Management of scarred uterus in subsequent pregnancies

Caesarean section (CS) rates continue to rise. Vaginal birth after Caesarean section (VBAC) for a woman needs to be determined on an individual basis. With careful selection, the majority of women (60–80%) will achieve vaginal delivery with minimal risks. There are two randomized controlled trials underway that are likely to have an impact on clinical management of women who have undergone prior Caesarean. The first is the CAESAR study, which will evaluate whether the single or two layers closure of the uterine incision has a significant impact on immediate morbidity and that of future pregnancies. The second is the ACTOBAC trial (A collaborative trial of birth after Caesarean) in which women who have undergone prior Caesarean will be randomized to vaginal versus Caesarean birth. Until data from these studies are available, the evidence to date suggests that for most women who have undergone prior low segment Caesarean a trial of labour should be offered after providing adequate information. The fetal condition and progress of labour should be monitored closely. Prompt resort to emergency CS should be undertaken with signs of fetal compromise or of scar dehiscence.