ACOG Committee

Opinion
Committee on
Obstetric Practice

Number 342, August 2006 (Replaces No. 271, April 2002)

This document reflects emerging

clinical and scientific advances as
Induction of Labor for Vaginal Birth
of the date issued and is subject to
change. The information should
After Cesarean Delivery
not be construed as dictating an
exclusive course of treatment or ABSTRACT: Induction of labor in women who have had cesarean deliveries
procedure to be followed. may be necessary because of fetal or maternal indications. The potentially
increased risk of uterine rupture should be discussed with the patient and
Copyright © August 2006 documented in the medical record. Selecting women most likely to give birth
by the American College of vaginally and avoiding the sequential use of prostaglandins and oxytocin
Obstetricians and Gynecologists.
All rights reserved. No part of this
appear to offer the lowest risks. Misoprostol should not be used in patients
publication may be reproduced, who have had cesarean deliveries or major uterine surgery.
stored in a retrieval system,
posted on the Internet, or trans- An ongoing controversy surrounds whether induction of labor with or with-
mitted, in any form or by any out prostaglandins (specifically, the prostaglandin E2 series) significantly
means, electronic, mechanical, increases the baseline risk of uterine rupture during labor. Induction with
photocopying, recording, or oth- misoprostol (prostaglandin E1) in women who have had cesarean deliveries
erwise, without prior written per-
mission from the publisher. has been shown, in a randomized trial, to be associated with a significant risk
of uterine rupture, with two cases of uterine rupture out of 17 women treat-
Requests for authorization to ed with 25-mcg doses of misoprostol (1). This trial was stopped because of
make photocopies should be
directed to: the increased rupture rate, and the Committee on Obstetric Practice contin-
ues to recommend that misoprostol not be used for induction of labor in
Copyright Clearance Center women who have had cesarean deliveries or major uterine surgery (2–4).
222 Rosewood Drive
Danvers, MA 01923 Since the last Committee on Obstetric Practice Opinion on induction of labor
(978) 750-8400 for vaginal birth after cesarean delivery was published, additional studies
have addressed the issue of induction of labor with or without prostaglandins
in women who have had cesarean deliveries.
The American College of Several studies noted an increased risk of uterine rupture from induction
Obstetricians and Gynecologists of labor in women who have had cesarean deliveries (5–7). A population-
409 12th Street, SW
PO Box 96920 based, retrospective cohort study of the relationship of uterine rupture to
Washington, DC 20090-6920 vaginal birth after cesarean delivery using vital records and abstracted hos-
pital discharge International Classification of Diseases, 9th Revision,
12345/09876
Clinical Modification (ICD-9-CM) code diagnoses reviewed 20,095 women
Induction of labor for vaginal birth
after cesarean delivery. ACOG
with histories of cesarean deliveries for their first delivery (5). The risk of
Committee Opinion No. 342. uterine rupture was compared between patients who had repeat cesarean
American College of Obstetricians deliveries, patients giving birth after spontaneous onset of labor, and patients
and Gynecologists. Obstet Gynecol
2006;108:465–67.
who had labor induced with or without the use of prostaglandins. There were
91 cases of uterine rupture with rates of 1.6 per 1,000 (0.16%) for repeat

VOL. 108, NO. 2, AUGUST 2006 ACOG Committee Opinion Induction of Labor for VBAC 465
cesarean delivery, 5.2 per 1,000 (0.52%) for sponta- another large study evaluating 25,005 women,
neous labor, 7.7 per 1,000 (0.77%) for labor induced induction or augmentation of labor was associated
without prostaglandins, and 24.5 per 1,000 (2.4%) with an increased risk of uterine rupture (10). There
for prostaglandin-induced labor. Compared with was no significantly increased association between
women who gave birth by elective repeat cesarean oxytocin or prostaglandins not used in combination
delivery, the relative risk (RR) of uterine rupture was with uterine rupture compared with women who
significantly higher among women who had sponta- went into spontaneous labor (10). The risk of uterine
neous labor (RR, 3.3; 95% confidence interval [CI], rupture was significantly increased with sequential
1.8–6), induction of labor without prostaglandins use of prostaglandins and oxytocin (odds ratio, 4.54;
(RR, 4.9; 95% CI, 2.4–9.7), and induction of labor 95% CI, 1.66–12.42) (10). Uterine rupture was con-
with prostaglandins (RR, 15.6; 95% CI, 8.1–30). firmed with chart reviews in this study.
There was no difference in the risks of uterine rup- The rate of uterine rupture was significantly
ture between spontaneous labor and labor induced higher in women who had failed trials of labor
without prostaglandins. The authors acknowledged (2.3%) compared with successful trials of labor
that they did not confirm the diagnoses of uterine (0.1%) (9). These results are similar to a study that
rupture by examining medical records. Furthermore, reported nearly identical rates of uterine rupture (2%
their use of ICD-9-CM codes may have resulted in versus 0.1% in failed versus successful trials of
an overstatement of the actual incidence of uterine labor) (11). Together, these studies (5, 9–11) suggest
rupture because a single code is used for both uter- that rates of uterine rupture are likely increased by
ine incision extension and uterine rupture (5). In induction of labor more than by spontaneous labor,
another study, only 40% of ICD-9-CM-coded uter- but the magnitude of risk is still low (1–2.4%).
ine ruptures were actually found to be uterine rup- Additionally, sequential use of prostaglandins and
tures when the charts were reviewed, which raises a oxytocin may further increase risk. Consistently, the
concern about the reliability of these findings (8). highest rates of uterine rupture are associated with
In a larger, more recent, prospective, multicenter failed trials of labor (2–2.3% versus 0.1% for suc-
study, 33,699 women who had cesarean deliveries cessful trials of labor). These more recent data do
(17,898 and 15,801 with trial of labor or elective not confirm a specific increase in uterine rupture
repeat cesarean deliveries, respectively) were stud- with the use of prostaglandins alone. The three
ied (9). Charts were reviewed to document uterine largest studies vary in the quality of data, and data
rupture. There was no difference in the incidence of quality should be incorporated into any decision to
hysterectomy, thromboembolic disease, or maternal use these data. Two of the three studies were
death between these two groups. Augmentation or prospective and confirmed uterine rupture with chart
induction of labor was associated with an increased reviews (9–10). These two studies reported lower
risk of uterine rupture compared with spontaneous rates of uterine rupture with induction and prosta-
glandin induction of labor (1–1.4%). The third study
labor. There were 124 cases of uterine rupture, and
was smaller, retrospective, and did not confirm uter-
the rate of uterine rupture in the trial of labor group
ine rupture with chart reviews, and it reported the
was 0.4% for spontaneous labor, 0.9% for augmen-
highest rate of uterine rupture with the use of
tation of labor, and 1% for induction of labor. In prostaglandins (2.4%) (5).
the group of women in whom labor was induced, Induction of labor may be necessary for women
the rate of uterine rupture was 1.1% when only oxy- who have had cesarean deliveries, for a maternal or
tocin was used and 1.4% when any prostaglandins fetal indication. Induction of labor remains a rea-
were used in combination with oxytocin; this result sonable option, but the potentially increased risk of
was not significantly different. There were no cases uterine rupture associated with any induction should
of uterine rupture in the group of women in whom be discussed with the patient and documented in the
labor was induced who received only prostaglan- medical record. Selecting women most likely to
dins. The prostaglandins used in this group included give birth vaginally and avoiding sequential use of
misoprostol, dinoprostone, and prostaglandin E2 gel. prostaglandins and oxytocin appear to offer the low-
This absence of uterine rupture likely represents est risks of uterine rupture. Misoprostol should not
women who went into labor “easily,” requiring no be used in patients who have had cesarean deliveries
oxytocin after prostaglandin administration. In or major uterine surgery.

466 ACOG Committee Opinion Induction of Labor for VBAC OBSTETRICS & GYNECOLOGY
References mented labor in gravid women with one prior cesarean
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prior cesarean delivery. N Engl J Med 2001;345:3–8. Baskett T, et al. Comparison of maternal mortality and
6. Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during morbidity between trial of labor and elective cesarean sec-
induced trial of labor among women with previous cesar- tion among women with previous cesarean delivery.
ean delivery. Am J Obstet Gynecol 2000;183:1176–9. Maternal Health Study Group, Canadian Perinatal
7. Zelop CM, Shipp TD, Repke JT, Cohen A, Caughey AB, Surveillance System. Am J Obstet Gynecol 2004;191:
Lieberman E. Uterine rupture during induced or aug- 1263–9.

VOL. 108, NO. 2, AUGUST 2006 ACOG Committee Opinion Induction of Labor for VBAC 467