Evidence-based vaginal birth after Caesarean section

Predictors of vaginal delivery following balloon catheter for labor induction in women with one previous cesarean

BACKGROUND

The aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix.

METHODS

This 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL.

RESULTS

A total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight (< 4000 g) (odds ratio [OR]5.26; 95% confidence interval [CI] 2.09,13.27), lower body mass index (BMI,<30 kg/m²) (OR 2.27; CI 1.21, 4.26), Bishop score after cervical ripening > 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC.

CONCLUSIONS

The influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.

Oxytocin use in trial of labor after cesarean and its relationship with risk of uterine rupture in women with one previous cesarean section: a meta-analysis of observational studies

BACKGROUND

Trial of labor after a previous cesarean delivery (TOLAC) has reduced the rate of cesarean sections (CS). Nevertheless, the widespread use of TOLAC has been limited by an increase in adverse outcomes, the most serious one being the risk of symptomatic uterine rupture, which is possibly associated with oxytocin. In this meta-analysis, we explored the risk association between oxytocin use and uterine rupture in TOLAC.

METHODS

Multiple electronic databases (PubMed, Embase, Web of Science, and Google Scholar) were searched for cross-sectional studies reporting on TOLAC, oxytocin and uterine rupture, which were published between January 1986 and October 2019. The bias-corrected Hedge's g was calculated as the effect size using the random-effects model. A two-sample Z test was used to compare the differences in synthetic rates between groups. The Newcastle-Ottawa Scale (NOS) was used to evaluate the risk of bias. Quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty ratings system.

RESULTS

A total of 14 studies, which included 48,457 women who underwent TOLAC, met the inclusion criteria. The pooled rate of vaginal birth after a cesarean section (VBAC) and the rate of uterine rupture in spontaneous labor were 74.3 and 0.7%, respectively. In addition, the pooled rate of VBAC and the rate of uterine rupture in the induction labor group was 60.7 and 2.2%, respectively. The women who had spontaneous labor had a significantly higher rate of VBAC (p = 0.001) and a lower rate of uterine rupture (p = 0.0003) compared to induced labor. The pooled rates of uterine rupture in women using oxytocin and women not using oxytocin in TOLAC were 1.4% and 0.5%, respectively, and the difference was significant (p = 0.0002). Also, the synthetic rate of uterine rupture in oxytocin augmentation among women with spontaneous labor and women who had a successful induction of labor were 1.7% and 2.2%, respectively, without significant difference (p = 0.443).

CONCLUSIONS

Women with induced labor had a higher risk of uterine rupture compared to women with spontaneous labor following TOLAC. Oxytocin use may increase this risk, which could be influenced by the process of induction or individual cervix condition. Consequently, simplified and standardized intrapartum management, precise protocol, and cautious monitoring of oxytocin use in TOLAC are necessary.

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial

Background

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean.

Methods/design

The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis.

Discussion

The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management.

Trial registration

Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.

Uterine Rupture at 21 Weeks in Twin Pregnancy with TTTS and Previous C-Section

Uterine rupture is a health problem in every country. The diagnosis is not always obvious and fetal and maternal morbidity and mortality can be high.

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.

Survey on uterine closure and other techniques for Caesarean section among Quebec's obstetrician-gynaecologists

OBJECTIVE

To evaluate the preferred types of uterine closure at Caesarean section among Quebec's obstetrician-gynaecologists.

METHODS

An anonymous survey with multiple-choice and open questions was sent by email to all members of the Association des Obstétriciens-Gynécologues du Québec in clinical practice. The primary response of interest was the type of uterine closure that would be favoured for a primigravida undergoing an elective CS at term for a breech fetus. Secondary responses of interest included type of uterine closure for CS performed for other indications, and methods of closure for the bladder flap, parietal peritoneum, rectus abdominis muscle, subcutaneous tissue, and skin. Results were stratified according to the number of years in practice.

RESULTS

Of 454 persons targeted, 176 (39%) responded. Responders were more likely to have fewer years in practice than the targeted population in general. The closures for a primigravida undergoing an elective CS at term for a breech presentation were, in order of preference: (1) a double-layer closure combining a first locked layer and an imbricating second layer (61%), (2) a double-layer closure combining a first unlocked layer and an imbricating second layer (28%), (3) a locked single layer (5%), (4) an unlocked single layer (5%), and (5) other techniques (1%). A locked single-layer closure was more frequently used for repeat CS (29%), and it was the favoured technique (40%) when tubal ligation was performed at the time of CS (P < 0.05).

CONCLUSION

Double-layer closure is the type of uterine closure most preferred by obstetricians in Quebec. However, the first layer is locked by two thirds of obstetricians and unlocked by the remainder.

A Paradigm Shift to Check the Increasing Trend of Cesarean Delivery is the Need of Hour: But How?

OBJECTIVES

To check the progressive increasing trend of caesarean delivery in a tertiary facility care centre.

AIMS

The purpose of this study is to implement a paradigm shift in caesarean delivery by introducing a new classification system and a check list based management protocol.

METHODS

The study was conducted from 1st January, 2007 to 31st December, 2008 at CNMC G&O Department. All deliveries in the year 2007 were compared retrospectively and all deliveries in the year 2008 under prospective study with implementation of a new strategic protocol. Comparative audit and analysis of deliveries in retrospective and prospective year reveals significant changes in the caesarean delivery rate.

RESULTS

In retrospective group all women in labour were allowed for spontaneous delivery and in prospective group all women were subjected to intervention protocol and caesarean delivery done in both the groups in need for risk of fetal and maternal salvage. Incidence of caesarean delivery (CD) in retrospective group was 29 % while in the prospective group it was 18.4 %. Marked decrease in CD was observed for augmentation, induction and trial of labour (TOL) for delivery in prospective group. The result was compared with Robson's studies following similar type of classification system.

CONCLUSION

Marked improvement was noticed in this new paradigm and more multicentric trial is needed to check the increasing trend of CD.

Trial of labor and vaginal birth after cesarean section in patients with uterine Müllerian anomalies: a population-based study

OBJECTIVE

The aim of our study was to determine the success rate of vaginal birth after cesarean section among patients with Müllerian anomalies in comparison to the success rate of vaginal birth after cesarean section in patients with normal uterus with emphasis on the rate of uterine rupture.

STUDY DESIGN

A retrospective population-based study was designed, including all patients with a previous cesarean section that attempted vaginal birth after cesarean section during the study period. Women with known Müllerian anomalies were included in the study group. The control group consisted of women with normal uterus. The rates of vaginal birth after cesarean section, uterine rupture, maternal morbidity, and perinatal outcome were compared between the groups.

RESULTS

Of 5571 eligible patients, 165 (2.96%) had Müllerian anomalies. The rate of vaginal birth after cesarean section was significantly lower among patients with Müllerian anomalies than in patients with normal uterus, 37.6% (62/165) vs 50.7% (2740/5406), respectively (P = .0009). During the study period, there were 10 cases of uterine rupture, all in patients with normal uterus. The major indication for repeated cesarean delivery among Müllerian anomalies patients was malpresentation, 58.3% (60/103) vs 14.4% (385/2666) in patients with normal uterus (P < .001).

CONCLUSION

A trial of vaginal birth after cesarean section in patients with uterine Müllerian malformations and cephalic presentation is not associated with a higher rate of maternal morbidity and uterine rupture.

[Factors associated with preference for cesarean delivery]

OBJECTIVE

To study factors related to preference for cesarean delivery, among pregnant women without medical complications.

METHODS

A cross-sectional study was carried out among 156 pregnant women, in a private clinic in the city of Osasco, State of São Paulo, from October 2000 to December 2001. The pregnant women were at 28 weeks of pregnancy or more, with no formal contraindication for vaginal delivery at the time of the interview. Sociodemographic data and past and present obstetric history were assessed by applying a questionnaire. The pregnant women were specifically asked what their current preference for delivery was. Pearson's Chi-square test and logistic regression for multivariate analysis were performed with a 5% significance level.

RESULTS

Sixty-seven pregnant women (42.9%) said they had little motivation to undergo vaginal delivery. In the multivariate analysis, the following variables were statistically significant: previous vaginal birth (p=0.001; ORadj=0.04; 95% CI=0.01-0.12); husband's monthly income greater than 750 reais (p=0.006, ORadj=3.44; 95% CI=1.38-8.33). The women with a previous vaginal delivery presented 25-fold lower chance of choosing cesarean delivery. The opinion that the previous delivery experience was unsatisfactory was marginally associated with the main outcome (p=0.06; ORadj=0.42; 95% CI=0.16-1.05).

CONCLUSIONS

Motivation for cesarean delivery is associated with influences such as the type and degree of satisfaction with previous delivery and income.