Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery?

Evaluating the impact of a trial of labor after cesarean section on labor duration: a retrospective cohort study

BACKGROUND

Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases.

METHODS

This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor.

RESULTS

The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70-0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74-1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself.

CONCLUSIONS

After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration.

Understanding Obstetrical Surgical Planning for the Pediatrician

Cesarean deliveries are common in the United States, occurring in approximately one-third of deliveries in 2021. Given this high rate of cesarean deliveries, it is important for all clinicians caring for the pregnant person-infant dyad to be educated about cesarean deliveries. In this review, we describe the indications for cesarean delivery, the evidence-based practices of preoperative planning to ensure safe deliveries, and the clinical decision-making behind various cesarean incisions. In addition, we discuss the most common complications of cesarean deliveries for the pregnant person-infant dyad.

Trial of labor after 2 previous cesareans: a multicenter study

BACKGROUND

Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than trial of labor after cesarean after 1 previous cesarean delivery.

OBJECTIVE

This study aimed to investigate the factors associated with failed trial of labor after cesarean among women with 2 previous cesarean deliveries.

STUDY DESIGN

This was a multicenter retrospective cohort study, which included all women with singleton pregnancies attempting trial of labor after cesarean after 2 previous cesarean deliveries between 2003 and 2021. This study compared labor, maternal, and neonatal characteristics between women with failed trial of labor after cesarean and those with successful trial of labor after cesarean. Univariate analysis was initially performed, followed by multivariable analysis (adjusted odds ratios with 95% confidence intervals).

RESULTS

The study included a total of 1181 women attempting trial of labor after cesarean after 2 previous cesarean deliveries. Among these cases, vaginal birth after cesarean was achieved in 973 women (82.4%). Women with failed trial of labor after cesarean had higher rates of maternal and neonatal morbidities. Several factors were found to be associated with failed trial of labor after cesarean, including longer interpregnancy and interdelivery intervals, lower gravidity and parity, lower rates of previous successful vaginal delivery, smoking, earlier gestational age at delivery (38.3±2.1 vs 39.5±1.3 weeks), late preterm delivery (34-37 weeks of gestation), lower cervical dilation on admission, no use of epidural, and smaller neonatal birthweight. Our multivariable model revealed that late preterm delivery (adjusted odds ratio, 3.79; 95% confidence interval, 1.37-10.47) and cervical dilation on admission for labor <3 cm (adjusted odds ratio, 2.58; 95% confidence interval, 1.47-4.54) were associated with higher odds of failed trial of labor after cesarean.

CONCLUSION

In the investigated population of women with 2 previous cesarean deliveries undergoing trial of labor after cesarean, admission at the late preterm period with a cervical dilation of <3 cm, which reflects the latent phase, may elevate the risk of failed trial of labor after cesarean and a repeated intrapartum cesarean delivery.

Factors associated with successful vaginal birth after one lower uterine transverse cesarean section delivery

A Trial of labor after cesarean section is an attempt to deliver vaginally by a woman who had a previous cesarean delivery and when achieved by a vaginal delivery it is called successful vaginal birth after cesarean section. Vaginal birth after a caesarian section is a preferred method to decrease complications associated with repeated caesarian section delivery for both mother and fetus. It has a higher success rate when the right women are selected for a trial of labor. This study aimed to assess factors associated with successful vaginal birth after one lower uterine transverse cesarean section and to validate the Flamm and Geiger score at the public hospitals of Bahir Dar City, Northwest, Ethiopia, 2021. A health facility-based retrospective cross-sectional study was conducted from March 1 to 15/2021. A medical record review of 408 women charts with a trial of labor after one lower uterine transverse cesarean section from January 1/2020 to December 31/2020 was done and 345 women charts with complete maternal and fetal information were included in the study with a response rate of 84.6%. The data were collected using a structured checklist, entered into Epi data 3.1, and analyzed using SPSS 25.0 version. Logistic regression analyses were done to estimate the crude and adjusted odds ratio with a confidence interval of 95% and a P-value of less than 0.05 considered statistically significant. This study identified that the trial of labor after cesarean section rate was 69.5%, and the success rate of vaginal birth after one lower uterine transverse cesarean section was 35.07%. Of the failed trial of labor, fetal distress (38.9%) and failed progress of labor (32.1%) were the main indications for an emergency cesarean section. The maternal age group of 21-30 years, prior vaginal birth after or before cesarean section, non-recurring indication (fetal distress and malpresentation), ruptured membrane, cervical dilatation ≥ 4 cm, cervical effacement ≥ 50%, and low station (≥ 0) at admission were associated with successful vaginal birth after one lower uterine transverse cesarean section. For the Flamm and Geiger score at a cut point of 5, the sensitivity and specificity were 73.6% and 86.6% respectively. In this study area, the trial of labor after cesarean section rate is encouraging, however, the success rate of vaginal birth after one lower uterine transverse caesarian section was lower. The maternal socio-demographic and obstetric-related factors were significantly associated with successful vaginal birth after one lower transverse caesarian section delivery. This study indicated that when the Flamm and Geiger score increases, the chance of successful vaginal birth after one lower uterine transverse caesarian section also increases. We suggest emphasizing counselling and encouraging the women, as their chance of successful vaginal delivery will be high in the subsequent pregnancy, especially if the indications of primary caesarian section delivery were non-recurring.

Twenty-four versus 48 hours of expectant management in the setting of premature rupture of membranes at term among women with a prior cesarean delivery

OBJECTIVES

Compare two approaches of expectant management in the setting of term premature rupture of membranes (PROM) among women with prior cesarean delivery.

METHODS

A retrospective study conducted in a tertiary care center during 2006 to 2017, including primiparous women with singleton pregnancy and a prior low-transverse cesarean delivery who presented with term PROM and requested trial of labor after cesarean (TOLAC). Outcomes were compared between the two campuses at our center: campus A enabled expectant management up to 48 hours following PROM and campus B enabled up to 24 hours after PROM.

RESULTS

A total of 158 women met the inclusion criteria and were divided into two groups. Maternal characteristics of the two groups were similar. In campus B, the rate of oxytocin administration was significantly higher as compared with campus A (46.6% versus 26.0%, P = 0.01). The rate of successful TOLAC was similar between the groups (84.0% versus 84.5%, P = 0.96). Rates of chorioamnionitis, uterine rupture, postpartum hemorrhage, recurrent hospitalization, and Apg scores did not differ between the groups.

CONCLUSION

Expectant management up to 48 hours in women with TOLAC presenting with term PROM was associated with a lower rate of induction of labor and similar maternal and neonatal outcomes.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Methods of induction of labor after cesarean with no prior vaginal delivery-Perinatal outcomes

OBJECTIVE

To study the association between the method of induction of labor (IOL) and perinatal outcomes, among women undergoing labor after cesarean (LAC) with no prior vaginal delivery.

METHOD

A retrospective study including all women with no prior vaginal delivery undergoing IOL for LAC between March 2011 and January 2021. Oxytocin administration following prelabor rupture of membranes (PROM), oxytocin administration only, extra-amniotic balloon, and amniotomy were compared.

RESULTS

Overall, 363 women met the inclusion criteria: extra-amniotic balloon (157, 43.3%), oxytocin following PROM (95, 26.2%), amniotomy (72, 19.8%), and oxytocin (39, 10.7%). LAC success rate did not differ among study groups (P = 0.114), varying between 62.1% and 79.5%. There were three uterine ruptures (0.8%) in the entire cohort. The rate of uterine rupture, postpartum hemorrhage, and the composite of both were similar in all study groups. Neonatal outcomes did not differ between study groups, with composite adverse neonatal outcomes varying between 7.4% in the oxytocin following PROM to 1.9% in the extra-amniotic balloon group (P = 0.141). The following factors were independently associated with LAC success: taller maternal height, lower body mass index, earlier gestational age, and epidural analgesia.

CONCLUSIONS

All examined IOL methods with an unfavorable cervix carried similar outcomes. The clinical practice should be individualized.

Defining a Cesarean Delivery Rate for Optimizing Maternal and Neonatal Outcomes

After the global cesarean delivery rate nearly doubled between 2000 and 2015, cesarean deliveries now account for nearly one third of births in the United States. Although rates have plateaued, the high national cesarean delivery rate has garnered criticism from both lay and academic communities because it has not been associated with improvements in maternal or neonatal outcomes. Efforts are underway to lower the cesarean delivery rate through implementation of hospital-level and national guidelines. However, the cesarean delivery rate that optimizes maternal and neonatal outcomes is not known. Defining a cesarean delivery rate that optimizes perinatal outcomes and reduces morbidity seems simple. However, there are a host of challenges to such a task, including determining the outcomes that are most meaningful to use, deciding the population that should define the rate, and incorporating person-centered decision making, given that people place different value on different outcomes. Rather than a "call" for cesarean delivery rate reductions of a specific and arbitrary magnitude, we need further attention to defining an evidence-based optimal target. This commentary summarizes current national and international cesarean delivery rate targets, discusses the challenges of identifying an evidence-based national cesarean delivery rate target, and explores future considerations for best defining a cesarean delivery rate target.

Maternal and perinatal outcome of induction at 39 weeks versus expectant management in labor after cesarean section

OBJECTIVE

To study induction of labor (IOL) at 39 weeks compared with expectant management among women undergoing labor after cesarean section (LAC) with no prior vaginal delivery.

METHODS

A retrospective cohort study including all women undergoing LAC with no prior vaginal delivery, between March 2011 and January 2021. We allocated the study cohort into two groups: IOL at 39^0/7 to 39^6/7 and all LACs at ≥40^0/7 weeks of gestation. The primary outcome was a composite of adverse neonatal outcome. The secondary outcome was a composite of adverse maternal outcome.

RESULTS

Overall, 1022 women met inclusion criteria, of whom 89 (8.7%) had IOL at 39^0/7 -39^6/7 weeks and 933 (91.3%) had LAC at ≥40^0/7 weeks. The composite neonatal outcome rate was comparable between groups (0.186). There were three uterine ruptures (3.4%) in the IOL group and 11 (1.2%) in the LAC at ≥40 weeks group (P = 0.115). The rate of the composite maternal outcomes occurrence was higher in the IOL group (18.0% vs. 10.1%, P = 0.022).

CONCLUSION

IOL at 39 weeks among women undergoing LAC with no prior vaginal delivery is not associated with improved neonatal outcomes when compared with expectant management but may be associated with a higher rate of adverse maternal outcomes.

Risk management of vaginal birth after cesarean section (Review)

The increasing number of patients who desire to experience vaginal birth after cesarean (VBAC) and the optimized protocols for trial of labor after cesarean (TOLAC) has led to a shift of old obstetrical paradigms. The VBAC trend is accompanied with numerous challenges for healthcare professionals, from establishing suitability of each pregnant patient profile for TOLAC to active labor management, and ethical or legal issues, which occasionally are not included in specific guidelines. That is why an individualized risk assessment and management can serve obstetricians as a useful tool for improving outcomes of patients, satisfaction, and also for avoiding legal or moral liabilities. The risk management concept aims to reduce foreseen risks and to emulate strategies for prediction and prevention of unwanted events. In obstetrics, and particularly for the VBAC topic, this concept is relatively new and undefined, and thus its features are disparate between guideline recommendations and clinical studies. This narrative review intends to offer a new and organic perspective over clinical aspects of TOLAC and VBAC risk management.

The urological complications of vaginal birth after cesarean (VBAC) - a literature review

The appearance of urological complications is a major problem in obstetrics and gynecologic surgery; the bladder is the most common damaged organ. Due to a continuous increase in the rate of cesareans, the incidence of urologic complications will be potentially higher. We reviewed the most important risk factors for urinary tract injury and analyzed the strategies necessary to avoid these situations during vaginal birth after cesarean (VBAC). The risks and benefits of VBAC should be balanced before deciding the mode of delivery.

Neonatal and maternal outcomes with trial of labor after two prior cesarean births: stratified by history of vaginal birth

INTRODUCTION

To determine the impact of prior vaginal birth on neonatal and maternal outcomes among individuals undergoing a trial of labor after two cesarean births.

MATERIALS AND METHODS

This was a cross-sectional study using the U.S. National Vital Statistics 2014-2018 period linked birth and infant death data. Inclusion criteria were term, cephalic, singleton pregnancies with two prior cesarean births. The primary exposure variable was a trial of labor after cesarean vs prelabor repeat cesarean birth. Cohorts were defined by the presence or absence of a prior vaginal birth. The primary outcome was a composite of adverse neonatal outcomes (Apgar score <5 at 5 min, assisted ventilation >6 h, neonatal seizures, or neonatal death within 27 days). Secondary outcomes included a maternal composite and the cesarean birth rate. Propensity score matching was used to account for baseline differences in treatment allocation within each cohort, and conditional logistic regression assessed the association between the exposure and outcomes.

RESULTS

The composite neonatal adverse outcome was significantly higher in those undergoing a trial of labor after cesarean compared to prelabor repeat cesarean birth in both individuals without a prior vaginal birth (8.2 vs 11.6 per 1000 live births, OR 1.41; 95% CI 1.12-1.70) and with a prior vaginal birth (9.6 vs 12.4 per 1000 live births, OR 1.30; 95% CI 1.08-1.57). The composite maternal adverse outcome was significantly higher among individuals without a prior vaginal birth undergoing trial of labor after cesarean (6.0 vs 9.5 per 1000 live births, OR 1.59; 95% CI 1.26-2.09), but was similar in those with a prior vaginal birth (7.9 vs 9.3 per 1000 live births, OR 1.18; 95% CI 0.97-1.46).

CONCLUSION

In individuals with two prior cesarean births, trial of labor after cesarean was associated with increased neonatal adverse outcomes when compared to prelabor repeat cesarean birth, irrespective of a history of vaginal birth. In individuals with a prior vaginal birth, the composite maternal adverse outcome was not elevated in the trial of labor cohort.

Vaginal Birth after Two Previous Cesarean Sections versus Elective Repeated Cesarean: A Retrospective Study

OBJECTIVE

Trial of labor after cesarean delivery (TOLAC) is a common practice worldwide but the evidence is still scant regarding this practice in women who underwent 2 previous cesareans. The purpose of this study is to retrospectively review our experience with vaginal birth after two previous cesarean sections (VBA2C), with specific attention to the indications for previous cesarean and to the women's motivation for attempting trial of labor.

STUDY DESIGN

This was a retrospective cohort study conducted in a primary care hospital between January 2011 and December 2019. Inclusion criteria were: singleton pregnancies, absence of morphological abnormalities at ultrasonographic screening of the second trimester (or at any other stage of pregnancy), and two previous cesarean sections.

RESULTS

The final analysis included 114 cases for maternal and neonatal outcomes. In total, 40.4% of women chose trial of labor after two cesarean delivery (TOLA2C group). TOLA2C was associated with a success rate of 76.1%, a higher gestational age at birth, and a shorter hospital stay, compared with elective repeated cesarean delivery group. There were no significant differences in the rate of Apgar scores at 5 minutes <7 between both groups. The percentage of successful TOLA2C in women with prior vaginal delivery was 92.8%. Factors related to failed TOLA2C included failure to progress (3/11, 27.3%), nonreassuring fetal heart rate (3/11, 27.3%), and no onset of spontaneous labor after premature rupture of membranes (5/11, 45.4%). In the group of TOLA2C, more than 70% accepted to travel more than 45 minutes to reach our hospital, with the aim to attempt VBA2C.

CONCLUSION

TOLA2C is a possible option for both mothers and neonates in selected cases. Adequate counseling about pros and cons of TOLA2C is mandatory. The woman's motivation represents a key element to determine the success of VBA2C.

KEY POINTS

· Selection of candidates and motivation of the patients represent key elements for successful TOLA2C.. · A careful record of obstetrical history and previous deliveries can provide clinicians useful information.. · Mode of delivery in women with two previous cesareans is strongly associated with doctor's counseling..

The Association between Hospital Frequency of Labor after Cesarean and Outcomes in California

BACKGROUND

Labor after cesarean (LAC) is an alternative to planned repeat cesarean delivery. The effect of hospital-level factors on LAC frequency and vaginal birth after cesarean (VBAC) has been relatively understudied. It was our goal to determine if hospital frequency of LAC (number of women undergoing LAC/number of women with previous uterine scars) is associated with increased VBAC and associated outcomes among women undergoing LAC.

METHODS

We analyzed 43,331 term, singleton births to women who experienced LAC in California from 2007 to 2010. We conducted multivariable logistic regressions of infant and maternal outcomes for women at hospitals with high LAC frequency (≥median) compared with low LAC frequency (<median), adjusting for maternal and hospital characteristics. We stratified analyses by overall hospital birth volume (categories 1, low; 2, medium; 3, high).

RESULTS

We did not observe an association between high LAC frequency and VBAC in any category of hospital birth volume in regression models. We found that women in hospitals with high LAC frequency had higher odds of infection in category 1 (low) and 2 (medium) hospitals (category 1 hospitals adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04-2.48; category 2 hospitals, aOR, 2.12; 95% CI, 1.34-3.35) and postpartum hemorrhage in category 2 and 3 hospitals (category 2 hospitals: aOR, 2.49; 95% CI, 1.57-3.94; category 3 hospitals: aOR, 1.83; 95% CI, 1.24-2.70). We observed that high LAC frequency was associated with more adverse outcomes (e.g., infection, severe perineal lacerations, decreased Apgar scores) in category 2 than in category 1 and 3 hospitals.

CONCLUSIONS

We did not find that high LAC frequency was associated with more VBAC, nor with many perinatal complications in category 1 and 3 hospitals. The associations between high LAC frequency and both infection and postpartum hemorrhage are concerning and require further investigation. There may be a sensitive balance between increasing LAC access and determining appropriate LAC candidate selection.

ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland

BACKGROUND

Policy consensus in high-income countries supports offering pregnant women with previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or attempting a vaginal birth, known as a planned vaginal birth after previous cesarean (VBAC), provided they do not have contraindications to planned VBAC. However, robust comprehensive information on the associated outcomes to counsel eligible women about this choice is lacking. This study investigated the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section among women delivering a term singleton and considered eligible to have a planned VBAC.

METHODS AND FINDINGS

A population-based cohort of 74,043 term singleton births in Scotland between 2002 and 2015 to women with one or more previous cesarean sections was conducted using linked Scottish national datasets. Logistic or modified Poisson regression, as appropriate, was used to estimate the effect of planned mode of delivery on maternal and perinatal outcomes adjusted for sociodemographic, maternal medical, and obstetric-related characteristics. A total of 45,579 women gave birth by ERCS, and 28,464 had a planned VBAC, 28.4% of whom went on to have an in-labor nonelective repeat cesarean section. Compared to women delivering by ERCS, those who had a planned VBAC were significantly more likely to have uterine rupture (0.24%, n = 69 versus 0.04%, n = 17, adjusted odds ratio [aOR] 7.3, 95% confidence interval [CI] 3.9-13.9, p < 0.001), a blood transfusion (1.14%, n = 324 versus 0.50%, n = 226, aOR 2.3, 95% CI 1.9-2.8, p < 0.001), puerperal sepsis (0.27%, n = 76 versus 0.17%, n = 78, aOR 1.8, 95% CI 1.3-2.7, p = 0.002), and surgical injury (0.17% versus 0.09%, n = 40, aOR 3.0, 95% CI 1.8-4.8, p < 0.001) and experience adverse perinatal outcomes including perinatal death, admission to a neonatal unit, resuscitation requiring drugs and/or intubation, and an Apgar score < 7 at 5 minutes (7.99%, n = 2,049 versus 6.37%, n = 2,570, aOR 1.6, 95% CI 1.5-1.7, p < 0.001). However, women who had a planned VBAC were more likely than those delivering by ERCS to breastfeed at birth or hospital discharge (63.6%, n = 14,906 versus 54.5%, n = 21,403, adjusted risk ratio [aRR] 1.2, 95% CI 1.1-1.2, p < 0.001) and were more likely to breastfeed at 6-8 weeks postpartum (43.6%, n = 10,496 versus 34.5%, n = 13,556, aRR 1.2, 95% CI 1.2-1.3, p < 0.001). The effect of planned mode of delivery on the mother's risk of having a postnatal stay greater than 5 days, an overnight readmission to hospital within 42 days of birth, and other puerperal infection varied according to whether she had any prior vaginal deliveries and, in the case of length of postnatal stay, also varied according to the number of prior cesarean sections. The study is mainly limited by the potential for residual confounding and misclassification bias.

CONCLUSIONS

Among women considered eligible to have a planned VBAC, planned VBAC compared to ERCS is associated with an increased risk of the mother having serious birth-related maternal and perinatal complications. Conversely, planned VBAC is associated with an increased likelihood of breastfeeding, whereas the effect on other maternal outcomes differs according to whether a woman has any prior vaginal deliveries and the number of prior cesarean sections she has had. However, the absolute risk of adverse outcomes is small for either delivery approach. This information can be used to counsel and manage the increasing number of women with previous cesarean section, but more research is needed on longer-term outcomes.

Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study

BACKGROUND

The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China.

METHODS AND FINDINGS

This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010-September 2014 and October 2014-December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period. A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: -0.09 [95% CI -0.16 to -0.02] between Stage 1 and baseline, p = 0.014; -0.11 [95% CI -0.20 to -0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = -4.368, p < 0.001) and PMR (Z = -13.142, p < 0.001) declined by stage over the intervention period. One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed.

CONCLUSIONS

Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was most evident among nulliparous women who delivered term singletons. Despite some limitations for causal inference, Guangzhou's experience in controlling the CS rate by implementing composite interventions with public health education and perinatal healthcare service improvement could have implications for other similar areas with high rates of CS.

Validation of a predictive model for successful vaginal birth after cesarean section

Introduction:

A strategy for reducing the number of cesarean sections is to allow vaginal delivery after cesarean section.

Objective:

To validate two predictive models, Metz and Grobman, for successful vaginal delivery after a cesarean section.

Methods:

Retrospective cohort study involving women with previous history of a previous segmental cesarean section, single pregnancy ≥37 weeks and cephalic presentation. The proportion of vaginal delivery in all pregnant women was determined, and it was compared with those (women) with successful delivery after cesarean section. Then, there were elaborated the models, and their predictive capacity was determined by curve-receiver-operator.

Results:

The proportion of successful delivery in pregnant women with a previous cesarean section and indication of vaginal delivery was 85.64%. The observed proportion of birth for each decile predicted in the Grobman model was less than 15%, except for the 91-100% decile, where it was 64.09%; the area under the curve was 0.95. For the Metz model, the actual successful delivery rate was lower than predicted in scores between 4 and 14, and within expected for a score between 15 and 23; the area under the curve was 0.94.

Conclusions:

The vaginal delivery rate after cesarean was lower than expected according to the predictive models of Grobman and Metz. The implementation of these models in a prospective way can lead to a higher rate of successful birth.

Trial of labor after cesarean section in risk pregnancies: A population-based cohort study

INTRODUCTION

In most pregnancies after a cesarean section, a trial of labor is an option. The objective of the study was to explore trial of labor and its failure in pregnancies with medical risk conditions, in a population with a high trial of labor rate.

MATERIAL AND METHODS

In a cohort study (n = 57 109), using data from the Medical Birth Registry of Norway 1989-2014, women with a second delivery after a first pregnancy cesarean section were included. Preterm, multiple, and non-cephalic deliveries were excluded. The outcomes were trial of labor and failed trial of labor, assessed as rates and relative risk, using deliveries without risk conditions as reference. Temporal trends were assessed by 3-year periods. The exposures were selected medical risk conditions, ie previous offspring death, labor dystocia, diabetes, heart conditions, chronic hypertension, chronic kidney disease, rheumatoid arthritis, thyroid disease, asthma, prepregnancy psychiatric conditions, epilepsy, obesity, gestational diabetes, eclampsia and preeclampsia, gestational hypertension, major malformations, second-pregnancy psychiatric conditions, assisted reproduction, macrosomia, and small-for-gestational-age neonates. Induced onset of labor was compared with spontaneous onset of labor for each condition studied.

RESULTS

In risk pregnancies (n = 31 994) the trial of labor rate was 64.9% and failure rate was 27.6%, compared with 74.6% and 16.4% in pregnancies without any of the risk conditions studied (n = 25 115). The lowest trial of labor rates were observed in diabetes type 1 (49.5%), diabetes type 2 (46.7%), maternal heart conditions (54.5%), and pregnancy-related psychiatric conditions (19.7%). The highest failure rates were observed in diabetes type 1 (43.1%), diabetes type 2 (40.3%), maternal obesity (36.9%), gestational diabetes (36.0%), and offspring macrosomia (43.0%). Induced labor was associated with failed trial of labor (P < .05), whereas after spontaneous labor, failure rates were less than 40% in all conditions studied.

CONCLUSIONS

In conditions with high rates of failed trial of labor, eg diabetes, macrosomia, and obesity, a planned cesarean section might be a better option than a trial of labor, particularly if induction of delivery might be needed.

Trial of labor after cesarean (TOLAC) in women with premature rupture of membranes. J Matern Fetal Neonatal Med 2019;33:2976-2982. [PMID: 30652525 DOI: 10.1080/14767058.2019.1566312]

Introduction: The aim of this study was to assess the success rate of a trial of labor after a previous cesarean section (TOLAC) in the settings of premature rupture of membranes (PROM) and to compare conservative management with spontaneous labor and induction of labor.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2011 and March 2017. Women with singleton pregnancy and a previous cesarean section (CS) who presented with PROM and underwent TOLAC were included. Outcomes and rate of successful vaginal delivery after induction of labor were compared to conservative treatment and spontaneous labor.Results: Among 830 women who met the inclusion criteria, 723 (87.1%) had a spontaneous onset of labor following PROM and 107 (12.9%) had an induction of labor. The rate of successful TOLAC was similar between the groups (75.7 vs. 81.6%, respectively, p = .22). However, induction of labor was associated with an increased risk for uterine rupture (1.87 vs. 0.96%, p < .001), operative complications (6.7 vs. 2.3%, p < .001), and composite maternal postpartum complications (21.4 vs. 10.7%, respectively, p = .014) compared to conservative management with spontaneous initiation of labor. There was no difference in neonatal outcome between the groups.Conclusion: Induction of labor following PROM in women with a previous CS is associated with high successful vaginal delivery rate. However, the risk for uterine rupture and operative and maternal complications is significantly increased compared to spontaneous initiation of labor.

Vaginal Birth After Previous Cesarean Birth: A Comparison of 3 National Guidelines

Importance

Vaginal birth after previous cesarean birth (VBAC) is a reasonable option for many women with previous cesarean delivery.

Objective

The aim of this study was to summarize evidence and compare recommendations from national guidelines regarding VBAC.

Evidence Acquisition

A descriptive review of 3 national guidelines on VBAC was conducted: Royal College of Obstetricians and Gynaecologists on "Birth After Previous Caesarean Birth," American College of Obstetricians and Gynecologists on "Vaginal Birth After Cesarean Delivery," and Society of Obstetricians and Gynaecologists of Canada on "Guidelines for Vaginal Birth After Previous Caesarean Birth." These guidelines were summarized and compared in terms of the recommended antenatal and intrapartum care of women. Recommendations and strength of evidence were also reviewed based on method of reporting.

Results

The variations mentioned on the different guidelines reflect the heterogeneity of the published data on the management of VBAC during the antenatal and intrapartum care.

Conclusions

Evidence-based medicine could support the conception of international recommendations for VBAC, which may improve both safety and efficacy of this procedure.

A Study to Assess the Feasibility of Implementing a Web-Based Decision Aid for Birth after Cesarean to Increase Opportunities for Shared Decision Making in Ethnically Diverse Settings

INTRODUCTION

Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings.

METHODS

A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included women's knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making.

RESULTS

Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care.

DISCUSSION

Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve women's access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.

Association between first caesarean delivery and adverse outcomes in subsequent pregnancy: a retrospective cohort study

Background

Few studies have explored the association between a previous caesarean section (CS) and adverse perinatal outcomes in a subsequent pregnancy, especially in women who underwent a non-indicated CS in their first delivery. We designed this study to compare the perinatal outcomes of a subsequent pregnancy in women who underwent spontaneous vaginal delivery (SVD) or CS in their first delivery.

Methods

This retrospective cohort study included women who underwent singleton deliveries at the International Peace Maternity and Child Health Hospital from January 2013 to December 2016. Data on the perinatal outcomes of all the women were extracted from the medical records. Multivariate logistic regression was conducted to assessed the association between CS in the first delivery and adverse perinatal outcomes in the subsequent pregnancy.

Results

CS delivery in the subsequent pregnancy was more likely for women who underwent CS in their first birth than for women with previous SVD (97.3% versus 13.2%). CS in the first birth was also associated with a significantly increased risk of adverse outcomes in the subsequent pregnancy, especially in women who underwent a non-indicated CS. Adverse perinatal outcomes included pregnancy-induced hypertension [adjusted odds ratio (OR), 95% confidence interval (CI): 2.20, 1.59–3.05], gestational diabetes mellitus (1.82, 1.57–2.11), gestational anaemia (1.27, 1.05–1.55), placenta previa (3.18, 2.15–4.71), placenta accreta (2.75, 1.75–4.31), and polyhydramnios (2.60, 1.57–4.31) in the mother and preterm delivery (1.37, 1.06–1.78), low birth weight (3.78, 2.07–6.90), macrosomia (5.04, 3.95–6.44), and neonatal jaundice (1.72, 1.39–2.14) in the baby.

Conclusions

CS in the first delivery markedly increases the risk of repeated CS and maternal-fetal complications in the subsequent pregnancy, especially in women with a non-indicated CS.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC)

INTRODUCTION

Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.

MATERIALS AND METHODS

A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.

RESULTS

Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.

CONCLUSION

Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries

BACKGROUND

The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.

METHODS

A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.

RESULTS

Within a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.

CONCLUSIONS

In all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Limitations of Vaginal Birth After Cesarean Success Prediction

The Society for Maternal-Fetal Medicine endorses an algorithm for estimating the probability of successful vaginal birth for women undergoing trial of labor after cesarean (TOLAC). The algorithm is available online in the form of an easy-to-use calculator. This calculator has significant limitations that are easily overlooked by women and providers alike. The calculator has much greater positive than negative predictive power, and it cannot predict unsuccessful TOLAC or uterine rupture. Furthermore, the calculator cannot predict rare catastrophes, such as unplanned hysterectomy, permanent injury, or death. Predictions are heavily influenced by race and ethnicity, which are social and not biological constructs. Relevant variables, such as provider attitudes and institutional differences, are not accounted for. Providers should be mindful and transparent about calculator limitations when counseling women, particularly Latina and African American women. It may be appropriate to use the calculator to inform but not restrict women's options.

Outcome of the vaginal birth after cesarean section during the second birth order in West Kazakhstan

Background

Vaginal birth after cesarean section (VBAC) increases the chance of subsequent vaginal deliveries and reduces the repeat cesarean section (CS) rate with subsequent postoperative morbidity.

Objectives

To detect the outcome of VBAC during the second birth order in Aktobe region of West Kazakhstan.

Patients and Methods

A total of 832 women eligible for trial of VBAC were included in this study. Women who signed the consent of VBAC were evaluated thoroughly and data such as maternal age, body mass index, height, gestational age at admission, indication of the previous CS, estimated fetal weight, engagement of the fetal head, condition of the membranes, and cervical dilatation were collected. Data collected after delivery include duration from active phase of labor, mode of delivery, fetal, and neonatal outcomes. The collected data analyzed to detect the outcome of trial of VBAC during the second birth order in Aktobe region of West Kazakhstan.

Results

Logistic analysis and odds ratio (OR) showed that body mass index (BMI) ≤25 kg/m² (OR 1.7; P = 0.0004), height ≥150 cm (OR 1.7; P = 0.002), gestational age ≤40 weeks (OR 2.3; P = 0.0001), and inter-delivery interval ≥2 years (OR 1.6; P = 0.008) were significantly associated with successful VBAC. In addition, <2/5 of the fetal head palpable abdominally, station <-2 (OR 1.7; P = 0.0009), cervical dilatation ≥4 cm (OR 1.7; P = 0.003), and duration of active phase of labor ≤7 h (OR 1.6; P = 0.01) were significantly associated with successful VBAC.

Conclusion

VBAC is safe in properly selected cases. BMI ≤25 kg/m², gestational age ≤40 weeks, inter-delivery interval ≥2 years, and fetal head <-2 station increase the success of VBAC. Prolonged active phase of labor >7 h and the need for labor augmentation decrease the chance of VBAC success.

Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery

Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

The importance of clinically and ethically fine-tuning decision-making about cesarean delivery

In obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital's availability of resources and the obstetrician's training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.

Neonatal outcomes following a trial of labor after Caesarean delivery: a population-based study

PURPOSE

To evaluate the neonatal effects of trial of labor after Caesarean (TOLAC) births.

METHODS

We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth/Infant Death Public Use File (2011-2013) on women with a live singleton pregnancy and prior Caesarean delivery. Multivariate logistic regression compared neonatal outcomes between women who underwent a TOLAC with women who did not. Secondary analysis compared outcomes of birth with uterine rupture to those without.

RESULTS

A total of 1,036,554 births met inclusion criteria, of which 17.5% underwent TOLAC. Women who had a TOLAC were more likely to deliver infants requiring neonatal intensive care unit (NICU) admission (odds ratios (OR) 1.12, 95%CI 1.09-1.16) and assisted ventilation (OR 1.07, 95%CI 1.03-1.12). Among women with TOLAC, 0.18% of births were in context of a uterine rupture and those neonates had an increased risk of NICU admissions (OR 5.95, 95%CI 4.56-7.76), assisted ventilation (OR 8.89, 95%CI 6.73-11.75), seizures (OR 91.66, 95%CI 42.23-198.93), and death (OR 16.28, 95%CI 5.09-52.08).

CONCLUSIONS

Neonatal morbidity appears slightly increased among women with a TOLAC. However, morbidity and mortality are considerably increased in cases of uterine rupture. Appropriate selection and counseling of women for TOLAC should be undertaken as to minimize uterine rupture risk.

Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review

BACKGROUND

For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications.

OBJECTIVES

To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies.

METHODS

We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded.

RESULTS

Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD.

CONCLUSIONS

For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.

Management of uterine rupture: a case report and review of the literature

Background

Maternal morbidity and mortality has been a major World Health Organization concern over the years, especially in sub-Saharan Africa. This paper reports uterine rupture with severe hypovolemic shock managed at the Douala General Hospital, Cameroon. Early clinical diagnosis is paramount to maternal survival.

Case presentation

Mrs. MM aged 25 years, G3P2012, of the Bamileke tribe in Cameroon was admitted to our Department in hypovolemic shock BP = 70/40 mmHg, pulse 120 beats per minute, with altered consciousness (Glasgow Coma Scale = 13). She has a history of missed abortion at 19 weeks gestation and an attempt to evacuate the uterus with misoprostol that led to uterine rupture. She underwent a total abdominal hysterectomy and blood transfusion. Her post-operative stay in hospital was uneventful.

Conclusion

Uterine rupture is a complication that can be eliminated under conditions of best obstetric practice. To attain this objective, use of misoprostol in primary health facilities should be stopped or proper management of the medication instituted. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of blood products for transfusion.

Trial of labor after cesarean in the low-risk obstetric population: a retrospective nationwide cohort study

OBJECTIVE

The purpose of this study was to evaluate the risk of adverse maternal outcomes associated with trial of labor (TOL) after cesarean during subsequent pregnancies in the low-risk population.

STUDY DESIGN

We conducted a retrospective cohort study using the Nationwide Inpatient Sample and ICD-9 diagnostic and procedure codes from the years 2003 to 2011. A cohort of low-risk pregnant women with a history of previous cesarean delivery were identified and separated into two groups: TOL and no TOL. Logistic regression analysis was used to calculate odds ratios (ORs) comparing adverse maternal outcomes between these two groups.

RESULTS

Out of 7 290 474 registered deliveries, there were 685 137 low-risk women who met inclusion criteria. Of these women, 144 066 (21.0%) underwent a TOL, with rates remaining steady over the course of our study. The TOL group was at increased risk of overall morbidity (OR 1.74, 95% confidence interval (CI), 1.66-1.79), most notably uterine rupture (OR 22.52, 95% CI, 19.35-26.20, P<0.01). A secondary analysis showed no apparent correlation between TOL and concomitant adverse maternal outcomes in cases of uterine rupture.

CONCLUSION

Although these outcomes remain rare, low-risk women undergoing a TOL remain at increased risk of adverse maternal events as compared with those who chose elective repeat cesarean delivery.

Prediction of vaginal birth after cesarean delivery

OBJECTIVE

To examine factors associated with successful vaginal birth after cesarean (VBAC) and to validate a previously established prediction model.

METHODS

In a retrospective study, data were obtained for women with one prior low-transverse cesarean procedure who underwent a trial of labor with a cephalic singleton pregnancy at term at one UK hospital between January 2000 and August 2013. Univariate analysis and logistic regression analysis were used to identify maternal demographic characteristics significantly associated with successful VBAC and factors independently associated with this outcome, respectively. A prediction model was built, and predicted probabilities were compared with observed frequencies. For validation, probabilities were also calculated by a previous prediction model.

RESULTS

Overall, 1463 women formed the cohort. Successful vaginal delivery was achieved in 1050 (71.8%) women. The only factors significantly associated with unsuccessful VBAC were Asian (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.14-2.23) or African (OR 1.80, 95% CI 1.23-2.64) ethnic origin, and previous cesarean for failure to progress (OR 6.39, 95% CI 4.81-8.49). The predicted and observed probability of successful VBAC were well correlated (Spearman ρ, 0.905; P=0.002). The established prediction model was less accurate.

CONCLUSION

Previous cesarean performed for failure to progress and Asian/African ethnic origin were associated with unsuccessful VBAC. The performance of a previous prediction model was inferior.

Prediction of successful trial of labor after cesarean - the benefit of prior vaginal delivery

OBJECTIVE

To determine predictive factors for vaginal birth after cesarean section (VBAC).

METHODS

A retrospective cohort study of all women with singleton pregnancies and a prior single low transverse cesarean section (CS) who attempted vaginal delivery in a tertiary hospital (2010-2014). Pregnancy outcome of women with VBAC was compared to those who failed vaginal delivery. Sub-analysis for women with no prior vaginal deliveries was performed. Pregnancies with non-cephalic presentation, estimated fetal weight >4000 g and any contraindications for vaginal delivery were excluded.

RESULTS

Of the 40 714 deliveries, 1767 women met inclusion criteria. Among them 1563 (88.5%) had a VBAC and 204 (11.5%) failed. There was no significant difference between the groups regarding maternal age, comorbidities and pregnancy complications. Predictors for VBAC were (odds ratio, 95% confidence interval) interval from prior CS (1.13, 1.04-1.22, p=0.004), previous VBAC (2.77, 1.60-4.78, p < 0.001), prior vaginal delivery prior to the CS (3.05, 1.73-5.39, p < 0.001) and induction of labor (0.62, 0.40-0.97, p = 0.03). For women with no prior vaginal birth, only birthweight was associated with VBAC (0.99, 0.99-1.00, p = 0.02).

CONCLUSION

While different variables may influence the rate of VBAC, the predictive ability of VBAC for women with no previous vaginal deliveries remains poor.

Scar thickness measurement by transvaginal sonography in late second trimester and third trimester in pregnant patients with previous cesarean section: does sequential change in scar thickness with gestational age correlate with mode of delivery?

PURPOSE

The objective of this study was to evaluate whether scar thickness measured by transvaginal sonography and the sequential change in scar thickness from second to third trimester has any association with mode of delivery in patients with previous cesarean.

METHODS

Pregnant women with previous one cesarean section underwent transvaginal sonography between 24 and 28 weeks of gestation and then a repeat scan beyond 36 weeks of gestation to measure scar thickness. These scar thickness measurements were then correlated with the mode of delivery. The scar was measured at multiple sites (3-4) of the lower uterine segment and its thinnest portion was considered to be the scar.

RESULT

Scar thickness was thinner in those patients having cesarean delivery than those having vaginal delivery and this difference was statistically significant at both the gestational ages. Mean scar thickness at 24-28 weeks of gestation in patients who delivered vaginally is 4.8 ± 1.1 mm and in those who had repeat cesarean section is 4.4 ± 1.1 mm (p value = 0.043). Mean scar thickness beyond 36 weeks of gestation in patients who delivered vaginally is 3.3 ± 0.7 mm and in those who had repeat cesarean section is 2.9 ± 0.9 mm (p value = 0.003). The mean decrease in scar thickness was not significantly different between those who delivered vaginally (mean decrease = 1.73 ± 0.95 mm) and those who had a repeat cesarean (mean decrease = 1.91 ± 0.96 mm).

CONCLUSION

Our study concluded that thicker scars are associated with better chances of successful vaginal birth after cesarean. Measurement at both late second trimester and third trimester can be done but latter has better correlation with mode of delivery. This association may be explained by the fact that thinner scars have more chances of fetal bradycardia, meconium staining of liquor and previous cesarean for feto-pelvic disproportion.

Does midtrimester cervical length aid in predicting vaginal birth after cesarean?

OBJECTIVE

A longer midtrimester cervical length (CL) is associated with an increased chance of cesarean delivery, but CL has not been used to predict the chance of successful trial of labor after cesarean delivery (TOLAC). The objective of this study was to identify whether midtrimester CL improves the prediction of vaginal birth after cesarean delivery (VBAC) among women undergoing a TOLAC.

STUDY DESIGN

Women with 1 prior cesarean and a singleton gestation in the vertex position who had a routine CL assessment between 18 and 24 weeks and chose to undergo a TOLAC were identified. Midtrimester CL and characteristics identifiable in early prenatal care that have been used in a validated predictive model for VBAC (ie, age, body mass index, race/ethnicity, prior vaginal delivery, prior VBAC, and indication for prior cesarean delivery) were abstracted from the medical record. Multivariable regressions with VBAC as the dependent variable, with and without CL, were created and their predictive capacity compared using receiver-operating characteristic curves and reclassification tables.

RESULTS

Of the 678 women who met inclusion criteria, 517 (76.3%) experienced a VBAC. Mean midtrimester CL was lower in women who achieved a VBAC compared with those who required a cesarean delivery in labor (4.3 ± 0.8 cm vs 4.7 ± 0.8 cm, P < .001). In a multivariable logistic regression, midtrimester CL (centimeters) was significantly associated with a reduced chance of VBAC (adjusted odds ratio [aOR], 0.60; 95% confidence interval [CI], 0.47-0.76). Although the addition of CL improved the area under the receiver-operating characteristic curve (aOR, 0.695 [95% CI, 0.648-0.743] vs aOR, 0.727 [95% CI, 0.681-0.773]; P = .03), it did not significantly enhance the clinical value of the model, as quantified by net reclassification improvement (P = .11).

CONCLUSION

Shorter midtrimester CL is associated with a greater chance of vaginal birth after a TOLAC. However, midtrimester CL does not significantly improve the clinical value of a previously developed VBAC prediction model.

Maternal and newborn outcomes after a prior cesarean birth by planned mode of delivery and history of prior vaginal birth in British Columbia: a retrospective cohort study

BACKGROUND

As rates for cesarean births continue to rise, more women are faced with the choice to plan a vaginal or a repeat cesarean birth after a previous cesarean. The objective of this population-based retrospective cohort study was to compare the safety of planned vaginal birth with cesarean birth after 1-2 previous cesarean sections.

METHODS

We identified singleton term births in British Columbia from 2000 to 2008 using data from the British Columbia Perinatal Data Registry. Women carrying a singleton fetus in cephalic presentation at term (37-41 weeks of gestation completed) with 1-2 prior cesarean births were included. Those with gestational hypertension, pre-existing diabetes and cardiac disease were excluded. Maternal and neonatal outcomes were classified as either life-threatening or non-life threatening. We compared outcomes among women with none versus at least 1 previous vaginal birth, by planned method of delivery. We estimated relative risks (RR) and 95% confidence intervals (CI) for composite outcomes using Poisson regression.

RESULTS

Of the 33 812 women in the sample, 5406 had a history of vaginal delivery and 28 406 did not. The composite risk for life-threatening maternal outcomes was elevated among women planning vaginal compared with cesarean birth both with and without a prior vaginal birth (RR 2.06, 95% CI 1.20-3.52) and (2.52, 95% CI 2.04-3.11). Absolute differences (attributable risk [AR]) were 1.01% and 1.31% respectively. Non-life threatening maternal outcomes were decreased among women planning a vaginal birth if they had had at least 1 prior vaginal delivery (RR 0.51, 95% CI 0.33-0.77; AR 1.17%). The composite risk of intrapartum stillbirth, neonatal death or life-threatening neonatal outcomes did not differ among women planning vaginal or cesarean birth with a prior vaginal delivery and non-life threatening neonatal outcomes were decreased, (RR 0.67, 95% CI 0.52-0.86); AR 1.92%).

INTERPRETATION

After 1 or 2 previous cesarean births, risks for adverse outcomes between planned vaginal and cesarean birth are reduced among women with a prior vaginal birth. Our data offer women and their health care providers the opportunity to consider risk profiles separately for women who have and have not had a prior vaginal delivery.

A prospective observational study of trial of labor after cesarean in rural India

OBJECTIVE

To determine the success rate of trial of labor after cesarean (TOLAC) in rural India.

METHODS

The present prospective observational study enrolled pregnant women attending Dr Rajendra Prasad Government Medical College, Kangra, India, in 2013. Eligible women had a previous low-segment cesarean delivery and had a singleton pregnancy with cephalic presentation. Women in labor were managed as per the institutional protocol.

RESULTS

In total, 482 women were included. TOLAC led to a vaginal delivery in 383 (79.6%) women. Overall, 2 (0.4%) women had scar rupture, and 4 (0.8%) had scar dehiscence. Fetal death was recorded in one woman with scar rupture, for whom peripartum hysterectomy was necessary. Blood loss was significantly lower among the 316 women with normal vaginal delivery than among the 99 who underwent cesarean (P<0.001). Blood transfusion was required in 2 (0.6%) women with normal vaginal delivery and 2 (2.0%) with cesarean delivery (P=0.05). The proportion of neonates who had to be admitted to intensive care did not differ significantly by mode of delivery (P=0.06).

CONCLUSION

Under strict supervision, TOLAC is a reasonable option even in rural India.

Maternal and obstetrical factors associated with a successful trial of vaginal birth after cesarean section

OBJECTIVE

To detect the maternal and obstetrical factors associated with successful trial of vaginal birth among women with a previous cesarean delivery.

MATERIAL AND METHODS

A total of 122 women who were eligible for a trial of labor after cesarean section (TOLAC) according to departmental protocol were included in this comparative prospective study. After informed consent, the women included in this study were subjected to a thorough history to detect maternal and obstetric characteristics and a standard examination to estimate fetal weight, engagement of the fetal head, intra-partum features of fetal membranes, and cervical dilatation. After delivery, data on duration of labor, labor augmentation, mode of delivery, birth outcome, and neonatal intensive care (NICU) admission were recorded and analyzed.

RESULTS

Trial of labor after cesarean section was successful in 72.13% and was unsuccessful in 27.87%. Body mass index (BMI) was significantly lower in the successful TOLAC group compared to the unsuccessful group (23.8±0.03 versus 26.2±0.02 kg/m(2)), and the number of women with BMI >25 kg/m(2) was significantly high in the unsuccessful group; also, mean gestational age was significantly lower in the successful TOLAC group compared to the unsuccessful group (37.5±0.04 versus 38.5±0.03 weeks), and the number of women admitted in labor with gestation ≥40 weeks was significantly high in the unsuccessful group. The number of women admitted with >2/5 of fetal head palpable abdominally and fetal head station ≥-2 was significantly high in the unsuccessful TOLAC group.

CONCLUSION

In carefully selected cases, TOLAC is safe and often successful. Presence of BMI >25 kg/m(2), gestation ≥40 weeks, and vertex station ≥-2 were risk factors for unsuccessful TOLAC.

Complexities of choice after prior cesarean: a narrative analysis

BACKGROUND

High rates of primary cesarean internationally continue to create decision dilemmas for women and practitioners about birth in subsequent pregnancies. This article explores values and expectations that guide women during decision making about the next birth after cesarean and identifies factors that influence consistency between women's choices and actual birth experiences.

METHODS

Narrative analysis was used to identify key themes in decision-making experiences of women who were facing a choice about mode of birth after cesarean. A sample of 187 women provided qualitative data about their choices for birth at 36-38 weeks. At 6-8 weeks after the birth, 168 also wrote about their experiences of birth and the process of making the decision.

RESULTS

Decision making about birth after cesarean was complex and difficult for many women; strong emotions were expressed as they weighed birth options. Fear and anxiety were articulated as women explained their choices and expectations. Avoidance of the previous cesarean experience, an expectation of a "better" or "faster" recovery, and issues around "safety" for the baby were common reasons given for wanting either vaginal or cesarean birth. Practitioner preferences were influential and women's need for information about their options underpinned their confidence or certainty about their decision.

CONCLUSIONS

Strategies are needed to support practitioners to expand discussions beyond clinical algorithms about physical risks and benefits of birth options and to actively integrate women's values and preferences into decisions about birth.

Obstetric factors for unsuccessful trial of labor in second-order birth following previous cesarean

BACKGROUND AND OBJECTIVES

The trial of labor after previous cesarean (TOLAC) is an important strategy to limit repeat cesarean sections and their complications. An unsuccessful TOLAC leads to maternal and neonatal morbidities. The success or failure of TOLAC after the first cesarean is determinant for the subsequent vaginal birth. Limited studies are available from low-income countries, exclusively conducted in women in their sec.ond-order birth following the first cesarean section. This study aims at determining the frequency of unsuccessful attempts at vaginal delivery in the second-order term (37-41+6/7 weeks) birth among women with previous cesarean sections and to describe maternal and obstetric factors for unsuccessful laborTOLACs in the same group.

DESIGN AND SETTINGS

A cross-sectional study conducted from April to December 2010 at Obstetrics & Gynaecology Unit II, Civil Hospital Karachi.

PATIENTS AND METHODS

All eligible patients at term pregnancy in their second-order birth were included. The frequency of unsuccessful attempts at vaginal birth was determined, followed by secondary analysis by calculating odds ratio for maternal and obstetric factors, that is, body mass index (BMI), hight, gestation ≥40 weeks, interdelivery interval, engagement of head in 5th, estimated fetal weight, ruptured membranes, duration of labor ≥7 hours, augmentation of labor, cervical dilatation < 4 cm, and vertex station -2 or higher on admission.

RESULTS

Out of 122 study subjects, the proportion of unsuccessful vaginal birth after cesarean (VBAC) was 27.9% (n=34). Among maternal and obstetric factors, BMI > 25 (AOR, 5.00), gestation ≥40 weeks (AOR, 5.45), cervical dilatation < 4 cm (AOR, 5.90), and station of vertex -2 or higher (AOR, 3.83) had highly significant adjusted odds for failed TOLAC.

CONCLUSION

With a well-defined protocol, the rates of unsuccessful attempts at VBAC are not high for the second-order birth. The risk of failure can be anticipated by factors such as BMI > 25, pregnancy duration ≥40 weeks, cervical dilatation < 4 cm, and vertex station -2 or higher on admission.

Outcome of trial of labor after cesarean section in women with past failed operative vaginal delivery

OBJECTIVE

The objective of the study was to assess the outcome of trial of labor after cesarean (TOLAC) in women with past failed operative vaginal delivery (OVD).

STUDY DESIGN

A retrospective study of all women who underwent cesarean section (CS) because of a failed OVD in a tertiary medical center between 1996 and 2011. Women who had a subsequent delivery were identified, and the outcome of subsequent delivery was analyzed.

RESULTS

Overall, 533 women underwent CS because of failed OVD during the study period. A total of 204 women (38.3%) had a subsequent delivery, of whom 93 (45.6%) had a TOLAC and 111 (54.4%) had a repeat elective CS. The success rate in the TOLAC group was 61.3% (n = 57). The most common indication for repeat CS was lack of progress (72.3%) among the 36 women in whom TOLAC failed (38.7%). The rate of postpartum hemorrhage and prolonged maternal hospitalization was lower in the TOLAC group than in the repeat CS group (2.2% vs 10.8%, P = .02, and 0% vs 8.1%, P = .005). There were no cases of rupture or dehiscence of the uterine scar. Factors associated with failed TOLAC were the occiput-posterior position and prolonged the second stage as the indication for OVD in the index pregnancy, maternal age older than 30 years at the time of subsequent delivery, and a birthweight in the subsequent pregnancy that is higher than the birthweight in the index pregnancy.

CONCLUSION

TOLAC in women who underwent a previous CS because of a failed OVD is associated with a relatively high success rate compared with the reported success rates among women with past CS during the second stage of labor. This information and the risk factors for TOLAC failure can be used when counseling these women regarding mode of delivery in subsequent pregnancy.