Prediction of vaginal birth after one ceasarean delivery for non-progressive labor

Spontaneous labor patterns among women attempting vaginal birth after cesarean delivery

OBJECTIVE

This study evaluated spontaneous labor patterns among women achieving a vaginal birth after cesarean (VBAC), without a previous vaginal delivery in relation to nulliparous women.

METHODS

This historical cohort study included 422 women attempting VBAC and 150 nulliparas. We examined time intervals for each centimeter of cervical dilation and compared labor progression in 321 women who achieved spontaneous VBAC and 147 nulliparous women achieving a spontaneous vaginal delivery. Epidural anesthesia use, delivery mode, cord arterial pH and 5-minute Apgar score were also compared.

FINDINGS

Women in the VBAC group compared to nulliparous women had similar durations of first (4-10 cm: 4:22 (00:54-13:10) h vs. 4:47 (1:10-15:10) h, p = .61), second (1:07 (8:00-3:21), vs. 1:34 (10:00-3:40), p = .124) and third stages of labor (10:00 (2:00-22:00) vs. 08:00 (3:24-22:12), p = .788). When comparing women who had epidural analgesia to those who did not, no differences were found between the groups regarding durations of first and second stages of labor. Interestingly, among parturients without epidural anesthesia only, the VBAC group had shorter second stage compared to the nulliparous (00:19 (0:04-1:59) vs. 00:47 (0:08-2:09), p = .023).

CONCLUSION

Labor patterns among women achieving spontaneous VBAC are similar to those of nulliparous women with spontaneous vaginal deliveries.

Vaginal birth after cesarean (VBAC): fear it or dare it? An evaluation of potential risk factors

OBJECTIVES

The consultation of women aspiring a vaginal birth after caesarean may be improved by integrating the individual evaluation of factors that predict their chance of success. Retrospective analysis of correlating factors for all trials of labor after caesarean that were conducted at the Department of Obstetrics of Charité-Universitätsmedizin Berlin, Campus Virchow Clinic from 2014 to October 2017.

METHODS

Of 2,151 pregnant women with previous caesarean, 408 (19%) attempted a vaginal birth after cesarean. A total of 348 women could be included in the evaluation of factors, 60 pregnant women were excluded because they had obstetric factors (for example preterm birth, intrauterine fetal death) that required a different management.

RESULTS

Spontaneous delivery occurred in 180 (51.7%) women and 64 (18.4%) had a vacuum extraction. 104 (29.9%) of the women had a repeated caesarean delivery. The three groups showed significant differences in body mass index, the number of prior vaginal deliveries and the child's birth weight at cesarean section. The indication for the previous cesarean section also represents a significant influencing factor. Other factors such as maternal age, gestational age, sex, birth weight and the head circumference of the child at trial of labor after caesarean showed no significant influence.

CONCLUSIONS

The clear majority (70.1%) of trials of labor after caesarean resulted in vaginal delivery. High body mass index, no previous spontaneous delivery, and fetal distress as a cesarean indication correlated negatively with a successful vaginal birth after cesarean. These factors should be used for the consultation of pregnant women.

Prediction of vaginal birth after cesarean for labor dystocia by sonographic estimated fetal weight

OBJECTIVE

To estimate the association of the weight difference between the index trial of labor after cesarean (TOLAC) sonographic estimated fetal weight (sEFW) and prior delivery birth weight with TOLAC success rate among women with previous labor dystocia and no prior vaginal delivery.

METHODS

A retrospective cohort study including all women with prior cesarean for labor dystocia and no prior vaginal delivery undergoing TOLAC during between March 2011 and June 2020 with a sEFW within 1 week from delivery.

RESULTS

Overall, 168 women were included, of those 107 (63.7%) successfully delivered vaginally. The mean sEFW and mean birth weight were lower in the TOLAC success group (P = 0.010 and P = 0.013, respectively). The rate of higher sEFW in the current delivery compared with the previous delivery did not differ between study groups. The rate of higher TOLAC birth weight was lower in the TOLAC success group (odds ratio 0.30; 95% confidence interval 0.15-0.58). In multivariable regression analysis, maternal age older than 30 years, induction of labor, and higher birth weight were independently negatively associated with TOLAC success (adjusted odds ratio [95% confidence interval]: 0.27 [0.10-0.70], 0.27 [0.08-0.90], and 0.43 [0.19-0.94]; P = 0.008, P = 0.034, and P = 0.035, respectively).

CONCLUSIONS

sEFW characteristics did not predict the success or failure of TOLAC among women with prior labor dystocia and no previous vaginal delivery.

Implementation of machine learning models for the prediction of vaginal birth after cesarean delivery

OBJECTIVE

Accurate prediction of vaginal birth after cesarean is crucial for selecting women suitable for a trial of labor after cesarean (TOLAC). We sought to develop a machine learning (ML) model for prediction of TOLAC success and to compare its accuracy with that of the MFMU model.

METHODS

All consecutive singleton TOLAC deliveries from a tertiary academic medical center between February 2017 and December 2018 were included. We developed models using the following ML algorithms: random forest (RF), regularized regression (GLM), and eXtreme gradient-boosted decision trees (XGBoost). For developing the ML models, we disaggregated BMI into height and weight. Similarly, we disaggregated prior arrest of progression into prior arrest of dilatation and prior arrest of descent. We applied a nested cross-validation approach, using 100 random splits of the data to training (80%, 792 samples) and testing sets (20%, 197 samples). We used the area under the precision-recall curve (AUC-PR) as a measure of accuracy.

RESULTS

Nine hundred and eighty-nine TOLAC deliveries were included in the analysis with an observed TOLAC success rate of 85.6%. The AUC-PR in the RF, XGBoost and GLM models were 0.351±0.028, 0.350±0.028 and 0.336±0.024, respectively, compared to 0.325±0.067 for the MFMU-C. The algorithms performed significantly better than the MFMU-C (p-values = .0002, .0004, .0393 for RF, XGBoost, GLM respectively). In the XGBoost model, eight variables were sufficient for accurate prediction. In all ML models, previous vaginal delivery and height were among the three most important predictors of TOLAC success. Prior arrest of descent contributed to prediction more than prior arrest of dilatation, maternal height contributed more than weight.

CONCLUSION

All ML models performed significantly better than the MFMU-C. In the XGBoost model, eight variables were sufficient for accurate prediction. Prior arrest of descent and maternal height contribute to prediction more than prior arrest of dilation and maternal weight.

The Failure Rate, Related Factors, and Neonate Complications of Vaginal Delivery after Cesarean Section

Background

The rate of Cesarean Section (CS) is high in Iran. A successful Vaginal Birth After Cesarean (VBAC) section can protect mothers against the risk of having multiple CS. This study aimed to evaluate the success rate of VBAC, related factors, and the causes of failure.

Materials and Methods

This cross-sectional study was conducted on 150 pregnant women who were candidates for VBAC and admitted at maternity hospitals in Qom from 2016 to 2018. The required data were collected from the patients' records and entered into the checklist. Then, the success rate of VBAC was estimated, and related factors together with the causes of failure were determined by t-test, Chi-square, and independent-samples t-tests in SPSS v. 18 software.

Results

The mean (SD) maternal age was 32 (5.20) years and ranged from 21 to 45 years old. The success rate of VBAC was estimated to be 85.33%, and 14.67% of the patients had to repeat a CS after failure in vaginal delivery. The mean time between previous CS and present delivery was statistically significant between successful and failure groups (t ₁₂₅ = 2.32, p = 0.002). The results also revealed that the most important causes of VBAC failure were prolonged labor [odds ratio (OR) = 4.70)], full arrest (OR = 2.70), and decline fetal heart (OR = 5.31).

Conclusions

The success rate of VBAC in our study was high. However, VBAC was more successful when the interval between inter-deliveries was long, and lower complications were reported when the interval was 2-4 years.

Can recurrent cesarean section due to arrest of descent be predicted by newborn weight difference?

OBJECTIVE

To evaluate if newborn weight difference is associated with the mode of delivery in women with a previous cesarean section due to arrest of descent.

STUDY DESIGN

This retrospective cohort analysis included all women admitted to the delivery room of Carmel Medical Center with a singleton fetus at vertex presentation and a prior cesarean section for arrest of descent. A comparison was made between women who had a subsequent successful vaginal birth after cesarean delivery vs. a repeat cesarean section for arrest of descent. The primary outcome was newborn weight difference between the previous cesarean section and the present delivery. Secondary outcomes were gestational age, gravidity, age, induction of labor, previous vaginal birth and epidural analgesia.

RESULTS

Of 179 women with a prior cesarean section due to arrest of descent, 55 women (30.7 %) underwent an elective repeat cesarean section. Of the remaining 124 women, 95 women (76.6 %) achieved a vaginal delivery. Out of the 29 cases who underwent a repeat cesarean section, 18 women had a cesarean section for arrest of descent. Women who achieved vaginal delivery were more likely to be with higher gravidity, a previous vaginal delivery and a lower rate of epidural anesthesia. Following multivariate logistic regression, the women who required a cesarean section due to arrest of descent, had significantly higher birth weight in the current than in the previous pregnancy, compared to women achieving vaginal delivery (Odds Ratio 4.7, CI 95 % 1.4-15.7, P = 0.012).

CONCLUSION

Current birth weight higher than the previous newborn weight in a cesarean section for arrest of descent is associated with lower likelihood of successful vaginal birth after cesarean delivery and therefore should be taken in consideration during fetal weight estimation and the decision on the mode of delivery. This issue should be explored in future prospective large-cohort studies.

Third-trimester prediction of successful vaginal birth after one cesarean delivery-A Swedish model

INTRODUCTION

The objective was to create a clinically useful prediction model for vaginal birth in trial of labor after one cesarean section, appropriate for a third trimester consultation.

MATERIAL AND METHODS

Women with one cesarean section and at least one following delivery (N = 38 686) in the Swedish Medical Birth Register, 1998-2013, were studied. The women were randomly divided into one development and one validation data set. From the development data set, variables associated with vaginal birth after cesarean (VBAC) were identified by univariable logistic regression. Stepwise backward selection was performed until all variables were statistically significant. From the final fitted multivariable logistic model, likelihood ratios were calculated, in order to transpose odds ratios into clinically useful measurements. A constant, based on the delivery ward VBAC in trial of labor rate, was used. By applying the likelihood ratios on the validation data set, the VBAC chance for each woman was estimated with the Bayesian theorem, and the ability of the model to predict VBAC was explored using receiver operating characteristics (ROC) curves.

RESULTS

A previous VBAC, and a previous cesarean section for non-cephalic presentation, were the strongest VBAC predictors. The lowest chances were found for a previous cesarean section due to dystocia, and among women with <18 months since the last cesarean section. The area under the ROC curve was 0.67.

CONCLUSIONS

The new model was satisfactory in predicting VBAC in trial of labor. Developed as a software application, it would become a clinically useful decision-aid.

Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis

BACKGROUND

Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC.

METHODS

A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database's inception to March 16, 2018. Observational studies, identifying women with a trial of labor after one previous low-transverse cesarean section were included. Two reviewers independently abstracted the data. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale.

RESULTS

We included 94 eligible observational studies (239,006 pregnant women with 163,502 VBAC). Factors were associated with successful VBAC with the following odds ratios (OR;95%CI): age (0.92;0.86-0.98), obesity (0.50;0.39-0.64), diabetes (0.50;0.42-0.60), hypertensive disorders complicating pregnancy (HDCP) (0.54;0.44-0.67), Bishop score (3.77;2.17-6.53), labor induction (0.58;0.50-0.67), macrosomia (0.56;0.50-0.64), white race (1.39;1.26-1.54), previous vaginal birth before cesarean section (3.14;2.62-3.77), previous VBAC (4.71;4.33-5.12), the indications for the previous cesarean section (cephalopelvic disproportion (0.54;0.36-0.80), dystocia or failure to progress (0.54;0.41-0.70), failed induction (0.56;0.37-0.85), and fetal malpresentation (1.66;1.38-2.01)). Adjusted ORs were similar.

CONCLUSIONS

Diabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC.

Success of trial of labor in women with a history of previous cesarean section for failed labor induction or labor dystocia: a retrospective cohort study

Background

The rates of cesarean section (CS) are increasing worldwide leading to an increased risk for maternal and neonatal complications in the subsequent pregnancy and labor. Previous studies have demonstrated that successful trial of labor after cesarean (TOLAC) is associated with the least maternal morbidity, but the risks of unsuccessful TOLAC exceed the risks of scheduled repeat CS. However, prediction of successful TOLAC is difficult, and only limited data on TOLAC in women with previous failed labor induction or labor dystocia exists. Our aim was to evaluate the success of TOLAC in women with a history of failed labor induction or labor dystocia, to compare the delivery outcomes according to stage of labor at time of previous CS, and to assess the risk factors for recurrent failed labor induction or labor dystocia.

Methods

This retrospective cohort study of 660 women with a prior CS for failed labor induction or labor dystocia undergoing TOLAC was carried out in Helsinki University Hospital, Finland, between 2013 and 2015. Data on the study population was obtained from the hospital database and analyzed using SPSS.

Results

The rate of vaginal delivery was 72.9% and the rate of repeat CS for failed induction or labor dystocia was 17.7%. The rate of successful TOLAC was 75.6% in women with a history of labor arrest in the first stage of labor, 73.1% in women with a history of labor arrest in the second stage of labor, and 59.0% in women with previous failed induction. The adjusted risk factors for recurrent failed induction or labor dystocia were maternal height < 160 cm (OR 1.9 95% CI 1.1–3.1), no prior vaginal delivery (OR 8.3 95% CI 3.5–19.8), type 1 or gestational diabetes (OR 1.8 95% CI 1.0–3.0), IOL for suspected non-diabetic fetal macrosomia (OR 10.8 95% CI 2.1–55.9) and birthweight ≥4500 g (OR 3.3 95% CI 1.3–7.9).

Conclusions

TOLAC is a feasible option to scheduled repeat CS in women with a history of failed induction or labor dystocia. However, women with no previous vaginal delivery, maternal height < 160 cm, diabetes or suspected neonatal macrosomia (≥4500 g) may be at increased risk for failed TOLAC.