[2 or more cesarean sections--elective repeat cesarean or vaginal delivery?].

Cesarean section rates have been steadily increasing over the past two decades in most countries of the Western world. The review of the literature suggests that a trial of labor in patients with more than one previous cesarean delivery is appropriate, and that these women should be treated no differently from those who have had only one cesarean delivery. Obstetric management should be individualized after thorough patient counseling. If women are carefully selected for a trial of labor and supervised closely, the risk of serious complications can be minimized and a successful outcome achieved. Epidural anesthesia is safe, effective and justified. Similarly, if oxytocin administration is considered medically necessary either to augment or to induce labor, it should be given. It would appear from the present data, that the use of prostaglandins for priming and induction of labor is also safe and effective under consistent supervision. Rupture of the uterine scare is a rare but catastrophic complication (0-2.8%); fetal bradycardia may be the only diagnostic sign. Prompt intervention is necessary to minimize both maternal and neonatal complications. The maternal and fetal outcomes in women who have had multiple previous sections do not differ from those in women after ordinary cesarean section. At present there is no sufficiently predictive method to identify those women most likely to benefit from an elective repeat cesarean delivery.