7.7"1.7
Gestational age 40.0"2.0 Maternal height 154.9"3.0 Maternal weight 77.0"15.40
Note. Data are presented as mean"S.D.
( )
T.Y. Yamani, A.A. RouzirInternational Journal of Gynecology & Obstetrics 65 1999 251]253 253
ments for a few days and were diagnosed as intrauterine fetal death before induction .. 4. Discussion
Induction of labor with vaginal prostaglandin- E2 in multiparous women with one previous ce- sarean section is controversial. A recent review of the existing literature showed that there is no good analytic studies concerning the safety of vaginal prostaglandins with one previous cesarean
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section 3 . Eleven retrospective studies included 713 women with one previous cesarean section who were induced with vaginal and cervical prostaglandin-E . Only two women had dehis-2 cence of the uterine scar and the success rate of VBAC was 72.6%. This led to the conclusion that there is ‘insufficient evidence’ of any increased risk of rupture or dehiscence.
Grand multiparity has been traditionally con-
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sidered a high-risk situation 4]6 . However, cur- rent studies do not support such a statement w7]9 . In addition, one study based on the out-x come of delivery of 1700 grand multiparous women concluded that ‘grand multiparity no longer needs to be considered a high-risk cate-
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gory’ 10 . This is due to appropriate antenatal care, contemporary obstetrics, and improved neo- natal services. Two local reports showed that grand multiparity and even extreme grand multi-
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parity para 10 or more do not impose ‘special
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obstetric or perinatal risk’ 11,12 .
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We 2 and Abu El-Lail et al. 1 have shown that induction of labor in grand multiparous women is relatively safe. Management of grand multiparous women with one previous cesarean section is a special situation. Awaiting sponta- neous labor is the best strategy for successful VBAC. However, sometimes induction of labor for medical or obstetric indications may be neces- sary. This creates a management dilemma. Dyack
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et al. 13 suggested that induction of labor is not a contraindication, provided that it is performed by a senior member and emergency cesarean section is resorted to if labor does not progress
smoothly. The success rate of VBAC in our study was 76.9% and we did not have any maternal mortality, or serious morbidity such as uterine rupture or dehiscence. However, these results should be considered with caution because of the
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small number of patients. Furthermore, 19 73%
of the 26 women had had one or more successful VBAC before the index pregnancy.
In conclusion, our limited study suggests that induction of labor with vaginal prostaglandin-E2 in selected grand multiparous women with one previous cesarean section may be a reasonable option. However, further studies are needed to document its safety.
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