Assessment of placenta accreta spectrum at vaginal birth after cesarean delivery.

BACKGROUND: Previous cesarean delivery is a risk factor for developing placenta accreta spectrum in a subsequent pregnancy and patients with antenatally suspected placenta accreta spectrum frequently undergo planned cesarean hysterectomy. There is a paucity of data regarding unsuspected placenta accreta spectrum among patients undergoing trial of labor after cesarean delivery for attempted vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to investigate the incidence, characteristics, and delivery outcomes of patients with placenta accreta spectrum diagnosed at the time of vaginal birth after cesarean delivery. STUDY DESIGN: The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 184,415 patients with a history of low transverse cesarean delivery who had vaginal delivery in the current index hospital admission between 2017 and 2020. Those with placenta previa, previous vertical cesarean delivery, other uterine scars, and uterine rupture were excluded. This study identified placenta accreta spectrum cases using the World Health Organization International Classification of Disease, Tenth Revision, codes of O43.2. Coprimary outcomes were (1) the incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery; (2) clinical and pregnancy characteristics related to placenta accreta spectrum, assessed with multivariable binary logistic regression model; and (3) delivery outcomes associated with placenta accreta spectrum by fitting propensity score adjustment. The secondary outcome was to conduct a systematic literature review using 3 public search engines (PubMed, Cochrane, and Scopus). Data on incidence rate and maternal morbidity related to placenta accreta spectrum at vaginal birth after cesarean delivery were evaluated. RESULTS: The incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery was 8.1 per 10,000 deliveries. Most placenta accreta spectrum cases were placenta accreta (83.3%). In a multivariable analysis, older maternal age, tobacco use, preeclampsia, multifetal pregnancy, fetal anomaly, preterm premature rupture of membrane, chorioamnionitis, low-lying placenta, and preterm delivery were associated with an increased risk of placenta accreta spectrum (all, P<.05). Of these factors, low-lying placenta had the largest odds for placenta accreta spectrum (526.3 vs 7.3 per 10,000 deliveries; adjusted odds ratio, 35.02; 95% confidence interval, 18.19-67.42). Patients in the placenta accreta spectrum group were more likely to have postpartum hemorrhage (80.0% vs 5.5%), blood product transfusion (23.3% vs 1.0%), shock or coagulopathy (20.0% vs 0.2%), and hysterectomy (43.3% vs <0.1%) than those without placenta accreta spectrum (all, P<.001). In a systematic literature review, a total of 212 studies were screened, and none of these studies examined the incidence and morbidity of placenta accreta spectrum at vaginal birth after cesarean delivery. CONCLUSION: This nationwide assessment suggests that although placenta accreta spectrum with vaginal birth after cesarean delivery is uncommon (1 of 1229 cases), the diagnosis of placenta accreta spectrum at vaginal birth after cesarean delivery is associated with significant maternal morbidity. In addition, the data suggest that low-lying placenta in the setting of previous low transverse cesarean delivery warrants careful evaluation for possible placenta accreta spectrum before a trial of labor.

Attempted vaginal birth after cesarean: assessment of morbidity and predictors of success / Parto tras cesárea anterior: análisis de la morbimortalidad materno-fetal

Objective: Determining the appropriate approach for delivery after previous cesarean is a very controversial issue. Our objective was to establish whether pregnant women with a previous cesarean have an increased maternal and fetal morbidity and mortality after attempting vaginal delivery as well as to determine which factors may influence the achievement of a vaginal birth after cesarean. Materials and methods: A retrospective observational cohort study including 390 patients (196 cesarean group and 194 nulliparous group) was carried out. We compared neonatal and maternal outcomes between groups. Afterward, a multivariate logistic regression was applied for our second objective. Results: There were higher rates of uterine rupture (2% vs. 0%, p: 0.045) and puerperal hemorrhage (9.7% vs. 3.1%, p: 0.008) in the cesarean group and lower vaginal delivery rate (58.2% vs. 77.8%, p < 0.0005). We found that the induced onset of labor (OR = 2.9) and new born weight (OR = 1.0001) were associated with an increased risk of cesarean section. Conclusions: Our findings stress the need for further investigations in this field, which might provide a basis for a better management of patients with a previous cesarean.

Objetivo: Determinar el abordaje adecuado del tipo de parto tras una cesárea previa es un tema muy controvertido. Nuestro objetivo fue establecer si las gestantes con cesárea previa presentan mayor morbimortalidad materna y fetal tras intentar parto vaginal, así como determinar qué factores pueden influir en conseguir un parto vaginal posterior a la cesárea. Material y métodos: Estudio observacional de cohortes retrospectivo incluyendo 390 pacientes (196 con cesárea previa, 194 nulíparas). Comparamos los datos sobre los resultados neonatales y maternos. Posteriormente se aplicó un modelo de regresión logística multivariante. Resultados: Hubo mayores tasas de ruptura uterina (2% vs. 0%; p = 0.045) y hemorragia puerperal (9.7% vs. 3.1%, p: 0.008) en el grupo de cesárea anterior, así como una tasa de parto vaginal mas baja (58.2% vs. 77.8%, p < 0.0005). La inducción del parto (OR = 2,9) y el peso del recién nacido (OR = 1.0001) se asociaron a un mayor riesgo de cesárea. Conclusión: La probabilidad de parto vaginal en estas pacientes disminuye cuanto mayor sea el peso del recién nacido y con partos inducidos.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk.

BACKGROUND: The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. OBJECTIVE: Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy. METHODS: From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. RESULTS: The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. CONCLUSION: In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

The urological complications of vaginal birth after cesarean (VBAC) - a literature review.

The appearance of urological complications is a major problem in obstetrics and gynecologic surgery; the bladder is the most common damaged organ. Due to a continuous increase in the rate of cesareans, the incidence of urologic complications will be potentially higher. We reviewed the most important risk factors for urinary tract injury and analyzed the strategies necessary to avoid these situations during vaginal birth after cesarean (VBAC). The risks and benefits of VBAC should be balanced before deciding the mode of delivery.

Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study.

BACKGROUNDS: Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. METHODS: A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. RESULTS: ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and ß-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. CONCLUSIONS: Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Uterine dehiscence in pregnant with previous caesarean delivery.

BACKGROUND: The main risk factor for uterine scar dehiscence is a previous caesarean section. Better characterisation of the ultrasonographic features of uterine scar dehiscence may improve preoperative diagnostic accuracy in pregnant women with a caesarean scar. This study aimed to evaluate the ultrasonographic features of uterine scar dehiscence in pregnant women and maternal and neonatal outcomes. MATERIALS AND METHODS: This was a retrospective review of the records of 23 women with a previous caesarean section found to have uterine scar dehiscence during surgery. The integrity and thickness of the lower uterine segment were recorded, ultrasonographic features were evaluated, and maternal and infant outcomes were analysed. RESULTS: Of the 23 cases of uterine scar dehiscence, six were detected by preoperative ultrasonography, while 17 were missed. The ultrasonographic features of the 23 cases of uterine dehiscence included anechoic areas protruding through the caesarean section scar with an intact serosal layer (4/23), disappearance of the muscular layer (2/23), and a thinner lower uterine segment (17/23). There were no cases of maternal or neonatal mortality. One woman chose to undergo pregnancy termination. CONCLUSION: Preoperative detection of uterine scar dehiscence in women with previous caesarean delivery helps prevent maternal and neonatal morbidity and mortality. However, the maximum benefit can only be obtained by scanning at appropriate intervals during pregnancy and accurate recognition of the ultrasonographic features of uterine scar dehiscence.KEY MESSAGESPreoperative detection of uterine scar dehiscence in women with previous caesarean delivery helps prevent maternal and neonatal morbidity and mortality.Scanning at appropriate intervals during pregnancy and accurate recognition of the ultrasonographic features of uterine scar dehiscence could be beneficial.Even when uterine dehiscence is detected by ultrasound during the second trimester, conservative management via strict observation alone is also feasible.

Ten years of uterine rupture in an Australian tertiary hospital.

AIMS: Complete uterine rupture is a rare and serious complication of pregnancy. Although most commonly associated with attempted vaginal birth after caesarean (VBAC), rupture also occurs in atypical/non-VBAC cases. This retrospective, single-tertiary-institution observational study aimed to assess the prevalence and morbidity of complete uterine rupture during 2010-2020. METHODS: Hospital discharge codes and local maternity databases identified uterine rupture cases, with medical record reviews confirming the diagnosis, distinguishing complete rupture from dehiscence, and extracting additional data. VBAC attempt was defined as planned labour trial after one prior caesarean. RESULTS: Over the decade, 27 complete ruptures occurred among 58 614 women, a rate of 4.6 per 10 000 births. One woman with three successive fundal ruptures had only the first included in further analysis, leaving 25 discrete women; 19 ruptures occurred in term planned VBAC attempts and six in preterm atypical/non-VBAC cases (two nulliparas and four women with multiple prior caesareans). The VBAC-attempt rupture rate was 0.74%, similar to published reports. All five perinatal deaths occurred in preterm atypical/non-VBAC cases. In the term VBAC-attempt group, rupture-related perinatal morbidity included four cases (21%) of hypoxic-ischaemic encephalopathy, with two cases (11%) of cerebral palsy at follow-up. Overall, perinatal morbidity was highest with total fetal extrusion. Maternal blood loss ≥1500 mL or transfusion was almost threefold higher, and postnatal length-of-stay was three days longer, after vaginal than caesarean birth, with delay in rupture recognition being a factor. CONCLUSION: A high suspicion index for uterine rupture is imperative during any labour, particularly in the scarred uterus, with vigilance continuing after successful vaginal birth.

Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions.

BACKGROUND: Caesarean sections (CS) are increasing worldwide. Financial incentives and related regulatory and legislative factors are important determinants of CS rates. This scoping review examines the evidence base of financial, regulatory and legislative interventions intended to reduce CS rates. METHODS: We searched MEDLINE, EMBASE, CINAHL and two trials registers in June 2019. Both experimental and observational intervention studies were eligible for inclusion. Primary outcome measures were: CS, spontaneous vaginal and instrumental birth rates. We assessed quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. RESULTS: We identified 9057 articles and assessed 65 full-texts. We included 16 observational studies. Most of the studies were conducted in high-income countries. Three studies assessed payment methods for health workers: equalising physician fees for vaginal and caesarean delivery reduced CS rates in one study; however, little or no difference in CS rates was found in the remaining two studies. Nine studies assessed payment methods for health organisations: There was no difference in CS rates between diagnosis-related group (DRG) payment system compared to fee-for-service system in one study. However, DRG system was associated with lower odds for CS in another study. There was little or no difference in CS rates following implementation of global budget payment (GBP) system in two studies. Vaginal birth after caesarean section (VBAC) increased after implementation of a case-based payment system in one study. Caesarean section increased while VBAC rates decreased following implementation of a cap-based payment system in another study. Financial incentive for providers to promote vaginal delivery combined with free vaginal delivery policy was found to reduce CS rates in one study. Studied regulatory and legislative interventions (comprising legislatively imposed practice guidelines for physicians in one study and multi-faceted strategy which included policies to control CS on maternal request in another study) were found to reduce CS rates. The GRADE quality of evidence varied from very low to low. CONCLUSIONS: Available evidence on the effects of financial and regulatory strategies intended to reduce unnecessary CS is inconclusive given inconsistency in effects and low quality of the available evidence. More rigorous studies are needed.

Placental location and risk of retained placenta in women with a previous cesarean section: A population-based cohort study.

INTRODUCTION: Some studies have shown that women with a previous cesarean section, compared with women with a previous vaginal delivery, have an increased risk of retained placenta during a subsequent vaginal delivery. It is unknown whether this is mediated by anterior placental location, when the placenta might cover the uterine scar. The aim of this study was to evaluate whether the increased risk of retained placenta in women with a previous cesarean section is mediated by anterior placental location. MATERIAL AND METHODS: This is a population-based cohort study, with data from the regional population-based Stockholm-Gotland Obstetric Cohort, Sweden, from 2008 to 2014. The overall study population included 49 598 women with a vaginal second delivery, where adequate information about placental location from the second-trimester ultrasound scan was available. For the main analysis, including the 3921 women with a previous cesarean section, we calculated the relative risk of retained placenta in women with an anterior placental location, using women with non-anterior placental locations as reference. Relative risks were calculated as odds ratios (OR) with 95% CI. In a second model, adjustments were made for maternal age, height, country of birth, smoking in early pregnancy, infant sex, and in vitro fertilization. RESULTS: In the overall study population, the rate of retained placenta at the second delivery was 2.0%. The proportion of women with a retained placenta was higher among women with a previous cesarean compared with those with a previous vaginal delivery (3.4% vs 1.9%; P < .0001). In the main analysis, including women with a previous cesarean section, the risk for retained placenta was not increased with anterior compared with non-anterior placental location (OR 0.84, 95% CI 0.60-1.20). Adjustments did not affect the estimates in a significant way. CONCLUSIONS: The increased risk of retained placenta in women with a previous cesarean section is not mediated by anterior placental location.

Is failure of fetal head engagement during previous delivery a contraindication for trial of labor: A French retrospective study.

OBJECTIVE: To study whether history of cesarean delivery for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery), is a factor of unsuccessful vaginal birth after cesarean delivery. METHODS: Multicenter prospective study of patients undergoing TOL after previous caesarean delivery between May 2012 and May 2013 in 6 maternities. Univariate statistical analysis was performed depending of previous cesarean delivery indication. Multivariate analysis was used to determine independent association between these factors and TOLAC success. RESULTS: Four hundred and eighty women with previous cesarean delivery were included and separated into two groups: the study group was composed of patients with history of CD for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery) (n=31); control group included all other indications for CD (n=449). Overall, of the 480 women included in the study, 71.2 % underwent a TOL for a subsequent delivery (n=342): 68 % in the study group (n=21) vs 71.5 % in the control group (n=321). Vaginal birth after cesarean (VBAC) was obtained in 66.6 % vs 61% in the study and control group respectively (p=0.656). Univariate analysis of factors that may influence the success rate of (VBAC) did not show any difference between the two groups. Multivariate analysis showed that VBAC was only significantly associated with history of vaginal delivery subsequent to prior CD for arrest of descent. CONCLUSION: This study reassures us in our clinical practice allowing TOL in cases of history of CD for fetal head engagement failure or instrumental delivery failure in the second stage of labor.

No. 155-Guidelines for Vaginal Birth After Previous Caesarean Birth.

OBJECTIVE: To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. OUTCOME: Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. EVIDENCE: MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

Simultaneous Uterine and Bladder Rupture Following Successful Vaginal Birth After Cesarean Delivery: Laparoscopic Repair of Defect.

When gross hematuria occurs after a successful vaginal birth after cesarean section, bladder injury should be suspected. We report a postpartum patient who experienced progressively worsening abdominal pain a few hours after delivery and was found to have a simultaneous bladder and uterine rupture, which were successfully repaired via a laparoscopic approach. This case highlights a laparoscopic approach to repairing both defects in the immediate postpartum period.

[Spontaneus delivery after two previous caesarean sections - case report]. / Spontánní porod po dvou císarských rezech a jeho mozné komplikace - kazuistika.

OBJECTIVE: To demonstrate the higher risk of the uterine dehiscence/rupture in spontaneously delivering women with scared uterus. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, General Teaching Hospital in Prague and First Medical School, Charles University. CASE REPORT: We demonstrate the risk of uterine dehiscence on the example of 36 year-old woman with two previous caesarean sections who decided to give birth spontaneously. CONCLUSION: The scars on uterus are the risk factor for uterine dehiscence and rupture. In present, the rising number of caesarean sections leads to increasing number of women with scars on uterus. Despite the potential risk of scars on the uterus, small number of women with history of surgery on uterus plans to give birth spontaneously. We demonstrate the higher risk of the uterine dehiscence after spontaneous delivery in woman with history of two caesarean sections and successful conservative therapy.

Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System.

OBJECTIVES: We aimed to assess the prevalence of uterine rupture in Belgium and to evaluate risk factors, management and outcomes for mother and child. DESIGN: Nationwide population-based prospective cohort study. SETTING: Emergency obstetric care. Participation of 97% of maternity units covering 98.6% of the deliveries in Belgium. PARTICIPANTS: All women with uterine rupture in Belgium between January 2012 and December 2013. 8 women were excluded because data collection forms were not returned. RESULTS: Data on 90 cases of confirmed uterine rupture were obtained, of which 73 had a previous Caesarean section (CS), representing an estimated prevalence of 3.6 (95% CI 2.9 to 4.4) per 10 000 deliveries overall and of 27 (95% CI 21 to 33) and 0.7 (95% CI 0.4 to 1.2) per 10 000 deliveries in women with and without previous CS, respectively. Rupture occurred during trial of labour after caesarean section (TOLAC) in 57 women (81.4%, 95% CI 68% to 88%), with a high rate of augmented (38.5%) and induced (29.8%) labour. All patients who underwent induction of labour had an unfavourable cervix at start of induction (Bishop Score ≤7 in 100%). Other uterine surgery was reported in the history of 22 cases (24%, 95% CI 17% to 34%), including 1 case of myomectomy, 3 cases of salpingectomy and 2 cases of hysteroscopic resection of a uterine septum. 14 cases ruptured in the absence of labour (15.6%, 95% CI 9.5% to 24.7%). No mothers died; 8 required hysterectomy (8.9%, 95% CI 4.6% to 16.6%). There were 10 perinatal deaths (perinatal mortality rate 117/1000 births, 95% CI 60 to 203) and perinatal asphyxia was observed in 29 infants (34.5%, 95% CI 25.2% to 45.1%). CONCLUSIONS: The prevalence of uterine rupture in Belgium is similar to that in other Western countries. There is scope for improvement through the implementation of nationally adopted guidelines on TOLAC, to prevent use of unsafe procedures, and thereby reduce avoidable morbidity and mortality.

Trial of labor after cesarean versus repeat cesarean in women with small-for-gestational age neonates: a secondary analysis.

OBJECTIVE: The objective of this study was to determine whether trial of labor after cesarean (TOLAC) is associated with increased risk of adverse outcomes for small-for-gestational-age (SGA) neonates. METHODS: This secondary analysis of a multicenter prospective observational study evaluated SGA neonates born to women with a single prior cesarean delivery. Nonanomalous, singleton pregnancies delivered at 24-41 weeks were included. The primary exposure was whether women underwent planned cesarean versus attempted TOLAC. Log-linear regression models were developed to characterize the relationship between TOLAC and neonatal outcomes. The primary outcome was a composite measure of neonatal morbidity and/or mortality, including death, respiratory complications, treated hypoglycemia, sepsis, neonatal intensive care unit (NICU) admission and hospital stay >5 days. RESULTS: Of 1009 patients identified, 258 underwent repeat cesarean; 751 attempted TOLAC. Controlling for age, race, body mass index, smoking, maternal disease, prior vaginal birth after cesarean, corticosteroids, prematurity and nonreassuring fetal status as indication for delivery, the composite adverse outcome was similarly likely in both groups (adjusted risk ratio (RR) 0.99, 95% confidence interval (95% CI) 0.88-1.12, p = 0.93). CONCLUSIONS: SGA infants born to women who TOLAC have similar neonatal outcomes to those who deliver by planned repeat cesarean. We conclude that TOLAC is an acceptable option for women with a prior cesarean and suspected SGA neonates.

[Risk of uterine rupture after cervical ripening with ballon catheter on uterus with previous cesarean section]. / Risque de rupture utérine après maturation des utérus cicatriciels par sonde à ballonnet.

OBJECTIVE: To evaluate the rate of uterine rupture after cervical ripening by mechanical methods using balloon catheter in patients with a previous cesarean section. MATERIALS AND METHODS: A literature search using the Medline database, Cochrane Library(®) database. RESULTS: We identified 13 studies evaluating four types of ballon catheter. One thousand two hundred and seventy-eight patients underwent cervical ripening by balloon catheter and 8 (0.62%) cases of uterine rupture were reported. The vaginal delivery rate was 741/1278 (58%). CONCLUSION: The use of balloon catheters in case of previous cesarean section does not appear to be associated with an increased risk of uterine rupture compared with spontaneous labor. However, further studies are required to evaluate correctly this risk.

[Balloon catheter for cervical ripening on scarred uterus with unfavorable cervix: multicenter retrospective study of 151 patients]. / Maturation du col utérin défavorable par ballonnet supra-cervical sur utérus cicatriciel : étude rétrospective multicentrique de 151 patientes.

OBJECTIVES: To evaluate safety and efficacy of balloon catheter for labor induction in women with previous cesarean section. MATERIAL AND METHODS: In a multicenter retrospective cohort study, 151 patients were included with the following criteria: pregnancy over 37 weeks, singleton, vertex presentation, previous caesarean section with unique transversal segmentary incision, medical indication for induction of labor, unfavorable cervix with Bishop score inferior to 7, no premature rupture of membranes. Balloon catheter used for cervix ripening, is inflated from 30 to 80 mL of sterile of NaCl and is left until 24 hours. RESULTS: Overall rate of vaginal delivery was 53.7% (81/151). Labor began before balloon catheter removal for 58 out of 151 (38.4%) with vaginal delivery for 75% (42/58). Best prognosis factors for vaginal delivery were spontaneous labor after balloon removal (P=0.004) and anterior vaginal delivery (P=0.03). Side effects were rare bleeding or PROM, but didn't prevent continuing ripening labor. Other morbidity consisted in two uterus ruptures (1.2%) without maternofetal incidence. CONCLUSION: Supracervical balloon is a safe and efficiency method for inducing labor on scarred uterus with unfavorable cervix with low side effects.

Fertility after complete uterine rupture.

PURPOSE OF REVIEW: This review will address fertility and pregnancy outcome in women with history of uterine rupture. RECENT FINDINGS: Increasing rates of primary Cesarean delivery and vaginal birth after one or more Cesarean sections will lead to higher rates of uterine rupture. Recent advances in reproductive medicine, open fetal surgery and gynecological surgery may also play a role in increasing uterine rupture rate. The implementation of the American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines on birth after Cesarean section will decrease the Cesarean section rate but may transiently increase the rate of uterine rupture. The maternal and perinatal risks of multiple Cesarean birth are much higher than those of uterine rupture. Women with prior uterine rupture are fertile. They have higher risk of recurrent uterine rupture. SUMMARY: Every obstetrician is bound to face the challenge of uterine rupture or women with prior uterine rupture. Those women should have a favorable maternal and perinatal outcome when managed in a tertiary center.

Women's knowledge of options for birth after Caesarean Section.

OBJECTIVE: In Australia, the Caesarean Section rate has risen from 21.8% to 31.1% (2010) in a decade; in South Australia the rate was 32.2% in 2009. Caesarean Section is a life saving intervention in certain circumstances, but also a major surgical procedure with potential adverse effects on both mother and baby. The aim of this study was to ascertain the determinants of knowledge regarding options for subsequent birth in women who have experienced a previous Caesarean Section with a live baby. METHOD: A sample of 33 women in South Australia who had a previous Caesarean Section were surveyed to assess their awareness of birth options and their advantages versus disadvantages as well as the possible factors influencing their information gathering and decision-making on birth options for their subsequent pregnancy. FINDINGS: Most women perceived Caesarean Section to be major surgery but 69.6% were not aware that babies might have problems with breastfeeding, 60.6% did not know the rarity of uterine rupture during labour and/or birth and 48.5% were not aware that a caesarean may involve any complications for the baby at or after birth. CONCLUSION: Women's knowledge deficits relating to risks and benefits of birth options after previous caesarean can constrain them as most women chose caesarean rather than normal birth in their subsequent pregnancy.