Reasons for previous Cesarean deliveries impact a woman's independent decision of delivery mode and the success of trial of labor after Cesarean.

BACKGROUND: Cesarean delivery rates are increasing globally with almost half of them occurring due to a previous Cesarean delivery. A trial of labor after Cesarean (TOLAC) is considered a safe procedure, but most eligible women instead undergo Cesarean before 39 weeks of gestation. Lack of education about TOLAC is often associated with increased repeat Cesarean. To reveal the safety and feasibility of TOLAC, we conducted this observational, prospective study with women's independent decisions. We aimed to clarify the relationship between their chosen mode of delivery and the reason for their previous Cesarean. Additionally, we have tried to identify maternal and obstetric factors associated with failed TOLAC to improve its success rate. METHODS: This was a prospective, observational study of 1086 pregnant women with at least one previous Cesarean delivery. Of these, 735 women met our TOLAC criteria (Table 1), and then, could choose TOLAC or repeat Cesarean after receiving detailed explanations regarding the risks and benefits of both procedures. The primary outcomes were the number of successful TOLAC procedures and 5-min Apgar scores < 7 for the trial of labor after Cesarean group and elective Cesarean group. We collected the maternal and neonatal data including the reasons of previous Cesarean. RESULTS: In total, 64.1% of women chose TOLAC. The success rate was 91.3%. The uterine rupture rate was 0.6%. There were no significant differences in the rate of Apgar scores at 5 min < 7 between both groups. Histories of experience of labor in previous Cesarean delivery were observed in 30 and 50% of women who chose TOLAC and repeat Cesarean, respectively (p < 0.05). Factors related to failed TOLAC included ≥40 weeks of gestation (odds: 5.47, 95% CI: 2.55-11.70) and prelabor rupture of membranes (PROM) (odds: 4.47, 95% CI: 2.07-9.63). CONCLUSIONS: TOLAC is a favorable delivery option for both mothers and neonates when women meet criteria and choose after receiving detailed explanations. Women who experience PROM or ≥ 40 weeks of gestation, their modes of delivery should be reconsulted.

OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section.

BACKGROUND: Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. METHODS: OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. RESULTS: The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. CONCLUSIONS: Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances. TRIAL REGISTRATION: The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.

BACKGROUND: The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. METHODS: The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates. RESULTS: 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. CONCLUSIONS: This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.

Efforts to promote vaginal delivery after a previous cesarean section.

AIM: The aim of this study was to examine the results of vaginal delivery in patients with a past history of cesarean section. METHODS: The type of delivery, interventions during delivery, and the prognoses of the mothers and babies were examined in 145 women with a history of cesarean section over the 10-year period from January 2000 to December 2009. RESULTS: A scheduled cesarean section was performed in 27 cases. Vaginal delivery was recommended in 118 cases and the success rate was 94.9% (112/118). Uterine rupture was observed in one patient who experienced a natural rupture at home and whose previous cesarean section was an inverse T incision. No cases required a blood transfusion or hysterectomy. CONCLUSIONS: The prognoses of both mothers and babies were good and the vaginal delivery success rate was 94.9%. Uterine rupture was observed in one case. Vaginal delivery with previous cesarean section should be considered in cases with expectation and informed consent.

Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review.

AIM: The aim of this study was to review non-clinical interventions that increase the uptake and/or the success rates of vaginal birth after caesarean section. BACKGROUND: Increases in rates of caesarean section are largely due to repeat caesarean section in a subsequent pregnancy. Concerns about vaginal birth after caesarean section have centred on the risk of uterine rupture. Nonetheless, efforts to increase the vaginal birth rate in these women have been made. This study reviews these in relation to non-clinical interventions. DATA SOURCES: Literature was searched up until December 2008 from five databases and a number of relevant professional websites. REVIEW METHODS: A systematic review of quantitative studies that evaluated a non-clinical intervention for increasing the uptake and/or the success of vaginal birth after caesarean section was undertaken. Only study designs that involved a comparison group were included. Further exclusions were imposed for quality using the Critical Skills Appraisal Programme. RESULTS: National guidelines influence vaginal birth after caesarean section rates, but a greater effect is seen when institutions develop local guidelines, adopt a conservative approach to caesarean section, use opinion leaders, give individualized information to women, and give feedback to obstetricians about mode of birth rates. Individual clinician characteristics may impact on the number of women choosing and succeeding in vaginal birth after caesarean section. There is inconsistent evidence that having private health insurance may be a barrier to the uptake and success of vaginal birth after caesarean section. CONCLUSION: Non-clinical factors can have a significant impact on vaginal birth after caesarean section uptake and success.

Believing in birth--choosing VBAC: the childbirth expectations of a self-selected cohort of Australian women.

AIM: This study explored the childbirth expectations and knowledge of women who had experienced a caesarean and would prefer a vaginal birth in a subsequent pregnancy. BACKGROUND: Vaginal birth after caesarean is considered best practice. However, in most western world countries, despite the inherent risks of caesarean for both mother and baby, the number of women labouring after a previous caesarean is declining. METHODS: Newspaper advertisements were used to recruit Western Australian women who had experienced a caesarean. Thematic analysis was used to analyse the interview data collected from women who attempted a vaginal birth (n=24), or stated they would choose this option, in a subsequent pregnancy (n=11). FINDINGS: For this cohort of women, their caesarean experience reinforced their previously held expectations about birthing naturally. The women held strong views about the importance of working with their bodies to achieve a vaginal birth, which was considered an integral part of being a woman and mother. Positive support from family and friends and a reluctance to undergo another caesarean was also influential. Women articulated the risks of caesarean and considered vaginal birth enhanced the health and well-being of the mother and baby, promoted maternal infant connection and the eased the transition to motherhood. CONCLUSION: This study documents how the importance of birth, as a significant life event, remained the focus of these women's childbirth expectations influencing future decisions on birth mode and mediating against the 'pressure' of medical discourse promoting caesarean. RELEVANCE TO CLINICAL PRACTICE: Knowledge and appreciation of the multiple dimensions that contribute to women's decisions after a caesarean provides valuable information on which service providers and researchers can draw as they investigate interventions that enhance the uptake and success of women birthing vaginally after a caesarean.

Development of a Web-based childbirth education program for vaginal birth after C-section (VBAC) mothers.

The purpose of this study was to develop a web-based childbirth educational program for VBAC (vaginal birth after C-section) mothers. It contained two phases. In the first phase, analysis, design, development, implementation and evaluation (ADDIE) based on theoretical frameworks were used to establish the program. The second phase (implementation and evaluation) included: expert approval, posting on the Website of National Taipei College of Nursing, program registration through the Internet, implementing the educational program, and testing the results of the curriculum. Ten mothers who had experienced C-section previously and were currently pregnant for over 32 weeks participated in this program. The quantitative data was analyzed by descriptive statistics and pair-t test. Colaizzi's phenomenological method was used for the qualitative data. The first phase established the program goals, course content, teaching methods, and a 90- minute educational program. The outcomes of the second phase: the tests before and after the curriculum were significantly different in VBAC knowledge (p < .01) and attitude (p < .05), participants evaluated the program to be "thorough". This VBAC educational program can be offered to nursing staff as a means to promote VBAC.

Resident education regarding technical aspects of cesarean section.

OBJECTIVE: To survey obstetric/gynecologic residents around the country regarding different technical aspects of and indications for cesarean section, trends in vaginal birth after cesarean (VBAC) and patient choice of cesarean. STUDY DESIGN: A questionnaire was designed to address the above issues and selected demographic information. The questionnaire was sent by e-mail to all the residency programs in the country. The first 400 responses were analyzed. RESULTS: Although a midline vertical incision is considered faster for entry into the abdomen, 77% of residents use a Pfannenstiel incision for urgent/emergency cesarean sections. Fifty-five percent of respondents use single-layer closure of the uterine incision, 37% use double-layer closure, while 11% use single-layer closure only in patients undergoing concomitant sterilization. When questioned regarding a trial of labor, one-third of respondents stated that they would not induce labor in patients with a prior cesarean if the patients did not go into labor spontaneously but offer repeat cesarean for fear of a uterine rupture. Further, 42% said that they would never offer VBAC for an undocumented scar, 12% would and 45% would depending on the history. Regarding the issue of cesarean section by patient request, 94% would not offer an elective cesarean section for uncomplicated primigravidas, while 6% would. However, if a well-informed patient desired an elective cesarean delivery, the majority of residents would respect the patient's request. CONCLUSION: There is wide variation in the way residents are trained regarding different technical aspects of and indications for cesarean section, choice of repeat cesarean versus VBAC and patient choice of cesarean. Recent trends in the literature are not always reflected in reported practice patterns.