Maternal and neonatal outcomes associated with multiple repeat cesarean deliveries: A registry-based study from Qatar.

BACKGROUND: Cesarean delivery (CD) is associated with increased maternal and neonatal morbidity compared to vaginal delivery, particularly in cases classified as emergency procedures or when there are multiple CDs. This retrospective cohort study aims to examine the incidence of maternal and neonatal complications in women with multiple CDs. METHODS: This study used data from a national perinatal database obtained from a single tertiary maternity care hospital. Women who delivered a singleton live birth after 24 weeks of gestation by CD were stratified into five groups based on the number of CDs, with the last group having five or more CDs. The women were divided into those with five or more CDs (Group 5) versus those with fewer than five (Groups 1 to 4). The maternal outcomes included intra-operative surgical complications, blood loss, and intensive care unit (ICU) admission. The neonatal outcomes included preterm birth, neonatal ICU (NICU) admission, respiratory distress syndrome (RDS), and perinatal death. RESULTS: Of the 6,316 women in the study, 2,608 (41.3%) had a primary CD. 30.3%, 17.5%, and 7.3% of the cohort had their second, third, and fourth CDs, respectively. Women undergoing the 5th CD and above formed the remaining 3.5% (227). Women in Group 5 had the highest risk of suffering a surgical complication (3.1%, p = 0.015) and postpartum hemorrhage (7.5%, p = 0.010). 24% of babies in Group 5 were born preterm (p < 0.001). They also had a 3.5 times higher risk of having a surgical complication (RR = 3.5, 95% CI 1.6-7.6, p = 0.002), a 1.8 times higher risk of developing postpartum hemorrhage (RR = 1.8, 95% CI 1.1-2.9, p = 0.014), a 1.7 times higher risk of delivering between 32-37 weeks of gestation (RR = 1.7, 95% CI 1.3-2.2, p < 0.001), a higher risk of the baby getting admitted to NICU (RR = 1.3, 95% CI 1.0-1.6, p = 0.038), and developing RDS (RR = 1.5, 95% CI 1.2-2.0, p = 0.002) compared to Groups 1-4. The risks of neonatal outcomes such as NICU admission (RR 2.9, 95% CI 2.1-4.0) and RDS (RR 3.5, 95% CI 2.3-5.5) were much higher in elective CDs performed at term compared to preterm births (p < 0.001 for both). CONCLUSION: Maternal morbidity significantly increases with the increasing number of CD. The increased risk of RDS and NICU admissions in the neonate with multiple CDs reflects lower gestational age and birthweight in these groups-consideration of preoperative steroids for lung maturation in these women to reduce neonatal morbidity warrants further discussion.

Preferences of pregnant individuals to undergo labor after one cesarean in southern China.

BACKGROUND: Labor after cesarean (LAC) remains an optional delivery method among healthy pregnant individuals. Exploring women's attitudes, preferences, reasons for previous cesarean delivery, and the incentives underlying pregnant individuals' preferences could help us understand their choice of delivery mode. In this study we evaluated the preferences and attitudes of eligible pregnant women regarding participation in a LAC in Foshan, China. METHODS: A cross-sectional survey was conducted among 438 pregnant individuals with one prior cesarean delivery (CD) who attended their antenatal examination at a tertiary hospital in southern China, between November 1, 2018, and October 31, 2019. Information on demographic characteristics, obstetric data, preferences for LAC, and incentives for LAC were analyzed. RESULTS: Overall, 85.4% (374/438) of women preferred LAC if they did not have contraindications before delivery, whereas 12.3% (54/438) refused and 2.3% (10/438) were unsure. Participants reported that the most important factors affecting their willingness to undergo LAC were safety indicators (i.e., "ability of hospitals to perform emergency cesarean delivery" [score of 9.28 ± 1.86]), followed by accessibility indicators (i.e., "priority bed arrangements" [score of 9.17 ± 1.84]). Logistic regression analysis indicated that neonatal wellbeing with the prior CD was an independent influencing factor (OR = 2.235 [95%CI: 1.115-4.845], p = 0.024) affecting willingness to access LAC in the subsequent pregnancy. CONCLUSIONS: We found a high preference for LAC among pregnant individuals without contraindications before delivery in southern China. Healthcare providers need to ensure access to LAC and increase pregnant individuals' LAC willingness through high-quality shared decsision-making in alignment with patient preferences.

Risk factors and outcomes associated with type of uterine rupture.

PURPOSE: To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn. METHODS: Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared. RESULTS: 92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017). CONCLUSION: TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Women's perceptions of provider communication on birth options after cesarean: A qualitative study.

In the United States, Hispanic and non-Hispanic Black women are more likely to have a repeat cesarean birth (RCB) than non-Hispanic White women. The underrepresentation of Hispanic women and women with previous cesarean births in prior studies has resulted in a limited understanding of the reasons for this disparity. This study used in-depth interviews to investigate the perceptions of 27 Hispanic and non-Hispanic Black and White women about the communication that took place with their providers about their birth options after a previous cesarean. The roles of cultural norms and trust in providers in communication about RCBs were also explored. Results suggest that patient-provider communication and trust of providers for Hispanic and non-Hispanic Black and White women may influence their perception of choice, uptake of information, and ability to make an informed choice regarding birth options. Findings have implications for providers and healthcare management systems who need to account for and attempt to address these differences as they directly affect women's birth outcomes.

Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery.

BACKGROUND: Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. OBJECTIVE: This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. STUDY DESIGN: This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016. RESULTS: In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. CONCLUSION: Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.

Cervical ripening after cesarean section: a prospective dual center study comparing a mechanical osmotic dilator vs. prostaglandin E2.

OBJECTIVES: Worldwide, the overall cesarean section is rising. Trial of labor after cesarean (TOLAC) is an overall safe option with an immediate impact on neonatal and maternal short- and long-term health. Since the use of prostaglandins in cervical ripening is associated with an increased risk of uterine rupture, mechanical methods as balloon catheters or osmotic dilators have been suggested for cervical ripening prior to induction of labour. Here we are analyzing and comparing the VBAC rate, as well as maternal and fetal outcome in cervical ripening prior to TOLAC. METHODS: This prospective dual center study analyses maternal and neonatal outcomes of TOLAC in women with an unfavorable cervix requiring cervical ripening agent. The prospective application of an osmotic dilator (Dilapan-S, n=104) was analysed in comparison to the retrospective application of off-label dinoprostone (n=102). RESULTS: The overall fetal and neonatal outcome revealed no significant differences in both groups. Patients receiving cervical ripening with the osmotic dilator delivered vaginally/by ventouse in 52% of cases, compared to 53% when using dinoprostone (p=0.603). The interval between application to onset of labor was significantly higher in the osmotic dilator group (37.9 vs.20.7 h, p=<0.001). However, time from onset of labor to delivery was similar in both groups (7.93 vs. 7.44 h, p=0.758). There was one case of uterine rupture in the dinoprostone group. CONCLUSIONS: Our data shows that the application of the osmotic dilator leads to similar outcomes in VBAC rate and time from onset of labor to delivery as well as safety in both groups compared to off-label use dinoprostone. Cervical ripening using the mechanical dilator is a viable and effective option, without the risk of uterine hyperstimulation.

Third-trimester prediction of successful vaginal birth after one cesarean delivery-A Swedish model.

INTRODUCTION: The objective was to create a clinically useful prediction model for vaginal birth in trial of labor after one cesarean section, appropriate for a third trimester consultation. MATERIAL AND METHODS: Women with one cesarean section and at least one following delivery (N = 38 686) in the Swedish Medical Birth Register, 1998-2013, were studied. The women were randomly divided into one development and one validation data set. From the development data set, variables associated with vaginal birth after cesarean (VBAC) were identified by univariable logistic regression. Stepwise backward selection was performed until all variables were statistically significant. From the final fitted multivariable logistic model, likelihood ratios were calculated, in order to transpose odds ratios into clinically useful measurements. A constant, based on the delivery ward VBAC in trial of labor rate, was used. By applying the likelihood ratios on the validation data set, the VBAC chance for each woman was estimated with the Bayesian theorem, and the ability of the model to predict VBAC was explored using receiver operating characteristics (ROC) curves. RESULTS: A previous VBAC, and a previous cesarean section for non-cephalic presentation, were the strongest VBAC predictors. The lowest chances were found for a previous cesarean section due to dystocia, and among women with <18 months since the last cesarean section. The area under the ROC curve was 0.67. CONCLUSIONS: The new model was satisfactory in predicting VBAC in trial of labor. Developed as a software application, it would become a clinically useful decision-aid.

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.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery.

PURPOSE: To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes. METHODS: A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed. RESULTS: Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001). CONCLUSION: Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

Balloon catheter for induction of labor in women with one previous cesarean and an unfavorable cervix.

INTRODUCTION: When women with a previous cesarean section and an unfavorable cervix have an indication for delivery, the choice is to induce labor or to perform a cesarean section. This study aims to assess the effectiveness and safety of a balloon catheter as a method of induction of labor in women with one previous cesarean section and an unfavorable cervix compared with an elective repeat cesarean section. MATERIAL AND METHODS: We performed a prospective cohort study in 51 hospitals in the Netherlands on term women with one previous cesarean section, a live singleton fetus in cephalic position, an unfavorable cervix and an indication for delivery. We recorded obstetric, maternal and neonatal characteristics. We compared the outcome of women who were induced with a balloon catheter with the outcome of women who delivered by elective repeat cesarean section. Main outcomes were maternal and neonatal morbidity. Mode of delivery was a secondary outcome for women who were induced. Adjusted odds ratios (aOR) were calculated using logistic regression, adjusted for potential confounders. RESULTS: Analysis was performed on 993 women who were induced and 321 women who had a repeat cesarean section (August 2011 until September 2012). Among the women who were induced, 560 (56.4%) delivered vaginally and 11 (1.1%) sustained a uterine rupture. Composite adverse maternal outcome (uterine rupture, severe postpartum hemorrhage or postpartum infection) occurred in 73 (7.4%) in the balloon and 14 (4.5%) women in the repeat cesarean section group (aOR 1.58, 95% confidence interval [CI] 0.85-2.96). Composite adverse neonatal outcome (Apgar score <7 at 5 minutes or umbilical pH <7.10) occurred in 57 (5.7%) and 10 (3.2%) neonates, respectively (aOR 1.40, 95% CI 0.87-3.48). Women who were induced had a shorter postpartum admission time (2.0 vs 3.0 days (P < 0.0001)). CONCLUSIONS: In women with a previous cesarean section and a need for delivery, induction of labor with a balloon catheter does not result in a significant increase in adverse maternal and neonatal outcomes as compared with planned cesarean section.

Trial of labor versus elective repeat cesarean delivery in twin pregnancies after a previous cesarean delivery-A systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review of success rates of trial of labor after cesarean (TOLAC) and maternal and neonatal outcomes in twin pregnancy versus elective repeat cesarean delivery (ERCD). METHODS: We searched MEDLINE, EMBASE, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared twin TOLAC and ERCD for maternal and/or neonatal outcomes. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model. The pooled event rates for successful VBAC, cesarean delivery for twin B after vaginal delivery of twin A, and uterine rupture were determined. RESULTS: Of the 841 citations identified, 10 were eligible for analysis (2336 TOLAC cases and 5763 ERCD cases). The pooled event rates for successful VBAC and uterine rupture during TOLAC were 72.2% (95% CI 59.7%-83.2%) and 0.87% (95% CI 0.51%-1.31%), respectively. TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02 [95% CI 1.07-8.54]) with no significant differences in mean gestational age at birth, NICU admission rates, or 5-minute Apgar <7. Although the risk for maternal infectious morbidity was significantly lower with TOLAC (RR 0.48 [95% CI 0.25-0.90]), risks of uterine dehiscence, blood transfusions, and hysterectomy were comparable. CONCLUSIONS: Twin TOLAC is associated with a relatively high rate of successful vaginal delivery and a low risk of uterine rupture. The finding of higher neonatal mortality rates may be influenced by prematurity, but requires further investigation.

Does an increased number of cesarean sections result in greater risk for mother and baby in low-risk, late preterm and term deliveries?

OBJECTIVE: To compare surgical complications and maternal and neonatal outcomes of low-risk, late preterm and term pregnant women who have had one or two previous cesarean sections (CSs) with those who have had three or more CSs. METHODS: We conducted a retrospective study of 850 patients undergoing repeat CS at a tertiary level maternity hospital in Ankara, Turkey. Of those, 380 had previously undergone one or two CSs (Group-I: second or third CS) and 470 had previously undergone three or four CSs (Group-II: fourth or fifth CS). Outcomes and complications were compared between the groups. RESULTS: The two groups were statistically significantly different in terms of maternal age, parity, body mass index, maternal weight gain during pregnancy, and length of hospital stay (all p<0.001). Although the prevalence of intraperitoneal adhesions and placenta previa was higher in Group-II than in Group-I (p<0.001), there was no statistically significant difference in terms of cesarean hysterectomy and adjacent organ injuries (p>0.05). There were also no significant differences between the groups in terms of neonatal outcomes (p>0.05). CONCLUSION: Although the increase in the number of CSs appears to be associated with intraperitoneal adhesions and placenta previa, adverse maternal and neonatal outcomes were not observed in those women with low-risk pregnancies who underwent CS for the fourth or fifth time. Therefore, fourth and fifth CSs may be considered relatively safe surgical procedures in this cohort.

Sliding sign in third-trimester sonographic evaluation of intra-abdominal adhesions in women undergoing repeat Cesarean section: a novel technique.

OBJECTIVE: Intra-abdominal adhesions are associated with an increased risk of complications during repeat Cesarean section (CS), such as bladder and bowel injury, hemorrhage, infection and hysterectomy. We present a simple sonographic marker, the 'sliding sign' of the uterus, for the prediction of intra-abdominal adhesions in the third trimester of pregnancy in women undergoing repeat CS. METHODS: This was a prospective observational study of pregnant women with a history of at least one Cesarean delivery evaluated by transabdominal ultrasound during the third trimester of an ongoing pregnancy. In order to diagnose intra-abdominal adhesions, we assessed a sonographic sign, the sliding of the uterus under the inner part of the fascia of the abdominal muscles during deep breathing. Women were considered to be at high risk for severe adhesions if uterine sliding was absent and at low risk in the presence of obvious or moderate uterine sliding. A comparison between sonographic findings and intra-abdominal adhesions observed during surgery was performed. RESULTS: Of the 63 patients with one or more previous CS examined, 59 completed the study and underwent CS at our institution. In 16 of the 19 cases assigned to the high-risk group for severe adhesions due to absence of sliding of the uterus, the suspicion was confirmed at surgery. The prediction of low risk for adhesions was confirmed in 35 out of 40 patients. The sensitivity and specificity of the sliding sign in predicting presence of intra-abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively. Inter- and intraobserver correlation using Cohen's kappa coefficient were 0.52 and 0.77, respectively. CONCLUSION: Our data show that a simple sonographic sign might be able to discriminate between high and low risk for intra-abdominal adhesions in patients with a history of Cesarean delivery. This technique may aid clinical decisions in patients undergoing repeat CS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Induction of labor in patients with an unfavorable cervix after a cesarean using an osmotic dilator versus vaginal prostaglandin.

BACKGROUND: Trial of labor after cesarean (TOLAC) is a viable option for safe delivery. In some cases cervical ripening and subsequent labor induction is necessary. However, the commonly used prostaglandins are not licensed in this subgroup of patients and are associated with an increased risk of uterine rupture. METHODS: This cohort study compares maternal and neonatal outcomes of TOLAC in women (n=82) requiring cervical ripening agents (osmotic dilator vs. prostaglandins). The initial Bishop scores (BSs) were 2 (0-5) and 3 (0-5) (osmotic dilator and prostaglandin group, respectively). In this retrospective analysis, Fisher's exact test, the Kruskal-Wallis rank sum test and Pearson's chi-squared test were utilized. RESULTS: Vaginal birth rate (including operative delivery) was 55% (18/33) in the osmotic dilator group vs. 51% (25/49) in the dinoprostone group (P 0.886). Between 97% and 92% (32/33 and 45/49) (100%, 100%) of neonates had an Apgar score of >8 after 1 min (5, 10 min, respectively). The time between administration of the agent and onset of labor was 36 and 17.1 h (mean, Dilapan-S® group, dinoprostone group, respectively). Time from onset of labor to delivery was similar in both groups with 4.4 and 4.9 h (mean, Dilapan-S® group, dinoprostone group, respectively). Patients receiving cervical ripening with Dilapan-S® required oxytocin in 97% (32/33) of cases. Some patients presented with spontaneous onset of labor, mostly in the dinoprostone group (24/49, 49%). Amniotomy was performed in 64% and 49% (21/33 and 24/49) of cases (Dilapan-S® group and dinoprostone group, respectively). CONCLUSIONS: This pilot study examines the application of an osmotic dilator for cervical ripening to promote vaginal delivery in women who previously delivered via cesarean section. In our experience, the osmotic dilator gives obstetricians a chance to perform induction of labor in these women.

Evaluating Facility-Based Decision-Making in Women with a Prior Cesarean Delivery and Association with Maternal and Perinatal Outcomes.

Objective To describe facility-based decision-making for women with one prior cesarean delivery (CD) in a resource-limited setting and to characterize maternal and perinatal outcomes in these groups. Methods One year retrospective study of women with one prior CD delivering at Korle-Bu Teaching Hospital (KBTH), Ghana. Women were categorized into three groups based on initial plan of management on admission [trial of labor after cesarean (TOLAC), emergency repeat CD (EMCD) or non-emergent repeat CD (RCD)]. Characteristics and outcomes across these groups were then compared. Results During the study period, 1247 women with one prior CD delivered at KBTH, of which 377 (30.2%) were triaged to RCD, 439 (35.2%) to EMCD and 431 (34.6%) to TOLAC. Twelve uterine ruptures and no maternal deaths occurred. Perinatal mortality was 4.2% (n = 52). Compared to the RCD group, the TOLAC group had a lower risk for maternal adverse events (aOR 0.3, 95% CI 0.1-1.0; p = 0.04) and non-significant higher risk of perinatal adverse events (aOR 1.6, 95% CI 0.7-3.3; p = 0.25). Compared to women triaged to RCD, the EMCD group had a non-significant increase in risk of maternal adverse events (aOR 1.6, 95% CI 0.8-3.5; p = 0.2) and a significantly higher rate of perinatal adverse events (aOR 2.4, 95% CI 1.2-4.9; p = 0.01). Conclusions for Practice Women triaged to EMCD at admission are different when compared to women allowed a TOLAC or offered a non-emergent RCD. These women bear increased rates of adverse outcomes and should be considered as a separate group for analysis in future studies conducted in similar settings.

Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section.

PURPOSE OF INVESTIGATION: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS: We analyzed intra-abdominal adhesions of 672 patients. RESULTS: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS: Emergency operations and adhesions increased complications.

Is it safe to have multiple repeat cesarean sections? A high volume tertiary care center experience.

OBJECTIVE: To compare the obstetric outcomes of cesarean section in women who had a history of four or more previous cesarean sections with those who had a history of two or three previous cesarean sections. METHODS: Total 1318 women who underwent repeat cesarean section between January 2013 and January 2016 were retrospectively reviewed. Of these, 244 (18.5%) had previously had four or more cesarean sections (multiple repeat cesarean section group) and 1074 (81.5%) had previously had two or three cesarean sections (control group). Demographic characteristics and obstetric outcomes were compared using the Independent t and chi-square tests. RESULTS: The adhesion rate (p < 0.001), number of blood transfusion (p = 0.044), operation time (p = 0.012), length of hospital stay (p < 0.001) and tubal ligation surgery (p < 0.001) were significantly higher in multiple repeat cesarean section group compared to control group. CONCLUSION: Although multiple repeat cesarean section are asscociated with adhesion occurrence, higher number of blood transfusion, increased operation time and length of hospital stay, there is no remarkable difference in serious morbidity associated with multiple repeat cesarean section.

Evolution of cesarean categories in a modified Robson classification in a single center from 2002 to 2012 due to high rate of maternal pathology.

AIM: To study the evolution in cesarean section (CS) categories in a single center from 2002 to 2012. METHODS: We performed a retrospective study on all live births from 2002, 2007, and 2012 using a modified Robson classification accounting for cervical ripening in the induction groups, post-term pregnancies, and the number of uterine scars. RESULTS: We recorded 2162, 2105 and 2380 deliveries with caesarean delivery rates of 23.2%, 24.9%, and 30.4% in 2002, 2007, and 2012 respectively. Nulliparous women in spontaneous labor (group 1) decreased from 36.3% to 27.4% of the total population, but CS rates in this group increased from 14.1% to 19.5% (P < 0.05). Labor induction and CS before labor in nulliparous women category (group 2) increased from 6.7% to 14.2% but with stable CS rates. Induction of labor and cervical ripening in this group increased from 91 and nine in 2002 to 119 and 240 in 2012, respectively. In the same period, maternal pathology increased from 11% to 33%. Scarred uterus remained the major source of CS (almost 30% of all CS in 2012). CONCLUSION: CS rates increased throughout the studied period, associated with an increase in rates of maternal pathology, induction by cervical ripening, and scarred uterus.

Risk of neonatal mortality according to gestational age after elective repeat cesarean delivery.

PURPOSE: Despite the well-known neonatal morbidity risks after elective cesarean deliveries performed before 39 weeks, there are scarce data regarding mortality risks. The objective of this study was to calculate the risk of neonatal mortality after elective repeat cesarean delivery (ERCD) by gestational age. METHODS: The Linked Birth-Infant Death Data Files from the Vital Statistics Data of the Center for Disease Control and Prevention of the U.S. from 2004 to 2008 were analyzed. Only ERCD cases were included. Early death (<7 days), neonatal death (<28 days), and infant death (<1 year) were evaluated. A logistic regression model was used to calculate odds ratios. Cases delivered at 37-41 weeks were studied with 40 weeks as reference. RESULTS: A total of 483,052 cases were included for analysis. The distribution of rates and odds ratios for infant, neonatal and early death was U-shaped with the nadir at 39 weeks. There was a statistically significant increase in early death at 37 compared to 40 weeks' gestation [OR (95 %) CI = 1.929(1.172-3.176)]. No statistical increase was found in any of the other mortality risks. CONCLUSION: There is an increased risk in early death with ERCD performed at 37 weeks. Our study provides evidence of neonatal harm beyond the reported morbidity risks.

Obstetric outcomes associated with induction of labor after 2 prior cesarean deliveries.

OBJECTIVE: We sought to determine whether, in the setting of induction, obstetric outcomes differ based on the number of prior cesarean deliveries (CD) and to determine whether women with 2 cesareans undergoing induction face increased risks of adverse outcomes compared to women undergoing a repeat CD. STUDY DESIGN: This is a secondary analysis of a 4-year multicenter prospective cohort. Women with 1 or 2 CD were included. Frequencies of vaginal birth after cesarean as well as maternal and neonatal complications were compared among women with 1 CD undergoing induction, women with 2 CD undergoing induction, and women undergoing repeat CD with 2 cesareans. RESULTS: Of the 10,262 women included in this study, 4100 (40.0%) underwent an induction after 1 CD, 152 (1.5%) underwent an induction after 2 CD, and 6010 (58.6%) had a repeat CD after 2 CD. In women undergoing induction, the chance of vaginal birth after cesarean was no different in women with 2 compared to 1 prior CD (65% vs 69%, P = .28). Similarly, composite maternal (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 0.6-2.3) and neonatal (aOR, 1.1; 95% CI, 0.7-1.7) outcomes were not different between the 2 groups. In women who had 2 prior CD, undergoing an induction carried similar composite adverse maternal and neonatal outcomes compared to having a repeat CD (aOR, 0.7; 95% CI, 0.3-2.0; aOR, 1.1; 95% CI, 0.6-2.2). CONCLUSION: Labor induction outcomes are similar regardless of whether women have had 1 or 2 CD. After 2 CD, undergoing an induction carries similar maternal and neonatal risks as having a repeat CD.