Validation of a new calculator for predicting success of vaginal birth after cesarean delivery.

BACKGROUND: Race as a variable in a predictive model for a successful vaginal birth after cesarean delivery has been challenged as contributing to health inequity. In May 2022, the National Institute of Child Health and Development released a modified calculator that removed race as a variable. OBJECTIVE: The aim of this study was to externally validate the revised calculator amongst a cohort at our institution. STUDY DESIGN: We reviewed all patients who underwent a trial of labor after cesarean delivery in 2018 to 2020 at a tertiary academic medical center and calculated the predicted probability of successful vaginal birth after cesarean delivery for each patient using both original and revised classification calculators and compared these to observed birth outcomes. The area under the receiver operating characteristic curve was calculated for each model. RESULTS: From the cohort of 225 patients that fit inclusion criteria, 37% (n=83) identified as African American or Hispanic, the vaginal birth after cesarean delivery success rate was 75% for the entire population, and 76% among African American and/or Hispanic patients. The area under the receiver operating characteristic curve of the original calculator was 0.71, compared to 0.74 for the new calculator. For African American and/or Hispanic patients, the average predicted success rates between the models rose from 60% to 69%. CONCLUSIONS: Our review confirmed that African American and Hispanic patients were calculated to have a lower prediction score for a successful vaginal birth after cesarean delivery based on the original calculator as compared to the revised calculator. Our results also suggest that race/ethnicity did not significantly contribute to classification ability of the calculator in our patient population.

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.

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.

Trial of labor after caesarean section in low risk pregnancies: is it risky?

PURPOSE: To evaluate the influence of a previous caesarean section on adverse composite maternal and perinatal outcome in women who attempted a trial of labor. METHODS: This historical cohort study analyzed maternal and perinatal outcome in women with otherwise low risk pregnancies at term who underwent a trial of labor after a caesarean section (TOLAC). The primary outcome measure was the adverse composite outcome. Secondary outcome measures were amongst others the caesarean section rate and the mode of vaginal delivery. RESULTS: The adverse composite outcome was more frequently in the previous caesarean section group compared to women with no previous caesarean Sect. (22.3% vs. 15.6%, p < 0.0001). The percentage of caesarean Sect. (15.4% vs. 8.2%, p < 0,0001), uterine rupture (1.0% vs. 0.02%, p < 0.0001), placental abruption (1.1% vs. 0.3%, p = 0.0014), vaginal operative delivery (16.0% vs. 8.6%, p < 0.0001), pH < 7.10 (3.7% vs. 2.5%, p = 0.0151), base excess < -12 (3.2% vs. 2.2%, p = 0.0297), abnormal cardiotocography (22.5% vs. 13.9%, p < 0,0001) and fetal blood analysis (6.2% vs. 2.6%, p < 0.0001) was significantly higher in women with a previous caesarean section. Taking the parity into account, these differences could only been seen in women without a previous vaginal delivery. In parous women with a previous vaginal delivery and a caesarean section in history, the adverse composite did not differ between the groups. Only the rate of pH < 7.1 was higher in women after a caesarean Sect. (4.5% vs. 1.8%, p = 0.0436). CONCLUSION: Trial of labor after caesarean in otherwise low risk pregnancies is associated with a higher rate of complications especially if there is no history of vaginal delivery.

Preferred mode of delivery and its associated factors in pregnant women with a previous cesarean scar at a tertiary care hospital in Ethiopia: institutional-based cross-sectional study.

BACKGROUND: Vaginal births after cesarean or elective repeat cesarean sections (CS) are the options for delivery after one cesarean scar. However, there is a lack of data regarding the preferred next mode of delivery in Ethiopia after a previous cesarean section. Thus, this study assessed the preferred mode of delivery and determinants after one previous CS in the antenatal clinic at the University of Gondar Comprehensive Specialized Hospital (UoGCSH). METHODS: An institutional-based cross-sectional study was conducted among pregnant mothers with one previous CS at UoGCSH from March to August 2022. Structured questionnaires were used to collect the data. The collected data were entered, cleaned, and edited using Epi-data 4.6 and exported to SPSS version 26 for analysis. A binary logistic regression was performed to assess the determinants of the preferred mode of delivery. A p-value of < 0.05 at the 95% confidence level (CI) was considered statistically significant. RESULTS: The majority, 71.5% (95% CI: 64.7, 77.1), of participants preferred the trial of labor after cesarean (TOLAC) as their mode of delivery. Mothers who were married (AOR = 4.47, 95% CI: 1.19-16.85), had a diploma educational level (AOR = 3.77, 95% CI: 1.84-12.36), had previous post-cesarean complications (AOR = 3.25, 95% CI: 1.08-9.74), and knew about the success of the trial of labor after cesarean (AOR = 13.56, 95% CI: 4.52-37.19) were found to prefer the trial of labor compared with their counterparts. CONCLUSION: This study concluded that most pregnant mothers preferred labor trials after one CS, which is a bit lower but comparable with recommended practice guidelines. Providing adequate information and counseling mothers to make informed decisions about their preferred mode of delivery could be substantial.

Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero.

Randomized controlled trial comparing efficacy of a combination regime containing two cervical sensitizers (mifepristone + Foley's catheter) versus single agent mifepristone or Foley's catheter for labor induction in women attempting TOLAC at late third trimester with a dead fetus in utero. AIM: To compare efficacy and safety of a new combination regime comprising of two cervical sensitizers used simultaneously with single agents, for labor induction in women attempting TOLAC at ≥34 weeks' gestation with a dead fetus. METHOD: This was a multiarm randomized controlled trial (RCT) where participants received one of the three regimes-single agent oral Mifepristone 200 mg, intracervical Foley's catheter (16 Fr size, filled with 40 mL normal saline after intracervical instillation), and combination regime consisting of both used simultaneously. Number of women undergoing vaginal birth within 48 h of induction (VB48 ) was the primary outcome compared between groups. RESULTS: VB48 was higher in participants on combination regime in comparison to participants on Foley's catheter (54 vs. 42). Total vaginal births were higher in participants on combination regime compared to both single agents (58 vs. 48 and 44). Duration and dose of oxytocin augmentation was lower in participants on combination regime compared to both single agents. Induction birth interval was short in participants on combination regime compared to those on Foley's catheter. Maternal complications between groups were similar. CONCLUSION: Combination of cervical sensitizers for labor induction in late third trimester among women with dead fetus attempting TOLAC resulted in higher proportion of vaginal births and might reduce risk of scar dehiscence due to requirement of a lower dose of oxytocin for augmentation.

The association between trial of labor after cesarean in obese patients and adverse maternal outcomes.

PURPOSE: We hypothesized that among obese patients with a history of cesarean birth, a TOLAC is associated with decreased composite maternal adverse outcomes (CMAO) compared to planned repeat low transverse cesarean section (RLTCS). METHODS: In this population-based cross-sectional study using the National Birth Certificate database from 2016 to 2020, we compared obese patients who attempted TOLAC at term (≥ 37 weeks estimated gestational age) to planned RLTCS. The primary outcome was a CMAO, defined as delivery complications, including intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or maternal blood transfusion. RESULTS: Overall, 794,278 patients met inclusion criteria for the study; 126,809 underwent a TOLAC, and 667,469 had a planned RLTCS. The overall CMAO was significantly higher for patients undergoing TOLAC (9.0 per 1000 live births) compared to RLTCS (5.3 per 1000 live births; aRR 1.64, 95% CI 1.53-1.75). CONCLUSION: This data demonstrate that in obese patients with prior cesarean birth, a trial of labor is associated with increased maternal morbidity when compared to a planned repeat cesarean birth.

Development of a multivariate predictive nomogram among women with antepartum fetal death diagnosed at ≥ 34 weeks of gestation for outcome of TOLAC.

OBJECTIVE: The present study was planned to develop a nomogram that will give a priori estimate on the probability of vaginal birth from maternal features in women with antepartum fetal death diagnosed at ≥ 34 week's gestation and previous one low transverse cesarean section (LTCS). This will help to reduce maternal complications and increase confidence when planning a trial of labor after cesarean section (TOLAC). METHODS: A prospective observational study was planned where participants underwent induction of labor with Foley's catheter (unless already in spontaneous labor) within 24 h of enrolment. Participants with absent or inadequate contractions, oxytocin infusion as an additional agent was used. Data was collected on maternal predelivery features. Outcome of participants was categorized into two classes-vaginal and cesarean delivery. Classifiers were trained with data on maternal features and the accuracy of predicting outcome class determined. The classifier with maximum accuracy was used to develop a nomogram. RESULT: Three hundred and one women underwent treatment as per protocol. Two hundred and twenty women attained successful vaginal delivery and eighty-one women underwent caesarean section. Factors having a significant impact on outcome were maternal body mass index (BMI), bishop score, duration of augmentation, estimated foetal weight, interval from previous LTCS, admission to active labor interval, vaginal delivery after LTCS and gestational age. The Naïve -Bayes model gave the highest prediction accuracy (0.88). CONCLUSION: Non-linear classifiers by using selective features could predict the outcome of TOLAC among women with intra-uterine fetal death attempting vaginal birth at or beyond 34 weeks gestation with high accuracy.

Trial of labor following cesarean in preterm deliveries: success rates and maternal and neonatal outcomes: a multicenter retrospective study.

PURPOSE: To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC. METHODS: A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37 weeks) and term (37-42 weeks) births. Multifetal gestations and postterm deliveries (≥ 42 weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis. RESULTS: 4865 second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62-3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5 min Apgar score (aOR 1.76, 95% CI 0.92-3.40). CONCLUSION: In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode.

Trial of labor following cesarean in patients with bicornuate uterus: a multicenter retrospective study.

OBJECTIVE: This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. METHODS: A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. RESULTS: Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. CONCLUSIONS: This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.

Planned mode of birth after previous caesarean section and women's use of psychotropic medication in the first year postpartum: a population-based record linkage cohort study.

BACKGROUND: Policy in many high-income settings supports giving pregnant women with previous caesarean section a choice between an elective repeat caesarean section (ERCS) or planning a vaginal birth after previous caesarean (VBAC), provided they have no contraindications to VBAC. Despite the potential for this choice to influence women's mental health, evidence about the associated effect to counsel women and identify potential targets for intervention is limited. This study investigated the association between planned mode of birth after previous caesarean and women's subsequent use of psychotropic medications. METHODS: A population-based cohort study of 31 131 women with one or more previous caesarean sections who gave birth to a term singleton in Scotland between 2010 and 2015 with no prior psychotropic medications in the year before birth was conducted using linked Scottish national datasets. Cox regression was used to investigate the association between planned mode of birth and being dispensed psychotropic medications in the first year postpartum adjusted for socio-demographic, medical, pregnancy-related factors and breastfeeding. RESULTS: Planned VBAC (n = 10 220) compared to ERCS (n = 20 911) was associated with a reduced risk of the mother being dispensed any psychotropic medication [adjusted hazard ratio (aHR) 0.85, 95% confidence interval (CI) 0.78-0.92], an antidepressant (aHR 0.83, 95% CI 0.76-0.90), and at least two consecutive antidepressants (aHR 0.83, 95% CI 0.75-0.91) in the first year postpartum. CONCLUSIONS: Women giving birth by ERCS were more likely than those having a planned VBAC to be dispensed psychotropic medication including antidepressants in the first year postpartum. Further research is needed to establish the reasons behind this new finding.

Secundiparas following a failed vacuum delivery-factors associated with a successful vaginal delivery: a historical prospective cohort.

BACKGROUND: Few studies have focused on the delivery subsequent to a failed vacuum delivery (failed-VD) in secundiparas. The objective of the current study was to examine the factors associated with a vaginal delivery following a failed-VD. METHODS: An historical prospective cohort. Obstetric characteristics of secundiparas who underwent a planned caesarean delivery (CD) were compared to those who elected a trial of labour (TOLAC) at single medical-centre, throughout 2006-2019. The latter were further analysed to study for factures associated with successful vaginal birth (VBAC). RESULTS: Among the 115 secundiparas included, 89 (77%) underwent TOLAC. Compared to women who underwent an elective CD, those who underwent TOLAC were younger by a mean of 4 years, were more likely to have conceived spontaneously, and had a more advanced gestation by a mean of 10 days. VBAC was achieved in 62 women (70%). New-borns of women with VBAC had in average a lower birth weight compared to those with failed TOLAC, (-)195 g ± 396 g versus ( +)197 g ± 454 g respectively, P < 0.01. Having a higher neonatal birthweight at P2 by increments of 500 g, 400 g or 300 g was associated with a failed TOLAC; OR of 9.7 (95%CI; 2.3, 40.0), 11.5 (95%CI; 2.8, 46.7) and 4.5 (95%CI; 1.4, 13.9), respectively. CONCLUSIONS: Among secundiparas with a previous CD due to a failed-VD, the absolute difference of neonatal BW was found to be significantly associated with achieving VBAC.

Outcomes and risk factors for failed trial of labor after cesarean delivery (TOLAC) in women with one previous cesarean section: a Chinese population-based study.

OBJECTIVE: To evaluate the outcomes and risk factors for trial of labor after cesarean delivery (TOLAC) failure in patients in China. METHODS: Consecutive patients who had a previous cesarean delivery (CD) and attempted TOLAC were included from 2014 to 2020. Patients who successfully delivered were classified into the TOLAC success group. Patients who attempted TOLAC but had a repeat CD due to medical issues were classified into the TOLAC failure group. Multiple logistic regression analyses were performed to examine the risk factors for TOLAC failure. RESULTS: In total, 720 women who had a previous CD and attempted TOLAC were identified and included. The success rate of TOLAC was 84.2%(606/720). Seven patients were diagnosed with uterine rupture, none of whom underwent hysterectomy. Multiple logistic regression analysis showed that the induction of labor (OR = 2.843, 95% CI: 1.571-5.145, P < 0.001) was positively associated with TOLAC failure, but the thickness of the lower uterine segment (LUS) (OR = 0.215, 95% CI: 0.103-0.448, P < 0.001) was negatively associated with TOLAC failure. CONCLUSIONS: This study suggested that TOLAC was effective in decreasing CD rates in the Chinese population. The induction of labor was positively associated with TOLAC failure, but the thickness of the LUS was negatively associated with TOLAC failure. Our findings need to be confirmed in larger samples with patients of different ethnicities.

Association between the second-stage duration of labor and perinatal outcomes in women with a prior cesarean delivery.

BACKGROUND: The cesarean delivery (CD) rate has been increasing globally. Trial of labor after cesarean delivery (TOLAC) has been used as a key method for the reduction of the CD rate. Little is known, however, about the association between the second-stage duration of TOLAC and adverse maternal and neonatal outcomes. This study evaluated the association between perinatal outcomes and the duration of second-stage labor in women undergoing TOLAC. METHODS: A 10-year retrospective cohort study was performed at the Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, between January 2010 and January 2020. Women undergoing TOLAC who reached the second stage of labor were included in this study. Duration of the second stage of labor was examined as a categorical variable (group I: <0.5 h, group II: 0.5-2 h and group III: ≥2 h) and as a continuous variable to evaluate the association with adverse perinatal outcomes by using multivariable regression models and a Cox proportional hazards regression model adjusting for potential confounders. RESULTS: Of the 1,174 women who met the inclusion criteria, the median (interquartile range) length of the second stage was 0.5 h (0.3-0.9 h). Among them, 1,143 (97.4%) delivered vaginally and 31 underwent an unplanned CD. As the second-stage duration increased, operative vaginal delivery (OVD), CD, and postpartum hemorrhage (PPH) rates increased. Women in group III had higher risks of OVD (aOR = 11.34; 95% CI [5.06-25.41]), CD (aOR = 4.22; 95% CI [1.32-13.43]), and PPH (aOR = 2.43; 95% CI [1.31-4.50]) compared with group I. Correspondingly, blood loss and the oxytocin used to treat PPH increased significantly, while the postpartum hemoglobin reduced significantly in group III compared with group I. The incidence of uterine rupture, uterine atony, cervical laceration, red blood cell transfusion, and intensive care unit admission were similar in all three groups. Neonatal outcomes were not affected by the second-stage duration. CONCLUSIONS: Women undergoing TOLAC with second-stage duration of ≥2 h have higher odds of OVD, unplanned intrapartum CD, and PPH.

Artificial rupture of membranes as a mode for induction of labor in women with a previous cesarean section- a retrospective cohort study.

BACKGROUND: Induction of labor in women with a previous cesarean section (CS) is associated with increased rates of uterine rupture and failed attempt for vaginal delivery. Prostaglandins use is contraindicated in this population, limiting available options for cervical ripening. OBJECTIVE: To evaluate the efficacy and safety of artificial rupture of membranes (AROM) as a mode of Induction of labor (IOL) in women with a previous cesarean section. METHODS: A retrospective cohort study conducted in a single tertiary care center between January 2015 and October 2020. Women with one previous cesarean section and a current singleton term pregnancy requiring IOL, with an unfavorable cervix, were included. The primary outcome was a successful vaginal delivery (VBAC); secondary outcomes were rates of chorioamnionitis, uterine rupture and low Apgar score (< 7). RESULTS: Of the 665 women who met the inclusion criteria, 492 (74%) did not receive subsequent oxytocin and 173 (26%) did. There were significant differences in the baseline characteristics between these two groups, including maternal age, cervical dilation at presentation, parity, and a history of a previous VBAC. Among women who were induced solely by AROM the rate of a successful TOLAC was higher (81.3% vs 73.9%), total time of IOL was shorter (mean 8.7 h vs.16.1 h) and the risk of chorioamnionitis was lower (7.3% vs 18.4%). When subdividing the women who received oxytocin into early (< 12 h after AROM) vs late (> 12 h after AROM) administration, there were no significant changes in the rates of successful VBAC or of chorioamnionitis. CONCLUSION: AROM as a single mode of IOL in women with a previous CS is a safe and efficient practice with high rates of successful VBAC. When spontaneous labor does not develop, there is no advantage to delay the administration of oxytocin.

Uterine rupture risk in a trial of labor after cesarean section with and without previous vaginal births.

PURPOSE: Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for the trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. METHODS: A retrospective cohort study was conducted, including women who underwent TOLACs from 2003 to 2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥ 24 weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was a uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. RESULTS: A total of 11,235 women were included, 6795 of which had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p < 0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p < 0.0001), were more likely to undergo labor induction (OR 1.56, p < 0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p < 0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. CONCLUSION: PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

Predicting vaginal birth after caesarean section: Validation of the Grobman model in a New Zealand population.

BACKGROUND: The decision regarding mode of birth following a primary caesarean section is important. Women may choose an elective repeat caesarean section or a trial of labour in an attempt to achieve a vaginal birth after caesarean (VBAC). The highest morbidity and mortality is associated with those who have an emergency caesarean section following a trial of labour. Therefore, the ability to accurately predict successful VBAC is important in antenatal counselling. AIMS: To test the validity of the Grobman prediction nomogram in a New Zealand (NZ) population. MATERIALS AND METHODS: A retrospective cohort study was performed of women carrying a singleton, cephalic pregnancy at term and who had one previous lower segment caesarean section in Northland, NZ. The probabilities of successful VBAC were calculated using the variables in the Grobman model and compared with observed VBAC rates using a calibration curve. The predictive ability of the model was assessed using area under the receiver operating characteristic curve (AUC). RESULTS: Of the 421 eligible women, 354 elected to undergo a trial of labour, of whom 69.5% had a successful VBAC. The AUC for the Grobman model was 0.72 (95% CI 0.67-0.78) with predicted and actual outcomes being similar when predicted success was over 50%. The predictive ability of the model appeared more accurate for Maori and Pacifika women compared to the NZ European population. CONCLUSIONS: The Grobman model predicts successful VBAC reasonably well in a NZ population and can be used as an antenatal counselling aid.

Factors associated with the outcome of TOLAC after one previous caesarean section: a retrospective cohort study.

The factors associated with the outcome of trial of labour after one previous Caesarean Section; a retrospective cohort study. A retrospective observational study was performed on all eligible consecutive singleton pregnancies planned for trial of labour after one previous Caesarean Section (TOLAC) over a period of 18 months to study the success rate of vaginal birth after Caesarean Section (VBAC) and to find out the factors associated with successful and failed TOLAC. All of the data were entered in electronic format and the data was analysed in detail. Of the 1324 women studied, the VBAC rate was 65.3% and the incidence of scar rupture was 0.5%. The composite adverse maternal (postpartum haemorrhage and intensive care admission) and foetal outcome (still birth, 5-minute APGAR <7 and NICU admission) was more in the failed TOLAC group. Various demographic, clinical and obstetric factors were studied in detail between the successful and failed TOLAC groups. The favourable Bishop Score (>4) was independently associated with successful TOLAC (OR 4.3; 95% CI 3.3-5.6 p < .001). Maternal age of >30 years, (OR 0.57; 95% CI 0.41-0.79; p = .001), labour induction (OR 0.43; 95% CI 0.33-0.56; p < .001) and estimated foetal weight of >3500 g (0.31; 95% CI 0.14-0.6; p = .002) were the factors independently associated with failed TOLAC. Previous indication for a Caesarean Section and previous vaginal delivery were not found to be independently associated with the outcome of TOLAC. The predictive models for TOLAC need to be used cautiously and the risk assessment should be done on an individual basis.IMPACT STATEMENTWhat is already known on this subject? TOLAC is a reasonable strategy in Obstetrics especially after one Caesarean Section to minimise the morbidity associated with rising Caesarean Section. However, the maternal and foetal morbidity are more following unsuccessful TOLAC. The factors which predict the outcome of TOLAC are multifactorial which include maternal demographic factors, previous obstetric factors like indication for Caesarean Section, intraoperative complications, inter-pregnancy interval, current obstetric factors such as gestational age, Bishop Score before delivery, labour factors and foetal factors, e.g. sex and foetal size.What do the results of this study add? We tried to include all the possible factors which probably influence TOLAC and found only Bishop Score, maternal age, foetal size and labour induction were the factors independently associated with the outcome of TOLAC. A Bishop Score of >4 admission was the greatest predictor of successful TOLAC (OR 4.3). Similarly, labour induction and foetal size of >3.5 kg were associated with 60% and 70% less chance of VBAC, respectively.What are the implications of these findings for clinical practice and/or further research? The factors found to be associated with successful and failed TOLAC may be utilised to develop a predictive model. More so, prospective studies are needed to test such predictive models.

Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study.

OBJECTIVE: To investigate the association between planned mode of birth after previous caesarean section and a child's risk of having a record of special educational needs (SENs). DESIGN: Population-based cohort study. SETTING: Scotland. POPULATION: A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections. METHODS: Linkage of Scottish national health and education data sets. MAIN OUTCOME MEASURES: Any SENs and specific types of SEN recorded when a child was aged 4-11 years and attending a Scottish primary or special school. RESULTS: Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99-1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child's risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01-1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98-1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09-2.34). CONCLUSIONS: This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices. TWEETABLE ABSTRACT: There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

Influence of the second stage of labor on maternal and neonatal outcomes in vaginal births after caesarean section: a multicenter study in Germany.

BACKGROUND: The American College of Obstetricians and Gynecologists (ACOG) introduced a new standard of care in 2014, extending the duration of the second stage of labor in order to reduce caesarean delivery (CD) rates and its severe complications. The aim of the present study is to evaluate success rates of trial of labor after caesarean section (TOLAC), as well as maternal and neonatal outcomes after the establishment of the recent guidelines. METHODS: A retrospective study was performed at two large departments in Germany from January 2008 to January 2018. Patients undergoing TOLAC were divided into two groups. Group I (958 patients) was constituted before the establishment of the current guidelines, and Group II (588 patients) after the establishment of the guidelines. A subgroup analysis was performed to compare neonatal outcomes after successful TOLAC and operative vaginal delivery with those after failed TOLAC and secondary CD. RESULTS: The success rate of vaginal births after cesarean section (VBAC) fell from 66.4% in Group I to 55.8% in Group II (p < 0.001). The median duration of the second stage of labor was statistically significantly longer in Group II than in Group I (79.3 ± 61.9 vs. 69.3 ± 58.2 min) for patients without previous vaginal birth. The incidence of operative vaginal delivery decreased from Group I to Group II (9.6% vs. 6.8%). The incidence of third- and fourth-degree perineal lacerations, blood loss and emergency CD were similar in the two groups. Concerning the neonatal outcome, our groups did not differ significantly in regard of rates of umbilical artery cord pH < 7.1 (p = 0.108), the 5-min Apgar scores below 7 (p = 0.224) and intubation (p = 0.547). However, the transfer rates to the neonatal care unit were significantly higher in Group II than in Group I (p < 0.001). Neonatal outcomes did not differ significantly in the subgroup analysis. CONCLUSION: Extending the second stage of labor does not necessarily result in more vaginal births after TOLAC. Maternal and neonatal outcomes were similar in both groups. Further studies will be needed to evaluate the role of operative vaginal delivery and the duration of the second stage of labor in TOLAC.