Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

Comparison of Clinical and Radiological Findings for the Prediction of Scar Integrity in Women With Previous Lower Segment Cesarean Sections

INTRODUCTION

We aimed to compare the clinical and radiological findings to predict scar integrity in term antenatal mothers with a previous lower segment cesarean section (LSCS).

METHODOLOGY

This prospective study was conducted in the obstetrics and gynecology department of LN Medical College, Bhopal, India, from August 2020 to August 2021. We included all pregnant women with term gestation (37+0 to 42+0 weeks) who were admitted either for elective repeat LSCS or for emergency LSCS and had a history of a previous LSCS. A detailed history and clinical examinations were performed. We noted the presence of scar tenderness and conducted transabdominal ultrasound (USG) to assess the integrity of the uterine scar in all women. During surgery, the surgeon identified the lower uterine segment scar and graded it as normal, thinned-out, dehiscent, or ruptured. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both clinical findings (scar tenderness) and ultrasound findings as predictors of scar integrity.

RESULTS

A total of 60 pregnant women were included in the study. During a repeat cesarean section, we found a thinned-out scar in 26 women out of 60 (43.3%). Out of 60 women, 13 had scar tenderness, and among these 13 women, 12 had thinned-out scars intraoperatively. Forty-seven women had no scar tenderness; 14 had thinned-out scars intraoperatively. The sensitivity of scar tenderness as a predictor of a thinned-out scar was 46.2%, specificity was 97.1%, PPV was 92.3%, and NPV was 70.2%. Whereas the sensitivity of ultrasound scar thickness as a predictor of a thinned-out scar was only 19.2%, with a specificity of 94.1%, a PPV of 71.4%, and an NPV of 60.4%. Thus, we documented a significant correlation between intraoperative and clinical findings (κ = 0.46; p<0.05), but no agreement could be found between ultrasound and intraoperative findings (p>0.05).

CONCLUSIONS

Clinically evident scar tenderness continues to be a useful parameter to predict intraoperative scar status.

Unexpected Uterine Rupture-A Case Report, Review of the Literature and Clinical Suggestions

BACKGROUND AND OBJECTIVES

Women with a history of cesarean section are a high-risk group because they are likely to develop uterine rupture during their next pregnancy. Current evidence suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC).

CASE DESCRIPTION

A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally, underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction, she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was performed. The presumed diagnosis was confirmed during the procedure-a full-thickness rupture of the pregnant uterus was found. The fetus was delivered without signs of life and successfully resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient was discharged 4 days after the cesarean section without significant complications, with a healthy newborn girl.

CONCLUSIONS

Uterine rupture is a rare but severe obstetric emergency and can be associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC attempt should always be considered, even if it is a subsequent TOLAC.

Factors Associated with Failed Trial of Labor after Cesarean, among Women with Twin Gestation-A Multicenter Retrospective Cohort Study

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40−0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36−19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65−1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01−20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery.

Intrapartum ultrasound measurement of the lower uterine segment thickness in parturients with previous scar in labor: a cross-sectional study

Background

There is a lack of reliable methods to estimate the risk of uterine rupture or dehiscence during a trial of labor in women with previous cesarean sections. This study aimed to assess the lower uterine segment and myometrial thickness by ultrasonography in women with previous cesarean sections during labor and assess their association with the uterine defect.

Methods

A cross-sectional study was conducted on 161 women in the active phase of labor having one previous cesarean section. The study was conducted et al.-Azhar University Hospital, Assiut City, Egypt, from March 2018 to March 2019. Ultrasound measurements of lower uterine segment thickness and myometrial thickness were conducted by vaginal and abdominal ultrasound by two observers. The correlation of both thicknesses with the uterine defect was analyzed.

Results

Uterine defects were reported in 42 women (25.9%), uterine rupture in four women (2.5%), and dehiscence in 38 women (23.5%). The uterine defects were not associated with maternal factors (maternal age, gestational age at labor, body mass index, birth weight, interpregnancy, and inter-delivery interval). Receiver operating curve analysis demonstrated that lower uterine segment thickness was linked with uterine defect, with an area under the curve of 60% (95% CI, 51–70%, P = 0.044). Myometrial thickness was also linked to the uterine defect, with an area under the curve of 61% (95% CI, 52–71%, P = 0.025). Full lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm were the cutoff value with the best combination of sensitivity and specificity for the uterine defect. Lower uterine segment thickness (OR = 0.49, 95%CI 0.24–0.96) and myometrial thickness (OR = 0.44, 95%CI 0.20–0.94) were significantly associated with the uterine defect. Lower uterine segment thickness (OR = 0.41, 95%CI 0.22–0.76) and myometrial thickness (OR = 0.33, 95%CI 0.16–0.66) were also significantly associated with cesarean section delivery.

Conclusion

A lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm during the first stage of labor are associated with a high risk of uterine defects during a labor trial. These measurements during labor can have a practical application in deciding the mode of delivery in women with previous cesarean sections and might reduce uterine rupture.

Labour induction in twin pregnancies

Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.