Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean

The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: A meta-analysis

BACKGROUND

The increasing global incidence of cesarean section has prompted efforts to reduce cesarean delivery rates. A trial of labor after cesarean (TOLAC) has emerged as an alternative to elective repeat cesarean delivery (ERCD) for women with a prior cesarean delivery. However, the available evidence on the comparative outcomes of these 2 options remains inconsistent, primarily due to varying advantages and risks associated with each. Our meta-analysis aims to compare the maternal-neonatal results in TOLAC and ERCD in women with prior cesarean deliveries.

METHODS

A comprehensive search was performed in PubMed, Embase, Cochrane library databases up to September,2022 to identity studies evaluating perinatal outcomes in women who underwent TOLAC compared to ERCD following a previous cesarean delivery. The included studies were subjected to meta-analysis using RevMan 5.3 software to assess the overall findings.

RESULTS

A total of 13 articles were included in this meta-analysis. Statistically significant differences were identified in the rate of uterine rupture (OR = 2.01,95%CI = 1.48-2.74, P < .00001) and APGAR score < 7 at 5 minutes (OR = 2.17,95%CI = 1.69-2.77, P < .00001) between the TOLAC and ERCD groups. However, no significant differences were observed in the rates of hysterectomy, maternal blood transfusion, postpartum infection, postpartum hemorrhage and neonatal intensive care unit (P ≥ .05) admission between the 2 groups.

CONCLUSIONS

Our analysis revealed that TOLAC is associated with a higher risk of uterine rupture and lower incidence APGAR score < 7 at 5 minutes compared to ERCD. It is vital to consider predictive factors when determining the appropriate mode of delivery in order to ensure optimal pregnancy outcomes. Efforts should be made to identify the underlying causes of adverse outcomes and implement safety precautions to select suitable participants and create safe environments for TOLAC.

Vaginal birth after cesarean section: Experience from a regional hospital

OBJECTIVE

Trial of labor after cesarean section (TOLAC) is an option for women with previous cesarean section. However, few women choose this option because of safety concerns. We evaluate the safety and risks associated with TOLAC and the success rate of vaginal birth after cesarean delivery (VBAC).

MATERIAL AND METHODS

We reviewed all patients with a history of previous cesarean section that underwent elective repeat cesarean section (ERCS) or TOLAC in a regional teaching hospital from Nov, 2013 to May, 2018. Maternal basic clinical information, intrapartum management, postpartum complications, and neonatal outcomes were analyzed.

RESULTS

199 pregnant women with a history of at least one previous cesarean section were enrolled. 156 women received ERCS and 43 women (21.6%) underwent TOLAC, with 37 (86.0%) who underwent successful VBAC. The VBAC rate was 18.6%. Higher success rate was found in women with previous vaginal birth than in women without vaginal birth (100% vs. 81.8%). One case (2.3%) in the VBAC group was complicated with uterine rupture and inevitable neonatal death during second stage of labor. The uterus was repaired without maternal complications. In another case, the newborn's condition was complicated with low APGAR score (<7) at birth due to maternal chorioamnionitis. Among indications for previous cesarean section, cephalo-pelvic disproportion (CPD) was associated with TOLAC failure and uterine rupture after VBAC.

CONCLUSION

VBAC is a feasible and safe option. Modes of delivery should be thoroughly discussed when considering TOLAC for women with history of previous cesarean section due to CPD, considering its association with TOLAC failure in second stage of labor.

Health Care System Barriers to Vaginal Birth after Cesarean Section: A Qualitative Study

BACKGROUND

Approximately half of mothers give birth by cesarean section in Iran and two-thirds of them are repeated cesareans. Repeated cesarean is threatening for the mothers and newborns and not compatible with fertility policies in Iran. Vaginal Birth After Cesarean (VBAC) is a reasonable strategy but its prevalence is very low due to some barriers. The aim of this study was to explore barriers to VBAC in health care system.

MATERIALS AND METHODS

In this qualitative study, 26 semi-structured individual interviews with maternity care providers and mothers with prior cesarean section as well as one focus group discussion with maternity care providers were conducted. Interviews and focus group discussions were tape-recorded, transcribed verbatim and analyzed with conventional content analysis developed by Graneheim and Lundman using MXQDA10 software.

RESULTS

Barriers to VBAC in health care system identified in the main category of "the climate of restriction, fear and discourage" and eight subcategories including: "defective access to specialized services," "insufficient encouragement system," "modeling in cesarean section," "physician-centeredness in VBAC," "fear of legal responsibilities," "imposed policies," "marginalization of midwives," and "unsupportive birth team."

CONCLUSIONS

To remove barriers of VBAC in health care system, appropriate strategies including establishment of specialized VBAC counseling centers, performance-based incentive policies, cultural development and promotion of natural childbirth, promoting of teamwork culture, shared decision making, improvement of knowledge and skills of maternal care providers and implementation of clinical guidelines, should be considered. Future research could be focused on the effect of implementing these strategies to decrease repeat cesarean section rate.

Reasons for previous Cesarean deliveries impact a woman's independent decision of delivery mode and the success of trial of labor after Cesarean

BACKGROUND

Cesarean delivery rates are increasing globally with almost half of them occurring due to a previous Cesarean delivery. A trial of labor after Cesarean (TOLAC) is considered a safe procedure, but most eligible women instead undergo Cesarean before 39 weeks of gestation. Lack of education about TOLAC is often associated with increased repeat Cesarean. To reveal the safety and feasibility of TOLAC, we conducted this observational, prospective study with women's independent decisions. We aimed to clarify the relationship between their chosen mode of delivery and the reason for their previous Cesarean. Additionally, we have tried to identify maternal and obstetric factors associated with failed TOLAC to improve its success rate.

METHODS

This was a prospective, observational study of 1086 pregnant women with at least one previous Cesarean delivery. Of these, 735 women met our TOLAC criteria (Table 1), and then, could choose TOLAC or repeat Cesarean after receiving detailed explanations regarding the risks and benefits of both procedures. The primary outcomes were the number of successful TOLAC procedures and 5-min Apgar scores < 7 for the trial of labor after Cesarean group and elective Cesarean group. We collected the maternal and neonatal data including the reasons of previous Cesarean.

RESULTS

In total, 64.1% of women chose TOLAC. The success rate was 91.3%. The uterine rupture rate was 0.6%. There were no significant differences in the rate of Apgar scores at 5 min < 7 between both groups. Histories of experience of labor in previous Cesarean delivery were observed in 30 and 50% of women who chose TOLAC and repeat Cesarean, respectively (p < 0.05). Factors related to failed TOLAC included ≥40 weeks of gestation (odds: 5.47, 95% CI: 2.55-11.70) and prelabor rupture of membranes (PROM) (odds: 4.47, 95% CI: 2.07-9.63).

CONCLUSIONS

TOLAC is a favorable delivery option for both mothers and neonates when women meet criteria and choose after receiving detailed explanations. Women who experience PROM or ≥ 40 weeks of gestation, their modes of delivery should be reconsulted.

Association between uterine contractions before elective caesarean section and transient tachypnoea of the newborn: a retrospective cohort study

OBJECTIVE

We evaluated the association between the presence of predelivery uterine contractions and transient tachypnoea of the newborn (TTN) in women undergoing an elective caesarean section.

DESIGN

A retrospective cohort study.

SETTING

National Hospital Organization Kofu National Hospital, which is a community hospital, between January 2011 and May 2019.

PARTICIPANTS

The study included 464 women who underwent elective caesarean section. The exclusion criteria were missing data, twin pregnancy, neonatal asphyxia, general anaesthesia and elective caesarean section before term.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were grouped according to the presence or absence of uterine contractions on a 40-min cardiotocogram (CTG) performed within 6 hours before caesarean delivery. We performed a multivariable logistic regression analysis to examine the association between predelivery uterine contractions and TTN.

RESULTS

The incidence of TTN was 9.9% (46/464), and 38.4% (178/464) of patients had no uterine contraction. The absence of uterine contractions was significantly associated with an increased risk of TTN (adjusted OR 2.04; 95% CI 1.09 to 3.82) after controlling for gestational diabetes mellitus, small for gestational age, male sex and caesarean section at 37 weeks.

CONCLUSIONS

Accurate risk stratification using a CTG could assist in the management of infants who are at risk of developing TTN.

Shared decision-making for delivery mode: An OPTION scale observer-based evaluation

OBJECTIVE

Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.

METHODS

Fifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.

RESULTS

The OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.

CONCLUSION

A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.

PRACTICE IMPLICATIONS

The OPTION¹² scale may prove useful for testing the extent of pregnant women's involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.

Defining the patient safety attitudes and influencing factors of health professionals working at maternity hospitals

AIM

To determine patient safety attitudes of midwives, nurses and physicians and to examine the difference or correlation in patient safety attitudes of midwives, nurses and physicians working in maternity hospitals.

BACKGROUND

It has been suggested that it is necessary to define the factors affecting patient safety attitudes of health professionals working in maternity hospitals.

METHODS

A descriptive and correlational design was employed.The sample comprised 58 midwives, 134 nurses and 63 physicians (255) in two maternity hospitals in Istanbul, Turkey. The data were collected using an 'information form' and a 'Patient Safety Attitude Questionnaire'.

RESULTS

The safety attitudes of participants were generally found to be negative. However, midwives had more positive patient safety attitudes and the age, unit, adequacy of patient safety training and the importance of patient safety were the most effective variables.

CONCLUSIONS

As health professionals working in maternity hospitals generally have negative patient safety attitudes and because patient safety training provided better attitudes among the participants, these training programmes should be developed and implemented considering the differences among age groups and units.

IMPLICATIONS FOR PRACTICE

Health professionals have different views on the patient safety culture; therefore, training needs to involve everyone to create a shared vision for patient safety.

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.

Labor after cesarean delivery managed without induction or augmentation of labor

BACKGROUND

This study aimed to describe the perinatal outcomes of women opting for vaginal birth after cesarean delivery (VBAC) managed without induction or augmentation of labor.

METHODS

This was a retrospective cohort study of candidates for VBAC at a tertiary center in Japan from April 2003 to March 2012. Women with singleton gestations and one prior low-transverse cesarean delivery who intended VBAC at 36 weeks of gestation were identified as candidates for VBAC and included in the study. Participants were managed without induction or augmentation of labor. Maternal characteristics and perinatal outcomes were obtained from medical records. Factors associated with successful VBAC were analyzed with a multivariable logistic regression model.

RESULTS

Of 333 candidates for VBAC, 242 (72.7%) had vaginal birth, 49 (14.7%) had repeat cesarean delivery with spontaneous labor, and 42 (12.6%) had repeat cesarean delivery without spontaneous labor. The rate of uterine rupture was 0.3% (1/333). Prior vaginal delivery and nonrecurring indications for prior cesarean delivery were associated with successful VBAC.

CONCLUSIONS

Management of candidates for VBAC without induction or augmentation of labor resulted in a high VBAC rate and favorable perinatal outcomes. Such restrictive VBAC policies may be an acceptable alternative to standard management or abandonment of VBAC.

Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome

AIM

Cesarean scar syndrome (CSS) is characterized by increased risk of postmenstrual abnormal uterine bleeding, dysmenorrhea, and infertility, due to a post-cesarean scar defect known as an isthmocele. This study aimed to assess the impact of hysteroscopic surgery on isthmocele associated with CSS.

METHODS

Eighteen patients with CSS were enrolled. Surgical methods included resection of the inferior edge and superficial cauterization of the isthmocele via hysteroscopic surgery. We evaluated the residual myometrial thickness and isthmocele volume using magnetic resonance imaging, before and after hysteroscopic surgery.

RESULTS

All patients underwent surgery without any complications. The residual myometrium was thicker after hysteroscopic surgery (median: 2.1 mm and 4.2 mm, before and after surgery, respectively; P = 0.0001). Isthmocele volume was significantly reduced after hysteroscopic surgery (median: 494.9 mm³ and 282.8 mm³ , before and after surgery, respectively; P = 0.0016).

CONCLUSION

This study demonstrated that hysteroscopic surgery is effective in increasing the residual myometrial thickness and reducing the size of isthmocele.