Labour duration and timing of interventions in women planning vaginal birth after caesarean section

Duration time of labor progression for pregnant women of vaginal birth after cesarean in Hubei, China

OBJECTIVE

There have been limited reports on the duration of labor progression in pregnant women undergoing vaginal birth after cesarean (VBAC). This study aimed to investigate the duration of labor progression during VBAC in Hubei, China.

METHODS

A total of 359 pregnant women undergoing VBAC were enrolled as the VBAC group, meeting the following criteria: singleton pregnancy, gestational age ≥ 37 weeks, live birth, history of cesarean delivery, and a willingness to attempt a vaginal delivery. At the same time, 359 primiparas successfully undergoing vaginal delivery were randomly enrolled in the control group at a 1:1 ratio. Subsequently, the durations of the first, second, and third stages of labor were comparatively analyzed between the two groups.

RESULTS

The duration of the first, second, and total stages of labor in the VBAC group was significantly shorter than that in the control group (p < 0.05). There was no significant difference in the duration of the third stage of labor between the two groups (p > 0.05). The amount of blood loss, the rate of postpartum hemorrhage (PPH), and episiotomy were higher in the VBAC group than in the control group (p < 0.05). The rate of labor analgesia and intrapartum fever in the VBAC group was significantly lower than that in the control group (p < 0.05).

CONCLUSION

The duration of labor progression of the first, second, and total stages of VBAC is shorter than that in primiparous women in our observation in China.

Delivery Progress, Labor Interventions and Perinatal Outcome in Spontaneous Vaginal Delivery of Singleton Pregnancies between Nulliparous and Primiparous Women with One Previous Elective Cesarean Section: A Retrospective Comparative Study

Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal-neonatal outcomes between the two groups.

METHODS

This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally.

RESULTS

The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used.

CONCLUSIONS

Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.

Labor characteristics and intrapartum interventions in women with vaginal birth after cesarean section

Background

With the development of China’s two-child-policy, vaginal birth after cesarean section (VBAC) has aroused public concern. It is important to understand the labour characteristics and intrapartum management of women attempting VBAC to enhance the rates of successful VBAC. The purpose of our research was to investigate the differences in the characteristics of labor, intervention measures and perinatal outcomes between women who had a VBAC and primiparas or multiparas not undergoing VBAC, providing clinical references of intrapartum management for women who are planning a VBAC.

Material and methods

This observational retrospective study enrolled all women who laboured spontaneously and who had a VBAC (n = 139) at the Second Affiliated Hospital of Wenzhou Medical University in China between 2016 and 2019. They were allocated into VBAC group A (the previous cesarean section was performed before dilation of the cervix) and VBAC group B (the previous cesarean section was performed after dilation of the cervix). The primipara control group included 149 primiparae, and the multipara control group included 155 multiparae with second vaginal birth. Durations of labor, intervention measures and perinatal outcomes were compared among the groups.

Results

The durations of labor, intrapartum interventions and maternal and neonatal outcomes in VBAC group A were similar to those of the VBAC group B. However, all women who had a VBAC and those in VBAC group A had shorter first, second and the total stages of labor than primiparae. All women with VBAC and those in VBAC group B had longer second stage of labor, but shorter third stage of labor than multiparae. Oxytocin, labor analgesia and artificial rupture of membranes were administered less often in women with VBAC than in primiparae, while phloroglucinol was administered more often in women with VBAC than in multiparae. Women who had a VBAC were more likely to receive episiotomy and had higher incidences of postpartum hemorrhage than primipara and multipara women.

Conclusions

Labor characteristics, intrapartum interventions and perinatal outcomes in women who had a VBAC with cervical dilation were similar to those in women who had a VBAC without cervical dilation before the previous cesarean section, but differed significantly from those of multiparae and primiparae who did not undergo VBAC.

Development and validation of a tool for advising primiparous women during early labour: study protocol for the GebStart Study

INTRODUCTION

Pregnant women experience early labour with different physical and emotional symptoms. Early admission to hospital has been found to be associated with increased intervention and caesarean section rates. However, primiparous women often contact the hospital before labour progresses because they encounter difficulties coping with symptoms of onset of labour on their own. An evidence-based instrument for assessing the individual needs to advise primiparous women during early labour is currently missing. The study aims to develop and validate a tool to inform the joint decision for or against hospital admission.

METHODS AND ANALYSIS

A scale development and validation study will be conducted including following steps: (1) Generation of a pool with 99 items based on a scoping review and focus group discussions with primiparous women, (2) Assessment of content and face validity by an expert panel and item reduction to 32 items, (3) Multicentre data collection in six study sites in Switzerland, with application of the preliminary tool and the validation items with a target sample size of approximately n=400 women and (4), item reduction using exploratory factor analysis, factor loading and item-to-item correlation. Internal consistency of the tool will be assessed using Cronbach's alpha and convergent validity computing correlations of items of the tool with the German versions of the Childbirth Self-Efficacy Inventory and the Cambridge-Worry Scale. Analyses will be performed using Stata V.17.

ETHICS AND DISSEMINATION

Ethical approval was obtained by the Ethics Committees Zurich and Northwestern and Central Switzerland (BASEC-Nr. 2021-00687). Results will be disseminated at the final study conference, at national and international congresses and by peer reviewed and not peer-reviewed articles in scientific and professional journals. Approved and anonymised data will be shared. The dissemination of the findings will have a contributable impact on clinical practice, scientific discussions and future research.

TRIAL REGISTRATION NUMBER

DRKS00025572, SNCTP000004555.

Increased risk of obstetric anal sphincter injury in women undergoing vaginal delivery after caesarean section: A systematic review and meta-analysis

BACKGROUND

There is increased focus on obstetric anal sphincter injury (OASI) and there are several well-established risk factors such as birthweight, instrumental delivery and median episiotomy. Some studies have found increased risk of OASI in women delivering vaginally after a previous caesarean section (VBAC).

OBJECTIVE

To evaluate whether there is increased prevalence of OASI in VBAC compared with primiparous women.

SEARCH STRATEGY

Literature search using PubMed, Embase and Cochrane databases.

SELECTION CRITERIA

All studies with data on both primiparous women and women undergoing VBAC were included. All included studies were evaluated using the "SIGN - methodology checklist" to verify if the quality was acceptable.

DATA COLLECTION AND ANALYSIS

This systematic review included 23 articles conducted in 11 countries over 19 years. Included studies were analysed using RevMan version 5.4.

MAIN RESULTS

We found increased prevalence of OASI in the VBAC group; 8.18% (95% confidence interval [CI] 8.07-8.29) compared with 6.59% (95% CI 6.56-6.62) in primiparous women. Correspondingly, the meta-analysis revealed increased prevalence for OASI in the VBAC group (odds ratio 1.27, 95% CI 1.10-1.47). We found a high level of heterogeneity (I²  = 98%).

CONCLUSION

Women undergoing VBAC had a higher prevalence of OASI compared with primiparous women.

Pregnant women's clinical characteristics, intrapartum interventions, and duration of labour in urban China: a multi-center cross-sectional study

BACKGROUND

There is an increasing global trend towards the widespread over-medicalisation of labour and childbirth. The present study aimed to investigate pregnant women's clinical characteristics, intrapartum interventions, duration of labour and its associated factors; and to compare the differences of these variables between nulliparas and multiparas in China.

METHODS

A multi-center cross-sectional study was carried out in three tertiary hospitals of Fudan University in Shanghai, China. A total of 1523 participants were approched and assessed for eligibility. Data on women's sociodemographic characteristics, intrapartum interventions, and duration of labour were measured and collected. Kaplan-Meier survival analysis was performed to present the curves of total duration of labour by parity. After z-transformation of labour duration, multivariable linear regression was used to control for confounding and to identify independent associations between potential associated factors and the primary outcome of labour duration.

RESULTS

Overall, 1209 eligible women agreed to participate and were investigated. Rates of different intrapartum interventions were 27.4% in use of amniotomy, 37.9% in use of oxytocin, 53.0% in continuous electronic fetal monitoring, and 52.9% in epidural use, respectively. The curve of total duration of labour was significantly different between nulliparas and multiparas (P < .001). Of the 1209 participants, 983 (81.3%) women eventually achieved successful vaginal birth while 226 (18.7%) women ended in intrapartum caesarean section. The median duration of total stage of labour was significantly longer in the nulliparous group [9.38 (6.33,14.10) hours] than that in the multiparous group [5.08 (3.00,7.83) hours] (P < .001). The following factors were independently associated with longer duration of total stage of labour: epidural analgesia (P < .001), primiparity (P < .001), continuous electronic fetal monitoring (P = .035), and increased birth weight (P = .005).

CONCLUSIONS

Intrapartum medical interventions become common obstetric practices in urban China. Multifactorial variables independently associated with longer duration of labour were identified, including epidural analgesia, primiparity, continuous electronic fetal monitoring, and increased birth weight. Further research is required to validate these variables and to determine the modifiable factors for labour management. And models of care with lower intervention rates such as midwife-led models of care should be developed and implemented in China.

Intrapartum interventions that affect maternal and neonatal outcomes for vaginal birth after cesarean section

Objective

To investigate maternal and neonatal outcomes after different intrapartum interventions for vaginal birth after cesarean section (VBAC) in mainland China.

Methods

A retrospective study was performed on 143 VBAC cases from Beijing Obstetrics and Gynecology Hospital between January 2015 and November 2016. These cases were divided into two groups on the basis of different intrapartum interventions. Maternal and neonatal outcomes were compared.

Results

The durations of the first stage and total labor after oxytocin were significantly longer than those before oxytocin use. The proportion of operative vaginal delivery with oxytocin was significantly higher than that without oxytocin (43.9% vs. 11.8%). The times of the first stage, second stage, and total labor with analgesia were significantly longer than those without analgesia (548.4±198.1 vs. 341.8±233.0 minutes, 52.0±38.9 vs. 36.0± 29.1 minutes, and 606.3±212.1 vs. 387.3±233.0 minutes, respectively). Postpartum hemorrhage and operative vaginal delivery occurred significantly more frequently in women with epidural analgesia than in those without epidural analgesia (29.7% vs. 12.3 and 35.1% vs. 16.0%, respectively).

Conclusions

Induction can increase the rate of operative vaginal delivery in VBAC. Oxytocin and epidural analgesia may increase the risk of operative vaginal delivery, and may be associated with a prolonged duration of labor.

Timing of cesarean and its impact on labor duration and genital tract trauma at the first subsequent vaginal birth: a retrospective cohort study

Background

The objectives of this study were to explore the course of labor and the risk of obstetric anal sphincter injury at the first vaginal birth after cesarean section (fVBAC) in comparison to primiparous vaginal birth (PVB) in women without epidural analgesia and to assess if laboring before the previous cesarean affected these outcomes.

Methods

All fVBACs without epidural analgesia and the subsequent PVBs (controls) between 2012 and 2016 were included in this retrospective cohort study. Data were collected from health records and included maternal demographics, gestational age, and labor details (duration of 1st and 2nd stages, labor induction or augmentation, birthweight, operative vaginal birth, estimated blood loss, extent of childbirth trauma) in both groups as well as cervical dilation at the time of previous cesarean in the fVBAC group. Wilcoxon and Chi-square tests were used for data analyses.

Results

The study comprised 510 women; 255 fVBACs and 255 controls. The majority of fVBACs were after a pre-labor cesarean section – 177 (69.4%). There was a statistically significant difference in the recorded duration of first stage between the fVBACs and controls (289 vs. 347 min respectively, p < .001). Women were less likely to have an intact perineum in the fVBAC group (29.8 vs. 43.1%, p < 0.01), however, there was no statistically significant difference in anal sphincter injury rates between both groups (2.3 vs. 1.9%, p = 0.76). The groups differed in rates of cervical tears requiring suturing (21.2 vs. 12.9%, p = 0.01). On further subgroup analysis, the duration of first stage of labor was shorter in women who previously had a caesarean section late in labor (≥ 8 cm cervical dilatation) compared to a pre-labor cesarean section, however, there were no differences in other outcomes.

Conclusion

Compared to primiparous women having a vaginal birth, women having their first vaginal birth after a cesarean section have a shorter 1st stage of labor (particularly if the cesarean was performed in advanced labor), a higher risk of sustaining cervical lacerations and perineal trauma. However, there was no difference in the risk of sustaining obstetric anal sphincter injuries between the study groups.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2359-7) contains supplementary material, which is available to authorized users.

Maternal and neonatal outcomes for women giving birth after previous cesarean

INTRODUCTION

Rising rates of caesarean section (CS) is an issue of particular concern. Recently, there has been research supporting Vaginal Births After Caesarean (VBAC), which is controversial. In Greece, over half of births in the country are by CS, placing Greece among countries with the highest CS rates. The aim of this study was to investigate the prevalence and the factors associated with VBACs and to compare the maternal/neonatal outcomes with a 'non-caesarean' control group.

METHODS

The data were evaluated and retrospectively gathered on archived singleton births, from medical records of a midwifery-led team, between May 2006 and May 2013. The target group of the study included mothers with a previous CS, who had a second birth. The sample consisted of 71 VBAC women and 583 who had normal spontaneous vaginal delivery (NSVD) as the 'non-caesarean' control group.

RESULTS

The duration of labour was longer for the VBACs compared with first-time mothers who gave birth naturally (for duration 481-720 min, 27% vs 10.3%, respectively), episiotomy was more common for VBAC (20.7% vs 7.9%), and epidural analgesia was more often for VBAC (68.4% vs 10%). The percentage of 1-min Apgar score in the range 0-7 in the VBAC group was 5%, and there was no significant difference in women who had NSVD (3.6%). The Apgar score in the 5th minute was always above 8 for both groups.

CONCLUSIONS

Severe maternal and neonatal complications are infrequent, and therefore the necessity arises for further continuous studies to ascertain the safety of VBAC.

Labour characteristics of women achieving successful vaginal birth after caesarean section in three European countries

OBJECTIVE

Knowledge about labour characteristics of women achieving successful vaginal birth after caesarean section (VBAC) might be used to improve labour and birth management. This study examined sociodemographic and labour process-related factors regarding a) differences between countries, b) the comparison of successful VBAC with unplanned caesarean section, and c) predictors for the success of planned VBAC in three European countries.

DESIGN

We analysed observational data collected within the OptiBIRTH trial, a cluster-randomised controlled trial.

SETTING

Fifteen study sites in Ireland, Italy and Germany, five in each country.

PARTICIPANTS

790 participants going into labour for planned VBAC.

MEASUREMENTS

Descriptive statistics and random-effects logistic regression models were applied.

FINDINGS

The pooled successful VBAC-rate was 74.6%. Italy had the highest proportion of women receiving none of the four intrapartum interventions amniotomy (ARM), oxytocin, epidural or opioids (42.5% vs Ireland: 26.8% and Germany: 25.3%, p < 0.001). Earlier performance of ARM was associated with successful VBAC (3.50 hrs vs 6.08 hrs, p = 0.004). A positive predictor for successful vaginal birth was a previous vaginal birth (OR=3.73, 95% CI [2.17, 6.44], p < 0.001). The effect of ARM increased with longer labour duration (OR for interaction term=1.06, 95% CI [1.004, 1.12], p = 0.035). Higher infant birthweight (OR per kg=0.34, 95% CI [0.23, 0.50], p < 0.001), ARM (reference spontaneous rupture of membranes (SROM), OR=0.20, 95% CI [0.11, 0.37], p < 0.001) and a longer labour duration (OR per hour=0.93, 95% CI [0.90, 0.97], p < 0.001) decreased the odds of a vaginal birth.

KEY CONCLUSION

Women with a previous vaginal birth, an infant with a lower birth weight, SROM and a shorter labour duration were most likely to have a successful vaginal birth. If SROM did not occur, an earlier ARM increased the odds of a vaginal birth.

IMPLICATION FOR PRACTICE

Labour progress should be accelerated by fostering endogenous uterine contractions. With slow labour progress and intact membranes, ARM might increase the chance of a vaginal birth.

Labor Onset, Oxytocin Use, and Epidural Anesthesia for Vaginal Birth after Cesarean Section and Associated Effects on Maternal and Neonatal Outcomes in a Tertiary Hospital in China: A Retrospective Study

Background

In the mainland of China, the trial of labor after cesarean section is still a relatively new technique. In this study, we aimed to investigate the effects of labor onset, oxytocin use, and epidural anesthesia on maternal and neonatal outcomes for vaginal birth after cesarean section (VBAC) in a tertiary hospital in China.

Methods

This was a retrospective study carried out on 212 VBAC cases between January 2015 and June 2017 in Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Relevant data were acquired on a form, including maternal age, gravidity and parity, body mass index before pregnancy, weight gain during pregnancy, type of labor onset, gestational age, the use of oxytocin and epidural anesthesia, birth mode, the duration of labor, and neonatal weight. The factors affecting maternal and neonatal outcomes for cases involving VBAC, especially with regards to postpartum hemorrhage (PPH) and fetal distress, were evaluated by univariate analysis and multivariable logistic regression.

Results

Data showed that 36 women (17.0%) had postpartum hemorrhage (PPH) and 51 cases (24.1%) featured fetal distress. Normal delivery took place for 163 infants (76.9%) while 49 infants (23.1%) underwent operative vaginal deliveries with forceps. There were 178 cases (84.0%) of spontaneous labor and 34 cases (16.0%) required induction. Oxytocin was used in 54 cases (25.5%) to strengthen uterine contraction, and 65 cases (30.7%) received epidural anesthesia. The rate of normal delivery in cases involving PPH was significantly lower than those without PPH (61.1% vs. 80.1%; χ² = 6.07, P = 0.01). Multivariate logistic analysis showed that the intrapartum administration of oxytocin (odds ratio [OR] = 2.47; 95% confidence interval [CI] = 1.07-5.74; P = 0.04) and birth mode (OR = 0.40; 95% CI = 0.18-0.87; P = 0.02) was significantly associated with PPH in VBAC cases. Operative vaginal delivery occurred more frequently in the group with fetal distress than the group without (49.0% vs. 14.9%, χ² = 25.36, P = 0.00). Multivariate logistic analysis also revealed that the duration of total labor (OR = 1.01; 95% CI = 1.00-1.03; P = 0.04) and the gestational week of delivery (OR = 1.08; 95% CI = 1.05-1.11; P = 0.00) were significantly associated with fetal distress in VBAC.

Conclusions

The administration of oxytocin during labor and birth was identified as a protective factor for PPH in VBAC while birth mode was identified as a risk factor. Finally, the duration of total labor and the gestational week of delivery were identified as risk factors for fetal distress in cases of VBAC. This information might help obstetricians provide appropriate interventions during labor and birth for VBAC.