Aplicación de la clasificación de Robson como método útil para estandarizar el manejo del parto. Un ejercicio que reduce la tasa de cesáreas / Application of Robson's Ten Group Classification System to standardize patient management. A useful way to reduce cesarean rates

Introducción: La tasa de cesárea es un motivo de controversia y la clasificación de Robson es un método de estandarización que evalúa las causas de esta. En nuestro trabajo analizamos si las medidas de mejora de manejo prenatal e intraparto implementadas tras la revisión de Robson suponen un descenso de índice de cesáreas sin incrementar los de morbimortalidad neonatal y materna. Material y método: Estudio cuasi experimental antes-después, entre 2019 y 2020, con un total de 2.181 pacientes con parto en el Hospital Universitario de Valme (1.027 en el grupo 2019 y 1.154 en el de 2020). Resultados: Observamos que se produjo una disminución estadísticamente significativa de la tasa de cesárea entre 2019 y 2020 (21 vs. 15,8%; p = 0,001) sin ser relevante la reducción en ningún subgrupo de estudio. Hubo un menor índice de parto inducido (29,3 vs. 24,6%; p = 0.01), un aumento en la tasa de parto vaginal (79 vs. 84,2%; p = 0,001) tanto de eutócicos como instrumentales (57,9 vs. 60,3%; 21 vs. 23,9%; p = 0.005) y una baja estadísticamente significativa de la de cesáreas por fallo de inducción o no progresión del parto (NPP) (34,7 vs. 20,9%; p = 0,008). En las inducciones mediante balón de Cook observamos una disminución del índice de cesárea (45,3 vs. 22,2% p = 0,001). Hallamos que redujo el porcentaje de ingreso en la Unidad de Cuidados Intensivos Neonatales (UCIN) (10,5 vs. 7.6%; p = 0,016) y la morbilidad neonatal global (11,4 vs. 8,2%; p = 0,013) sin encontrar diferencia en los resultados maternos. Conclusiones: La aplicación de la clasificación de Robson puede ser un método útil para identificar grupos que requieran de medidas específicas destinadas a estandarizar el manejo de las pacientes, con lo que se permite reducir la tasa de cesáreas.(AU)

Background: Cesarean section rate is controversial and the Robson classification is a method for standardizing the evaluation of the causes of cesarean section. The aim of this study was to evaluate whether the measures to improve prenatal and intrapartum management implemented after the Robson classification evaluation lead to a decrease in the rate of cesarean sections without increasing the rates of neonatal and maternal morbidity and mortality. Material and method: Quasi-experimental study before-after,between-2019 and 2020, including a total of 2181 patients with delivery at Hospital-Universitario-Valme(1027 patients in Group-2019, and 1154 patients in group-2020).Results: We observed that there was a statistically significant decrease in the cesarean section rate between 2019 and 2020 (21.0% vs 15.8%; p = 0.001) without the decrease being significant in any study subgroup. There was a lower rate of induced labor(29.3% vs 24.6%; p = 0.01), an increased rate of vaginal delivery (79.0% vs 84.2%; p = 0.001), both eutocic and instrumental deliveries (57.9% vs 60.3%; 21% vs 23.9%; p = 0.005) and a statistically significant decrease in the rate of cesarean sections due to failure of induction or non-progression of labor(34.7% vs 20.9%;p = 0.008). In inductions using the balloon-Cook we observed a decrease in the rate of cesarean section (45.3% versus 22.2% p = 0.001). We found a decrease in the percentage of admission to the Neonatal ICU (10.5% vs 7.6%; p = 0.016) and global neonatal morbidity(11.4% vs 8.2%; p = 0.013) without observing a difference in maternal outcomes. Conclusions: The application of the Robson classification can be a useful method to identify groups that require the application of specific measures aimed at standardizing the management of these patients, thus allowing to reduce the rate of cesarean sections.(AU)

Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery.

BACKGROUND: Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group. METHODS: This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit. RESULTS: Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality. CONCLUSIONS: This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.

Examining provider practice-level disparities in delivery outcomes among patients with a history of Cesarean Delivery.

BACKGROUND: Choosing whether to pursue a trial of labor after cesarean (TOLAC) or scheduled repeat cesarean delivery (SRCD) requires prenatal assessment of risks and benefits. Providers and patients play a central role in this process. However, the influence of provider-associated characteristics on delivery methods remains unclear. We hypothesized that different provider practice groups have different obstetric outcomes in patients with one prior cesarean delivery (CD). METHODS: This was a retrospective cohort study of deliveries between April 29, 2015 - April 29, 2020. Subjects were divided into three cohorts: SRCD, successful VBAC, and unsuccessful VBAC (patients who chose TOLAC but had a CD). Disparities were reviewed between five different obstetric provider practice groups, determined from a breakdown of different providers delivering at the study site during the study period. Proportional differences were examined using Chi-squared tests and logistic regression models. RESULTS: 1,439 deliveries were included in the study. There were significant proportional disparities between patients in the different groups. Specifically, patients from Group D were significantly more likely to undergo successful VBAC, while patients seeing a provider from Group A were more likely to deliver by SRCD. In our multivariate analysis of successful versus unsuccessful VBAC, patients from Group D had greater odds ratios of successful VBAC compared to Group A. Patients delivered by Group E had a significantly lower odds ratio of successful VBAC. CONCLUSION: This study suggests an association between provider practice groups and delivery outcomes among patients with one prior CD. These data contribute to a growing body of literature around patient choice in pregnancy and the interplay of patients and providers. These findings help to guide future investigations to improve outcomes among patients with a history of CD.

Predictors of successful trial of labor after cesarean section (TOLAC) in women with one prior transverse cesarean section at Tertiary Hospitals in northwest Ethiopia: a multicenter study.

BACKGROUND: Trials of labor after cesarean section is the preferred strategy to decrease the cesarean delivery rate and reducing complications associated with multiple cesarean sections. The success rate of trials of labor after cesarean section and associated factors have not been well documented in Ethiopia. Hence, this study was aimed to determine the success rate and factors associated with the trial of labor after one cesarean section in five Comprehensive Specialized Hospitals located in northwest Ethiopia. METHODS: An institutional-based cross-sectional study was conducted among 437 women who came for the trial of labor from December 1, 2021, to March 30, 2022. All women who fulfilled the eligibility criteria were included to this study. Data was collected using structured and pre-tested questionnaire. Then, the data was entered into Epi Data 4.6 software and exported to SPSS version 26 for analysis. To identify the variables influencing the outcome variable, bivariable and multivariable logistic regression analyses were conducted. The model's fitness was checked using the Hosmer-Lemeshow goodness of fit test, and an adjusted odds ratio with a 95% confidence interval was used to declare the predictors that are significantly associated with TOLAC. RESULTS: The success rate of the trial of labor after one cesarean section was 56.3% (95% CI, 51.3%, 61.2%). Maternal age ≥ 35 years (AOR: 3.3, 95% CI 1.2, 9.3), the fetal station at admission ≤ zero (AOR: 5. 6, 95% CI 3.3, 9.5), vaginal delivery before cesarean section (AOR: 1.9, 95% CI 1.2, 3.2), and successful vaginal birth after cesarean delivery (AOR 2.2, 95% CI 1.2, 4.1) were found to have a significant association with the success rate of trial of labor after cesarean section. CONCLUSIONS: In this study, the success rate of the trial of labor after a cesarean section was low as compared to the ACOG guideline and other studies in different countries. Therefore, the clinicians ought to offer counsel during antenatal and intrapartum period, encourage the women to make informed decision on the mode of delivery, and the practitioners need to follow fetal and maternal conditions strictly to minimize adverse birth outcomes.

Validation of a Predictive Model of Vaginal Birth after Caesarean Section in Pakistani Women.

OBJECTIVE: To determine the frequency of successful trials of vaginal birth after Caesarean section (VBAC) using the Flamm and Geiger model. STUDY DESIGN: Observational study. Place and Duration of the Study: Obstetrics and Gynaecology Unit II of Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan, from August 2022 to January 2023. METHODOLOGY: Women with singleton pregnancy having cephalic presentation, previous one lower segment caesarean section (LSCS), and without any contraindication for vaginal delivery were included. Women bearing foetus having estimated weight >3.5kg, morbid obesity, multiple pregnancies, non-cephalic presentation, placenta praevia, abruptio placentae, uncontrolled maternal comorbidities, or had previous two or more Caesarean sections were excluded. Flamm and Geiger score was applied to record observations of successful and unsuccessful trials. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the score were calculated by ROC curve, along with its area under the curve (AUC) and Youden's index curve, with 95% confidence interval. RESULTS: This study included 258 participants. Successful vaginal delivery was possible in 125 (48.4%) participants, whereas 133 (51.6%) underwent emergency Caesarean section. Cervical dilatation and effacement were the main factors assessing the success. The Flamm and Geiger score of >5 had an area under the curve of 0.813 (0.762-0.864). The score's sensitivity was 75% (67-82%), specificity 76% (68-82%), and PPV of 75% with an accuracy of 76%. CONCLUSION: The Flamm and Geiger score of >5 demonstrated high sensitivity, specificity, PPV, and accuracy in predicting later successful vaginal birth. It is recommended as a promising and valuable tool for assessing VBAC's success in low-resource countries. KEY WORDS: Vaginal birth after caesarean, Flamm and Geiger Model, Indication of caesarean, trial of labour after caesarean, VBAC risk scoring criteria.

Trial of labor after 2 previous cesareans: a multicenter study.

BACKGROUND: Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than trial of labor after cesarean after 1 previous cesarean delivery. OBJECTIVE: This study aimed to investigate the factors associated with failed trial of labor after cesarean among women with 2 previous cesarean deliveries. STUDY DESIGN: This was a multicenter retrospective cohort study, which included all women with singleton pregnancies attempting trial of labor after cesarean after 2 previous cesarean deliveries between 2003 and 2021. This study compared labor, maternal, and neonatal characteristics between women with failed trial of labor after cesarean and those with successful trial of labor after cesarean. Univariate analysis was initially performed, followed by multivariable analysis (adjusted odds ratios with 95% confidence intervals). RESULTS: The study included a total of 1181 women attempting trial of labor after cesarean after 2 previous cesarean deliveries. Among these cases, vaginal birth after cesarean was achieved in 973 women (82.4%). Women with failed trial of labor after cesarean had higher rates of maternal and neonatal morbidities. Several factors were found to be associated with failed trial of labor after cesarean, including longer interpregnancy and interdelivery intervals, lower gravidity and parity, lower rates of previous successful vaginal delivery, smoking, earlier gestational age at delivery (38.3±2.1 vs 39.5±1.3 weeks), late preterm delivery (34-37 weeks of gestation), lower cervical dilation on admission, no use of epidural, and smaller neonatal birthweight. Our multivariable model revealed that late preterm delivery (adjusted odds ratio, 3.79; 95% confidence interval, 1.37-10.47) and cervical dilation on admission for labor <3 cm (adjusted odds ratio, 2.58; 95% confidence interval, 1.47-4.54) were associated with higher odds of failed trial of labor after cesarean. CONCLUSION: In the investigated population of women with 2 previous cesarean deliveries undergoing trial of labor after cesarean, admission at the late preterm period with a cervical dilation of <3 cm, which reflects the latent phase, may elevate the risk of failed trial of labor after cesarean and a repeated intrapartum cesarean delivery.

Trial of labor versus elective cesarean delivery for patients with two prior cesarean sections: a systematic review and meta-analysis.

OBJECTIVE: Cesarean section (CS) rates have been on the rise globally, leading to an increasing number of women facing the decision between a Trial of Labor after two Cesarean Sections (TOLAC-2) or opting for an Elective Repeat Cesarean Section (ERCS). This study evaluates and compares safety outcomes of TOLAC and ERCS in women with a history of two previous CS deliveries. METHODS: PubMed, MEDLINE, EMbase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for studies published until 30 June 2023. Eligible studies were included based on predetermined criteria, and a random-effects model was employed to pool data for maternal and neonatal outcomes. RESULTS: Thirteen studies with a combined sample size of 101,011 women who had two prior CS were included. TOLAC-2 was associated with significantly higher maternal mortality (odds ratio (OR)=1.50, 95% confidence interval (CI)= 1.25-1.81) and higher chance of uterine rupture (OR = 7.15, 95% CI = 3.44-14.87) compared to ERCS. However, no correlation was found for other maternal outcomes, including blood transfusion, hysterectomy, or post-partum hemorrhage. Furthermore, neonatal outcomes, such as Apgar scores, NICU admissions, and neonatal mortality, were comparable in the TOLAC-2 and ERCS groups. CONCLUSION: Our findings suggest an increased risk of uterine rupture and maternal mortality with TOLAC-2, emphasizing the need for personalized risk assessment and shared decision-making by healthcare professionals. Additional studies are needed to refine our understanding of these outcomes in the context of TOLAC-2.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review.

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation.

BACKGROUND: Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery. MATERIALS AND METHODS: This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery). RESULTS: Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04-1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10-1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00-1.37). Uterine rupture was observed in three women (1 %). CONCLUSION: The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.

The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: A meta-analysis.

BACKGROUND: The increasing global incidence of cesarean section has prompted efforts to reduce cesarean delivery rates. A trial of labor after cesarean (TOLAC) has emerged as an alternative to elective repeat cesarean delivery (ERCD) for women with a prior cesarean delivery. However, the available evidence on the comparative outcomes of these 2 options remains inconsistent, primarily due to varying advantages and risks associated with each. Our meta-analysis aims to compare the maternal-neonatal results in TOLAC and ERCD in women with prior cesarean deliveries. METHODS: A comprehensive search was performed in PubMed, Embase, Cochrane library databases up to September,2022 to identity studies evaluating perinatal outcomes in women who underwent TOLAC compared to ERCD following a previous cesarean delivery. The included studies were subjected to meta-analysis using RevMan 5.3 software to assess the overall findings. RESULTS: A total of 13 articles were included in this meta-analysis. Statistically significant differences were identified in the rate of uterine rupture (OR = 2.01,95%CI = 1.48-2.74, P < .00001) and APGAR score < 7 at 5 minutes (OR = 2.17,95%CI = 1.69-2.77, P < .00001) between the TOLAC and ERCD groups. However, no significant differences were observed in the rates of hysterectomy, maternal blood transfusion, postpartum infection, postpartum hemorrhage and neonatal intensive care unit (P ≥ .05) admission between the 2 groups. CONCLUSIONS: Our analysis revealed that TOLAC is associated with a higher risk of uterine rupture and lower incidence APGAR score < 7 at 5 minutes compared to ERCD. It is vital to consider predictive factors when determining the appropriate mode of delivery in order to ensure optimal pregnancy outcomes. Efforts should be made to identify the underlying causes of adverse outcomes and implement safety precautions to select suitable participants and create safe environments for TOLAC.

Context-sensitive holistic care of women with one previous Caesarean section.

This article's emphasis is on the holistic care of women who are assessed as suitable for and amenable to vaginal birth after Caesarean section (VBAC) in the South African state health sector context. It is beyond its scope to deal with the minutiae of VBAC conduct, operative conduct of repeat Caesarean section (CS), or management of uterine rupture. It is also beyond the scope of the article to reflect on practices, which are accepted in other healthcare contexts. The intention is not to promote VBAC over elective repeat CS, but rather to assist healthcare workers with providing high-quality holistic care. The goal is that women with previous CS are given access to the mode of delivery, which is safest for them and their fetus, while minimising adverse psychological effects of previous and future negative birth experiences.

Risk of uterine rupture in multiparous women after induction of labor with prostaglandin: A national population-based cohort study.

OBJECTIVE: To assess whether, after induction of labor with prostaglandin, multiparous (≥2 para) women have an increased risk of uterine rupture compared with nulliparous or uniparous women. METHODS: This was a retrospective population-based cohort study including women who underwent induction with prostaglandin in all maternity wards in Sweden between May 1996 and December 2019 (n = 56 784). The study cohort was obtained by using data from the Swedish Medical Birth Register, which contains information from maternity and delivery records. The main outcome measure was uterine rupture. RESULTS: Overall, multiparous women induced with prostaglandin had an increased risk of uterine rupture compared with nulliparous women (adjusted odds ratio [OR], 3.33 [95% confidence interval (CI), 1.38-8.04]; P < 0.007). Multiparous women with no previous cesarean section (CS) induced with prostaglandin had more than three times higher risk of uterine rupture (crude OR, 3.55 [95% Cl, 1.48-8.53]; P = 0.005) compared with nulliparous women and four times higher risk compared with uniparous women (OR, 4.10 [95% CI, 1.12-15.00]; P < 0.033). Multiparous women with previous CS had a decreased risk of uterine rupture compared with uniparous women with one previous CS (crude OR, 0.41 [95% Cl, 0.21-0.78]; P = 0.007). CONCLUSION: Our study implies that multiparity in women with no previous CS is a risk factor for uterine rupture when induced with prostaglandin. This should be taken into consideration when deciding on the appropriate method of induction.

Can we predict peritoneal adhesions formation after cesarean delivery?

OBJECTIVE: To examine demographic and obstetrical factors that are associated with adhesion formation following cesarean delivery. METHODS: We conducted a population-based study that included all women over 18 years og age who underwent two cesarean deliveries between the years 1988 and 2016 in a large tertiary medical center. We excluded women with adhesions already diagnosed during the first cesarean delivery, history of other abdominal or pelvic surgery, history of pelvic infection or pelvic inflammatory disease, history of endometriosis and history of uterine Müllerian anomalies. In addition, women with a classical or T-shaped uterine incision, non-singleton pregnancies, and fetal chromosomal or structural abnormalities were excluded. RESULTS: During the study period, 32.6% (n = 2283) of women were diagnosed with peritoneal adhesions during the second cesarean delivery. Factors found to be significantly associated with peritoneal adhesions were maternal age 35 years or older at the first cesarean delivery, Bedouin Arab ethnicity, composite of intrapartum and postpartum infectious morbidity, and cesarean deliveries that were performed after the onset of labor. In contrast, having a previous vaginal birth was found to be protective. CONCLUSIONS: Our results suggest that a woman's characteristics at her first cesarean delivery and her obstetrical history may be predictive of the likelihood of adhesion formation.

Decision-making experiences and the need for decision aids in women considering vaginal birth after cesarean: A qualitative meta-synthesis.

AIMS: This study aims to comprehensively explore the decision-making requirements of women contemplating vaginal birth after cesarean (VBAC). DESIGN & METHODS: A meta-synthesis approach was employed for this study. Using an integrative methodology, we conducted a systematic assessment of women's experiences and needs related to VBAC decision-making. A comprehensive search was conducted across The Cochrane Library, PubMed, EMBASE, Ovid Medline, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Wan Fang databases to identify pertinent studies between 2000 and 2022. Furthermore, the reference lists of the included studies were thoroughly examined. RESULTS: Fifteen studies were incorporated, from which seven themes emerged: emotional changes, preference for vaginal birth, unmet information needs, influences on decision-making, decision-making autonomy, aligning information provision with decision-support needs, and the requirement for support systems. Two primary syntheses were constructed on the decision-making process and the need for decision-making aids, respectively. CONCLUSION: Women opting for VBAC experienced emotional shifts during their decision-making process in pregnancy. There remains a need for an enhanced decision-making tool to guide them in their choice. Recommendations for implementation in VBAC decision aids include facilitating women's involvement in decision-making, satisfying their information needs, and delivering appropriate emotional support.

Impact of prior use of topical hemostatic agents on trial of labor after cesarean: Insights from a multicenter cohort study.

OBJECTIVE: To evaluate the association between a topical hemostatic agent used at the time of cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean (TOLAC). METHODS: A multicenter retrospective cohort study was conducted (2005-2021). Parturients with a singleton pregnancy in whom a topical hemostatic agent was placed during the primary cesarean delivery were compared with patients in whom no such agent was placed. We assessed the uterine scar disruption rate after the subsequent TOLAC and the rate of adverse maternal outcomes. Univariate analyses were followed by multivariate analysis (adjusted odds ratio [aOR]; 95% confidence interval [CI]). RESULTS: During the study period, 7199 women underwent a trial of labor and were eligible for the study; 430 (6.0%) had prior use of a hemostatic agent, 6769 (94.0%) did not. In univariate analysis, a history of topical hemostatic agent use was not found to be significantly associated with uterine scar rupture, dehiscence, or failed trial of labor. This was also confirmed on multivariate analysis for uterine rupture (aOR 1.91, 95% CI 0.66-5.54; P = 0.23), dehiscence of uterine scar (aOR 1.62, 95% CI 0.56-4.68; P = 0.37), and TOLAC failure (aOR 1.08, 95% CI 0.79-1.48; P = 0.61). CONCLUSION: A history of hemostatic agent use is not associated with an increased risk for uterine scar disruption after subsequent TOLAC. Further prospective studies in other settings are needed to strengthen these findings.

A jump into the deep end - Women's strategies on the way to VBAC in Poland.

PROBLEM: In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BACKGROUND: Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AIM: This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC. METHODS: The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FINDING: Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. CONCLUSIONS: Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12-year single-center experience.

OBJECTIVE: To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. METHODS: A retrospective single-center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not. RESULTS: Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699). CONCLUSION: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks.

The association between obesity and the success of trial of labor after cesarean delivery (TOLAC) in women with past vaginal delivery.

OBJECTIVES: To evaluate the effect of overweight (body mass index; BMI 25.0-29.9 kg/m2), and obesity (BMI>30 kg/m2), on the success of trial of labor after cesarean delivery (TOLAC), with consideration of successful past vaginal birth. METHODS: This retrospective cohort study was performed using electronic database of obstetrics department at a university-affiliated tertiary medical center. All women admitted for TOLAC at 37-42 weeks of gestational age, carrying a singleton live fetus at cephalic presentation, with a single previous low segment transverse cesarean delivery between 1/2015 and 5/2021 were included. Primary outcome was the rate of cesarean delivery during labor, and subgroup analysis was performed for the presence of past vaginal birth. RESULTS: Of the 1200 TOLAC deliveries meeting the inclusion criteria, 61.9 % had BMI in the normal range, 24.6 % were overweight (BMI 25.0-29.9 kg/m2), and 13.4 % were obese (BMI of 30 kg/m2 and over). Using a multivariate analysis, BMI≥30 kg/m2 was associated with increased risk of cesarean delivery compared to normal weight. However, in the subgroup of 292 women with a history of successful vaginal birth BMI did not affect TOLAC success. CONCLUSIONS: BMI does not affect the success of TOLAC in women with previous vaginal birth. This information should be considered during patients counselling, in order to achieve a better selection of mode of delivery and higher patients' satisfaction.