Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study.

OBJECTIVES: Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights to make an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications. METHODS: In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages. RESULTS: A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation (SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen. CONCLUSIONS: Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.

[Inter-observer variability of decision concerning the route of delivery in case of one previous cesarean section and abnormal pelvic measures]. / Étude de la variabilité inter-observateur de la décision de la voie d'accouchement en cas d'utérus uni-cicatriciel et bassin anormal.

OBJECTIVES: To study inter-observer variability of decision concerning the route of delivery using pelvimetry in case of one previous cesarean section and abnormal pelvic measures. MATERIALS AND METHOD: Observational study conducted in 2014 in 4 university maternity units among 36 obstetricians. Two groups of obstetricians - as they practiced in a center where pelvimetry was routinely performed (n=12) or not (n=24) - had to choose a route of delivery for 10 clinical cases of women with a single uterine scar and a tight pelvis. The "routine pelvimetry" group had pelvimetry results. The group "no pelvimetry" became aware of pelvimetry results as a second step and had to indicate whether this information changed or not their management. The measurement of the inter-observer variability was estimated by estimating the proportion of agreement according to Grant method. RESULTS: The proportion of agreements of an attempted vaginal delivery between obstetricians in the group "routine pelvimetry" was 64.7% (95% CI [61-68.5]) and 97.3% (95% CI [96.4 to 98.3]) in the group "no pelvimetry", prior knowledge of pelvimetry results. An attempted vaginal delivery was decided in 77.5% versus 98.7% (P<0.001). After knowledge of pelvimetry results in the group "no pelvimetry" had, the number of attempted vaginal deliver was not different (77.5% vs. 78%, P=0.920). CONCLUSION: In women with one previous cesarean section, in case of tight pelvis discovered after pelvimetry, inter-observer variability of decision concerning the route of delivery is increased. Centers that choose to continue using the routine pelvimetry should develop procedures to limit this variability.

Maternal, care provider, and institutional-level risk factors for early term elective repeat cesarean delivery: a population-based cohort study.

To identify maternal, care provider, and institutional-level risk factors for early term (37-38 weeks) elective repeat cesarean delivery in a population-based cohort. Retrospective cohort study of women in the British Columbia (BC) Perinatal Data Registry, BC, Canada, 2008-2011, with an elective repeat cesarean delivery at term. Absolute percent differences (risk differences) in early term delivery rates were calculated according to maternal characteristics, type of care provider, calendar time (day of the week, time of year), and annual institutional obstetrical volume. Of the 7,687 elective repeat cesareans at term in BC, 55 % occurred before 39 + 0 weeks. Early term delivery was significantly more common with multiple previous cesareans [8.2 percentage points (95 % CI 5.5, 10.9) for 2 previous cesareans, 11.3 (95 % CI 5.1, 17.4) for 3 or more previous cesareans], obesity [6.7 percentage points (95 % CI 1.6, 11.7)], and a hospital obstetrical volume <2,500 deliveries per year. Type of care provider and calendar time were not significant risk factors for early term delivery. Early term elective repeat cesarean was common across a wide range of maternal, care provider, and institutional characteristics, suggesting that most obstetrical care settings would benefit from quality-improvement programs to reduce elective repeat cesarean deliveries before 39 weeks. A better understanding of the risks and benefits of early term delivery among obese women and women with multiple previous cesareans is needed given the higher rates of early term delivery observed in these women.

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

Timing of elective repeated cesarean delivery in patients with previous two or more cesarean section.

OBJECTIVE: To assess the maternal and neonatal consequences of scheduling elective repeated cesarean section (ERCS) at 39 weeks rather than 38 weeks and to assess the impacts of delivering by emergency cesarean section (CS) before the planned date. DESIGN: Retrospective Cohort study. POPULATION: Patients with previous two or more CS planned for ERCS at term during the period from January to June 2011. METHODS: Medical records were reviewed for demographic and clinical data, planned timing of CS, emergency cesarean and any adverse maternal or neonatal outcome. MAIN OUTCOME MEASURES: Adverse maternal or neonatal outcome. RESULTS: Four hundred and twenty women were included, 71.4% of cases were posted <39 weeks and 28.6% were posted at ≥39 weeks. Patients posted ≥ 39 weeks were more prone to deliver by emergency CS (16.6 vs. 10.6%) and the neonates were less prone to RDS and NICU admission (p < 0.05). CONCLUSION: Our data support the justification to book patients for ERCS at ≥39 weeks.

Nonclinical factors affecting women's access to trial of labor after cesarean delivery.

The use of trial of labor after cesarean (TOLAC) has declined in the last decade, and the clinical risks of TOLAC remain low. Nonclinical factors continue to affect women's access to TOLAC. This article considers 5 categories of factors that seem to be influencing rates of TOLAC and vaginal birth after cesarean: opinion leaders and professional guidelines, hospital facilities and cesarean availability, reimbursement for providing TOLAC, medical liability, and patient-level factors. An evidence base and strategies to provide guidance to create a safe environment for vaginal birth after cesarean are needed. Obstetric information systems are critical to this effort.

Induction of labour for women with a previous Caesarean birth: a systematic review of the literature.

AIMS: To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy. METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section. RESULTS: There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate. CONCLUSIONS: There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.

[Indications for third and more than three cesarean sections--analysis and pattern of practice]. / Indikatsii za treto i poveche ot tri tsezarovi secheniia--analiz, nasoki za povedenie.

PURPOSE OF THE STUDY: Authors aimed to analyse indications for third and more than three times cesarean sections (c. s.), as well as, to make an assessment of the adequacy of the taken decisions. METHODS AND MATERIALS: It was conducted a retrospective study for third and more than three times cesarean, including period 1991-2003 in the Department of Obstetrics and Gynaecology, Medical University, Pleven. During that time 28645 births has taken place, 2971 of which are by cesarean section. 2,5% from the last, has been third and more than three times cesarean. Using expert judging, indications for the last were divided into three groups-right, disputable and wrong. RESULTS: In the cases with only one mentioned indication "Re-re c.s." 37,8% (28 patients), ratio between right, disputable and wrong was 2:1:1 and the same ratio in the cases with indication "Re-re c.s.+ other indications" 58,1% (43 patients), was 5:1:1. In 4,3% of the cases (3 patients) no indication "Re-re c.s." was mentioned. CONCLUSION: Reduction of third and more than three times cesarean can be achieved by more careful judgement of indications in second, "disputable", group and erradication of the "wrong", which most commonly are jatrogenic reasons. This will result in diminishing the increasing frequency of abdominal births, as well as, preventing possible complications for mother, connected with operation.