Trends and determinants of the use of episiotomy in a prospective population-based registry from central India.

BACKGROUND: Findings from research and recommendations from the World Health Organization favor restrictive use of episiotomy, but whether this guidance is being followed in India, and factors associated with its use, are not known. This study sought to document trends in use of episiotomy over a five-year period (2014-2018); to examine its relationship to maternal, pregnancy, and health-system characteristics; and to investigate its association with other obstetric interventions. METHODS: We conducted a secondary analysis of data collected by the Maternal Newborn Health Registry, a prospective population-based pregnancy registry established in Central India (Nagpur, Eastern Maharashtra). We examined type of birth and use of episiotomy in vaginal deliveries from 2014 to 2018, as well as maternal and birth characteristics, health systems factors, and concurrent obstetric interventions associations with its use with multivariable Poisson regression models. RESULTS: During the five-year interval, the rate of episiotomy in vaginal birth rose from 13 to 31% despite a decline in assisted vaginal birth. Associations with episiotomy were found for the following factors: prior birth, multiple gestations, seven or more years of maternal education, higher gestational age, higher birthweight, delivery by an obstetrician (as compared to midwife or general physician), and birth in hospital (as compared to clinic or health center). After adjusting for these factors, year over year rise in episiotomy was significant with an adjusted incidence rate ratio (AIRR) of 1.10 [95% confidence interval (CI) 1.08-1.12; p = 0.002]. We found an association between episiotomy and several other obstetric interventions, with the strongest relationship for maternal treatment with antibiotics (AIRR 4.23, 95% CI 3.12-5.73; p = 0.001). CONCLUSIONS: Episiotomy in this population-based sample from central India steadily rose from 2014 to 2018. This increase over time was observed even after adjusting for patient characteristics, obstetric risk factors, and health system features, such as specialty of the birthing provider. Our findings have important implications for maternal-child health and respectful maternity care given that most women prefer to avoid episiotomy; they also highlight a potential target for antibiotic stewardship as part of global efforts to combat antimicrobial resistance. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov under reference number NCT01073475.

Episiotomy is a surgical procedure to widen the vaginal opening for childbirth. It was once commonly used worldwide. However, because the procedure can cause pain to mothers and place them at risk for infections and serious tears to the vagina­especially when the cut is directly downward­research suggests it should be used sparingly. As such, it is now less often practiced in high-income countries, but whether the same is true in India is not known. To answer this question, we used a large population-based pregnancy registry, the Maternal Newborn Health Registry, from Central India (Nagpur) to assess the frequency of episiotomy use between 2014 and 2018 and if there were certain maternal characteristics, features of the health care system, and other pregnancy interventions that were related with its use. Over this five-year period, the use of episiotomy during vaginal birth rose more than two-fold. It was more often used on women who had never delivered a baby before, were further along in pregnancy, had higher levels of education, had heavier babies, or were carrying more than one baby. Obstetricians were more likely to perform episiotomy than midwives or general physicians and it was more likely to be performed in hospitals than in clinics or primary health centers. This rise during the five-year interval was significant even when accounting for these patient and provider characteristics, suggesting a shift in medical practice. Because this was an observational study more research is needed to determine if the associations we found are causal.

Duration of double balloon catheter for patients with prior cesarean: a before and after study.

Background: Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries. Objective: To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery. Study Design: A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan-Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used. Results: From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes. Conclusion: In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.

A Systematic Review of the Use of Routine Versus Selective Episiotomy for Vaginal Birth.

Episiotomy is a common obstetric surgical procedure involving an incision to enlarge the vaginal opening, facilitating the delivery of the fetus during the second stage of labor. Hence, the current review was conducted to assess the impact of using selective versus routine episiotomy during vaginal birth on birth outcomes. This systematic review used the Joanna Briggs Institute (JBI) methodology for systematic reviews and research syntheses. PubMed, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and SCOPUS were searched for relevant studies. Two reviewers independently screened and extracted data from relevant studies. Four studies met the eligibility criteria and were included in this review. The findings suggest selective episiotomy is associated with better maternal and fetal outcomes than routine episiotomy in certain contexts. However, results varied, indicating the importance of tailoring episiotomy practices to specific patient populations and healthcare settings. To conclude, the review supports the use of selective episiotomy over routine episiotomy during vaginal birth, as it is associated with fewer adverse maternal outcomes.

The effects of a quality improvement project to reduce caesarean sections in selected private hospitals in Brazil.

BACKGROUND: Brazil is one of the countries with the highest rates of caesarean sections (CS), reaching almost 90% of births in the private sector. A quality improvement project called "Adequate Childbirth Project (PPA)" was conceived to reduce CS in the private sector. This project consisted of four primary components: "Governance", "Participation of Women", "Reorganization of Care" and "Monitoring". This paper aims to evaluate: (1) which specific activities of the PPA had the largest effect on the probability of a woman having a vaginal delivery; (2) which primary component of the PPA had the largest effect on the probability of vaginal delivery and (3) which scenarios combining the implementation of different activities planned in the PPA had a higher effect on the probability of vaginal delivery. METHODS: A sample of 12 private hospitals participating in the PPA was evaluated. We used a Bayesian Network (BN) to capture both non-linearities and complex cause-effect relations. The BN integrated knowledge from experts and data from women to estimate 26 model parameters. The PPA was evaluated in 2473 women belonging to groups 1-4 of the Robson classification, who were divided into two groups: those participating or not participating in the PPA. RESULTS: The probability of a woman having a vaginal delivery was 37.7% higher in women participating in the PPA. The most important component of the project that led to an increase in the probability of vaginal delivery was "Reorganization of Care", leading to a 73% probability of vaginal delivery among women in labor. The activity that had the greatest effect on the type of delivery was access to best practices during labor, with a 72% probability of vaginal delivery. Considering the 12 scenarios combining the different activities of the PPA, the best scenarios included: a non-scheduled delivery, access to information about best practices, access to at least 4 best practices during labor and respect of the birth plan, with an 80% probability of vaginal delivery in the best combinations. CONCLUSION: PPA has been shown to be an effective quality improvement program, increasing the likelihood of vaginal delivery in private Brazilian hospitals.

INTRODUCTION: Brazil boasts one of the highest rates of caesarean sections (CS) globally, with nearly 90% of births in private facilities being delivered via CS. In response, the 'Adequate Childbirth Project ­ PPA' was launched as a quality improvement initiative aimed at curbing CS rates in private healthcare. Its goal is to improve the quality of childbirth and reduce the number of CS in private healthcare. The project has four main parts: 'Governance', 'Participation of Women', 'Reorganization of Care', and 'Monitoring'. METHOD: an evaluative study was conducted across 12 private hospitals involved in the PPA, involving 2473 women who were categorized into PPA participants and non-participants. They used a method called a cause-effect network to see which parts of the PPA helped more women have vaginal deliveries. RESULTS: They found that women in the PPA were 37.7% more likely to have a vaginal delivery. Giving women access to good practices during labor and birth was really important. Also, 'Reorganization of Care' was the most important part of the project. It led to a 73% chance of vaginal delivery for women in labor. CONCLUSION: The PPA is effective in helping more women in private hospitals have vaginal deliveries. This means it's a good program for improving childbirth in Brazil's private hospitals.

Could a simple manual technique performed by a midwife reduce the incidence of episiotomy and perineal lacerations? A non-randomized pilot study.

INTRODUCTION: Women experience medical interventions, episiotomy, and perineal lacerations during childbirth, impacting their physical, psychological, and sexual well-being. This study compares the perineal status of prospective women who had the midwifery intervention of perineal myofascial release during childbirth, to a matched retrospective control sample of women who received standard care during childbirth. METHODS: A non-randomized pilot study with prospective data collected for 50 women after informed verbal consent was obtained to having the midwifery intervention of perineal myofascial release during childbirth, and the matched retrospective data for the control group of 49 women were collected from a random sample generated from the medical records. Quantitative analyses included descriptive statistics, independent t-tests, regression, and chi-squared analyses. Retrospective trial registration was granted with The Australian New Zealand Clinical Trials Registry ANZTR. RESULTS: Women were six times (OR=0.15; 95% CI: 0.0-0.37) less likely to have a non-intact perineum and twice (OR=0.44; 95% CI: 0.35-0.56) less likely to have an episiotomy if they were in the intervention group. Chi-squared analysis found no statistically significant differences between groups for normal vaginal birth and instrumental births, excluding cesareans and waterbirth [χ2(1)= -0.37, p=0.542]. CONCLUSIONS: This study found perineal myofascial release benefits women by reducing perineal trauma and episiotomy. However, there were no significant differences in the duration of the active pushing stage of labor or mode of birth. This study has shown some promise in obtaining data for a larger, definitive, randomized controlled trial. CLINICAL TRIAL REGISTRATION: The study was registered on the Australian New Zealand Clinical Trials Registry ANZTR. IDENTIFIER: ID ACTRN12623000807651.

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

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

Birth outcomes for women planning Vaginal Birth after Caesarean (VBAC) in midwifery led settings: A systematic review and meta-analysis.

PROBLEM: There is a limited knowledge base available to midwives, obstetricians and women planning vaginal birth after caesarean (VBAC), impeding their ability to make informed choices regarding planned place of birth. BACKGROUND: A VBAC is associated with fewer complications for both mother and baby, but little is known on the safety and success of planning a VBAC in midwifery led settings such as birth centres and home birth, compared to obstetric led settings. AIM: To synthesise the findings of published studies regarding maternal and neonatal outcomes with planned VBAC in midwifery setting compared to obstetric units. METHODS: PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were systematically searched on 16/08/2022 for all quantitative research on the outcomes for women planning VBAC in midwifery led settings compared to obstetric led settings in high income countries. Included studies were quality assessed using the CASP Checklist. Binary outcomes are incorporated into pairwise meta-analyses, effect sizes reported as risk ratios with 95 % confidence intervals. A τ² estimate of between-study variance was performed for each binary outcome analysis. Other, more heterogeneous outcomes are narratively reported. FINDINGS: Two high-quality studies, out of 420 articles, were included. VBAC planned in a midwifery-led setting was associated with a statistically significant increase in unassisted vaginal birth (RR=1.42 95 % CI 1.37 to 1.48) and decrease in emergency caesarean section (RR= 0.46 95 % CI 0.39 to 0.56) and instrumental birth (RR= 0.33 95 % CI 0.23 to 0.47) compared with planned VBAC in an obstetric setting. There were no significant differences in uterine rupture (RR= 1.03 95 % CI 0.52 to 2.07), admission to special care nursery (RR= 0.71 95 % CI 0.47 to 1.23) or Apgar score of 7 or less at 5 min (RR= 1.16 95 % CI 0.66 to 2.03). CONCLUSION: Planning VBAC in midwifery led settings is associated with increased vaginal birth and a reduction in interventions such as instrumental birth and caesarean section. Adverse perinatal outcomes are rare, and further research is required to draw conclusions on these risks.

Balancing Maternal Melanoma and Vaginal Birth After Cesarean (VBAC) Delivery: A Case Report Highlighting Shared Decision-Making.

Melanoma is increasingly common among reproductive-age women and is one of the most common cancers diagnosed during pregnancy. The literature for melanoma in pregnancy, especially among those with prior uterine scars, is limited. We present an interesting case of a 22-year-old woman who went to her dermatologist for a suspicious lesion on her thigh. The lesion was excised, and histopathology confirmed that it was a melanoma. The dermatologist recommended immediate delivery. The patient then urged her obstetrician to undergo the risks of an induction of labor (IOL) for a trial of labor after cesarean (TOLAC) because she desired a large family, and a second cesarean would make this more difficult to happen. She ultimately had a successful vaginal birth after cesarean (VBAC) and subsequent excision of the melanoma with surgical oncology in the immediate postpartum period. Therefore, the decision for IOL for TOLAC in this case was based on the patient's fears regarding melanoma disease progression in her 39th week. Given the short time course between delivery and excision of her melanoma, it is possible that she may have been able to wait for spontaneous labor, which would have avoided the risks associated with IOL for TOLAC. The optimal timing of surgical intervention for melanoma in pregnant patients who desire TOLAC is unknown. In pregnancies that are approaching their due date, waiting for spontaneous labor may be a reasonable approach to avoid the risks of labor induction, especially in women with prior cesarean delivery. A multidisciplinary approach involving dermatology, surgical oncology, and the obstetric team is warranted to optimize both dermatologic and obstetric outcomes.

Observed Versus Predicted Vaginal Birth After Cesarean for Patients of a Community Health Center.

INTRODUCTION: The Maternal-Fetal Medicine Units Network calculator for vaginal birth after cesarean (VBAC) probability was updated to exclude a race and ethnicity variable, but its impact on marginalized groups is unknown. We assessed the tool with attention to birth history and body mass index (BMI) in a predominately Hispanic cohort and examined the possible effect of discouraging labor after cesarean (LAC) with a low score. METHODS: We conducted a retrospective cohort study of LACs by patients who entered spontaneous or induced labor with a live, nonanomalous fetus in cephalic presentation between 2012 and 2022. Observed VBAC rates were compared with the mean predicted VBAC probability derived from the calculator. Areas under the curve (AUCs) were calculated for the entire cohort and for individuals with LAC with and without prior vaginal birth. A z-test was used to determine the significance between VBAC rates in 4 BMI categories. The impact of discouraging LAC with VBAC probability below 70% was examined. RESULTS: A total of 400 people experienced 507 LACs, with 417 (82.2%) resulting in VBAC compared with a mean predicted probability of 71.2%. The AUC for all LACs was 0.76 (95% CI, 0.71-0.81), whereas the AUC for LACs with prior vaginal birth was 0.70 (95% CI, 0.56-0.85) and without was 0.60 (95% CI, 0.52-0.67). Observed VBAC rates exceeded predicted rates for individuals with overweight and obese BMIs: <25 (79.6% vs 75.6%; P = .520), 25 to 30 (83.2% vs 71.9%; P = .007), 30 to 40 (82.7% vs 70.0%; P = .004), and ≥40 (82.8% vs 58.3%; P = .040). Discouraging LAC below 70% probability might have prevented 71 unsuccessful LACs, 160 initial VBACs, and 57 subsequent VBACs, decreasing the VBAC rate to 39.4% (200/507). DISCUSSION: In a predominately Hispanic cohort, the updated calculator underestimated VBAC potential for people with no vaginal birth history and/or an elevated BMI. Discouraging LAC based on low VBAC probability may prevent both initial and subsequent VBACs.

Evaluating the impact of a trial of labor after cesarean section on labor duration: a retrospective cohort study.

BACKGROUND: Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases. METHODS: This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor. RESULTS: The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70-0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74-1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself. CONCLUSIONS: After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration.

Case report: Perineal swelling: A rare case of scar endometriosis.

We report a rare case of episiotomy site scar endometriosis manifested as painful perineal swelling near the anus for 2 years affecting daily routine activity, especially during menses. A 33-year-old female, para 2 with both vaginal deliveries with last child birth 8 years back. A 2.5 × 3 cm firm, tender nodule was present on the posterior vulva at the right mediolateral episiotomy site. Trans-perineal and trans-anal ultrasound scan was done, anal sphincter involvement was ruled out and the nodule was excised with free margins. histopathology confirmed the diagnosis of scar endometriosis. The key takeaway from this case is endometriosis can present after 8 years of vaginal delivery. The timely diagnosis and treatment is necessary as delay may cause anal sphincter involvement or malignant transformation.

Quantifying the association between doula care and maternal and neonatal outcomes.

BACKGROUND: The United States suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and to decrease this disparity. OBJECTIVE: This study aimed to evaluate the association between doula care and a broad range of maternal and neonatal outcomes in various subpopulations. STUDY DESIGN: This was a retrospective cohort study of deliveries that were recorded from January 2021 to December 2022 at a single institution where they received prenatal care. The exposure was receipt of doula care prenatally and at delivery. We evaluated both the maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean, gestational hypertension, preeclampsia, postpartum emergency department visit, readmission, and attendance of postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine growth restriction) outcomes. Because our institution previously employed targeted outreach by offering doula services to patients at highest risk, we used multiple methods to generate an appropriate comparison population. We conducted a multivariate logistic regression and conditional regressions using propensity scores to model the likelihood of doula care to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White vs Black) and then by payor status (public vs commercial). RESULTS: Our cohort included 17,831 deliveries; 486 of those received doula care and 17,345 did not. Patients who received doula care were more likely to self-report Black race, be publicly insured, and to live in a more disadvantaged neighborhood. Regardless of the analytical approach, for every 100 patients who received doula care, there were 15 to 34 more vaginal births after cesarean (adjusted risk difference, 15.6; 95% confidence interval, 3.8-27.4; adjusted risk difference, 34.2; 95% confidence interval, 0.046-68.0) and 5 to 6 more patients who attended a postpartum office visit (adjusted risk difference, 5.4; 95% confidence interval, 1.4-9.5; adjusted risk difference, 6.8; 95% confidence interval, 3.7-9.9) when compared with those who did not receive doula services. Infants born to these patients were 20% more like likely to be exclusively breastfed (adjusted risk ratio, 1.22; 95% confidence interval, 1.07-1.38), and doula care was associated with 3 to 4 fewer preterm births (adjusted risk difference, -3.8; 95% confidence interval, -6.1 to -1.5; -4.0; 95% confidence interval, -6.2 to -1.8) for every 100 deliveries that received doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula. CONCLUSION: Doula care was associated with more vaginal births after cesarean delivery, improved attendance of postpartum office visits, improved breastfeeding rates, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

How the Mode of Delivery Is Influenced by Patient's Opinions and Risk-Informed Consent in Women with a History of Caesarean Section? Is Vaginal Delivery a Real Option after Caesarean Section?

Background/Objectives: In recent years, there has been a noticeable increase in the rates of caesarean section (CS), being one of the most commonly performed surgical procedures. For the following pregnancy, the previous CS represents the backbone of the risks and complications, such as uterine scar formation, uterine rupture, massive bleeding, and serious negative outcomes for both the mother and child. Our study followed patients with a history of CS from the birth planning prenatal check-up to delivery. Methods: We reviewed the records of 125 pregnant women with previous CS who presented in the third trimester for a prenatal check-up and completed our questionnaire from March 2021 to April 2022 in the Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Germany. Results: Before the prenatal check-up, 74 patients (59.2%) preferred vaginal delivery (VD), while 51 (40.8%) preferred CS. After discussing birth planning with the obstetrician, 72 women (57.6%) decided upon VD, while 53 (42.4%) preferred CS. Ultimately, 78 (62.4%) of women gave birth through CS (either planned or by medical necessity) and 47 (37.6%) gave birth vaginally (either natural or per vacuum extraction). Conclusions: VD for patients with CS in their medical history is a real option. The patient must be well informed about the risks and benefits of the medical situation and should be empowered and supported on their chosen mode of delivery, which should be respected.

Identifies Current Trends in Vaginal Birth after Cesarean Section in IRAN: A Qualitative Study.

Background: The growing prevalence of Cesarean Sections (CS), particularly repeated CS, is a major issue in contemporary midwifery. This study seeks to gain a comprehensive understanding of the experiences of pregnant women and specialists with vaginal delivery after CS, as well as the obstacles that may arise. Materials and Methods: From March 2020 to May 2021, 10 women, 12 midwives, and 8 obstetricians and obstetricians affiliated with Qom University of Medical Sciences were interviewed to investigate the experiences and challenges associated with Vaginal Birth After Cesarean section (VBAC). We used the content analysis method, and the sampling was purposive. Semi-structured interviews were conducted to collect data, which were then analyzed using qualitative content analysis based on conventional content analysis. Results: The results show that subcategories "individual aspects of VBAC" and "family-social aspects of VBAC" formed "positive aspects of VBAC." Subcategories "self-efficacy" and "decision-making participation" formed the "empowerment for the woman." Subcategories "technical team challenges" and "woman's challenges" formed the main category of "upcoming challenges." Conclusions: Positive relationships, choice-making ability, and self-confidence impact a woman's decision to choose VBAC. Informing women of alternative delivery options after a CS and pursuing their dreams increases the likelihood of successful VBAC.

Influence of Antenatal Education on Birth Outcomes: A Systematic Review Focusing on Primiparous Women.

The primary objective of prenatal education programs is to furnish expectant mothers with the necessary knowledge for childbirth and early parenting. Despite the extensive implementation of these programs, the efficacy of these interventions remains unclear. This systematic review endeavored to consolidate the extant evidence pertaining to the effects of prenatal education on birth outcomes and experiences. Fourteen studies, comprising various study designs executed across diverse countries, were incorporated in this review. The outcomes assessed in these studies encompassed fear and anxiety, pain, delivery mode, interventions, postpartum depression, and self-efficacy. Additionally, the risk of bias and study limitations were also summarized. The results manifested that prenatal education was effective in diminishing the fear and anxiety associated with childbirth and enhancing self-efficacy in the majority of the studies. Moreover, several studies found that engaging in prenatal education augmented the preference for unmedicated vaginal birth. However, the effects of prenatal education on postpartum outcomes were less consistent. The primary constraints of the included studies were their minute sample sizes and brief follow-up periods. Nonetheless, the existing evidence proposes that prenatal education is beneficial for first-time mothers in terms of alleviating anxiety and augmenting agency during delivery. Prenatal education can equip pregnant individuals with the necessary knowledge and skills to navigate the perinatal period successfully. Further research is requisite to identify the optimal practices for diverse populations on a global scale.

Obstetrics and Gynecologic Hospitalists and Their Focus: Impact on Safety and Quality Metrics.

Obstetrics and gynecologic hospitalists play a pivotal role in the evolution of perinatal care. Hospitalists improve patient safety by providing on-site, reliable, high-quality care. Hospitalists help to reduce the rates of unnecessary cesarean deliveries and increase the rates of vaginal deliveries.

Do Birth Outcomes Predicted by Occipital Position Inform Definitions of Occiput Posterior and Occiput Transverse?

Fetal head position significantly influences birth outcomes, with higher rates of complications observed when the fetal head is in the Occiput Posterior (OP) position compared to Occiput Transverse (OT) or Occiput Anterior (OA) positions. There is no consensus in the current literature on the precise rotational point at which the fetal occiput shifts from posterior to transverse, reducing clarity in both scientific and clinical communication. Different studies employ varying definitions of these positions, which affects management decisions. This study aims to determine if a definable threshold exists between the directly posterior and directly transverse positions that correlates with different birth outcomes, thereby proposing a consistent and clinically useful definition for OP versus OT. We analyzed ultrasound data from 570 patients at full dilatation from five previous studies, correlating the angle of the fetal occiput (noted on a clock-face) with birth outcomes. Adverse outcomes were defined as cesarean delivery, instrumental vaginal delivery, significant postpartum hemorrhage (500 ml or more), obstetric anal sphincter injury, five-minute Apgar scores <7, arterial cord pH <7, base excess less than -12, or neonatal intensive care unit admission. The analysis was conducted using SAS version 9.4. The study found a continuous relationship between the fetal occipital angle and adverse birth outcomes without a distinct threshold separating OP from OT positions. No clear inflection point was demonstrated in pregnancy outcomes between OT and OP. The relationship between the angle of occiput position and pregnancy outcomes was continuous: the closer the fetal head was to directly OP, the higher the likelihood of adverse outcomes. Given the lack of a clear cut-off and to improve consistency in future research, we recommend dividing the occiput position into four quadrants of 90 degrees each. This classification could standardize reporting and potentially improve clinical decision-making regarding fetal position during labor.

Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis.

BACKGROUND: Approximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime. OBJECTIVE: To evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI. SEARCH STRATEGY: MEDLINE/PubMed, Embase 1974-2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442). SELECTION CRITERIA: All studies reporting outcomes after OASI and a subsequent birth, by any mode. DATA COLLECTION AND ANALYSIS: Eighty-six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta-analyse the primary outcome of 'adjusted AI' after OASI and subsequent birth. Subgroups: short-term AI, long-term AI, AI in asymptomatic women. SECONDARY OUTCOMES: total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre- to post- subsequent birth. MAIN RESULTS: There was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72-1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65-1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre- to post- subsequent birth (OR = 0.79 95% CI 0.51-1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31). CONCLUSIONS: Due to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision-making for asymptomatic women and to determine the effect of subsequent birth mode on long-term AI outcomes.

Development and validation of a technical skill score for internal version and total breech extraction of the second twin: An interventional prospective study.

OBJECTIVE: To develop and test an Objective Structured Assessment of Technical Skills (OSATS) score for the internal version and total breech extraction of the second twin if in a non-engaged cephalic position. MATERIALS AND METHODS: This prospective interventional study took place in a tertiary obstetrics department in France. An objective scoring system was developed, and a standardized simulation scenario was set up. Score evaluation was blinded and analyzed according to group and number of past successful vaginal twin deliveries in real life. A satisfaction evaluation was performed, based on the "Student Design Scale" questionnaire. RESULTS: Simulation was performed on 33 participants in three groups: novice group (15 first- and second-year residents), intermediate group (11 third- to sixth-year residents), and expert group (seven senior obstetricians). The total score obtained by experts was higher than that of the intermediate group (P = 0.001), which was higher than that of the novice group (P < 0.001). In the intermediate group, no correlation was found between OSATS score and number of past successful vaginal twin deliveries. Participants' satisfaction was excellent. CONCLUSION: The OSATS score developed was reliable and valid to evaluate an internal version and a total breech extraction of the second twin, and to differentiate novice, intermediate, and expert practitioners.

Presentation and Management of Postpartum Granulation Tissue: A Single-Institution Retrospective Study.

INTRODUCTION: Although the development of postpartum granulation tissue (PPGT) is an expected phase of healing of perineal and vaginal lacerations, the persistence of this tissue can result in delayed wound healing, pain, bleeding, and discharge. There is a paucity of information on the efficacy of the treatments used for pathologic PPGT. The objective of this study was to describe characteristics associated with the development of PPGT and the treatment methods currently used for management. METHODS: This was a retrospective cohort study of 140 patients diagnosed with PPGT within one year of birth from 2012 through 2022 within a single health care system. Patients were identified by International Classification of Diseases and Current Procedural Terminology codes. Demographics, birth characteristics, symptoms, and treatment information were obtained and assessed in frequencies and means. Treatments were compared with 95% CIs and P values. Time to resolution was assessed by the number of weeks and the number of visits. RESULTS: It was the first vaginal birth for 129 (92%) patients in the study cohort. The majority (84.3%) of patients presented with pain. Almost half of all patients (45%) were diagnosed after 6 weeks postpartum. 30.0% of patients were initially treated conservatively. 76.4% of patients were treated with silver nitrate, and 33.6% had an excisional procedure. Successful conservative management had the lowest average number of visits to resolution with 1.39 visits (95% CI, 1.15-1.69), followed by silver nitrate alone with 1.95 visits (95% CI, 1.73-2.19), and excision with or without silver nitrate with 2.40 visits (95% CI, 2.07-2.78). Conservative management was unsuccessful 45% of the time, requiring additional treatment with silver nitrate or excision. 30% of patients treated with silver nitrate or excision continued to report pain even after the resolution of granulation tissue upon examination. CONCLUSION: PPGT is commonly associated with first vaginal births, often presents beyond 6 weeks postpartum, and frequently requires treatment.