Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

OBJECTIVE: The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS: We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS: Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION: Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

Influence of Caesarean section-pregnancy interval on uterine rupture risk and IVF pregnancy rates: systematic review and mathematical modelling.

RESEARCH QUESTION: What is the influence of the Caesarean section-pregnancy interval (CSPI) on the risk of uterine rupture, and what are the repercussions on IVF pregnancy rates of prolonging it? STUDY DESIGN: Systematic searches were performed using PubMed MEDLINE to identify studies published up until July 2017 for articles with the following keywords: 'interdelivery interval' and 'uterine rupture'; 'interpregnancy interval' and 'uterine rupture'; 'interpregnancy interval' and 'cesarean section'; and 'uterine rupture' and 'cesarean section'. The search identified 1609 articles, of which six were included (involving 56,419 women). Four reported significantly higher uterine rupture rates in cases of a short CSPI. RESULTS: From the analysis, the uterine rupture rate can be modelled by a formula corresponding to a hyperbolic curve. There is no clear cut-off in uterine rupture in relation to CSPI. The curve showed a sharp decrease in uterine rupture until the 10th month of CSPI (uterine rupture rate 0.7%), then a moderate and steady decrease until the 40th month (uterine rupture rate 0.4%) and afterwards a very mild decrease. From the data it is possible to calculate, according to the age of the woman, the expected reduction in IVF rates and uterine rupture as CSPI increases. CONCLUSION: The risk of uterine rupture in relation to CSPI can be represented by means of a hyperbolic curve. After a 10-month CSPI, the expected uterine rupture rate is close to 0.7%. The impact of prolonging or reducing this interval on IVF pregnancy rates can be easily obtained from the table included in the article. This should be helpful in the decision-making process for both patients and physicians.

Hospital variation in utilization and success of trial of labor after a prior cesarean.

BACKGROUND: Trial of labor after cesarean delivery is an effective and safe option for women without contraindications. OBJECTIVES: The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes. STUDY DESIGN: Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery. RESULTS: In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate. CONCLUSION: Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).

Automated early detection of obstetric complications: theoretic and methodologic considerations.

Compared with adults who are admitted to general medical-surgical wards, women who are admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems, such as those used for nonpregnant adults. Predictive models that use data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues that are involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been addressed explicitly in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop 2 obstetric predictive models with the use of data from 262,071 women who were admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.

[Correlation between uterine scar condition and uterine rupture for pregnancy women after previous cesarean section].

Objective: To investigate the relationship between the previous cesarean scar thickness, previous cesarean scar defect and the occurrence of uterine rupture for pregnancy women after previous cesarean section and to predict the occurrence of uterine rupture in the third trimester for pregnancy women after previous cesarean section by analyzing the lower uterine segment (LUS) situation or quantitatively measure LUS myometrium thickness. Methods: A total of 154 pregnant women who have a prior cesarean from January 2015 to March 2016 were selected, all of them regularly did the prenatal examination in the pregnancy period and finally gave birth in hospital. By the transvaginal sonograph, the LUS myometrium thickness (transverse and longitudinal thickness) and the size of the previous cesarean scar defect were measured in the first trimester, the LUS myometrium thickness (longitudinal thickness) and qualitatively analysis LUS condition were measured in the third trimester. They were divided into two groups according to the pregnancy outcome: uterine rupture group (found in the cesarean operation or during the pregnancy) and without uterine rupture group (including the vaginal delivery women and those without uterine rupture in the cesarean operation period). The sensitivity and specificity of LUS myometrium thickness in the first trimester and the qualitative analysis LUS situation, the quantitative measurement of LUS myometrium thickness in the third trimester were compared in the prediction of occurrence of uterine rupture (dehiscence or complete rupture). Results: The group without uterine rupture included 134 women (6 vaginal delivery and 128 cesarean delivery), and the group with uterine rupture included 20 women (all of them cesarean delivery). The LUS myometrium thickness in the third trimester in the group without uterine rupture was (1.6±0.5) mm, and was (1.1±0.7) mm in the uterine rupture group (P= 0.004). There were no significant difference between two groups in the mean value of age, height, weight, the interdelivery interval, the LUS myometrium thickness (transverse and longitudinal thickness) in the first trimester. Qualitative analysis of LUS condition had higher specificity (99%), higher positive predictive value (92%), higher negative predictive value (94%) and slightly lower sensitivity (60%) than quantitative measure of LUS myometrium thickness in predicting uterine rupture. Conclusions: Measurement of the LUS myometrium thickness in the first trimester is helpful for predicting the occurrence of uterine rupture, so it is not necessary to terminate the pregnancy because of the thin LUS or the little prior cesarean scar defect in the first trimester. However it should be paid close attention to the LUS situation during the whole gestation. Qualitatively analyzing LUS situation is more meaningful than quantitatively measuring LUS myometrium thickness in predicting the uterine rupture in the third trimester.

Prior caesarean section and likelihood of vaginal birth, 2012-2016, China.

OBJECTIVE: To examine the trends and safety of vaginal birth after caesarean section around the period of the one-child policy relaxation in China. METHODS: We used data from China's National Maternal Near Miss Surveillance System between 2012 and 2016. To examine trends in vaginal birth after caesarean section, we used Poisson regression with a robust variance estimator. We also assessed the association between vaginal birth after caesarean section and maternal and perinatal outcomes. FINDINGS: We analysed 871 636 deliveries by women with a previous caesarean section. Both in 2012 and 2016, the rate of vaginal birth after caesarean section was 9.8%. After adjusting for institutional, sociodemographic and obstetric characteristics, the rate increased by 14% between 2012 and 2016 (adjusted relative risk, aRR: 1.14; 95% confidence interval, CI: 1.07-1.21). Compared to women with a repeat caesarean section, women with a vaginal birth after caesarean section experienced lower incidence of uterine rupture (aRR: 0.26, 95% CI: 0.16-0.42), blood transfusion (aRR: 0.68, 95% CI: 0.53-0.87) and admission to the intensive care unit (aRR: 0.36, 95% CI: 0.25-0.52), but higher incidence of intrapartum stillbirths, (aRR: 7.20, 95% CI: 6.09-8.51), newborns with a 5-minute Apgar score less than 7 (aRR: 1.75, 95% CI: 1.54-1.99) and neonatal death before discharge (aRR: 1.90, 95% CI: 1.61-2.24). CONCLUSION: Promotion of vaginal birth after caesarean section could increase the rate even further in China. To ensure the safety of mothers and their newborns, national policies and guidelines on vaginal birth after caesarean section are needed.

Preoperative 3-dimensional Magnetic Resonance Imaging of Uterine Myoma and Endometrium Before Myomectomy.

Uterine myomas are the most common gynecologic benign tumor affecting women of childbearing age, and myomectomy is the main surgical option to preserve the uterus and fertility. During myomectomy for women with multiple myomas, it is advisable to identify and remove as many as possible to decrease the risk of future myomectomies. With deficient preoperative imaging, gynecologists are challenged to identify the location and size of myomas and the endometrium, which, in turn, can lead to uterine rupture during future pregnancies. Current conventional 2-dimensional imaging has limitations in identifying precise locations of multiple myomas and the endometrium. In our experience, we preferred to use 3-dimensional imaging to delineate the myomas, endometrium, or blood vessels, which we were able to successfully reconstruct by using the following imaging method. To achieve 3-dimensional imaging, we matched T2 turbo spin echo images to detect uterine myomas and endometria with T1 high-resolution isotropic volume excitation-post images used to detect blood vessels by using an algorithm based on the 3-dimensional region growing method. Then, we produced images of the uterine myomas, endometria, and blood vessels using a 3-dimensional surface rendering method and successfully reconstructed selective 3-dimensional imaging for uterine myomas, endometria, and adjacent blood vessels. A Web-based survey was sent to 66 gynecologists concerning imaging techniques used before myomectomy. Twenty-eight of 36 responding gynecologists answered that the 3-dimensional image produced in the current study is preferred to conventional 2-dimensional magnetic resonance imaging in identifying precise locations of uterine myomas and endometria. The proposed 3-dimensional magnetic resonance imaging method successfully reconstructed uterine myomas, endometria, and adjacent vessels. We propose that this will be a helpful adjunct to uterine myomectomy as a preoperative imaging technique in future studies.

Tocogram characteristics of uterine rupture: a systematic review.

PURPOSE: Timely diagnosing a uterine rupture is challenging. Based on the pathophysiology of complete uterine wall separation, changes in uterine activity are expected. The primary objective is to identify tocogram characteristics associated with uterine rupture during trial of labor after cesarean section. The secondary objective is to compare the external tocodynamometer with intrauterine pressure catheters. METHODS: MEDLINE, EMBASE, and the Cochrane library were systematically searched for eligible records. Moreover, clinical guidelines were screened. Studies analyzing tocogram characteristics of uterine rupture during trial of labor after cesarean section were appraised and included by two independent reviewers. Due to heterogeneity, a meta-analysis was only feasible for uterine hyperstimulation. RESULTS: Thirteen studies were included. Three tocogram characteristics were associated with uterine rupture. (1) Hyperstimulation was more frequently observed compared with controls during the delivery (38 versus 21 % and 58 versus 53 %), and in the last 2 h prior to birth (19 versus 4 %). Results of meta-analysis: OR 1.68 (95 % CI 0.97-2.89), p = 0.06. (2) Decrease of uterine activity was observed in 14-40 % and (3) an increasing baseline in 10-20 %. Five studies documented no changes in uterine activity or Montevideo units. A direct comparison between external tocodynamometer and intrauterine pressure catheters was not feasible. CONCLUSIONS: Uterine rupture can be preceded or accompanied by several types of changes in uterine contractility, including hyperstimulation, reduced number of contractions, and increased or reduced baseline of the uterine tonus. While no typical pattern has been repeatedly reported, close follow-up of uterine contractility is advised and hyperstimulation should be prevented.

Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation.

STUDY OBJECTIVE: Owing to the increase in cesarean sections (C-sections) worldwide, long-term complications such as postmenstrual spotting, chronic pelvic pain, and C-section scar ectopic pregnancies have created a new medical era of gynecologic disease. A new type of vaginal repair is evaluated to repair C-section diverticulum (CSD) and rebuild the muscular layer to improve symptoms of abnormal uterine bleeding and decrease the risk of uterine rupture. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: A total of 121 patients with CSD diagnoses by transvaginal ultrasound (TVU) presented with postmenstrual spotting between June 2012 and March 2015. All patients had undergone at least 1 C-section delivery and had no history of postmenstrual spotting before undergoing C-section. INTERVENTION: Vaginal excision and suture of CSD. MEASUREMENT AND MAIN RESULTS: The mean duration of menstruation was 14.87 ± 3.46 days preoperatively and decreased to 8.22 ± 2.73 days at 1 month after surgery, 8.89 ± 2.67 days at 3 months after surgery, and 9.02 ± 2.47 days at 6 months after surgery (p < .01). The length, width, depth, and thickness of the remaining muscular layer (TRM) at 1 month, 3 months, and 6 months assessed by TVU also improved significantly after surgery (p < .05). However, postoperative menstruation and imaging data did not differ markedly between 3 months and 6 months, suggesting that follow-up at 3 months represents an adequate endpoint for evaluating the effectiveness of surgery. At 6 months, 80.3% of patients (94 of 117) reached ≤10 days of menstruation. Further study revealed that a TRM at 6 months of ≥8.5 mm measured by TVU (relative risk [RR], 6.418; 95% confidence interval [CI], 1.478-28.443) and an interval between CS and vaginal repair of ≤2.5 years (RR, 12.0; 95% CI, 1.541- 93.454) were good prognostic factors associated with surgery. CONCLUSION: Vaginal repair of CSD improved the symptoms of postmenstrual spotting and anatomically corrected the scars. An interval between C-section and a surgery of ≤2.5 years was optimal for vaginal repair, and a TRM at 6 months of ≥8.5 mm represented the standard healing of CSD.

[Induction of labor]. / Indukce porodu.

UNLABELLED: Data published in this guideline are based on previous guideline issued by Society of Perinatal Medicine of Czech Gynecological and Obstetrical Society (CGPS) [55], international guidelines and data from peer-reviewed journals. The fundamental document for this guideline is guideline issued by The Society of Obstetricians and Gynaecologists of Canada (SOGS) Induction of labor, No. 296, 2013 (reviewed 2015) [61]. The literature review is added to the aforementioned document and some of its recommendations are further discussed in this guideline. DESIGN: Review of literature.

Case records of the Massachusetts General Hospital: Case 34-2012: a 27-year-old woman in Ethiopia with severe pain, bleeding, and shock during labor.

A 27-year-old woman was admitted to a hospital in Ethiopia because of severe abdominal pain during labor, with cessation of contractions. She had been in labor at home, pushing for 24 hours. On arrival at the hospital 3 hours later, she was in shock. A procedure was performed.

Vaginal birth after cesarean: an effective method to reduce cesarean.

Cesarean deliveries represent almost one third of US births. Given that repeat cesarean is the most common single indication for cesarean, trial of labor after cesarean (TOLAC) with subsequent vaginal birth after cesarean (VBAC) is an important mechanism to reduce the overall cesarean rate. The 2010 National Institutes of Health Conference found that one of the biggest barriers to VBAC is the lack of patient access to TOLAC. Many women who currently deliver by repeat cesarean would be candidates for a TOLAC. This manuscript will summarize the evidence on VBAC to help clinicians identify candidates, provide evidence-based counseling, and guide management of TOLAC.

Variables influencing the integrity of lower uterine segment in post-cesarean pregnancy.

BACKGROUND: There is significant increase in proportion of cases with previous cesarean delivery requiring obstetric care. The available literature fails to provide uniform opinion on each woman's characteristics to identify risk of uterine rupture while planning trial of labor after cesarean. OBJECTIVE: To study the association of abnormal lower uterine segment with some of the present and previous obstetric variables including patient characteristics and surgical techniques at previous cesarean operation. MATERIALS AND METHODS: Consenting consecutive 96 post-cesarean singleton pregnancies admitting after 36 weeks gestation at the same facility from July 2011 to December 2012 for repeat cesarean, were studied. Only the cases with cephalic presentation and vertex as presenting part, having no placenta previa, polyhydramnios, uterine anomaly or fibroid and those who had previous one lower segment cesarean were recruited. Based on the intra-operative finding the lower uterine segment (LUS) was categorized into those having a normal and abnormal (grades 2-4) LUS. Sonographic assessment of LUS thickness and any abnormalities if any were noted. The findings of abnormal LUS (direct observation at surgery and sonographic impression within a week before surgery) were looked for association with some of the present and previous obstetric variables including patient characteristics and surgical techniques at previous cesarean operation using Student t, Chi square or Fisher's exact test for analysis as appropriate. Receiver operating curve analysis was used to determine the optimal cut off value for prediction of LUS integrity by ultrasound. RESULTS: Of the women recruited for the study, 36 were admitted in early labor and ultrasound evaluation of LUS was performed in 48 of the remaining 60 women admitted antenatal for elective cesarean delivery. There were 38 abnormal LUS (39.6%) with 22 of them (57.9%) graded as 'thinned out LUS'. The incidence of scar dehiscence (grade 3, cases 5) was 5.2% of 96 cases and there were no cases of scar rupture. Proportion of cases with abnormal LUS was significantly high when primary cesarean was done in preterm (p = 0.02); it was a single layer uterine closure (p = 0.02), and inter-cesarean interval was 54 months (p = 0.01). Abnormal LUS was also seen to be associated with maternal age beyond 35 years (p = 0.2), when cesarean was performed in labor (p = 0.5), following 18 h of rupture of membranes (p = 0.75), for a baby weight more than 3 kg (p = 0.4), and different suture materials (polyglactin 910 and chromic catgut) were used to close uterus at primary cesarean delivery (p = 0.1), and also if they had post-partum fever (p = 0.3). Ultrasound measurement of LUS by abdominal scan correlated with the intra-operative LUS grading and a thickness of more than 3.2 mm within a week before delivery and was seen to be the safe cut off above which most of the women had a normal LUS (sensitivity 92.3%, specificity 81.1%). CONCLUSION: Factors at primary cesarean operation significantly influence the state of LUS at term in subsequent pregnancy .

Intrapartum care and substandard care: juridical recommendations to reduce the risk of liability.

PURPOSE: To develop juridical recommendations to reduce medical liability of the obstetrician, providing intrapartum care. METHODS: 107 legal proceedings of the past 40 years from Belgium, France and the Netherlands, involving medical negligence of the obstetrician during intrapartum care, were analyzed in depth. The legal databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (the Netherlands). A minority of the cases were retrieved through contacts with insurance companies (Belgium only) and courts. RESULTS: The judicial assessment of negligence is focused on four domains of expertise of the obstetrician: 36 % (38/107) recognizing a specific pathology, 33 % (35/107) interpreting fetal monitoring, 19 % (21/107) performing a forceps/vacuum-assisted delivery and 12 % (13/107) managing shoulder dystocia. The highest liability rate of 86 % (30/35) was reflected in the category of interpreting fetal monitoring. CONCLUSION: To reduce the liability rate of 66 %, several policy recommendations can be made. Respond to the first symptoms of obstetric complications (particularly placental abruption and uterine rupture). Secondly, respond to disturbing messages of the midwife concerning fetal distress and evaluate every deviation in fetal heart rate monitoring. Education concerning the interpretation of fetal monitoring is a must for every midwife and obstetrician. Use proper methods to monitor the heart rate to optimize the quality of the signal. The third recommendation is to be cautious about opting for a forceps/vacuum-assisted delivery, consider all circumstances. Consider the risk of failed instrumental delivery. And finally in relation to shoulder dystocia, recognize the risk factors by ordering further examinations to purchase a diagnosis.

Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid.

OBJECTIVE: To develop a patient decision aid (PtDA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean (VBAC) with the elicitation of patient preferences and evidence-based information. DESIGN: A PtDA was developed and pilot tested using the International Patients Decision Aid Standards (IPDAS) criteria. SETTING: Obstetric health care in the Netherlands. POPULATION: A multidisciplinary steering group, an expert panel, and 25 future users of the PtDA, i.e. women with a previous caesarean section. METHODS: The development consisted of a construction phase (definition of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. MAIN OUTCOME MEASURES: Usability, clarity, and relevance. RESULTS: The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The PtDA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness (n = 7) were not evaluated. CONCLUSIONS: An evidence-based PtDA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the PtDA enhances the quality of decision-making on mode of birth after caesarean section.

Intrapartum management of trial of labour after caesarean delivery: evidence and experience.

Few studies have focused specifically on the intrapartum management of patients following a prior caesarean delivery. Contemporary assessments and recommendations on attempting vaginal birth after caesarean delivery (VBAC) vary. The actual conduct of labour and delivery of the infant in an uncomplicated trial of labour after caesarean (TOLAC) is similar to the management of a patient without a previous caesarean. Intrapartum management of TOLAC differs primarily in the need for caution with induction of labour in women with an unfavourable cervix, the avoidance of overstimulation with oxytocin augmentation, and surveillance for prompt recognition of the rare case of uterine rupture.

Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.

OBJECTIVE: Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. METHODS: We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy. RESULTS: Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins. CONCLUSION: Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.

Objectif : En raison de préoccupations au sujet de la rupture utérine, de nombreux obstétriciens recommandent la tenue d'une césarienne planifiée pour ce qui est des femmes ayant déjà subi une myomectomie. Cette pratique a mené à la hausse du taux de césarienne planifiée et, subséquemment, à celle du taux de césarienne itérative. Cette étude avait pour objectif d'évaluer les points de vue des obstétriciens en ce qui concerne le travail et l'accouchement à la suite d'une myomectomie abdominale ou laparoscopique. Méthodes : Nous avons mené un sondage auprès de 49 obstétriciens praticiens, entre juillet 2012 et janvier 2013, au moyen d'un questionnaire standard. Ce dernier comptait des questions sur le travail et l'accouchement à la suite d'une myomectomie menée par laparotomie ou par laparoscopie. Résultats : De façon globale, le consensus inter-répondants était assez bon (kappa 0,3; P < 0,001). Aucune différence significative n'a été constatée en ce qui concerne la probabilité que les répondants permettent la tenue d'un accouchement vaginal à la suite d'une myomectomie menée par laparotomie ou par laparoscopie (27 % et 14 %, si la cavité utérine avait été pénétrée, et 76 % et 71 %, si la cavité utérine n'avait pas été pénétrée, respectivement). Cependant, la probabilité que les répondants permettent la tenue d'un accouchement vaginal était considérablement atténuée lorsque la cavité utérine avait été pénétrée, peu importe l'approche chirurgicale utilisée (P < 0,001). La probabilité que les obstétriciens recommandent la tenue d'une césarienne planifiée, plutôt que celle d'un déclenchement du travail, connaissait également une hausse significative lorsque la cavité utérine avait été pénétrée au cours de la myomectomie. Aucune différence significative n'a été constatée au niveau de la pratique en ce qui concerne l'utilisation d'oxytocine conjointement avec une amniotomie, d'oxytocine en perfusion ou de prostaglandines. Conclusion : Malgré le manque de données sur le sujet, les obstétriciens considèrent que la pénétration de la cavité utérine pendant la myomectomie (et ce, peu importe l'approche chirurgicale utilisée dans le cadre de cette dernière) constitue un facteur important au moment de prendre des décisions quant au mode d'accouchement, à l'utilisation d'oxytocine et au recours à une césarienne planifiée.

Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a meta-analysis.

OBJECTIVE: To evaluate the accuracy of antenatal sonographic measurement of lower uterine segment (LUS) thickness in the prediction of risk of uterine rupture during a trial of labor (TOL) in women with a previous Cesarean section (CS). METHODS: PubMed and EMBASE were searched to identify articles published on the subject of sonographic LUS measurement and occurrence of a uterine defect after delivery. Four independent researchers performed identification of papers and data extraction. Selected studies were scored on methodological quality, and sensitivity and specificity of measurement of LUS thickness in the prediction of a uterine defect were calculated. We performed bivariate meta-analysis to estimate summary receiver-operating characteristics (sROC) curves. RESULTS: We included 21 studies with a total of 2776 analyzed patients. The quality of included studies was good, although comparison was difficult because of heterogeneity. The estimated sROC curves showed that measurement of LUS thickness seems promising in the prediction of occurrence of uterine defects (dehiscence and rupture) in the uterine wall. The pooled sensitivity and specificity of myometrial LUS thickness for cut-offs between 0.6 and 2.0 mm was 0.76 (95% CI, 0.60-0.87) and 0.92 (95% CI, 0.82-0.97); cut-offs between 2.1 and 4.0 mm reached a sensitivity and specificity of 0.94 (95% CI, 0.81-0.98) and 0.64 (95% CI, 0.26-0.90). The pooled sensitivity and specificity of full LUS thickness for cut-offs between 2.0 and 3.0 mm was 0.61 (95% CI, 0.42-0.77) and 0.91 (95% CI, 0.80-0.96); cut-offs between 3.1 and 5.1 mm reached a sensitivity and specificity of 0.96 (95% CI, 0.89-0.98) and 0.63 (95% CI, 0.30-0.87). CONCLUSIONS: This meta-analysis provides support for the use of antenatal LUS measurements in the prediction of a uterine defect during TOL. Clinical applicability should be assessed in prospective observational studies using a standardized method of measurement.