Risk factors for obstetric anal sphincter injuries at vaginal birth after caesarean: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Vaginal birth after caesarean (VBAC) is associated with an increased risk of obstetric anal sphincter injuries (OASIS). However, specific factors that influence the risk of OASIS at VBAC have not been studied, particularly whether there are specific baseline characteristics of the first delivery which affect the subsequent perineal outcomes. METHODS: Retrospective analysis of prospectively collected data from University of Southampton NHS Foundation Trusts' maternity database. This included secundiparous women with a previous caesarean delivery (CS) who achieved a singleton, term, cephalic vaginal delivery from 2004 to 2014. Univariate analysis compared maternal, intrapartum and neonatal factors of those who suffered OASIS at VBAC with those who did not. A binary logistic regression model calculated the adjusted, independent odds ratio (OR) of OASIS. RESULTS: A total of 1375 women met the inclusion criteria. The OASIS rate was 8.1%, a 1.4-fold increase compared with primiparous women [difference 2.4% (95% CI 1.1, 3.6)]. Those sustaining OASIS at VBAC were older (p = 0.011) and had infants of greater birth weight at initial caesarean (p < 0.001) and VBAC (p = 0.04). Analysis of odds ratios revealed that mediolateral episiotomy (MLE) at VBAC halved the risk of OASIS [37.5% VBAC with OASIS vs. 52.2% VBAC without OASIS (OR 0.51, 95% CI 0.32-0.81)], whereas an urgent CS at initial delivery doubled the risk [52.3% VBAC with OASIS vs. 34.9% VBAC without OASIS (OR 2.05, 95% CI 1.31-3.21)]. CONCLUSIONS: Advanced maternal age, increased infant birth weight and an urgent category of initial CS increase the risk of OASIS at VBAC, whereas MLE is protective.

Estimating success of vaginal birth after caesarean section in a regional Australian population: Validation of a prediction model.

BACKGROUND: Following a primary caesarean section (CS), women must decide between attempted vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS) in subsequent pregnancies. Both options carry potential morbidity and mortality for mother and child, with the most feared being uterine rupture and its consequences. In attempts to reduce morbidity, several predictive nomograms have been developed to assist in delivery mode decisions. AIM: To assess the validity of the predictive nomogram developed by Grobman et al. in our regional Australian population. MATERIALS AND METHODS: In our retrospective analysis, patients at term, with one previous CS who had a trial of labour were assigned a 'Grobman score' based on antenatal details. Outcomes were noted and patient groups analysed according to percentage deciles of estimated VBAC success, compared with actual VBAC success rates. RESULTS: A total of 395 women underwent trial of labour after a single prior CS, with a VBAC success rate of 83%. The Grobman model displayed adequate calibration and the re-calibrated model good calibration with the slope coefficient of 0.87 (95% CI 0.54-1.19) and intercept 0.19 (95% CI -0.34-0.72). Discrimination was moderate with receiver operating characteristic area of 0.71 (95% CI 0.67-0.76). CONCLUSION: This analysis supports further validation studies in larger Australian settings, and suggests that use of the original Grobman predictive nomogram may be appropriate in Australia.

A randomized comparative study of serial membrane sweeping at term for vaginal birth after caesarean section in two tertiary hospitals in Delta State.

Introduction: postdate pregnant women with one previous caesarean section that are planned for vaginal birth after caesarean sections are faced with adverse pregnancy outcomes. This trial was conducted to determine the effect of serial membrane sweeping from 38 weeks gestation in pregnant women planned for vaginal birth after caesarean section. Methods: this randomized controlled trial (RCT) was conducted on 90 women at 38 weeks with one previous caesarean section. In the study group, membranes sweeping commenced at 38 weeks and repeated weekly till labour onset. If no labour onset at 41 weeks and 3 days, elective caesarean section was done. In the control group, patients awaited labour onset till 41 weeks and 3 days, after which elective caesarean section was done. Data collected were analyzed using the Statistical Package for Social Sciences (SPSS ver. 22). All analyses were done at p<0.05. Results: labour onset before 41 weeks and 3 days was statistically significantly higher in the study group compared to the control group (RR= 1.5; 95% CI: 1.1 - 2.0; P=0.006). Likewise, successful vaginal birth after caesarean section was statistically significantly higher in the study group (RR=1.7; 95% CI: 1.2-2.5; P = 0.001). Conclusion: serial membrane sweeping from 38 weeks gestation has significant beneficial effect on labour onset and successful vaginal delivery in women with one previous caesarean section.

Trial of labour following two previous caesarean sections - A UK cohort study.

OBJECTIVES: To assess the (i) predictors of and associated rates of success and; (ii) maternal and perinatal outcomes of women undergoing trial of labour after two previous caesarean sections (TOLA2C). STUDY DESIGN: This retrospective cohort study collected data from two regional obstetric centres with 12,000 deliveries per annum collectively. The population included singleton pregnancies undergoing (i) TOLA2C, (ii) elective repeat caesarean section following two caesarean sections (ERCS) and (iii) trial of labour after one caesarean section (TOLA1C). Data was collected electronically from 2013 to 2021. Statistical analysis included Fisher exact and Kruskal-Wallis test to compare unpaired samples alongside univariate and multivariable logistic regression. The primary outcome measure was maternal and perinatal outcome. RESULTS: The three groups included; n = 146 TOLA2C, n = 206 ERCS and n = 99 TOLA1C. TOLA2C had a success rate of 65 % compared to 74 % for TOLA1C (p = 0.16). The optimal predictor of successful TOLA2C was previous successful TOLA1C OR 8.65 (95 % CI 2.75-38.41). TOLA2C was associated with greater risk of endometritis and/or sepsis postnatally compared to the other two groups [10.3 % (n = 15) versus 0.5 % (n = 1) and 3 % (n = 3) for ERCS and TOLA1C respectively p < 0.01]. It was also associated with longer maternal hospital stay [2.4 days (+/-1.8) versus 1.8 (+/-0.8) and 1.8 (+/-1.7) p < 0.01], a greater proportion of neonates with Apgar scores less than 7 (p=<0.01) and higher rates of neonatal unit admission [14 % (n = 20) versus 5 % (n = 11) versus 4 % (n = 4) (p=<0.01)]. CONCLUSION: Women considering trial of labour following two caesarean sections should be counselled regarding the potential increased risk of endometritis, sepsis and adverse neonatal outcome.

Frequency Of Vaginal Birth After Caesarean Section And Its Fetomaternal Outcome.

BACKGROUND: Vaginal birth after caesarean section (VBAC) is associated with reduced blood loss and transfusions, fewer infections, and fewer thromboembolic events as compared to caesarean delivery. The current rate of repeat caesarean after one previous caesarean is above the WHO standard of 15%. We aimed to determine the occurrence of VBAC and to determine the occurrence of feto-maternal outcomes in successful VBAC cases so that trials of VBAC can be given to carefully selected patients to reduce the rate of repeat caesarean section. METHODS: The Combined Military Hospital (CMH) Rawalpindi's Obstetrics and Gynaecology department conducted this cross-sectional study from March 20 to September 19, 2021. After obtaining ethical committee approval, data was collected using a non-probability, consecutive sampling technique from 150 patients on a self-developed structured proforma. Patients between the age range of 20-35 years with a history of previous lower segment caesarean section, having gestational age between 37-41 weeks and who presented in spontaneous labour were included in this study. After taking informed consent, all women were given a trial of labour and the outcome of the trial was noted. Women were followed for the feto-maternal outcomes. The gathered information was analysed using SPSS version 25.0. Post-stratification, a p-value of 0.05 or lower on the chi-square test was deemed statistically significant. RESULTS: Following a C-section, 28.67% of patients experienced successful vaginal births. PPH was found in 2.32%, scar dehiscence in 0.0%, low birth weight babies in 16.28%, APGAR score <7 at 1 minute was 23.26% and NICU admission as 9.30% in women undergoing vaginal birth after caesarean section. CONCLUSIONS: Appropriate selection of patients for the trial of VBAC can help reduce the higher rate of repeat caesarean section after a previous caesarean section and increase the chances of successful vaginal birth.

Effect of a Locally Tailored Clinical Pathway Tool on VBAC Outcomes in a Private Hospital in India.

BACKGROUND: Customized clinical and administrative interventions in the form of a care pathway tool can improve VBAC outcomes and reduce the alarming rise in caesarean sections globally. OBJECTIVE: To determine the effect of a locally tailored clinical pathway tool on VBAC outcomes in a private hospital in India. METHODS: A pre- and post-implementation study was conducted in a private hospital in India. All women with one previous caesarean section term pregnancy and cephalic presentation were included at baseline from January 2013 to December 2015 (Phase 1) and from January 2016 to December 2018 (Phase 2) after ongoing implementation of a clinical pathway tool by all providers. Background characteristics and clinical outcomes in both phases were reviewed retrospectively from case files. RESULTS: Overall 223 (13.42%) women among 1661 total births and 244 (11.62%) women among 2099 total births were included in Phase 1 and Phase 2, respectively. Total number of women who underwent trial of labour (TOLAC) increased from 36.77% to 64.34% (P < 0.001) and VBAC rate increased from 23.76% to 58.19% (P < 0.001) in Phase 2. There was no significant difference in perinatal morbidity and mortality in the two phases. CONCLUSION: A locally customized clinical care pathway tool implemented to support both mothers and care givers for TOLAC seemed to improve VBAC outcomes in a private setting in India.

A randomised controlled trial comparing 30 mL and 80 mL in Foley catheter for induction of labour after previous Caesarean section.

Inducing labour with a Foley balloon catheter rather than using oxytocin or prostaglandins is considered to be less risky if the uterus is scarred.1 It is not known if more fluid in the balloon is more effective without being more dangerous. Volumes of 80 mL and 30 mL were compared in 154 eligible women. Mode of delivery, duration of labour and delivery within 24 h were similar in both groups. However, the second group required oxytocin more frequently. Though more scar dehiscences occurred in the first group, the difference was not significant.

Evaluating trial of scar in patients with a history of caesarean section.

AIMS: To analyze the outcome of trial of scar in patients with previous caesarean section and to assess the fetal and maternal complications after trial of scar. PATIENTS AND METHODS: The study was conducted at Military Hospital, Rawalpindi, Pakistan, with 375 pregnant patients who had a previous delivery by caesarean and who had regular antenatal checkup. Data were recorded on special pro-forms designed for the purpose. RESULTS: The results from the 375 patients who had one previous lower segment caesarean section due to non-recurrent causes were analyzed and compared with national and international studies. Indications of previous caesarean section (non-recurrent causes) included malpresentations, fetal distress/cord prolapse, failure to progress, severe pregnancy-induced hypertension/eclampsia and twins with abnormal lie of the first twin. 0 218 patients reported spontaneous labor. Among these patients, 176 delivered vaginally and 42 patients had repeat caesarean sections. There were a total of 157 patients who experienced induction of labor. 97 patients were induced by cervical ripening with mechanical method, followed by artificial rupture of membranes and augmentation (if required) with syntocinon infusion. 60 patients were induced with prostaglandin E(2) vaginal tablet. CONCLUSION: This study concludes that females with a prior caesarean are at increased risk for subsequent caesareans, regardless of mode of delivery. Eliminating vaginal-birth-after-caesarean will not eliminate the risk. Therefore, vaginal birth after caesarean should be encouraged in selected cases from obstetric units to reduce the risks of repeated caesarean sections. Failed vaginal-birth-after-caesarean can result in increased morbidity than that with elective caesarean section.