Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland.

BACKGROUND: Policy consensus in high-income countries supports offering pregnant women with previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or attempting a vaginal birth, known as a planned vaginal birth after previous cesarean (VBAC), provided they do not have contraindications to planned VBAC. However, robust comprehensive information on the associated outcomes to counsel eligible women about this choice is lacking. This study investigated the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section among women delivering a term singleton and considered eligible to have a planned VBAC. METHODS AND FINDINGS: A population-based cohort of 74,043 term singleton births in Scotland between 2002 and 2015 to women with one or more previous cesarean sections was conducted using linked Scottish national datasets. Logistic or modified Poisson regression, as appropriate, was used to estimate the effect of planned mode of delivery on maternal and perinatal outcomes adjusted for sociodemographic, maternal medical, and obstetric-related characteristics. A total of 45,579 women gave birth by ERCS, and 28,464 had a planned VBAC, 28.4% of whom went on to have an in-labor nonelective repeat cesarean section. Compared to women delivering by ERCS, those who had a planned VBAC were significantly more likely to have uterine rupture (0.24%, n = 69 versus 0.04%, n = 17, adjusted odds ratio [aOR] 7.3, 95% confidence interval [CI] 3.9-13.9, p < 0.001), a blood transfusion (1.14%, n = 324 versus 0.50%, n = 226, aOR 2.3, 95% CI 1.9-2.8, p < 0.001), puerperal sepsis (0.27%, n = 76 versus 0.17%, n = 78, aOR 1.8, 95% CI 1.3-2.7, p = 0.002), and surgical injury (0.17% versus 0.09%, n = 40, aOR 3.0, 95% CI 1.8-4.8, p < 0.001) and experience adverse perinatal outcomes including perinatal death, admission to a neonatal unit, resuscitation requiring drugs and/or intubation, and an Apgar score < 7 at 5 minutes (7.99%, n = 2,049 versus 6.37%, n = 2,570, aOR 1.6, 95% CI 1.5-1.7, p < 0.001). However, women who had a planned VBAC were more likely than those delivering by ERCS to breastfeed at birth or hospital discharge (63.6%, n = 14,906 versus 54.5%, n = 21,403, adjusted risk ratio [aRR] 1.2, 95% CI 1.1-1.2, p < 0.001) and were more likely to breastfeed at 6-8 weeks postpartum (43.6%, n = 10,496 versus 34.5%, n = 13,556, aRR 1.2, 95% CI 1.2-1.3, p < 0.001). The effect of planned mode of delivery on the mother's risk of having a postnatal stay greater than 5 days, an overnight readmission to hospital within 42 days of birth, and other puerperal infection varied according to whether she had any prior vaginal deliveries and, in the case of length of postnatal stay, also varied according to the number of prior cesarean sections. The study is mainly limited by the potential for residual confounding and misclassification bias. CONCLUSIONS: Among women considered eligible to have a planned VBAC, planned VBAC compared to ERCS is associated with an increased risk of the mother having serious birth-related maternal and perinatal complications. Conversely, planned VBAC is associated with an increased likelihood of breastfeeding, whereas the effect on other maternal outcomes differs according to whether a woman has any prior vaginal deliveries and the number of prior cesarean sections she has had. However, the absolute risk of adverse outcomes is small for either delivery approach. This information can be used to counsel and manage the increasing number of women with previous cesarean section, but more research is needed on longer-term outcomes.

Perinatal outcome in births after a previous cesarean section at high trial of labor rates.

INTRODUCTION: Trial of labor (TOLAC) is an option in most preganancies after a cesarean section The objective of the study was to compare perinatal outcome in TOLAC and non-TOLAC deliveries in a population with high TOLAC rates. MATERIAL AND METHODS: This was a cohort study based on population data from the Medical Birth Registry of Norway. We included term, cephalic, single, second deliveries, 1989-2009, after a first cesarean section (n = 43 422). TOLAC, TOLAC failure, non-TOLAC deliveries, and after high-risk and low-risk pregnancies (no risk/any risk), were compared with respect to offspring mortality, 5-minute Apgar score Apgar < 7 and < 4, transfer to a neonatal intensive care unit, and neonatal respiratory distress syndrome. RESULTS: Statistically significant differences were observed (P <0.05). In the low-risk group the offspring mortality was 2.3/1000 in TOLAC compared with 0.9/1000 in non-TOLAC. In the high-risk group, the offspring mortality was 3.7/1000 in TOLAC compared with 0.9/1000 in non-TOLAC, and the 5-minute Apgar score < 4 was 3.1/1000 in TOLAC compared with 0.9/1000 in non-TOLAC. In both risk groups, TOLAC delivery had a higher rate of 5-minute Apgar score < 7. In the low-risk group, non-TOLAC deliveries had a higher rate of neonatal respiratory distress syndrome than TOLAC deliveries. CONCLUSIONS: We observed higher risk of offspring mortality and lower 5-minute Apgar score in TOLAC than in non-TOLAC. Possible causes and preventive measures should be explored.

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.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth.

BACKGROUND: When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean (VBAC), current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution. OBJECTIVES: To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned VBAC for women with a previous caesarean birth. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Two randomised trials involving 320 women and their infants were included. However, data for maternal and infant clinical outcomes were available from one trial with very low event rates, involving 22 women only.For the primary outcomes maternal death or serious morbidity (one study; 22 women; risk ratio (RR) not estimable), and infant death or serious morbidity (one study; 22 women; RR not estimable), there were no statistically significant differences between planned caesarean birth and planned vaginal birth identified. AUTHORS' CONCLUSIONS: Planned elective repeat caesarean section and planned VBAC for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is largely drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

Neonatal morbidity and mortality for repeated cesarean section vs. normal vaginal delivery to uncomplicated term pregnancies at Srinagarind Hospital.

OBJECTIVE: To evaluate the morbidities and mortality of neonates delivered by elective repeated cesarean section vs. normal vaginal delivery among women with uncomplicated term pregnancies. MATERIAL AND METHOD: A retrospective descriptive study was done between January 2009 and December 2011 to determine the morbidities and mortality among uncomplicated term pregnancies at Srinagarind Hospital. Three hundred seventy two neonates delivered by elective repeated cesarean section vs. 1,581 by normal vaginal delivery. RESULTS: A significantly greater number of neonates in the elective repeated cesarean section group required oxygen for neonatal resuscitation compared to neonates in the normal vaginal delivery group (37.6% vs. 20.9%, p < 0.001). Neonates delivered by elective repeated cesarean section were more frequently admitted to the neonatal intensive care unit (1.1% vs. 0%, p < 0.001) and had longer hospital stays (4.56 +/- 2.45 vs. 4.07 +/- 1.44 days, p < 0.001). The latter not only had a higher rate of respiratory distress syndrome (0.8% vs. 0%, p < 0.001) and transient tachypnea of the newborn (3.2% vs. 0.3%, p < 0.001), which required more respiratory support, they also had a higher rate of infection (2.4% vs. 0.8%, p < 0.05) than neonates delivered by normal vaginal delivery. Neonates born by normal vaginal delivery, however had more birth trauma and hyperbilirubinemia than neonates born by elective repeated cesarean section (8.8% vs. 2.4%, p < 0.001 and 31.8% vs. 22.6%, p < 0.05, respectively). There was no difference in the mortality rate between the groups. CONCLUSION: Even among uncomplicated term pregnancies, cesarean section is associated with more neonatal respiratory morbidity and sepsis while those delivered by normal vaginal delivery tend to have a higher rate of birth trauma and hyperbilirubinemia. Clinicians should therefore be concerned about the route of delivery and the probability of negative neonatal outcomes.

Maternal mortality in the United States--why is it important and what are we doing about it?

Following dramatic reductions between the early 1900s and the early 1980s, the maternal mortality ratio began to rise, reaching a peak of almost 17 maternal deaths per 100,000 live births. Although this number pales in comparison with that found in sub-Saharan Africa and India, the troubling rise in the United States is a surrogate for medical care in general and obstetrical care in particular. Both Healthy People 2010 and the United Nations Millennium Goals were aimed at reducing maternal mortality worldwide. This presentation will review the trends in maternal mortality along with the efforts some jurisdictions, along with the American Congress of Obstetricians and Gynecologists, have taken to address this obstetrical tragedy. Although maternal death is the tip of the iceberg, thousands more women suffer a "near-miss" but survive to deal with lifelong medical consequences. Finally, you will be reminded that each maternal death is not just an isolated medical event but rather it permanently affects an ever-enlarging circle of society.

Timing of elective repeat caesarean section: maternal and neonatal morbidity and mortality.

Timing of elective repeat caesarean section should take into account both fetal and maternal considerations. The percentage of caesarean deliveries has dramatically increased during the last decades. It undoubtedly leads to an increase in the number of women having multiple caesarean sections. While maternal morbidity increases with increased number of caesarean sections, when compared with their term counterparts, late pre-term infants face increased morbidity. Establishing the optimal time of delivery for both mother and child is a major challenge faced by clinicians. The aim of this review is to better understand neonatal and maternal morbidity and mortality that are associated with elective repeat caesarean section, and to provide an educated decision regarding the optimal timing for elective repeat caesarean section.

Cesarean delivery and peripartum hysterectomy.

OBJECTIVE: To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. METHODS: A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. RESULTS: The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6-4.5). Maternal mortality was 0.6% (95% CI 0-1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35-5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66-3.58), parity of three or greater (OR 2.30, 95% CI 1.26-4.18), previous manual placental removal (OR 12.5, 95% CI 1.17-133.0), previous myomectomy (OR 14.0, 95% CI 1.31-149.3), and twin pregnancy (OR 6.30, 95% CI 1.73-23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37-3.33], 18.6 with two or more [95% CI 7.67-45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71-13.7). CONCLUSION: Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3. LEVEL OF EVIDENCE: II.

Vaginal births after C-section are not necessarily riskier in a birth center than in the hospital.

Recent research concluded that VBACs are riskier in a birth center than in the hospital. This conclusion is only true if the woman is sure she will not have any more pregnancies and if she does not suffer from "Fear of Hospitals." Since childbirth centers offered a VBAC rate of 87%, whereas US hospitals currently offer a VBAC rate of less than 10%, the woman has a much higher risk of a repeat cesarean if she delivers in hospital, which increases her risk on subsequent pregnancies.

[Perinatal mortality after previous cesarean section]. / Perinatale kindliche Todesfälle bei Kaiserschnitt in der mütterlichen Anamnese.

BACKGROUND: Perinatal neonatal mortality is increased where there is a maternal history of cesarean section (0.45 vs. 0.31 % in deliveries after previous vaginal delivery). In this study we have analyzed the causes of the perinatal deaths. PATIENTS AND METHODS: The increased risk was found by analyzing the database of the Swiss Working Group of Obstetric and Gynecological Institutions with its 29 046 deliveries with a history of previous cesarean section between 1983 and 1996. In this time period 130 perinatal neonatal deaths in deliveries after previous cesarean were recorded. RESULTS: The cause of death could be established in 124 cases. In the 42 term deliveries the causes of death were the following: malformations 20, uterine rupture 5, placental abruption 5, respiratory distress syndrome 5, and other causes 7. In the 82 preterm deliveries: prematurity caused by premature contractions/rupture of membranes 38, malformations 12, chorioamnionitis 12, placental abruption 9, severe growth retardation 4, complications of placenta praevia 2, uterine rupture 1, other causes 4. DISCUSSION: Preterm deliveries are more frequent (in births) after a previous c/s (7.75 vs. 5.55 % in multiparous mothers without previous cesarean) - not because of a higher frequency of preterm labor or premature rupture of membranes, but because of placental abruption, chorioamnionitis, placental insufficiency and severe growth retardation. Although some of the neonatal deaths are linked to the previous cesarean delivery, perinatal death after previous cesarean is a very rare event. A recommendation to routinely perform a repeat cesarean instead of a trial of labor seems not appropriate.

Maternal morbidity after elective repeat caesarean section after two or more previous procedures.

OBJECTIVES: To determine the incidence of maternal morbidity following elective caesarean section in women with a history of at least two previous caesarean sections, and to determine if the incidence of morbidity correlates with the number of previous sections. STUDY DESIGN: We conducted an individual chart review of all women who had an elective caesarean section because of a history of two previous sections from 1990 to 1999. RESULTS: There were 67,097 deliveries of babies weighing 500 g or more. The total number of cases eligible for the study was 250. There were 12 cases (4.8%) of placenta praevia of which four required a transfusion and two a hysterectomy. The incidence of wound infection was 6.3% and urinary tract infection was 11.2%. There were no cases of thromboembolism recorded. CONCLUSIONS: Maternal morbidity with elective repeat caesarean section is low. The major morbidity is associated with placenta praevia. We found no correlation between the incidence of maternal morbidity and the number of previous sections.

Cost-effectiveness of elective cesarean delivery after one prior low transverse cesarean.

OBJECTIVE: This analysis was undertaken to better understand the costs and health consequences of a trial of labor after cesarean when compared with a policy of routine elective repeat cesarean delivery. METHODS: A decision-tree model incorporating a Markov analysis was used to examine the reproductive life of a hypothetical cohort of 100,000 pregnant women whose only prior pregnancy was delivered through a low transverse cesarean incision. Using this model, the policy of performing routine elective cesarean delivery was compared with a policy of allowing a trial of labor. Main outcome measures were maternal and neonatal morbidity and mortality, total costs to the health care system, and cost per major neonatal complication avoided (death or permanent neurologic sequelae). RESULTS: The consequences of routine elective cesarean delivery for a second birth are significant, with an additional 117,748 cesarean deliveries, 5500 maternal morbid events, and $179 million incurred during the reproductive life of 100,000 women. The prevention of one major adverse neonatal outcome requires 1591 cesarean deliveries and $2.4 million. Sensitivity analysis confirms the robustness of the analysis. CONCLUSION: Routine elective cesarean for a second delivery for women with a prior low transverse cesarean incision results in an excess of maternal morbidity and mortality and a high cost to the medical system.

Can the rate of cesarean section be reduced?

OBJECTIVE: To look into all cases with previous one cesarean section who were cared for and delivered at Armed Forces Hospital, Riyadh, between January 1990 and December 1998, to determine its prevalence, final method of delivery, and outline measures of reducing its incidence. METHODS: Retrospective analysis of hospital records of all women with previous one cesarean section who had either a repeat cesarean section or delivered vaginally after cesarean section. RESULTS: Between 1990 and 1998, 61,060 mothers were delivered. Two thousand five hundred and seventy eight patients had one previous cesarean section. They represented 3.5% of the total number of deliveries. Nine hundred and sixty eight (37.5%) cases had repeat cesarean section. Of the 1610 (62.5%) mothers who achieved vaginal delivery, 102 (6%) had ventouse, 42 (3%) had forceps and 22 (1%) had an assisted breech delivery. Rupture of uterine scar was reported in 15 cases. There were no maternal or perinatal deaths. CONCLUSION: Patients with one previous cesarean section are three times more likely to have a cesarean section as compared to mothers with unscarred uterus. Reducing the overall cesarean section rate is possible through a closer look at the primary indication for the first cesarean section. A protocol is needed to allow more cases with one or more previous cesarean section to have trial of vaginal delivery under close monitoring and involve the senior staff more in the diagnosis and management of cases of dystocia and the use of Oxytocin when indicated.

[Predictive factors of the delivery method in women with cesarean section scars]. / Facteurs prédictifs de la voie d'accouchement des femmes ayant un utérus cicatriciel.

OBJECTIVE: To determine the independent effect of clinical and non clinical factors on the mode of delivery after previous cesarean section. METHODS: We performed a retrospective multicenter study of 579 women who had previously undergone a cesarean section and who delivered between January 1995 and June 1997. Maternal and perinatal morbidity associated with trial of labor and elective repeat cesarean was assessed. Multiple logistic regression was used to identify prognostic factors for the outcome of a trial of labor. The odds ratios provided indicate the risk of cesarean section when the factor is present. RESULTS: The rate of successful trial of labor was 74.5%. Overall morbidity was not increased in the trial of labor group. The variables of significant predictive value were the Bishop's score (OR = 15.2 for a score < 3; 95% CI: 5.54 to 41.9), an anomaly of the pelvis (OR = 5.89; 95% CI: 2.37 to 14.7), a previous vaginal delivery (OR = 0.27; 95% CI: 0.12 to 0.60), a fetal distress (OR = 4.11; 95% CI: 2.01 to 8.43), the weight gain during pregnancy (OR = 2.01; 95% CI: 1.10 to 3.68), a delivery between 11 p.m. and 7 a.m. (OR = 0.29; 95% CI: 0.13 to 0.66), a hypertension (OR = 3.10; 95% CI: 1.09 to 8.80) and the use of an intra-uterine pressure catheter (OR = 0.26; 95% CI: 0.11 to 0.57). CONCLUSION: A trial of labor should be allowed in most of the women with previous cesarean section. The Bishop's score is the best predictor of the mode of delivery. Induction of labor and a first cesarean for dystocia do not affect the chances of vaginal birth.

Caesarean section and maternal mortality at the Lagos University Teaching Hospital.

There were sixteen maternal deaths following 1,450 Caesarian sections at the Lagos University Teaching Hospital in an eight year period 1966 to 1974, a maternal mortality rate of 1.1%. The chief causes of maternal deaths in this environment are pre-eclamptic toxaemia, eclampsia and haemorrhage. Most of the obstetric deaths following Caesarian sections are preventable through the application of current knowledge and availability of modern facilities. Reduction of maternal deaths will follow recognition and attention to the most frequent causes.