No. 155-Guidelines for Vaginal Birth After Previous Caesarean Birth

Effectiveness of shared decision-making for mode of delivery after caesarean section: A systematic review and meta-analysis of randomized controlled trials

AIM

To review the content, format and effectiveness of shared decision-making interventions for mode of delivery after caesarean section for pregnant women.

DESIGN

Systematic review and meta-analysis.

METHODS

Six databases (PubMed, Web of science Core Collection, Cochrance Network, Embase, CINAHL, PsycINFO) were searched starting at the time of establishment of the database to May 2023. Following the PRISMAs and use Review Manager 5.3 software for meta-analysis. Two review authors independently assessed the quality of the studies using the risk of bias 2 tool. The protocol was registered in PROSPERO (CRD42023410536).

RESULTS

The search strategy obtained 1675 references. After abstract and full text screening, a total of seven studies were included. Shared decision-making interventions include decision aids and counselling that can help pregnant women analyse the pros and cons of various options and help them make decisions that are consistent with their values. The pooled results showed that shared decision-making intervention alleviated decisional conflicts regarding mode of delivery after caesarean section, but had no effect on knowledge and informed choice.

CONCLUSION

The results of our review suggest that shared decision-making is an effective intervention to improve the quality of decision-making about the mode of delivery of pregnant women after caesarean section. However, due to the low quality of the evidence, it is recommended that more studies be conducted in the future to improve the quality of the evidence.

CORRELATION WITH CLINICAL PRACTICE

This systematic review and meta-analysis provides evidence for the effectiveness of shared decision-making for mode of delivery after cesarean section and may provide a basis for the development of intervention to promote the participation of pregnant women in the decision-making process.

Is the surge in cesarean section rates during the COVID-19 pandemic truly substantiated?

BACKGROUND

Cesarean section (C-section) rates, deemed a critical health indicator, have experienced a historical increase. The advent of the COVID-19 pandemic significantly impacted healthcare patterns including delays or lack of follow-up in treatment and an increased number of patients with acute problems in hospitals. This study aimed to explore whether the observed surge is a genuine consequence of pandemic-related factors.

METHODS

This study employs an Interrupted Time Series (ITS) design to analyze monthly C-section rates from March 2018 to January 2023 in Kurdistan province, Iran. Segmented regression modeling is utilized for robust data analysis.

RESULTS

The C-section rate did not show a significant change immediately after the onset of COVID-19. However, the monthly trend increased significantly during the post-pandemic period (p < 0.05). Among primigravid women, a significant monthly increase was observed before February 2020 (p < 0.05). No significant change was observed in the level or trend of C-section rates among primigravid women after the onset of COVID-19.

CONCLUSION

This study underscores the significant and enduring impact of the COVID-19 pandemic in further increasing the C-section rates over the long term, the observed variations in C-section rates among primigravid women indicate that the COVID-19 pandemic had no statistically significant impact.

Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation

BACKGROUND

Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery.

MATERIALS AND METHODS

This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery).

RESULTS

Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04-1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10-1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00-1.37). Uterine rupture was observed in three women (1 %).

CONCLUSION

The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.

Perinatal Outcomes of Pregnancy in Women with Scarred Uteri

Objective

Uterine scarring is risky for the pregnancy and is closely associated with adverse pregnancy outcomes. Here, we investigated risk factors and associated perinatal outcomes in singleton pregnant women with uterine scars.

Methods

This retrospective cohort study was conducted on singleton pregnant women who delivered at the West China Second University Hospital between January 1, 2021, and December 31, 2021.

Results

The control group included 13,433 cases without uterine scars. The study group involved 2397 cases with one previous cesarean delivery (PCD), 163 cases with two PCDs, 12 cases with three PCDs, and 184 cases with non-cesarean uterine scars. The study group had a significantly higher incidence of placenta previa (6.4%), placenta percreta (5.3%), preterm delivery (10.3%), postpartum hemorrhage (3.4%), uterine rupture (9.4%), hysterectomy (0.18%), and bladder injury (0.4%) when compared with the control group (P <0.05). The scarred uterus cases with 1, 2, or 3 PCDs had significantly different complications, with the higher PCD frequency correlating with increased rates of placenta previa, placenta percreta, postpartum hemorrhage, uterine rupture, and uterine resection. Moreover, the hospitalization time, cesarean operation time, and intrapartum bleeding in the current pregnancy significantly increased with increasing PCD frequency (P <0.05). Analysis of the association between the duration of the interval between PCD and re-pregnancy and pregnancy complication revealed that the incidence of pernicious placenta previa was statistically higher in cases with intervals of <2 years or ≥5 years (4.7%) than in cases with 2 years ≤ interval time <5 years (2.5%) (P <0.05).

Conclusion

Pregnancies with uterine scars may experience higher rates of adverse perinatal outcomes. This calls for increased observation during pregnancy and delivery to reduce maternal and fetal complications.

Diagnosis and Management of Uterine Rupture in the Third Trimester of Pregnancy: A Case Series and Literature Review

BACKGROUND

 Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity requiring prompt cesarean delivery and uterine repair or hysterectomy. Previous cesarean section is the most common risk factor. The most consistent early indicator of it is the onset of prolonged and profound fetal bradycardia.

OBJECTIVE

In this study, we present six cases of uterine rupture highlighting risk factors, and challenges in diagnosis and management, along with a review of the literature.

METHOD

A retrospective case series identified eight cases during the five-year study period. All cases from January 1, 2018 to December 31, 2022 were reviewed. Cases with multiple previous cesarean sections were excluded.

RESULT

Six cases meeting the study criteria were included in our case series. Uterine rupture was a rare occurrence with a prevalence of nine in 31,315 births representing 0.03% of deliveries. No maternal mortality or need for hysterectomy occurred in our study. Fifty percent of uterine ruptures were associated with stillbirths. The most common risk factor was a previous cesarean section in 83.3%. The most common presenting sign was non-reassuring fetal status patterns in 66.6%. A single case had a silent rupture.

CONCLUSION

Signs and symptoms of uterine rupture are nonspecific making diagnosis challenging. Delay in definitive management causes significant fetal morbidity and mortality. For best outcomes, vaginal birth after a previous cesarean section needs close monitoring in appropriately prepared units with the ability to perform immediate cesarean delivery and provide advanced neonatal support.

Induction of Labor in Women with Previous Cesarean Section and Unfavorable Cervix: A Retrospective Cohort Study

Background: The efficacy and safety of a cervical ripening balloon (CRB) in women with a previous cesarean section (CS) and unfavorable Bishop score are still controversial. Methods: A retrospective cohort study was performed across six tertiary hospitals from 2015 to 2019. Women with one previous transverse CS, singleton cephalic term pregnancy and BS < 6 were included if submitted to labor induction with a CRB. The main outcome was the rate of vaginal birth after cesarean (VBAC) after CRB ripening. Secondary outcomes were abnormal composite fetal and maternal outcomes. Results: Of the 265 women included, 57.3% had successful vaginal birth. Augmentation improved vaginal delivery (32.2% vs. 21.2%). Intrapartum analgesia was associated with an increased VBAC rate (58.6% vs. 34.5%). Maternal BMI ≥30 and age ≥40 years increased emergency CS rate (11.8% vs. 28.3% and 7.2 vs. 15.9%). Composite adverse maternal outcome occurred in 4.8% of CRB group women and increased to 17.6% when associated with oxytocin. Uterine rupture occurred in one case (0.4%) in the CRB-oxytocin group. Poorer fetal outcome occurred after emergency CS, if compared to successful VBAC (12.4% vs. 3.3%). Conclusions: In women with a previous CS and unfavorable Bishop score, induction of labor with a CRB can be considered safe and effective.

Influence of Oxytocin Usage and Dose Difference During Delivery on Pregnancy Outcome of VBAC Pregnant Women

In order to explore the influence of oxytocin usage and dose difference during delivery on the pregnancy outcome of VBAC pregnant women, the clinical data of 166 VBAC pregnant women from January 2017 to March 2020 are retrospectively analyzed. All women are divided into different groups according to the usage of oxytocin during delivery and the oxytocin dose difference. Binary logistic regression is used to analyze the factors affecting the pregnancy outcome of pregnant women with VBAC. The gestational weeks and the thickness of the lower uterine segment in the oxytocin group are significantly more than those in the nonoxytocin group (P < 0.05). The time of the first stage of labor, second stage of labor, and total stage of labor in the oxytocin group are significantly longer than the nonoxytocin group (P < 0.05). The proportion of entering NICU in the oxytocin group is significantly lower than the nonoxytocin group (P < 0.05). There is no significant difference in labor duration and pregnancy outcome between low-dose and medium-dose oxytocin groups. Binary logistic regression analysis shows that prenatal BMI <30 kg/cm², gestational age ≤40 weeks, history of vaginal delivery, uterine expansion, and admission to hospital are the influencing factors for pregnancy success of pregnant women with VBAC. The usage of oxytocin in VBAC pregnant women during delivery may increase the duration of labor. For those with poor uterine contraction, oxytocin can be increased to 4∼18 mU/min to speed up the labor process, without increasing the risk of adverse pregnancy outcomes.

Induction of Labor with Vaginal Dinoprostone (PGE2) in Patients with a Previous Cesarean Section: Obstetric and Neonatal Outcomes

BACKGROUND

Vaginal dinoprostone (PGE2) is currently used as the prostaglandin of choice in many obstetric units. However, few studies have evaluated its safety, especially in women who previously had a cesarean section.

OBJECTIVE

To evaluate the efficacy and safety of PGE2 in pregnant women who are undergoing induction of labor (IOL), and who have had a previous cesarean section.

MATERIALS AND METHODS

A prospective observational study was conducted in La Mancha Centro Hospital in Alcázar de San Juan, Spain, from 1 February 2019 to 30 August 2020. Obstetric and neonatal outcomes, following IOL with PGE2, in 47 pregnant women who wanted a trial of labor after cesarean (TOLAC), and 377 pregnant women without a history of cesarean section, were analyzed. The outcomes were analyzed by bivariate and multivariate analyses using binary and multiple linear regression.

RESULTS

A total of 424 women were included in this study. The percentage of cesarean sections in the TOLAC group was 44.7% (21), compared with 31.6% (119) in the group without a history of cesarean section (adjusted odds ratio: 1.4; 95% CI: 0.68-2.86). In the multivariate analysis, no statistically significant differences were observed between both groups for obstetric and neonatal outcomes (p > 0.05). However, two uterine ruptures (4.3%) occurred in the group of patients with a history of cesarean section who underwent IOL with PGE2.

CONCLUSIONS

The induction of labor with vaginal dinoprostone (PGE2), in patients with a previous history of cesarean section, was not associated with worse obstetric or neonatal outcomes compared with the group of patients without a history of cesarean section in our study sample. However, further research is needed regarding this IOL method, and it should be used with caution in this population group.

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.

Revisiting the Care Pathway for Trial of Labour After Cesarean: The Decision-to-Delivery Interval Is Key

Centres providing maternity care and offering a trial of labour after cesarean must develop and use maternal educational and consent processes that emphasize choice and autonomy related to options for and decisions surrounding vaginal birth after cesarean and elective repeat cesarean delivery. These centres should have administrative systems and processes that take into account local resources for cesarean delivery services, including team-based complex maternity risk support and an urgency consensus on the fetal, maternal, and maternal-fetal indications for a surgical delivery to ensure an appropriate decision-to-delivery interval.

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..

Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study

Background

Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women’s decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method.

Methods

A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis.

Results

Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women’s choice … with conditions, their assessment of women’s chances of a successful TOLAC, their perception of women’s risk tolerance, women’s preferred delivery method, and their perception of women’s beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers’ perspectives on risk of TOLAC.

Conclusion

The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

Term cesarean breech delivery in the first pregnancy is associated with an increased risk for maternal and neonatal morbidity in the subsequent delivery: a national cohort study

Purpose

To determine whether there is an association between term cesarean breech delivery in the first pregnancy and maternal and neonatal morbidities in the subsequent pregnancy and delivery.

Methods

We conducted a retrospective, nationwide Finnish population-based cohort study, including all deliveries from January 2000 to December 2017. We included all women with the first two consecutive singleton deliveries of which the first one was a breech delivery regardless of mode of delivery (n = 11,953), and constructed a data set in which the first two deliveries for these women were connected. The outcomes of the second delivery of the women with a first pregnancy that resulted in cesarean breech delivery at term were compared with women whose first pregnancy resulted in a vaginal breech delivery at term. P-value, odds ratio, and adjusted odds ratio were calculated.

Results

Neonates of a subsequent delivery after cesarean breech delivery had an increased risk for arterial umbilical cord pH below seven, a higher rate of a 5 min APGAR score < 7 and a higher rate of neonatal intensive care unit admission. The women with a history of cesarean section with the fetus in breech presentation were more often in need of a blood transfusion and suffered more often a uterus rupture. In this group, the second delivery was more often a planned cesarean section, an emergency cesarean section, or an instrumental vaginal delivery.

Conclusions

Primary cesarean breech section in the first pregnancy is associated with adverse neonatal and maternal outcomes in the subsequent delivery.

Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario

OBJECTIVE

To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice.

METHODS

Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores.

RESULTS

The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average.

CONCLUSION

The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Clinical interventions that influence vaginal birth after cesarean delivery rates: Systematic Review & Meta-Analysis

Background

To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates.

Methods

We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT).

Results

Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence.

Conclusions

This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

Examining Cesarean Section Rates in Canada Using the Modified Robson Classification

OBJECTIVE

Canada's cesarean delivery (CD) rate continues to increase. The Society of Obstetricians and Gynaecologists of Canada advocates the use of the modified Robson classification for comparisons. This study describes national and provincial CD rates according to this classification system.

METHODS

All 2016-2017 in-hospital births in Canada (outside Québec) reported to the Discharge Abstract Database were categorized using the modified Robson classification system. CD rates, group size, and contributions of each group to the overall volume of CD were reported. Rates by province and hospital peer group were also examined (Canadian Task Force Classification III).

RESULTS

A total of 286 201 women gave birth; among these, 83 262 (29.1%) had CDs. Robson group 5 (term singleton previous CD) had a CD rate of 80.5% and was the largest contributing group to the overall number of CD (36.6%). Women whose labour was induced (Robson group 2A) had a CD rate almost double the rate of women with spontaneous labour (Robson group 1): 33.5% versus 18.4%. These latter two groups made the next largest contributions to overall CD (15.7% and 14.1%, respectively). There were substantial variations in CD rates across provinces and among hospital peer groups.

CONCLUSION

The study found large variations in CD rates across provinces and hospitals within each Robson group, thus suggesting that examining variations to determine the groups contributing the most to CD rates (Robson groups 5, 2A, and 1) may provide valuable insight for reducing CD rates. This study provides a benchmark for measuring the impact of future initiatives to reduce CD rates in Canada.

Resident Attitudes Towards Caesarean Delivery in Canadian Obstetrics and Gynaecology Residency Programs

OBJECTIVE

This study aimed to explore the attitudes of obstetrics and gynaecology residents in Canada towards interventions that influence caesarean section rates. The study looked at residents' attitudes towards four guidelines that support vaginal and assisted delivery (vaginal birth after caesarean section, induction of labour, operative vaginal birth, and fetal health surveillance in labour) and towards Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines in general. The study also sought to investigate whether these attitudes vary by residency training location.

METHODS

An online survey of obstetrics and gynaecology residents across Canada was conducted. Residents responded to statements derived from guidelines using a five-point attitudinal scale and to an optional long-answer question about how residency has prepared them to make decisions around interventions. Descriptive summary statistics are used to present the findings (Canadian Task Force Classification III).

RESULTS

A total of 27% of residents completed the survey. The majority demonstrated attitudes congruent with guidelines and favourable towards SOGC guidelines in general. Residents attitudes were least favourable towards electronic fetal monitoring, with 67.4% of responses congruent with the guideline. Attitudes were most aligned with the operative vaginal birth guideline, with 87.9% of responses congruent with the guideline. This sample was underpowered to detect statistically significant differences among residency programs, although there was some variation in attitudes across programs, with the most congruent scoring program at 81.8% congruent responses and the lowest at 66.7%.

CONCLUSION

Obstetrics and gynaecology residents in Canada have favourable attitudes towards interventions that support vaginal and assisted delivery. There was variability in observed attitudes across programs, although this was not statistically significant.

Trial of labor after cesarean delivery in twin gestations: systematic review and meta-analysis

BACKGROUND

Trial of labor after cesarean is offered as a routine option for singleton gestations with previous cesarean delivery. However, adequate data are not available to determine whether the approach is equally valid in women with twin gestation.

OBJECTIVE

This systematic review and meta-analysis aimed to assess maternal morbidities associated with trial of labor after cesarean delivery in twin gestations.

STUDY DESIGN

Electronic databases were searched for cohort studies and randomized controlled trials evaluating the association between trial of labor after cesarean delivery in twin gestations and pregnancy outcomes. Maternal mortality and severe morbidities, such as uterine rupture and hysterectomy, were compared between women who had trial of labor and women who had a planned repeat cesarean delivery. Pooled odds ratios were calculated using a random-effects model. Additional analyses were performed to compare trial of labor after cesarean outcomes in singleton and twin gestations.

RESULTS

Eleven cohort studies including a total of 8209 twin gestations with previous cesarean delivery were included in the present study. Of these gestations, 2484 were intended for planned vaginal birth and 5725 were intended for planned repeat cesarean delivery. The rate of uterine rupture in twin gestations was higher in the trial of labor after cesarean group than the elective cesarean group (odds ratio, 10.09, 95% confidence interval, 4.30-23.69, I² = 68%). However, no statistically significant difference was found in the rate of uterine rupture between twin and single gestations attempting trial of labor after cesarean delivery (odds ratio, 1.34, 95% confidence interval, 0.54-3.31, I² = 0%). Women who attempted a trial of labor after cesarean delivery with twins did not have an increased risk of uterine scar dehiscence, hemorrhage, blood transfusion, or neonatal morbidity and mortality compared with elective repeat cesarean delivery. Patients with twins had similar rates of successful vaginal delivery as patients with singletons (odds ratio, 0.85, 95% confidence interval, 0.61-1.18, I² = 36%).

CONCLUSION

This meta-analysis demonstrates that, although trial of labor with twins after previous cesarean delivery is associated with higher rates of uterine rupture compared with elective cesarean delivery, pregnancy outcomes and success rates are similar to a trial of labor after previous cesarean delivery in singleton gestations. Planned vaginal birth for women with twin gestation and previous cesarean delivery may be a safe alternative to a planned repeat cesarean.

Adjunct clinical interventions that influence vaginal birth after cesarean rates: systematic review

Background

Rates of cesarean deliveries have been increasing, and contributes to the rising number of elective cesarean deliveries in subsequent pregnancies with associated maternal and neonatal risks. Multiple guidelines recommend that women be offered a trial of labor after a cesarean (TOLAC). The objective of the study is to systematically review the literature on adjunct clinical interventions that influence vaginal birth after cesarean (VBAC) rates.

Methods

We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any adjunct clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting changes in TOLAC or VBAC rates. One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT).

Results

Twenty-three studies of overall moderate to good methodological quality examined adjunct clinical interventions affecting TOLAC and/or VBAC rates: system-level interventions (three studies), provider-level interventions (three studies), guidelines or information for providers (seven studies), provider characteristics (four studies), and patient-level interventions (six studies). Provider-level interventions (opinion leader education, laborist, and obstetrician second opinion for cesarean sections) and provider characteristics (midwifery antenatal care, physicians on night float call schedules, and deliveries by family physicians) were associated with increased rates of VBAC. Few studies employing heterogeneous designs, sample sizes, interventions and comparators limited confidence in the effects. Studies of system-level and patient-level interventions, and guidelines/information for providers reported mixed findings.

Conclusions

Limited evidence indicates some provider-level interventions and provider characteristics may increase rates of attempted and successful TOLACs and/or VBACs, whereas other adjunct clinical interventions such as system-level interventions, patient-level interventions, and guidelines/information for healthcare providers show mixed findings.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2065-x) contains supplementary material, which is available to authorized users.