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1.
Zhonghua Fu Chan Ke Za Zhi ; 56(10): 671-676, 2021 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-34823315

RESUMO

Objective: To analyze the outcome of vaginal trial labor of pregnant women with low-lying placenta detected by translabial ultrasonography, and to explore the influencing factors of vaginal trial delivery and the risk factors of postpartum hemorrhage (PPH). Methods: A total of 80 pregnant women who were diagnosed by translabial ultrasonography with low-lying placenta and underwent vaginal trial delivery in Women's Hospital, School of Medicine Zhejiang University were collected. Based on the distance of placenta lower edge to cervical internal os (IOD) 1 cm, and the general characteristics and pregnancy outcomes of pregnant women with IOD≤1 cm and 1-2 cm were compared and the related factors of PPH were analyzed by binary logistic regression analysis. Results: Among the 80 pregnant women with low-lying placenta, 41 cases with IOD≤1 cm and 39 cases with IOD 1-2 cm, respectively. The rate of cesarean section in the two groups were 15% (6/41) and 15% (6/39), respectively. The birth weight of newborns were (3 334±360) and (3 460±365) g, respectively. PPH rates were 24% (10/41) and 26% (10/39), respectively, and the differences were not statistically significant (all P>0.05). Among the 80 pregnant women with low-lying placenta, 60 cases did not have PPH, and 20 cases did. The rates of placenta manual removal were 2% (1/60) and 20% (4/20), respectively. The birth weight of newborns were (3 330±368) and (3 591±284) g, respectively. The differences were statistically significant (all P<0.05). Binary logistic regression analysis suggested that placenta manual removal was a risk factor for PPH in pregnant women with low-lying placenta (OR=30.448, P=0.029). Conclusions: The results of vaginal trial labor in women with IOD≤1 cm and 1-2 cm are comparable, and vaginal trial labor could be attempted in those without contraindications of vaginal delivery. The main adverse complication of vaginal trial labor is PPH, and those with placenta manual removal need to make corresponding plans.


Assuntos
Cesárea , Hemorragia Pós-Parto , Parto Obstétrico , Feminino , Humanos , Recém-Nascido , Placenta/diagnóstico por imagem , Hemorragia Pós-Parto/epidemiologia , Gravidez , Resultado da Gravidez , Prova de Trabalho de Parto
2.
Ann Acad Med Singap ; 50(8): 606-612, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34472555

RESUMO

INTRODUCTION: An antenatal scoring system for vaginal birth after caesarean section (VBAC) categorises patients into a low or high probability of successful vaginal delivery. It enables counselling and preparation before labour starts. The current study aims to evaluate the role of Grobman nomogram and the Kalok scoring system in predicting VBAC success in Singapore. METHODS: This is a retrospective study on patients of gestational age 37 weeks 0 day to 41 weeks 0 day who underwent a trial of labour after 1 caesarean section between September 2016 and September 2017 was conducted. Two scoring systems were used to predict VBAC success, a nomogram by Grobman et al. in 2007 and an additive model by Kalok et al. in 2017. RESULTS: A total of 190 patients underwent a trial of labour after caesarean section, of which 103 (54.2%) were successful. The Kalok scoring system (area under curve [AUC] 0.740) was a better predictive model than Grobman nomogram (AUC 0.664). Patient's age (odds ratio [OR] 0.915, 95% CI [confidence interval] 0.844-0.992), body mass index at booking (OR 0.902, 95% CI 0.845-0.962), and history of successful VBAC (OR 4.755, 95% CI 1.248-18.120) were important factors in predicting VBAC. CONCLUSION: Neither scoring system was perfect in predicting VBAC among local women. Further customisation of the scoring system to replace ethnicity with the 4 races of Singapore can be made to improve its sensitivity. The factors identified in this study serve as a foundation for developing a population-specific antenatal scoring system for Singapore women who wish to have a trial of VBAC.


Assuntos
Nascimento Vaginal Após Cesárea , Área Sob a Curva , Cesárea , Feminino , Humanos , Lactente , Gravidez , Estudos Retrospectivos , Prova de Trabalho de Parto
3.
Am J Perinatol ; 38(12): 1231-1235, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34282578

RESUMO

OBJECTIVE: Preventing the first cesarean delivery (CD) is important as CD rates continue to rise. During the novel coronavirus disease 2019 (COVID-19) pandemic, quality improvement metrics at our hospital identified lower rates of CD. We sought to investigate this change and identify factors that may have contributed to the decrease. STUDY DESIGN: We compared nulliparous singleton deliveries at a large academic hospital during the COVID-19 pandemic (April through July 2020 during a statewide "stay-at-home" order) to those in the same months 1 year prior to the pandemic (April through July 2019). The primary outcome, mode of delivery, was obtained from the electronic medical record system, along with indication for CD. RESULTS: The cohort included 1,913 deliveries: 892 in 2019 and 1,021 in 2020. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ between the groups. Median gestational age at delivery was the same in both groups. The CD rate decreased significantly during the COVID-19 pandemic compared with prior (28.9 vs. 33.6%; p = 0.03). There was a significant increase in the rate of labor induction (45.7 vs. 40.6%; p = 0.02), but no difference in the proportion of inductions that were elective (19.5 vs. 20.7%; p = 0.66). The rate of CD in labor was unchanged (15.9 vs. 16.3%; p = 0.82); however, more women attempted a trial of labor (87.0 vs. 82.6%; p = 0.01). Thus, the proportion of CD without a trial of labor decreased (25.1 vs. 33.0%; p = 0.04). CONCLUSION: There was a statistically significant decrease in CD during the COVID-19 pandemic at our hospital, driven by a decrease in CD without a trial of labor. The increased rate of attempted trial of labor suggests the presence of patient-level factors that warrant further investigation as potential targets for decreasing CD rates. Additionally, in a diverse and medically complex population, increased rates of labor induction were not associated with increased rates of CD. KEY POINTS: · Primary CD rate fell during COVID-19 pandemic.. · Decrease was driven by more women attempting labor.. · Higher rate of induction without rise in CD rate was found..


Assuntos
COVID-19 , Cesárea/estatística & dados numéricos , Pandemias , Paridade , Adulto , Boston , Estudos de Coortes , Feminino , Humanos , Trabalho de Parto Induzido/estatística & dados numéricos , Gravidez , Estudos Retrospectivos , Prova de Trabalho de Parto
4.
BMC Pregnancy Childbirth ; 21(1): 527, 2021 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-34303355

RESUMO

BACKGROUND: For most women who have had a previous cesarean section, vaginal birth after cesarean section (VBAC) is a reasonable and safe choice, but which will increase the risk of adverse outcomes such as uterine rupture. In order to reduce the risk, we evaluated the factors that may affect VBAC and and established a model for predicting the success rate of trial of the labor after cesarean section (TOLAC). METHODS: All patients who gave birth at Northwest Women's and Children's Hospital from January 2016 to December 2018, had a history of cesarean section and voluntarily chose the TOLAC were recruited. Among them, 80% of the population was randomly assigned to the training set, while the remaining 20% were assigned to the external validation set. In the training set, univariate and multivariate logistic regression models were used to identify indicators related to successful TOLAC. A nomogram was constructed based on the results of multiple logistic regression analysis, and the selected variables included in the nomogram were used to predict the probability of successfully obtaining TOLAC. The area under the receiver operating characteristic curve was used to judge the predictive ability of the model. RESULTS: A total of 778 pregnant women were included in this study. Among them, 595 (76.48%) successfully underwent TOLAC, whereas 183 (23.52%) failed and switched to cesarean section. In multi-factor logistic regression, parity = 1, pre-pregnancy BMI < 24 kg/m2, cervical score ≥ 5, a history of previous vaginal delivery and neonatal birthweight < 3300 g were associated with the success of TOLAC. The area under the receiver operating characteristic curve in the prediction and validation models was 0.815 (95% CI: 0.762-0.854) and 0.730 (95% CI: 0.652-0.808), respectively, indicating that the nomogram prediction model had medium discriminative power. CONCLUSION: The TOLAC was useful to reducing the cesarean section rate. Being primiparous, not overweight or obese, having a cervical score ≥ 5, a history of previous vaginal delivery or neonatal birthweight < 3300 g were protective indicators. In this study, the validated model had an approving predictive ability.


Assuntos
Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Peso ao Nascer , Recesariana/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Nomogramas , Paridade , Gravidez , Estudos Retrospectivos , Ruptura Uterina/epidemiologia
5.
Acta Obstet Gynecol Scand ; 100(10): 1902-1909, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34114644

RESUMO

INTRODUCTION: Uterine rupture is an obstetric emergency associated with maternal and neonatal morbidity. The main risk factor is a prior cesarean section, with rupture occurring in subsequent labor. The aim of this study was to assess the risk of uterine rupture by labor duration and labor management. MATERIAL AND METHODS: This is a Swedish register-based cohort study of women who underwent labor in 2013-2018 after a primary cesarean section (n = 20 046). Duration of labor was the main exposure, calculated from onset of regular labor contractions and birth; both timepoints were retrieved from electronic medical records for 12 583 labors, 63% of the study population. Uterine rupture was calculated as events per 1000 births at different timepoints during labor. Risk estimates for uterine rupture by labor duration, induction of labor, use of oxytocin and epidural analgesia were calculated using Poisson regression, adjusted for maternal and birth characteristics. Estimates were presented as adjusted rate ratios (ARR) with 95% confidence intervals (CI). RESULTS: The prevalence of uterine rupture was 1.4% (282/20 046 deliveries). Labor duration was 9.88 hours (95% CI 8.93-10.83) for women with uterine rupture, 8.20 hours (95% CI 8.10-8.31) for women with vaginal delivery, and 10.71 hours (95% CI 10.46-10.97) for women with cesarean section without uterine rupture. Few women (1.0/1000) experienced uterine rupture during the first 3 hours of labor. Uterine rupture occurred in 15.6/1000 births with labor duration over 12 hours. The highest risk for uterine rupture per hour compared with vaginal delivery was observed at 6 hours (ARR 1.20, 95% CI 1.11-1.30). Induction of labor was associated with uterine rupture (ARR 1.54, 95% CI 1.19-1.99), with a particular high risk seen in those induced with prostaglandins and no risk observed with cervical catheter (ARR 1.19, 95% CI 0.83-1.71). Labor augmentation with oxytocin (ARR 1.60, 95% CI 1.25-2.05) and epidural analgesia (ARR 1.63, 95% CI 1.27-2.10) were also associated with uterine rupture. CONCLUSIONS: Labor duration is an independent factor for uterine rupture among women attempting vaginal delivery after cesarean section. Medical induction and augmentation of labor increase the risk, regardless of maternal and birth characteristics.


Assuntos
Complicações do Trabalho de Parto/epidemiologia , Prova de Trabalho de Parto , Ruptura Uterina/epidemiologia , Nascimento Vaginal Após Cesárea , Adulto , Estudos de Coortes , Feminino , Humanos , Complicações do Trabalho de Parto/etiologia , Gravidez , Prevalência , Sistema de Registros , Fatores de Risco , Suécia/epidemiologia , Fatores de Tempo , Ruptura Uterina/etiologia
7.
BMC Pregnancy Childbirth ; 21(1): 356, 2021 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-33947354

RESUMO

BACKGROUND: The American College of Obstetricians and Gynecologists (ACOG) introduced a new standard of care in 2014, extending the duration of the second stage of labor in order to reduce caesarean delivery (CD) rates and its severe complications. The aim of the present study is to evaluate success rates of trial of labor after caesarean section (TOLAC), as well as maternal and neonatal outcomes after the establishment of the recent guidelines. METHODS: A retrospective study was performed at two large departments in Germany from January 2008 to January 2018. Patients undergoing TOLAC were divided into two groups. Group I (958 patients) was constituted before the establishment of the current guidelines, and Group II (588 patients) after the establishment of the guidelines. A subgroup analysis was performed to compare neonatal outcomes after successful TOLAC and operative vaginal delivery with those after failed TOLAC and secondary CD. RESULTS: The success rate of vaginal births after cesarean section (VBAC) fell from 66.4% in Group I to 55.8% in Group II (p < 0.001). The median duration of the second stage of labor was statistically significantly longer in Group II than in Group I (79.3 ± 61.9 vs. 69.3 ± 58.2 min) for patients without previous vaginal birth. The incidence of operative vaginal delivery decreased from Group I to Group II (9.6% vs. 6.8%). The incidence of third- and fourth-degree perineal lacerations, blood loss and emergency CD were similar in the two groups. Concerning the neonatal outcome, our groups did not differ significantly in regard of rates of umbilical artery cord pH < 7.1 (p = 0.108), the 5-min Apgar scores below 7 (p = 0.224) and intubation (p = 0.547). However, the transfer rates to the neonatal care unit were significantly higher in Group II than in Group I (p < 0.001). Neonatal outcomes did not differ significantly in the subgroup analysis. CONCLUSION: Extending the second stage of labor does not necessarily result in more vaginal births after TOLAC. Maternal and neonatal outcomes were similar in both groups. Further studies will be needed to evaluate the role of operative vaginal delivery and the duration of the second stage of labor in TOLAC.


Assuntos
Segunda Fase do Trabalho de Parto , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea , Adulto , Feminino , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Estudos Retrospectivos
8.
Arch Gynecol Obstet ; 304(6): 1433-1441, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-33877401

RESUMO

PURPOSE: To determine factors associated with a successful twin trial of labor after Cesarean delivery (TOLAC). METHODS: A retrospective cohort study was conducted at a single medical center in a population highly motivated for TOLAC (> 80%). The effect of maternal demographic and obstetric characteristics on the likelihood of twin TOLAC success was analyzed. Maternal complications and combined adverse outcome (uterine rupture, Apgar < 7 at 5 min, and umbilical cord pH < 7.1) were compared between singleton and twin TOLAC groups. RESULTS: Ninety-five women with a twin gestation and one previous Cesarean delivery comprised the study group. Five thousand seven hundred and three women with a singleton gestation and one previous Cesarean delivery comprised the control group. 30.5% and 83% of women with twin and singleton gestation, respectively, underwent a trial of labor. Women in the twin TOLAC group were significantly less likely to succeed and less likely to have a spontaneous unassisted vaginal delivery compared to women in the singleton TOLAC group. Maternal age less than 35 years, parity greater than two, and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, maternal complications, and for combined adverse outcome. CONCLUSIONS: Twin TOLAC is not common, even in parturients highly motivated for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture, maternal complications, and combined adverse perinatal outcome than women undergoing TOLAC with a singleton gestation. Demographic and obstetric risk factors were identified which can aid the attending obstetrician in the counseling of these challenging cases.


Assuntos
Cesárea/efeitos adversos , Cesárea/estatística & dados numéricos , Complicações do Trabalho de Parto/etiologia , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Feminino , Humanos , Recém-Nascido , Gravidez , Gravidez de Gêmeos , Estudos Retrospectivos , Fatores de Risco , Gêmeos
9.
Medicine (Baltimore) ; 100(17): e25757, 2021 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-33907172

RESUMO

ABSTRACT: The purpose of this study was to explore the relevant factors that affect the risk of cesarean scar diverticulum (CSD).A retrospective, case-control study was designed among women with a history of cesarean section (CS) who were admitted in Zhejiang Tongde Hospital from January 2017 to December 2019. Women with missing information were excluded. The basic clinical characteristics and the risk factors for CSD were assessed using univariate analysis and multivariate logistic regression analysis.A total of 216 women were analyzed, including 87 patients with CSD and 129 cases without CSD as control. Significant differences in number of CS, trial of labor (elective or urgent CS), CS interval, uterine position, intraoperative hemorrhage, and dysmenorrhea between CSD group and control group (P < .05). Multivariate logistic regression analysis showed that number of CS, trial of labor, interval of CS, and uterine position were independent risk factors of CSD.In women with a history of CS, multiple cesarean deliveries, elective CS, cesarean interval of less than 5 years, and retroflexed position of the uterus may be associated with an elevated risk of CSD.


Assuntos
Cesárea , Cicatriz , Divertículo , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Estudos de Casos e Controles , Cesárea/efeitos adversos , Cesárea/métodos , Cesárea/estatística & dados numéricos , China , Cicatriz/complicações , Cicatriz/etiologia , Cicatriz/patologia , Divertículo/diagnóstico , Divertículo/epidemiologia , Divertículo/etiologia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Gravidez , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Prova de Trabalho de Parto , Técnicas de Fechamento de Ferimentos
10.
Eur J Obstet Gynecol Reprod Biol ; 260: 37-41, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33721622

RESUMO

OBJECTIVE: Data regarding the risks of obstetrical anal sphincter injury (OASI) among women who never delivered vaginally undergoing a trial of labor after cesarean (TOLAC) are scarce. We aimed to evaluate the risk factors and the rate of OASI among women undergoing TOLAC who never delivered vaginally. STUDY DESIGN: A retrospective cohort study of all women undergoing a TOLAC and never delivered vaginally between 3/2011 and 6/2020. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to earliest gestational age in which OASI has occurred. A further comparison was made between the study cohort and a cohort of primiparous women undergoing a vaginal delivery, including gestational ages at which OASI has occurred in that cohort. RESULTS: During the study period there were 2061 TOLACs among women without prior vaginal delivery. Of these, 76 % (1566/2061) had a successful vaginal delivery. Overall, 22/2061 (1.1 %) cases of OASI occurred. There was no difference in maternal demographic, obstetrical and medical history characteristics between the study groups. The mean gestational age at TOLAC was lower in the OASI group (390/7 ± 12/7 vs. 395/7 ± 12/7, p = 0.012). In multivariable regression analysis, gestational age was negatively associated with OASI [adjusted odds ratio, 95 % (confidence interval) 0.95 (0.91-0.99), for each day increase in gestational age)]. The rate of OASI in the study cohort did not differ from the rate of OASI among primiparous women during the same study period (347/27975, 1.2 %, p = 0.686). CONCLUSION: Gestational age at delivery is the only predictor of OASI among women with no prior vaginal deliveries undergoing a TOLAC. The incidence of OASI in this population is 1.1 % and does not differ from that of primiparous women.


Assuntos
Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea , Canal Anal , Feminino , Humanos , Gravidez , Estudos Retrospectivos , Fatores de Risco , Nascimento Vaginal Após Cesárea/efeitos adversos
11.
Eur J Obstet Gynecol Reprod Biol ; 260: 150-153, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33773261

RESUMO

The clinical management of intrauterine fetal demise (IUFD) in women with a previous cesarean delivery presents a dilemma for the obstetrician. With the current reluctance of obstetricians to perform vaginal birth after cesarean (VBAC) and the paucity of data to counsel women regarding maternal risks, management options are limited by physician's clinical experience and biases. In the setting of fetal demise, maternal safety becomes the primary concern. Medicolegal pressures may prevent physicians from attempting a trial of labor in this situation. In this review we will a focus on frequency of birth with IUFD after cesarean section (CS), we discuss the options (VBAC vs CS), different complications, methods for induction of vaginal birth as well as risk factors of vaginal birth and cesarean delivery.


Assuntos
Trabalho de Parto , Nascimento Vaginal Após Cesárea , Cesárea/efeitos adversos , Feminino , Morte Fetal/etiologia , Humanos , Parto , Gravidez , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/efeitos adversos
12.
Am J Obstet Gynecol ; 225(2): 173.e1-173.e8, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33617798

RESUMO

BACKGROUND: Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. STUDY DESIGN: This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016. RESULTS: In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. CONCLUSION: Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.


Assuntos
Canal Anal/lesões , Extração Obstétrica/estatística & dados numéricos , Lacerações/epidemiologia , Obesidade Materna/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Uso de Tabaco/epidemiologia , Nascimento Vaginal Após Cesárea , Adulto , Anestesia Epidural/estatística & dados numéricos , Tomada de Decisão Compartilhada , Feminino , Humanos , Idade Materna , Forceps Obstétrico , Gravidez , Reprodutibilidade dos Testes , Medição de Risco , Prova de Trabalho de Parto , Vácuo-Extração/estatística & dados numéricos , Adulto Jovem
13.
Arch Gynecol Obstet ; 304(2): 329-336, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33389110

RESUMO

PURPOSE: To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD. METHODS: This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries. RESULTS: Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73-8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39-0.97, and aOR 0.49; 95% CI 0.25-0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC. CONCLUSION: Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.


Assuntos
Cesárea , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/efeitos adversos , Adulto , Feminino , Humanos , Recém-Nascido , Idade Materna , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Ruptura Uterina
15.
BMC Pregnancy Childbirth ; 21(1): 89, 2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509100

RESUMO

BACKGROUND: As the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has thus become a major contributor to the increasing CS rate in China. Promoting trial of labor after CS (TOLAC) can reduce the CS rate without compromising delivery outcomes. This study aimed to investigate Chinese obstetricians' perspectives regarding TOLAC, and the factors associated with their decision-making regarding recommending TOLAC to pregnant women with a history of CS under the two-child policy. METHODS: A cross-sectional survey was carried out between May and July 2018. Binary logistic regression was used to determine the factors associated with the obstetricians' intention to recommend TOLAC to pregnant women with a history of CS. The independent variables included sociodemographic factors and perceptions regarding TOLAC (selection criteria for TOLAC, basis underlying the selection criteria for TOLAC, and perceived challenges regarding promoting TOLAC). RESULTS: A total of 426 obstetricians were surveyed, with a response rate of ≥83%. The results showed that 31.0% of the obstetricians had no intention to recommend TOLAC to pregnant women with a history of CS. Their decisions were associated with the perceived lack of confidence regarding undergoing TOLAC among pregnant women with a history of CS and their families (odds ratio [OR] = 2.31; 95% CI: 1.38-1.38); obstetricians' uncertainty about the safety of TOLAC for pregnant women with a history of CS (OR = 0.49; 95% CI: 0.27-0.96), and worries about medical lawsuits due to adverse delivery outcomes (OR = 0.14; 95% CI: 0.07-0.31). The main reported challenges regarding performing TOLAC were lack of clear guidelines for predicting or avoiding the risks associated with TOLAC (83.4%), obstetricians' uncertainty about the safety of TOLAC for women with a history of CS (81.2%), pregnant women's unwillingness to accept the risks associated with TOLAC (81.0%) or demand for ERCS (80.7%), and the perceived lack of confidence (77.5%) or understanding (69.7%) regarding undergoing TOLAC among pregnant women and their families. CONCLUSION: A proportion of Chinese obstetricians did not intend to recommend TOLAC to pregnant women with a history of CS. This phenomenon was closely associated with obstetricians' concerns about TOLAC safety and perceived attitudes of the pregnant women and their families regarding TOLAC. Effective measures are needed to help obstetricians predict and reduce the risks associated with TOLAC, clearly specify the indications for TOLAC, improve labor management, and popularize TOLAC in China. Additionally, public health education on TOLAC is necessary to improve the understanding of TOLAC among pregnant women with a history of CS and their families, and to improve their interactions with their obstetricians regarding shared decision making.


Assuntos
Cesárea/estatística & dados numéricos , Tomada de Decisão Clínica , Obstetrícia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Recesariana/estatística & dados numéricos , China , Estudos Transversais , Características da Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Direitos Sexuais e Reprodutivos/legislação & jurisprudência , Inquéritos e Questionários
16.
BMC Pregnancy Childbirth ; 21(1): 11, 2021 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-33407241

RESUMO

BACKGROUND: Trial of labor after a previous cesarean delivery (TOLAC) has reduced the rate of cesarean sections (CS). Nevertheless, the widespread use of TOLAC has been limited by an increase in adverse outcomes, the most serious one being the risk of symptomatic uterine rupture, which is possibly associated with oxytocin. In this meta-analysis, we explored the risk association between oxytocin use and uterine rupture in TOLAC. METHODS: Multiple electronic databases (PubMed, Embase, Web of Science, and Google Scholar) were searched for cross-sectional studies reporting on TOLAC, oxytocin and uterine rupture, which were published between January 1986 and October 2019. The bias-corrected Hedge's g was calculated as the effect size using the random-effects model. A two-sample Z test was used to compare the differences in synthetic rates between groups. The Newcastle-Ottawa Scale (NOS) was used to evaluate the risk of bias. Quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) certainty ratings system. RESULTS: A total of 14 studies, which included 48,457 women who underwent TOLAC, met the inclusion criteria. The pooled rate of vaginal birth after a cesarean section (VBAC) and the rate of uterine rupture in spontaneous labor were 74.3 and 0.7%, respectively. In addition, the pooled rate of VBAC and the rate of uterine rupture in the induction labor group was 60.7 and 2.2%, respectively. The women who had spontaneous labor had a significantly higher rate of VBAC (p = 0.001) and a lower rate of uterine rupture (p = 0.0003) compared to induced labor. The pooled rates of uterine rupture in women using oxytocin and women not using oxytocin in TOLAC were 1.4% and 0.5%, respectively, and the difference was significant (p = 0.0002). Also, the synthetic rate of uterine rupture in oxytocin augmentation among women with spontaneous labor and women who had a successful induction of labor were 1.7% and 2.2%, respectively, without significant difference (p = 0.443). CONCLUSIONS: Women with induced labor had a higher risk of uterine rupture compared to women with spontaneous labor following TOLAC. Oxytocin use may increase this risk, which could be influenced by the process of induction or individual cervix condition. Consequently, simplified and standardized intrapartum management, precise protocol, and cautious monitoring of oxytocin use in TOLAC are necessary.


Assuntos
Cesárea/estatística & dados numéricos , Ocitocina/efeitos adversos , Prova de Trabalho de Parto , Ruptura Uterina/epidemiologia , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Feminino , Humanos , Trabalho de Parto Induzido/efeitos adversos , Trabalho de Parto/fisiologia , Estudos Observacionais como Assunto , Ocitocina/uso terapêutico , Gravidez , Fatores de Risco
17.
J Matern Fetal Neonatal Med ; 34(22): 3750-3755, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31709871

RESUMO

AIM: Despite the increasing trend in delayed childbirth and the known associated complications in advancing maternal age, limited information exists regarding outcomes in very advanced maternal age by delivery type. This study aims to evaluate maternal and neonatal outcomes in women age 40 or more undergoing cesarean delivery or trial of labor after cesarean delivery. MATERIALS AND METHODS: We performed a secondary analysis of the Cesarean Section Registry Maternal-Fetal Medicine Units (MFMU) Network data, which was a prospective study of women undergoing repeat cesarean delivery or trial of labor after cesarean delivery from 1 January 1999 to 31 December 2002. Women age 40 years or more at the time of delivery were compared to the control group of women less than 40 years of age. RESULTS: There were 67,389 cases identified that met inclusion criteria. 2,436 (3.6%) were age ≥40 years old, and 65,403 (97.05%) were <40 at delivery. The >40 group had a higher rate of PRBC transfusion (aRR 1.75; 95% CI 1.20-2.56), maternal ICU admission (aRR 2.02; 1.41-2.89), bowel injury (aRR 3.65; 1.43-9.31), placenta accreta (aRR 1.92; 1.09-3.38) and classical uterine incision (aRR 1.59; 1.43-9.31) compared to the control group. Maternal death rates were similar in both groups (p = .30). CONCLUSION: Women aged 40 or more undergoing repeat cesarean delivery or trial of labor after cesarean delivery are more likely to have maternal complications including intraoperative transfusion, maternal ICU admission, abnormal placentation and surgical complications in comparison to women under age 40.


Assuntos
Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea , Adulto , Transfusão de Sangue , Cesárea/efeitos adversos , Recesariana/efeitos adversos , Feminino , Humanos , Recém-Nascido , Gravidez , Estudos Prospectivos , Estudos Retrospectivos , Nascimento Vaginal Após Cesárea/efeitos adversos
18.
J Obstet Gynaecol ; 41(2): 200-206, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32172631

RESUMO

The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.


Assuntos
Cesárea , Parto Obstétrico/métodos , Trabalho de Parto Induzido/métodos , Sobremedicalização , Utilização de Procedimentos e Técnicas/tendências , Prova de Trabalho de Parto , Cesárea/efeitos adversos , Cesárea/economia , Cesárea/métodos , Cesárea/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Gravidez , Resultado da Gravidez/epidemiologia , Saúde Pública/métodos , Estudos Retrospectivos , Risco Ajustado/métodos , Espanha/epidemiologia , Centros de Atenção Terciária/estatística & dados numéricos
20.
Int J Gynaecol Obstet ; 153(1): 106-112, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33040352

RESUMO

OBJECTIVE: To examine the impact of the mode of delivery on neonatal and maternal outcomes in moderately and late preterm twin birth. METHODS: This single-center cohort study included 275 live diamniotic moderately and late preterm twin deliveries at 32+0 -36+6  weeks of gestation. These twin deliveries were divided into two groups according to the planned mode of delivery: trial of labor (TOL) (N=199, 72.4%) and planned cesarean section (CS) (N=76, 27.6%). The primary outcome was neonatal morbidity. Maternal outcome and the effects of gestational age and chorionicity on neonatal outcome were also studied. RESULTS: Of the women in the TOL group, 170 (85.4%) delivered vaginally. Both for the first and second twin, and for dichorionic or monochorionic deliveries, there were no differences between the TOL and CS groups in composite neonatal morbidity or in other neonatal outcomes. No significant differences were found between the TOL and CS groups when the moderately and late preterm gestational age cohorts were studied separately. Mothers in the planned CS group more often had puerperal infection and surgical complications in comparison with mothers in the TOL group. CONCLUSION: Among 275 moderately and late preterm twin deliveries, planned mode of delivery did not affect neonatal outcome.


Assuntos
Cesárea/estatística & dados numéricos , Parto Obstétrico/métodos , Gravidez de Gêmeos , Prova de Trabalho de Parto , Adulto , Córion/metabolismo , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Nascimento Prematuro , Estudos Retrospectivos , Gêmeos , Adulto Jovem
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