Perinatal outcome in births after a previous cesarean section at high trial of labor rates

Trial of Labor versus Repeat Cesarean Delivery in Individuals with Morbid Obesity after Previous Cesarean Delivery

OBJECTIVE

 This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m2) and the presence of previous vaginal delivery (VD).

STUDY DESIGN

 This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates.

RESULTS

 Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m2, 1,108,278 had BMI 30 to 39.9 kg/m2, and 320,031 had BMI 40 to 69.9 kg/m2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m2 (5.0 vs. 6.5%; aRR 1.33 [1.30-1.36]), BMI 30 to 39.9 kg/m2 (6.1 vs. 7.8%; aRR 1.29 [1.24-1.34]), and BMI 40 to 69.9 kg/m2 (8.2 vs. 9.0%; aRR 1.15 [1.07-1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m2 (6.2 vs. 5.8%; aRR 0.98 [0.96-1.00]), BMI 30 to 39.9 kg/m2 (7.4 vs. 7.1%; aRR 0.99 [0.95-1.02]), and BMI 40 to 69.9 kg/m2 (9.4 vs. 8.7%; aRR 0.96 [0.91-1.02]).

CONCLUSION

 TOLAC among obese individuals could be offered in selected cases.

KEY POINTS

· TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it.. · Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC.. · Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications..

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.

Planned mode of birth after previous cesarean section: A structured review of the evidence on the associated outcomes for women and their children in high-income setting

In many high-income settings policy consensus supports giving pregnant women who have had a previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or planning a vaginal birth after previous cesarean (VBAC), provided they have no contraindications to VBAC. To help women make an informed decision regarding this choice, clinical guidelines advise women should be counseled on the associated risks and benefits. The most recent and comprehensive review of the associated risks and benefits of planned VBAC compared to ERCS in high-income settings was published in 2010 by the US Agency for Healthcare Research and Quality (AHRQ). This paper describes a structured review of the evidence in high-income settings that has been published since the AHRQ review and the literature in high-income settings that has been published since 1980 on outcomes not included in the AHRQ review. Three databases (MEDLINE, EMBASE, and PsycINFO) were searched for relevant studies meeting pre-specified eligible criteria, supplemented by searching of reference lists. Forty-seven studies were identified as meeting the eligibility criteria and included in the structured review. The review suggests that while planned VBAC compared to ERCS is associated with an increased risk of various serious birth-related complications for both the mother and her baby, the absolute risk of these complications is small for either birth approach. The review also found some evidence that planned VBAC compared to ERCS is associated with benefits such as a shorter length of hospital stay and a higher likelihood of breastfeeding. The limited evidence available also suggests that planned mode of birth after previous cesarean section is not associated with the child’s subsequent risk of experiencing adverse neurodevelopmental or health problems in childhood. This information can be used to manage and counsel women with previous cesarean section about their subsequent birth choices. Collectively, the evidence supports existing consensus that there are risks and benefits associated with both planned VBAC and ERCS, and therefore women without contraindications to VBAC should be given an informed choice about planned mode of birth after previous cesarean section. However, further studies into the longer-term effects of planned mode of birth after previous cesarean section are needed along with more research to address the other key limitations and gaps that have been highlighted with the existing evidence.

Feeding Practices, Maternal and Neonatal Outcomes in Vaginal Birth after Cesarean and Elective Repeat Cesarean Delivery

Cesarean section rates are constantly rising, and the number of women with a prior cesarean considering a delivery mode for their next labor is increasing. We aimed to compare maternal and neonatal outcomes and feeding method in women undergoing vaginal birth after cesarean (VBAC) versus elective repeat cesarean delivery (ERCD). This was a retrospective cohort study of women with one prior cesarean delivery (CD) and no previous vaginal births, delivering vaginally or by a CD in a single institution between 2016 and 2018. 355 live singleton spontaneous vaginal and cesarean deliveries were included. 121 women delivered vaginally and 234 had a CD. Neonates born by a CD were more likely to have higher birth weight (p < 0.001), higher weight at discharge (p < 0.001), macrosomia (p = 0.030), lose >10% of their body mass (p = 0.001), be mixed-fed (p < 0.001), and be hospitalized longer (p < 0.001). Children born vaginally were more likely to be exclusively breastfed (p < 0.001). Women undergoing VBAC were more likely to deliver preterm (p = 0.006) and post-term (p < 0.001), present with PROM (p < 0.001), have greater PROM latency period (p < 0.001), and experience intrahepatic cholestasis of pregnancy (p = 0.029), postpartum anemia (p < 0.001), and peripartum blood loss >1 L (p = 0.049). The incidence of anemia during pregnancy was higher in the ERCD cohort (p = 0.047). Women undergoing VBAC are more likely to breastfeed their children, perhaps for the same reason they choose the vaginal method of delivery, as vaginal delivery and breastfeeding along with antibiotic use, are the most important factors decreasing the risk for future diseases in their offspring.

Prediction of vaginal birth after cesarean delivery in Southeast China: a retrospective cohort study

BACKGROUND

We aimed to develop and validate a nomogram for effective prediction of vaginal birth after cesarean (VBAC) and guide future clinical application.

METHODS

We retrospectively analyzed data from hospitalized pregnant women who underwent trial of labor after cesarean (TOLAC), at the Fujian Provincial Maternity and Children's Hospital, between October 2015 and October 2017. Briefly, we included singleton pregnant women, at a gestational age above 37 weeks who underwent a primary cesarean section, in the study. We then extracted their sociodemographic data and clinical characteristics, and randomly divided the samples into training and validation sets. We employed the least absolute shrinkage and selection operator (LASSO) regression to select variables and construct VBAC success rate in the training set. Thereafter, we validated the nomogram using the concordance index (C-index), decision curve analysis (DCA), and calibration curves. Finally, we adopted the Grobman's model to perform comparisons with published VBAC prediction models.

RESULTS

Among the 708 pregnant women included according to inclusion criteria, 586 (82.77%) patients were successfully for VBAC. Multivariate logistic regression models revealed that maternal height (OR, 1.11; 95% CI, 1.04 to 1.19), maternal BMI at delivery (OR, 0.89; 95% CI, 0.79 to 1.00), fundal height (OR, 0.71; 95% CI, 0.58 to 0.88), cervix Bishop score (OR, 3.27; 95% CI, 2.49 to 4.45), maternal age at delivery (OR, 0.90; 95% CI, 0.82 to 0.98), gestational age (OR, 0.33; 95% CI, 0.17 to 0.62) and history of vaginal delivery (OR, 2.92; 95% CI, 1.42 to 6.48) were independently associated with successful VBAC. The constructed predictive model showed better discrimination than that from the Grobman's model in the validation series (c-index 0.906 VS 0.694, respectively). On the other hand, decision curve analysis revealed that the new model had better clinical net benefits than the Grobman's model.

CONCLUSIONS

VBAC will aid in reducing the rate of cesarean sections in China. In clinical practice, the TOLAC prediction model will help improve VBAC's success rate, owing to its contribution to reducing secondary cesarean section.

Prediction of vaginal birth after cesarean deliveries using machine learning

BACKGROUND

Efforts to reduce cesarean delivery rates to 12-15% have been undertaken worldwide. Special focus has been directed towards parturients who undergo a trial of labor after cesarean delivery to reduce the burden of repeated cesarean deliveries. Complication rates are lowest when a vaginal birth is achieved and highest when an unplanned cesarean delivery is performed, which emphasizes the need to assess, in advance, the likelihood of a successful vaginal birth after cesarean delivery. Vaginal birth after cesarean delivery calculators have been developed in different populations; however, some limitations to their implementation into clinical practice have been described. Machine-learning methods enable investigation of large-scale datasets with input combinations that traditional statistical analysis tools have difficulty processing.

OBJECTIVE

The aim of this study was to evaluate the feasibility of using machine-learning methods to predict a successful vaginal birth after cesarean delivery.

STUDY DESIGN

The electronic medical records of singleton, term labors during a 12-year period in a tertiary referral center were analyzed. With the use of gradient boosting, models that incorporated multiple maternal and fetal features were created to predict successful vaginal birth in parturients who undergo a trial of labor after cesarean delivery. One model was created to provide a personalized risk score for vaginal birth after cesarean delivery with the use of features that are available as early as the first antenatal visit; a second model was created that reassesses this score after features are added that are available only in proximity to delivery.

RESULTS

A cohort of 9888 parturients with 1 previous cesarean delivery was identified, of which 75.6% of parturients (n=7473) attempted a trial of labor, with a success rate of 88%. A machine-learning-based model to predict when vaginal delivery would be successful was developed. When features that are available at the first antenatal visit are used, the model showed a receiver operating characteristic curve with area under the curve of 0.745 (95% confidence interval, 0.728-0.762) that increased to 0.793 (95% confidence interval, 0.778-0.808) when features that are available in proximity to the delivery process were added. Additionally, for the later model, a risk stratification tool was built to allocate parturients into low-, medium-, and high-risk groups for failed trial of labor after cesarean delivery. The low- and medium-risk groups (42.4% and 25.6% of parturients, respectively) showed a success rate of 97.3% and 90.9%, respectively. The high-risk group (32.1%) had a vaginal delivery success rate of 73.3%. Application of the model to a cohort of parturients who elected a repeat cesarean delivery (n=2145) demonstrated that 31% of these parturients would have been allocated to the low- and medium-risk groups had a trial of labor been attempted.

CONCLUSION

Trial of labor after cesarean delivery is safe for most parturients. Success rates are high, even in a population with high rates of trial of labor after cesarean delivery. Application of a machine-learning algorithm to assign a personalized risk score for a successful vaginal birth after cesarean delivery may help in decision-making and contribute to a reduction in cesarean delivery rates. Parturient allocation to risk groups may help delivery process management.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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