Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study.

OBJECTIVES: Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights to make an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications. METHODS: In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages. RESULTS: A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation (SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen. CONCLUSIONS: Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.

Vaginal birth after caesarean birth in Italy: variations among areas of residence and hospitals.

BACKGROUND: The rates of caesarean section (CS) are increasing globally. CS rates are one of the most frequently used indicators of health care quality. Vaginal Birth After Caesarean (VBAC) could be considered a reasonable and safe option for most women with a previous CS. Despite this fact, in some European countries, many women who had a previous CS will have a routine CS subsequently and VBAC rates are extremely variable across countries. VBAC use is inversely related to caesarean use. The objective of the present study was to analyze VBAC rates with respect to caesarean rates and the variations among areas of residence, hospitals and hospital ownership types in Italy. METHODS: This study was based on information from the Hospital Information System (HIS). We collected data from all deliveries in Italy from January 1, 2010 to December 31, 2014 and we considered only deliveries with a previous caesarean section. Applying multivariate logistic regression analysis, the adjusted proportions of VBAC for each Local Health Units (LHU), each hospital and by hospital ownership types were calculated. Cross-classified logistic multilevel models were performed to analyze within geographic, hospitals and hospital ownership types variations. RESULTS: We studied a total of 77,850 deliveries with a previous caesarean section in Italy between January 1, 2010 and December 31, 2014. The proportion of VBAC in Italy slightly increased in the last few years, from 5.8% in 2010 to 7.5% in 2014. Proportions of VBAC ranged from 0.29 to 50.05% in Italian LHUs. The LHUs with lower proportions of VBAC deliveries were characterized by higher values for primary caesarean deliveries. Private hospitals showed the lowest mean of crude VBAC proportions but the highest variation among hospitals, ranging from 0 to 47.1%. CONCLUSIONS: Hospital rates of caesarean section for women with at least one previous caesarean section vary widely, and only some of the variation can be explained by case-mix and hospital-level factors, suggesting that additional factors influence practices. Identifying disparities in VBAC may have important implications for health services planning and targeted efforts to reduce overall rates of caesarean deliveries.

Vaginal birth after cesarean section-The world trend and local experience in Taiwan.

OBJECTIVE: The trend of increasing cesarean section rates had evoked worldwide attention. Many approaches were introduced to diminish cesarean section rates. Vaginal birth after cesarean section (VBAC) is a route of delivery with diverse agreements. In this study, we try to reveal the world trend in VBAC and our experience of a 10-year period in a medical center in northern Taiwan. MATERIALS AND METHODS: This is a retrospective study of all women who underwent elective repeat cesarean delivery or trial of labor after cesarean (TOLAC) following primary cesarean delivery by a general obstetrician-gynecologist in the Tamshui Branch of MacKay Memorial Hospital (Taipei, Taiwan) between 2006 and 2015. We excluded cases of preterm labor, two or more cesarean deliveries, and major maternal diseases. We compared the characteristics and outcomes between these groups. RESULTS: We included 400 women with subsequent pregnancies who underwent elective repeat cesarean delivery or TOLAC during the study period. Among the study population, 112 women were excluded and 11 underwent repeat VBAC. A total of 204 (73.65%) cases underwent elective repeat cesarean delivery and 73 (26.35%) chose TOLAC. The rate of successful VBAC among the women who chose TOLAC was 84.93%. CONCLUSION: With respect to maternal and fetal safety, and success rates and adverse effects of VBAC, the results of this study are promising and compatible with the global data. It shows that a trial of VBAC can be offered to pregnant women without contraindications with high success rates.

Why wildly varying C-section rates persist.

There's little information on how hospitals, doctors and patients make delivery decisions, which could help drop related healthcare costs and our nation's high C-section rate.

Back to "once a caesarean: always a caesarean"? A trend analysis in Switzerland.

PURPOSE: Caesarean sections (CS) have significantly increased worldwide and a previous CS is nowadays an important and increasingly reported indication to perform a repeat CS. There is a paucity of information in Switzerland on the incidence of repeat CS after previous CS and relationship between the rates of vaginal birth after CS (VBAC). The aim of this study was to analyse the actual trend in VBAC in Switzerland. METHODS: We performed a retrospective cohort study to analyse the proportion of VBAC among all pregnant women with previous sections which give birth during two time periods (group 1:1998/1999 vs. group 2:2004/2005) in our tertiary care referral hospital and in the annual statistics of Swiss Women's Hospitals (ASF-Statistics). In addition, the proportion of induction of labour after a previous caesarean and its success was analysed. RESULTS: In both cohorts studied, we found a significant decrease of vaginal births (p < 0.05) and a significant increase of primary elective repeat caesarean section (p < 0.05) from the first to the second time period, while there was a decrease of secondary repeat caesarean sections. The prevalence of labour induction did not decrease. CONCLUSION: Our study shows that vaginal birth after a prior caesarean section has decreased over time in Switzerland. There was no significant change in labour induction during the study period. While this trend might reflect an increasing demand for safety in pregnancy and childbirth, it concomitantly increases maternal risks of further pregnancies, and women need to be appropriately informed about long-term risks.

Incidence and determinants of peripartum hysterectomy in the metropolitan area of the District of Columbia.

OBJECTIVE: To review the impact of the changes that have occurred in the standard of care in obstetrics and in the trend of cesarean delivery rates in recent times and factors associated with peripartum hysterectomy procedure. STUDY DESIGN: A retrospective analysis of all cases of peripartum hysterectomies among inpatient hospitalizations at 4 major hospitals in the Washington metropolitan areas of the District of Columbia from January 1, 2000, through December 31, 2009, was conducted. RESULTS: The total number of deliveries and postpartum hysterectomies that occurred at all 4 locations was 150,847 and 128, respectively. The rate of peripartum hysterectomies per 1,000 deliveries was 0.85. Primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity have direct association with peripartum hysterectomy. Up to 80% of all cases of peripartum hysterectomy are accounted for by class III and IV hemorrhage. Peripartum hysterectomy is associated with increased prevalence of uterine atony, placenta previa, and placenta accreta. CONCLUSION: Our results suggest that primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity, uterine atony, placenta previa, and placental accreta, and class III and IV hemorrhage are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern given the increasing rate of cesarean deliveries in the District.

Rates and success rates of trial of labor after cesarean delivery in the United States, 1990-2009.

This study compares rates of trial of labor after Cesarean delivery (TOLAC) and rates of successful TOLAC between 1990 and 2009. Serial cross-sectional analyses were performed using the National Hospital Discharge Survey data to compare rates of TOLAC and TOLAC success between 1990 and 2009. Joinpoint regression was used to assess trends over time, and logistic regression with marginal effects was used to examine the unadjusted and adjusted significance and magnitude of trends. The rate of TOLAC reached a high of 51.8 % (95 % CI 47.8-55.8 %) in 1995 and a low of 15.9 % (95 % CI 13.8-18.0 %) in 2006, declined, on average, 4.2 (95 % CI -4.8 to -3.9) percentage points per year between 1996 and 2005. Rates increased significantly from 1990 to 1996 and 2005 to 2009. TOLAC success was at its highest rate in 2000, 69.8 % (95 % CI 65.2-74.3 %) and its lowest in 2008, 38.5 % (95 % CI 28.1-48.8 %). The rate of TOLAC success increased significantly between 1990 and 2000, but declined thereafter an average of 3.4 % points per year (95 % CI -4.3 to -2.5). The rate of TOLAC in the US decreased between 1996 and 2005 and the rate of successful TOLAC has declined from 2000 to 2009.

Rise in cesarean section rate over a 20-year period in a public sector hospital in northern Thailand.

OBJECTIVE: To determine a trend of cesarean section rate (CSR) and main contributing factors in a public sector hospital, representing northern part of Thailand. METHODS: A retrospective descriptive analysis was conducted by assessing the database of maternal-fetal medicine unit, which had prospectively been collected for 20 years. Trends were evaluated using data for the years 1992-2011. Private sector patients were excluded. RESULTS: A total of 50,872 public sector patients were available for analysis. The number of deliveries was gradually decreased from 3,802 in 1992 to 1,748 in 2011. Of them, 7,480 underwent cesarean section, CSR of 14.7 %. However, the CSR was significantly increased from 11.3 % in 1992 to 23.6 % in 2011 (p value <0.001). The CSRs indicated by cephalopelvic disproportion (CPD) and previous CSs were mainly responsible for a marked increase over the study period. CSR due to CPD was increased from 3.2 % in 1992 to 7.9 % in 2011 (p value <0.0001). While CSR due to other indications either breech presentation, fetal distress and twin pregnancies were only slightly, but significantly increased in the last decades but they are relatively constant in the recent years. CONCLUSIONS: In our public sector, CSR has gradually increased. The main reasons of such an increase were likely to be associated with over-diagnosis of CPD and subsequent repeated CS, while other indications played only a minimal role. To achieve the appropriate CSR, audit system for diagnosis of CPD must be instituted.

VBAC in the trenches: a community perspective.

Is vaginal birth after cesarean in the community a disappearing practice? Since 1996 the rate of trial of labor after cesarean for low-risk women has dropped precipitously. This paper reviews the current literature and summarizes opinions of community obstetricians and midwives. Descriptive data are presented to document the scope of the problem and identify barriers: liability concerns, provider biases, and institutional restrictions. Our perspective draws on experience in our community hospital with a previously high vaginal birth after cesarean rate and a subsequent ban. Strategies to reduce the skyrocketing cesarean rate and encourage trial of labor after cesarean for low-risk women are outlined.

Epidemiology and trends for Caesarean section births in New South Wales, Australia: a population-based study.

BACKGROUND: Caesarean section (CS) rates around the world have been increasing and in Australia have reached 30% of all births. Robson's Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for international comparisons and trend analyses. This study aimed to investigate trends in CS rates in New South Wales (NSW), including trends in the components of the 10-group classification. METHODS: We undertook a cross-sectional study using data from the Midwives Data Collection, a state-wide surveillance system that monitors patterns of pregnancy care, services and pregnancy outcomes in New South Wales, Australia. The study population included all women giving birth between 1st January 1998 and 31st December 2008. Descriptive statistics are presented including age-standardised CS rates, annual percentage change as well as regression analyses. RESULTS: From 1998 to 2008 the CS rate in NSW increased from 19.1 to 29.5 per 100 births. There was a significant average annual increase in primary 4.3% (95%CI 3.0-5.7%) and repeat 4.8% (95% CI 3.9-5.7%) CS rates from 1998 to 2008. After adjusting for maternal and pregnancy factors, the increase in CS delivery over time was maintained. When examining CS rates classified according to the 10-group classification, the greatest contributors to the overall CS rate and the largest annual increases occurred among nulliparae at term having elective CS and multipara having elective repeat CS. CONCLUSIONS: Given that the increased CS rate cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.

Delivery after previous cesarean: short-term perinatal outcomes.

Women must often choose between a vaginal birth after previous cesarean and elective repeat cesarean delivery. Short-term risks of vaginal birth after cesarean can be potentially catastrophic in the setting of uterine rupture. Although randomized controlled trials comparing these 2 modes of delivery are lacking, observational studies suggest an increased risk of perinatal mortality and hypoxic-ischemic encephalopathy in infants whose mothers undergo a trial of labor. These rare risks compete with more common, albeit less severe, short-term risks associated with elective repeat cesarean delivery, with a particular emphasis on increased respiratory morbidities. Further studies are needed to identify potential strategies to improve perinatal outcomes and help guide physicians and patients in choosing optimal methods of delivery.

Neonatal mortality risk for repeat cesarean compared to vaginal birth after cesarean (VBAC) deliveries in the United States, 1998-2002 birth cohorts.

To examine trends in repeat cesarean delivery, the characteristics of women who have repeat cesareans, and the risk of neonatal mortality for repeat cesarean birth compared to vaginal birth after cesarean (VBAC). Trends and characteristics of repeat cesareans were examined for: the period 1998-2002 for [1] all births, [2] low-risk births (singleton, term, vertex births) and [3] "no indicated risk" (NIR) births (singleton, term, vertex presentation births with no reported medical risks or complications). For low-risk and NIR births, neonatal mortality rates for repeat cesareans and VBACs were compared. Multivariate logistic regression was used to examine the risk of neonatal mortality for repeat cesareans and VBACs, after controlling for demographic and health factors. In 2002 the repeat cesarean rate was 87.4%, and varied little by maternal risk status or by demographic and health characteristics. From 1998-2002 rates increased by 20% for low risk and by 21% for NIR births, respectively. For low-risk women for the 1998-2002 birth cohorts, the adjusted odds ratio for neonatal mortality associated with repeat cesarean delivery (compared with VBAC) was 1.36 (95% C.I. 1.20-1.55). For NIR women, the adjusted odds ratio was 1.24 (0.99-1.55). The experience of a prior cesarean has apparently become a major indication for a repeat cesarean. Regardless of maternal risk status, almost 90% of women with a prior cesarean have a subsequent (i.e., repeat) cesarean delivery. This is the case even if there was no other reported medical indication. Our findings do not support the widely-held belief that neonatal mortality risk is significantly lower for repeat cesarean compared to VBAC delivery.

Trends in indications for caesarean sections over 7 years in a Welsh district general hospital.

The National Sentinel Caesarean Section (CS) Audit showed that the overall CS rate was 21.5% in England and Wales. There have been concerns about the rising CS rate in the UK. We reviewed whether there were any changes in indications for CS over 7 years (2001-2007) in our district general hospital. A database was written and used to record data about each CS, electronically. A library of entries was used to record the indications for all caesarean sections. The data were analysed by each of the years from 2001 to 2007. The overall CS rate in the hospital was nearly 30% in 2007, a rise from 26% in 2001. The commonest indication was previous single CS, followed by other indications: failure-to-progress during the first stage of labour, fetal distress and breech presentation. Over the 7-year period, we have been unable to show any real change in the proportions of indications for CS. Despite heightened awareness and regular feedback, there has been no detectable reduction in CS rates. They appear instead to have increased with no change in the proportions of indications.

'I wanted desperately to have a natural birth': mothers' insights on vaginal birth after Caesarean (VBAC).

There is scant research available on the psycho-social aspects of births subsequent to Caesarean Section (CS). In particular, there is little psycho-social research available in regard to women who seek to have a Vaginal Birth After Caesarean (VBAC). To address this lack of information in the literature, this article explores, from a phenomenological perspective, the reasons motivating women to try for a VBAC, from the perspectives of four women who have tried for or achieved a VBAC. The findings indicate that these mothers differed to other women interviewed in the study who opted for repeat CS. The VBAC mothers expressed a strong belief in the importance of a natural birth as the best start for their infant, strived to reduce where possible drug interventions during labour and birth and believed in the importance of breastfeeding. The VBAC mothers viewed achieving a natural birth as a significant aspect of their femininity and a major life event for a woman.

Indications for caesarean delivery between 1955 and 2005.

INTRODUCTION: We wished to evaluate the changes in the indications and rates of caesarean delivery over the past 50 years (1955-2005) at the Ljubljana Maternity Hospital, the largest maternity hospital in Slovenia and a tertiary center. METHODS: We retrospectively analyzed data obtained from delivery records, archived at the Department of Obstetrics and Gynecology, University Medical Center Ljubljana, for the selected years 1955, 1965, 1975, 1985, 1995 and 2005. The records were archived in bound books (1955), folders (1965 and 1975), on microfilm (1985) and in the national perinatal information system (1995 and 2005). Caesarean delivery rates were calculated and indications statistically analyzed. RESULTS: Of the 38.499 reviewed delivery records, 3122 were the records of caesarean deliveries. The caesarean delivery rate was 2.5% in 1955, 4.95% in 1965, 7.36% in 1975, 7.54% in 1985, 11.76% in 1995 and 15.74% in 2005. Overall, 80 different indications were registered and analyzed, 35 with an incidence>1.0%. The most frequently used indications were caesarean after caesarean, cephalopelvic disproportion, acute fetal distress and malpresentation. DISCUSSION: During the 50-year period, the parameters contained in delivery records changed as the result of new approaches and changing attitudes toward the parturient woman, the course of labor and delivery. In 1955 and 1965, maternal indications prevailed, whereas in 1995 and 2005 some new and nonobstetrical indications were introduced and the fetal and maternal indications became equally important. A general observation was that combinations of indications had a constantly high share over the analyzed period, implying that the decision on caesarean delivery was often based on several different indications. The caesarean delivery rate is increasing, therefore obstetricians should, in line with a good clinical practice, base their decisions on well founded arguments.

Recent trends in caesarean delivery rates and indications for caesarean delivery in Canada.

OBJECTIVE: To examine recent trends in Caesarean delivery rates as well as the indications for Caesarean delivery in Canada, excluding the provinces of Manitoba and Quebec. METHODS: All deliveries (N = 1 807 388) recorded in the Canadian Institute for Health Information's Discharge Abstract Database for the years 1994/95 to 2000/01 were included in the study (all hospital deliveries in Canada except for those occurring in Manitoba and Quebec). Temporal trends and inter-provincial/territorial variations in Caesarean delivery rates were quantified, and the primary indications for Caesarean delivery during the study period were compared. RESULTS: The overall Caesarean delivery rate increased from 18.0% in 1994/95 to 22.1% in 2000/01. The primary Caesarean delivery rate increased from 12.7% to 16.3%, while the rate of vaginal birth after Caesarean decreased from 33.3% to 28.5% over the same period. Most of the increase in primary Caesarean deliveries was due to increases in Caesarean deliveries for dystocia, which increased from 6.9% in 1994/95 to 9.2% in 2000/01. The largest increase in repeat Caesarean deliveries was due to elective repeat Caesarean sections, which increased from 37.7% to 40.3%. Approximately 15% of the increase in overall Caesarean delivery rates was explained by increases in maternal age. The rate of vaginal deliveries following forceps rotation declined from 1.9% in 1994/95 to 1.3% in 2000/01. CONCLUSION: Most of the recent increase in Caesarean delivery rates in Canada was attributed to increases in primary Caesarean delivery for dystocia and elective repeat Caesarean deliveries.

[Indications for third and more than three cesarean sections--analysis and pattern of practice]. / Indikatsii za treto i poveche ot tri tsezarovi secheniia--analiz, nasoki za povedenie.

PURPOSE OF THE STUDY: Authors aimed to analyse indications for third and more than three times cesarean sections (c. s.), as well as, to make an assessment of the adequacy of the taken decisions. METHODS AND MATERIALS: It was conducted a retrospective study for third and more than three times cesarean, including period 1991-2003 in the Department of Obstetrics and Gynaecology, Medical University, Pleven. During that time 28645 births has taken place, 2971 of which are by cesarean section. 2,5% from the last, has been third and more than three times cesarean. Using expert judging, indications for the last were divided into three groups-right, disputable and wrong. RESULTS: In the cases with only one mentioned indication "Re-re c.s." 37,8% (28 patients), ratio between right, disputable and wrong was 2:1:1 and the same ratio in the cases with indication "Re-re c.s.+ other indications" 58,1% (43 patients), was 5:1:1. In 4,3% of the cases (3 patients) no indication "Re-re c.s." was mentioned. CONCLUSION: Reduction of third and more than three times cesarean can be achieved by more careful judgement of indications in second, "disputable", group and erradication of the "wrong", which most commonly are jatrogenic reasons. This will result in diminishing the increasing frequency of abdominal births, as well as, preventing possible complications for mother, connected with operation.