International Journal of Gynecology & Obstetrics 65 1999.

251 253

Article

Induction of labor with vaginal prostaglandin-E 2 in grand multiparous women with one previous cesarean section
T.Y. Yamani, A.A. RouziU
Department 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 2 in grand multiparous women with one previous cesarean section. Methods: Twenty-six grand multiparous women with one previous cesarean section were induced with vaginal prostaglandin-E 2 . Results: Twenty 76.9%. women delivered vaginally and six 23.1%. 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-E 2 in selected grand multiparous women with one previous cesarean section may be a reasonable option. However, further studies are needed to document its safety. 1999 International Federation of Gynecology and Obstetrics.
Keywords: Induction; Prostaglandin-E 2 ; Grand multipara; Previous cesarean

1. Introduction Induction of labor in grand multiparous women para 6 or more. with one previous cesarean section is considered a contraindication. This is because of the combination of three risk factors
U

Corresponding author. Tel.: q966 26772027; fax: q966 25372502.

for uterine rupture grand 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 2 in grand multiparous women without previous uterine scar proved to be relatively safe w1,2x. Furthermore, there is insufcient evidence against the use of vaginal prostaglandin-E 2 in multiparous women with one previous cesarean section w3x. The aim of

0020-7292r99r$20.00 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 9 8 . 0 0 0 1 5 - 6

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T.Y. Yamani, A.A. Rouzi r International Journal of Gynecology & Obstetrics 65 (1999) 251 253

this study is to review the outcome of induction of labor with vaginal prostaglandin-E 2 in grand multiparous women with one previous cesarean section.

A P-value - 0.05 was considered statistically signicant.

3. Results 2. Materials and method The maternal characteristics are shown in Table 1. The majority of our grand multiparous women were older than 30 years 84.6%.. All women responded to a maximum of three doses of 1.5 mg of prostaglandin-E 2 w18 women 69.2%. received 1.5 mg, ve women 19.3%. received 3.0 mg, and three women 11.5%. received 4.5 mgx. Twenty 76.9%. multiparous women delivered vaginally while six women 23.1%. delivered by emergency cesarean section three for fetal distress and three for failure to progress.. Seventeen women out of 19 89.5%. who had had successful VBAC before the index pregnancy delivered vaginally. In contrast, three women out of seven women 42.9%. who did not have VBAC before delivered vaginally. This was a statistically signicant difference P s 0.01.. The mean duration of labor was 6 " 3.6 h. There was no uterine rupture or dehiscence, however, two women 7.7%. developed postpartum hemorrhage due to uterine atony and were given blood transfusion. Four babies 15.4%. had 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 stillbirths came with history of absent fetal move-

Between 1 January 1991 and 31 July 1997, 26 grand multiparous women with one previous cesarean section were induced with vaginal prostaglandin-E 2 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Analysis of the hospital records showed that they all: 1. had medical or obstetrical indication for induction of labor; 2. requested vaginal birth after cesarean section VBAC. after counseling regarding the potential risks; 3. completed 37 weeks of gestation or more; and 4. had cephalic presentation with unripe cervix Bishop score - 4. at the time of induction. The indications for induction of labor were: 1. post-date, 13 women 50%.; 2. mild pregnancyinduced hypertension, six 23%.; 3. gestational diabetes mellitus, four 15.3%.; and 4. intrauterine fetal death, two 7.7%.; and fetal multiple congenital anomalies, one 4%.. Nineteen 73%. women had had one or more successful VBAC before the index pregnancy and seven women 27%. did not have VBAC before the last delivery was by cesarean section.. The induction of labor and the intrapartum monitoring were as reported before w2x. In short, vaginal prostaglandin-E 2 ; half a tablet 1.5 mg of Dinoprostone, Upjohn, London, UK. was inserted in the posterior vaginal fornix during vaginal examination. This was repeated every 6 h up to three doses provided that the cervix was still unripe and the fetal heart monitoring was reassuring. Intrapartum continuous fetal heart monitoring was carried out for all women. Pain relief in labor was provided by intramuscular administration of pethidine and phenergan. Statistical analysis was performed using SPSS-PC for windows, version 6.1. Results are expressed as mean " S.D. Statistical analysis was done with 2 test.

Table 1 Maternal characteristics Variable Age Gravidity Parity Gestational age Maternal height Maternal weight 34.6 " 4.4 9.0 " 2.1 7.7 " 1.7 40.0 " 2.0 154.9 " 3.0 77.0 " 15.40

Note. Data are presented as mean " S.D.

T.Y. Yamani, A.A. Rouzi r International Journal of Gynecology & Obstetrics 65 (1999) 251 253

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ments for a few days and were diagnosed as intrauterine fetal death before induction.. 4. Discussion Induction of labor with vaginal prostaglandinE 2 in multiparous women with one previous cesarean 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 section w3x. Eleven retrospective studies included 713 women with one previous cesarean section who were induced with vaginal and cervical prostaglandin-E 2 . Only two women had dehiscence of the uterine scar and the success rate of VBAC was 72.6%. This led to the conclusion that there is insufcient evidence of any increased risk of rupture or dehiscence. Grand multiparity has been traditionally considered a high-risk situation w4 6x. However, current studies do not support such a statement w7 9x. In addition, one study based on the outcome of delivery of 1700 grand multiparous women concluded that grand multiparity no longer needs to be considered a high-risk category w10x. This is due to appropriate antenatal care, contemporary obstetrics, and improved neonatal services. Two local reports showed that grand multiparity and even extreme grand multiparity para 10 or more. do not impose special obstetric or perinatal risk w11,12x. We w2x and Abu El-Lail et al. w1x 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 spontaneous labor is the best strategy for successful VBAC. However, sometimes induction of labor for medical or obstetric indications may be necessary. This creates a management dilemma. Dyack et al. w13x 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 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-E 2 in selected grand multiparous women with one previous cesarean section may be a reasonable option. However, further studies are needed to document its safety. References
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