Delivery mode and fetal outcome in attempted vaginal deliveries after previous cesarean section: a nationwide register-based cohort study in Finland.

PURPOSE: Even though the risks and advantages of repeat Cesarean sections (CSs) and vaginal births after cesarean section (VBACs) are well studied, there is a scarcity of information on the effects of previous CS on maternal and fetal outcomes during subsequent deliveries. The aim of this study is to evaluate delivery mode and fetal outcomes in a trial of labor after cesarean section (TOLAC). METHODS: In this nationwide retrospective cohort study, data from the National Medical Birth Register (MBR) were used to evaluate the outcomes of TOLACs. TOLACs were compared to the outcomes of the trial of labor after previous successful vaginal delivery. A multivariable logistic regression model was used to assess the primary outcomes (delivery mode, neonatal intensive care unit, and perinatal/neonatal mortality). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used for comparison. RESULTS: A total of 29 352 (77.0%) women attempted vaginal delivery in the TOLAC group. In the control group, 169 377 (97.2%) women attempted vaginal delivery. The adjusted odds for urgent CS (aOR 13.05, CI 12.59-13.65) and emergency CS (aOR 3.65, CI 3.26-4.08) were notably higher in the TOLAC group when compared to the control group. The odds for neonatal intensive care unit treatment (aOR 2.05, CI 1.98-2.14), perinatal mortality (aOR 2.15, CI 1.79-2.57), and neonatal mortality (aOR 1.75, CI 1.20-2.49) were higher in the TOLAC group. CONCLUSIONS: The odds for emergency CS were higher among women who underwent TOLAC. The odds for neonatal intensive care and perinatal mortality were also higher, and further research is needed to identify those expecting women who are better suited for TOLAC to minimize the risk for a neonate. The results of this study should be acknowledged by the mother and the clinician when considering the possibility of vaginal births after cesarean section.

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.

[Vaginal birth after caesarean section in out-of-hospital settings: a literature review]. / Literaturstudie zur vaginalen Geburt bei Status nach Sectio caesarea in der außerklinischen Geburtshilfe.

BACKGROUND: Even though vaginal birth after Caesarean section (VBAC) is recommended, an out-of-hospital setting is discussed controversially. First of all, uterine rupture and placental complications are named. Nevertheless, an increasing number of women with a prior Caesarean section decide to give birth in an out-of-hospital setting. What is the maternal and neonatal outcome in international studies in these cases? METHOD: The databases of Medline, Cinahl, Embase and Cochrane Library on vaginal birth after Caesarean section in out-of-hospital settings were searched. Included are studies in German and English language without a limit on year of publication, which describe maternal and neonatal outcomes. RESULTS: 5 studies were found. All of them describe a high VBAC rate (73.5-98%). Only one study found uterine ruptures. Haemorrhage/placental complications were described in 2 studies (0.5 and 1.7%). None of the studies found maternal deaths. Neonatal death was described in 3 studies in a range from 0 -1.7%. DISCUSSION: There is a wide difference in the population of the studies. An important difference is the parity of the women and the prior mode of birth. 4 of the 5 studies do not see a reason not to try VBAC in an out-of-hospital setting. Further studies are necessary to inform the increasing number of women who decide to try VBAC in an out-of-hospital setting.

A Population-based study on trends in the mode of delivery subsequent to stillbirth, infant mortality and severe infant malformations in the state of Hesse, Germany between 1990 and 2012.

BACKGROUND: Women giving birth to a child with severe infant malformations or suffering a stillbirth certainly experience a mental trauma. Therefore the objective of the present study is to examine the incidence of deliveries subsequent to such a traumatic experience as well as the mode of delivery. Secondly, the results are compared to the changes of a non-affected group of deliveries over the last 23 years in the state of Hesse, Germany. METHODS: The total obstetric dataset of the Hessian Perinatal Registry (HEPE) was assessed for women with regard to one item of the pregnancy risk factors. This particular HEPE item comprises information on the rates of stillbirth, early and late infant mortality (≤7 days,<1 year) as well as severe infantile malformations in women giving birth subsequent to such an extensive traumatic experience. The identified women were categorized with respect to the mode of delivery (spontaneous, vaginal operative or Cesarean section), pre- and full-term birth and according to 4 time-frames between 1990 and 2012. The results of women with a positive HEPE item were compared to those of women without such a traumatic experience (non-affected group) of the HEPE analyzed in the same categories and time-frames. RESULTS: The obstetric dataset from 1990 until 2012 of the HEPE comprised altogether 1 224 760 deliveries including a group of 19 726 (1.61%) deliveries subsequent to a positive result for the analyzed HEPE item. Over the duration of follow-up the rate of subsequent pregnancies following such a traumatic experience showed a significantly decrease of 43% in comparison to the previous time-frame, respectively (1990-1996: 30.3%; 2008-2013: 17%; P≤0.0001). With respect to the mode of delivery (spontaneous, vaginal operative, Cesarean section) the results in the group subsequent to the positive HEPE item (1 862, 55.5%; 70, 2.1%; 1 416, 42.2%) were significantly different (P<0.001) in comparison to the non-affected group (142 846, 59.9%; 13 875, 5.8%; 81 089, 34.0%), respectively. DISCUSSION: Rising rates of CSs and conversely decreased numbers of vaginal deliveries in most cases of full-term pregnancies contrast with the reduction of the positive HEPE item over the last 23 years. There seems to be an urgent need for action since this observed critical trend remains highly significant in comparison with the rising trend of CS in general. Pre-pregnancy counseling and continuous monitoring during pregnancy and delivery in consciousness of evident risk factors may be an opportunity to cope with these serious findings.

Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery.

OBJECTIVES: Uterine rupture is a rare but potentially catastrophic complication of pregnancy that requires rapid diagnosis. Classically, its signs and symptoms combine pain, fetal heart rate (FHR) abnormalities, and vaginal bleeding. The purpose of this study is to identify these signs and symptoms as well as the immediate complications of complete and incomplete (partial) ruptures of the uterine wall, whether or not they follow a previous cesarean delivery. STUDY DESIGN: Retrospective study of case records from two university hospital maternity units, from 1987 to 2008. RESULTS: In a total of 97,028 births during the study period, we identified 52 uterine ruptures (0.05%): 25 complete and 27 partial. Most (89%) occurred in women with a previous cesarean delivery. In complete ruptures, FHR abnormalities were the most frequent sign (82%), while the complete triad of FHR abnormalities-pain-vaginal bleeding was present in only 9%. The signs and symptoms of partial ruptures were very different; these were asymptomatic in half the cases (48%). Neonatal mortality reached 13.6% among the complete ruptures; 27 and 40% of these newborns had pH<6.80 and pH<7.0, respectively. Among the incomplete ruptures, only 7.7% of the newborns had a pH<7.0 and there were no deaths. CONCLUSION: Although complete rupture of the uterus has a severe neonatal prognosis, the complete set of standard symptoms is present in less than 10% of cases. FHR abnormalities are by far the most frequent sign.

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.

VBAC: what does the evidence show?

Declining rates of vaginal birth after cesarean (VBAC) are contributing to rising total cesarean delivery rates. The reasons behind the decreased utilization of VBAC are complex, but concerns about the safety of a trial of labor after cesarean are often cited. This manuscript will present a summary of existing evidence on maternal and fetal/neonatal outcomes associated with trial of labor after cesarean/VBAC, and highlight findings from recent contributions to this literature.

Delivery after prior cesarean: success rate and factors.

Cesarean delivery rates in the United States have reached an all-time high. The current rate of 31% is 6 times higher than the 1970s rate. Many factors including physician preference and hospital accessibility account for this trend. A decreased vaginal birth after cesarean (VBAC) rate and an increased repeat cesarean rate have important consequences for women in future pregnancies. Because of these considerations, VBAC has been an important issue within the obstetric community for over 3 decades. Identifying the best candidates for VBAC using factors available to the obstetrician can increase the VBAC success rate while minimizing maternal morbidity.

Delivery after prior cesarean: maternal morbidity and mortality.

Nearly 1 in 3 pregnant women in the United States undergo cesarean. This trend is contrary to the national goal of decreasing cesarean delivery in low-risk women. The decline in vaginal birth after cesarean (VBAC) contributes to the continual increase in cesarean deliveries. Prior cesarean delivery is the most common indication for cesarean and accounts for more than one-third of all cesareans. The appropriate use and safety of cesarean and VBAC are of concern not only at the individual patient and clinician level but they also have far-reaching public health and policy implications at the national level.

Predictors of successful vaginal delivery after previous caesarean section in a Nigerian tertiary hospital.

Achieving a successful vaginal birth after a previous caesarean section (VBAC) is an important strategy in reducing the rising rate of caesarean section and its associated morbidities. Records of 188 women attempting trial of vaginal delivery after a previous lower segment caesarean section were reviewed to predict factors favouring successful vaginal delivery. Of the 188 women, 64 had recurrent indications for caesarean section, while 124 had non-recurrent indications. The group with recurrent indications for previous caesarean section had less vaginal delivery and more repeat caesarean sections as compared with the group with non-recurrent indications (21.9% and 78.1% vs 46.8% and 53.2%, respectively, p = 0.01). Cephalopelvic disproportion was more frequent in the group with recurrent indications (65.6% vs 27.4%, p < 0.0001). Significant predictors of successful VBAC in this cohort of women were non-recurrent indications for the previous caesarean section (p < 0.001, odds ratio (95% CI) 0.32 (0.2-0.6)) and a previous vaginal delivery (p < 0.0001, odds ratio (95% CI) 3.90 (2.1-7.4)). A previous vaginal delivery and a non-recurrent indication for the previous caesarean section are important predictors of VBAC in this cohort of women.

[Method of delivery after cesarean section (review of the literature)].

The author shows, that pregnant women may give birth vaginally without compromise when they have spent one to three and more cesarean births.

Previous caesarean or vaginal delivery: which mode is a greater risk of perinatal death at the second delivery?

OBJECTIVE: To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean. STUDY DESIGN: Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history. RESULTS: A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p<0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason. CONCLUSION: Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.

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.

Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study.

OBJECTIVE: To determine the factors associated with an increased risk of perinatal death related to uterine rupture during attempted vaginal birth after caesarean section. DESIGN: Population based retrospective cohort study. SETTING: Data from the linked Scottish Morbidity Record and Stillbirth and Infant Death Survey of births in Scotland, 1985-98. PARTICIPANTS: All women with one previous caesarean delivery who gave birth to a singleton infant at term by a means other than planned repeat caesarean section (n = 35 854). MAIN OUTCOME MEASURES: All intrapartum uterine rupture and uterine rupture resulting in perinatal death (that is, death of the fetus or neonate). RESULTS: The overall proportion of vaginal births was 74.2% and of uterine rupture was 0.35%. The risk of intrapartum uterine rupture was higher among women who had not previously given birth vaginally (adjusted odds ratio 2.5, 95% confidence interval 1.6 to 3.9, P < 0.001) and those whose labour was induced with prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factors were also associated with an increased risk of perinatal death due to uterine rupture. Delivery in a hospital with < 3000 births a year did not increase the overall risk of uterine rupture (1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with >or= 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04). CONCLUSION: Women who have not previously given birth vaginally and those whose labour is induced with prostaglandin are at increased risk of uterine rupture when attempting vaginal birth after caesarean section. The risk of consequent death of the infant is higher in units with lower annual numbers of births.

[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.