Cervical dilatation at the time of cesarean section may affect the success of a subsequent vaginal delivery

Objective.?To evaluate the effect of labor progress prior to cesarean delivery on the outcome of vaginal birth after cesarean delivery (VBAC).

Methods. The medical records of women attempting VBAC between January 2000 and February 2008 were reviewed. All women had only one previous cesarean and underwent spontaneous labor.

Results.?Among 1148 enrolled women, 956 (83.3%) achieved a successful VBAC. Birth weight, previous indication for cesarean delivery and oxytocin augmentation were significantly associated with VBAC outcome. By multivariate analysis, a cervical dilatation ≥8 cm at previous cesarean was independently predictive of successful VBAC in women with a previous cesarean for non-recurrent indications (p = 0.046), yielding a VBAC success rate of 93.1%, whereas the extent of cervical dilatation at the previous cesarean did not affect the outcome of subsequent delivery in women with a previous cesarean for recurrent indications.

Conclusions.?Women with cesarean for non-recurrent indications who achieved a cervical dilatation ≥8 cm may be the best candidates for VBAC, with the greatest likelihood of a successful VBAC. Labor progress at previous cesarean can serve as a valuable indicator for VBAC outcome in women with a previous cesarean for non-recurrent indications, and therefore should be discussed as part of preconception counseling.     

Preferred and actual delivery mode after a cesarean in London, UK

OBJECTIVE: To determine the delivery mode preferred by pregnant women with 1 previous cesarean delivery and to investigate the relationship between preferred and actual mode of delivery. METHOD: We reviewed the records of 215 women who were delivered in a London hospital with a history of 1 cesarean delivery. Women who planned an elective repeat cesarean section (ERCS) were compared with those who planned a vaginal birth after cesarean (VBAC). RESULTS: Although 55.3% chose VBAC overall, only 37.8% of those who chose it were delivered by it, whereas 94.8% of those who chose ERCS were delivered by ERCS. Nonwhite women were more likely to choose VBAC than white women (odds ratio, 3.5; 95% confidence interval, 1.9-6.1) but less likely to be deliver by it (odds ratio, 0.31; 95% confidence interval, 0.14-0.68). CONCLUSION: In this study, VBAC was the method of delivery preferred by most women. Nonwhite women were more likely to choose VBAC over ERCS but less likely to be delivered by VBAC.     

Impact of First Childbirth on Changes in Women’s Preference for Mode of Delivery: Follow‐up of a Longitudinal Observational Study

ABSTRACT: Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty‐four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women’s wish to change to elective cesarean section. (BIRTH 35:2 June 2008)     

Primigravid Women's Views of Being Approached to Participate in a Hypothetical Term Cephalic Trial of Planned Vaginal Birth versus Planned Cesarean Birth

Background: Several papers have called for a trial of planned cesarean section versus planned vaginal birth for low‐risk women—a recommendation that is fiercely debated. Although proponents of a trial have voiced their support, evidence suggests that in the United Kingdom few midwives and obstetricians believe such a trial to be feasible, and no studies reporting women's views on the prospect of such a trial have been published. The purpose of this study is to explore women's views of participation in a trial of planned cesarean birth versus planned vaginal birth. Methods: A qualitative study was conducted using in‐depth interviews in a large maternity hospital in the United Kingdom. Sixty‐four women were interviewed 12 months after giving birth. Women were asked “How do you think you would have felt if you had been approached to take part in such a trial during your first pregnancy?” Data were analyzed thematically. Results: Only 3 of the 64 women stated that they would have participated in a trial of planned vaginal birth versus planned cesarean section, had they been asked. However, five other women said that they would have consented to participate if they had been asked during pregnancy, but with hindsight, would have regretted that decision. The remainder of women would not have participated, unless a preference arm was offered. Three main themes were identified: “feeling cheated,”“let nature take its course, ” and “just another trauma that you don't need.” Conclusions: Few women supported a trial and most suggested that it was intuitively wrong. Given the strong views voiced by women, it is unlikely that a trial of planned vaginal delivery versus planned cesarean delivery would be feasible.     

Randomised trial of assigned mode of delivery after a previous cesarean section – Impact on maternal psychological dynamics

Objective.?This randomised trial was designed to study the psychological status and morbidity during and after delivery among women with a previous cesarean section (CS) who were randomised to planned vaginal birth (VBAC) or planned CS.

Methods.?Two hundred and ninety-eight women with one previous lower segment CS were randomised to either planned VBAC or planned CS. Women were asked to complete psychometric scales during their pregnancy till 6 months after confinement. The primary outcome studied was the differences in psychometric scores between the two study groups.

Results.?There were no differences in anxiety, depression, psychological well-being or satisfaction scores between the two groups. Significantly more women in planned VBAC (27/123) requested to change to elective CS, compared to those who were randomised to planned CS (15/135) initially requested to change to planned VBAC (OR: 2.25; 95% CI: 1.13–4.47). Subgroup analyses showed that women who changed from planned CS to VBAC had lower satisfaction at delivery [Client Satisfaction Score: 24.0 (23.0–24.3), 23.0 (22.0–24.0); p?=?0.009] compared to women who did not change their plan for elective CS.

Conclusions.?The planned mode of delivery, either elective CS or VBAC, in pregnant women who had one previous CS did not influence the psychological dynamic during the course of or after the pregnancy. VBAC was not associated with higher psychological morbidity and therefore should be encouraged.     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.     

New mothers’ feelings of disappointment and failure after cesarean delivery

Background

Childbirth is an important life event and how women feel in retrospect about their first childbirth may have long‐term effects on the mother, child, and family. In this study, we investigated the association between mode of delivery at first childbirth and birth experience, using a new scale developed specifically to measure women's affective response.

Methods

This was a prospective cohort study of 3006 women who were interviewed during pregnancy and 1‐month postpartum. The First Baby Study Birth Experience Scale was used to measure the association between mode of delivery and women's postpartum feelings about their childbirth, taking into account relevant confounders, including maternal age, race, education, pregnancy intendedness, depression, social support, and maternal and newborn complications by way of linear and logistic regression models.

Results

Women who had unplanned cesarean delivery had the least positive feelings overall about their first childbirth, in comparison to those whose deliveries were spontaneous vaginal (P < .001), instrumental vaginal (P = .001), and planned cesarean (P < .001). In addition, those who delivered by unplanned cesarean were more likely to feel disappointed (adjusted odds ratio [OR] 6.21 [95% confidence interval (CI) 4.62‐8.35]) and like a failure (adjusted OR 5.09 [95% CI 3.65‐7.09]) in comparison to women who had spontaneous vaginal delivery; and less likely to feel extremely or quite a bit proud of themselves (adjusted OR 2.70 [95% CI 2.20‐3.30]).

Conclusions

Delivering by unplanned cesarean delivery adversely affects how women feel about their first childbirth in retrospect, and their self‐esteem.     

Vaginal birth after cesarean section: Experience from a regional hospital

ObjectiveTrial of labor after cesarean section (TOLAC) is an option for women with previous cesarean section. However, few women choose this option because of safety concerns. We evaluate the safety and risks associated with TOLAC and the success rate of vaginal birth after cesarean delivery (VBAC).Material and methodsWe reviewed all patients with a history of previous cesarean section that underwent elective repeat cesarean section (ERCS) or TOLAC in a regional teaching hospital from Nov, 2013 to May, 2018. Maternal basic clinical information, intrapartum management, postpartum complications, and neonatal outcomes were analyzed.Results199 pregnant women with a history of at least one previous cesarean section were enrolled. 156 women received ERCS and 43 women (21.6%) underwent TOLAC, with 37 (86.0%) who underwent successful VBAC. The VBAC rate was 18.6%. Higher success rate was found in women with previous vaginal birth than in women without vaginal birth (100% vs. 81.8%). One case (2.3%) in the VBAC group was complicated with uterine rupture and inevitable neonatal death during second stage of labor. The uterus was repaired without maternal complications. In another case, the newborn's condition was complicated with low APGAR score (<7) at birth due to maternal chorioamnionitis. Among indications for previous cesarean section, cephalo-pelvic disproportion (CPD) was associated with TOLAC failure and uterine rupture after VBAC.ConclusionVBAC is a feasible and safe option. Modes of delivery should be thoroughly discussed when considering TOLAC for women with history of previous cesarean section due to CPD, considering its association with TOLAC failure in second stage of labor.     

Prediction of successful trial of labor after cesarean – the benefit of prior vaginal delivery

Objective: To determine predictive factors for vaginal birth after cesarean section (VBAC).

Methods: A retrospective cohort study of all women with singleton pregnancies and a prior single low transverse cesarean section (CS) who attempted vaginal delivery in a tertiary hospital (2010–2014). Pregnancy outcome of women with VBAC was compared to those who failed vaginal delivery. Sub-analysis for women with no prior vaginal deliveries was performed. Pregnancies with non-cephalic presentation, estimated fetal weight?>4000 g and any contraindications for vaginal delivery were excluded.

Results: Of the 40 714 deliveries, 1767 women met inclusion criteria. Among them 1563 (88.5%) had a VBAC and 204 (11.5%) failed. There was no significant difference between the groups regarding maternal age, comorbidities and pregnancy complications. Predictors for VBAC were (odds ratio, 95% confidence interval) interval from prior CS (1.13, 1.04–1.22, p=0.004), previous VBAC (2.77, 1.60–4.78, p?<?0.001), prior vaginal delivery prior to the CS (3.05, 1.73–5.39, p?<?0.001) and induction of labor (0.62, 0.40–0.97, p?=?0.03). For women with no prior vaginal birth, only birthweight was associated with VBAC (0.99, 0.99–1.00, p?=?0.02).

Conclusion: While different variables may influence the rate of VBAC, the predictive ability of VBAC for women with no previous vaginal deliveries remains poor.     

Roundtable Discussion: “No One Can Condemn You to a C‐Section!”

Abstract: The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician. (BIRTH 37:3 September 2010)     

Care for Women Desiring Vaginal Birth After Cesarean

Women with a history of a prior cesarean birth may receive conflicting information regarding options in future pregnancies related to the choice of a trial of labor after a cesarean (TOLAC) or having an elective repeat cesarean delivery (ERCD). The National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean (VBAC) addressed questions related to safety and outcomes of having a VBAC compared to ERCD. Summary recommendations included increasing access to health care providers and facilities that care for women who desire a TOLAC yet factors were raised in determining what constitutes best practices. The purpose of this clinical bulletin by the American College of Nurse‐Midwives is to offer evidence‐based guidelines for midwives who are caring for women who have had a prior cesarean birth. Risk assessment, counseling, and education to support informed choices including considerations related to site of birth are provided.     

Does the interval since vaginal delivery influence the chance of vaginal birth after cesarean?

Objective: To examine the association between interval since vaginal delivery and vaginal birth after cesarean (VBAC).

Methods: Women with one prior low transverse cesarean and a prior vaginal delivery undergoing a trial of labor after cesarean at term were included in this cohort study. Multivariable analyses were performed to determine whether length of time since prior vaginal delivery was independently associated with VBAC and, if so, whether its inclusion enhanced the predictive capacity of previously published models.

Results: Of the 5628 women included, 4901 (87%) achieved a VBAC. Each additional year since vaginal delivery decreased the odds of VBAC by 11% (95% CI: 10–13%). When added to an existing predictive model that included only factors available at early prenatal care, interval since vaginal delivery marginally improved the model’s predictive ability (area under the curve [AUC] 0.73 versus 0.71, p?<?0.01). When added to a model that included factors available proximate to the time of delivery, the addition of interval since vaginal delivery did not change the AUC (0.76 versus 0.75, p?=?0.08).

Conclusions: A longer interval since vaginal delivery is associated with a decreased odd of VBAC. However, the addition of this interval to VBAC prediction models does not substantively improve their predictive ability.     

Comparison of maternal satisfaction following vaginal delivery after caesarean section and caesarean section after previous vaginal delivery

OBJECTIVES: To compare (i) satisfaction levels among women who delivered vaginally after one previous caesarean (VBAC) with women delivered by caesarean after previous vaginal delivery (CSAVD) and (ii) to assess reasons why women may request caesarean delivery on subsequent pregnancies. STUDY DESIGN: We conducted a prospective questionnaire-based study of maternal satisfaction following both modes of delivery during an 8-month period. RESULTS: One hundred and forty women completed an early postnatal questionnaire, 70 each in VBAC and CSAVD cohorts. The vast majority in both groups were satisfied with their respective mode of delivery, but would opt for vaginal delivery in their next pregnancy (89% in VBAC versus 94% in CSAVD). The VBAC group experienced minimal pain after delivery and had felt better prepared for delivery (74% versus 41% in the CSAVD group). Reasons for dissatisfaction in the VBAC group included the physical stress of labour and inadequacy of analgesia. CONCLUSION: Maternal satisfaction with vaginal delivery is high. Those who have experienced both modes of delivery would prefer vaginal birth on future pregnancies. These findings are reassuring to women contemplating vaginal delivery.     

Maternal Request for Cesarean Section due to Fear of Birth: Can It Be Changed Through Crisis‐Oriented Counseling?

ABSTRACT: Background: A psychosocial team was established to meet the needs of an increasing number of pregnant women referred for fear of birth who wished a planned cesarean. This study describes the intervention, the women’s psychosocial problems in relation to degree of fear of birth, changes in their wishes for mode of birth and birth outcome, women’s satisfaction with the intervention, and their wishes for future births. Methods: The study sample comprised 86 pregnant women with fear of birth and a request for planned cesarean, who were referred for counseling by a psychosocial team at the University Hospital of North Norway in the period 2000–2002. Data were gathered from referral letters, from antenatal and intrapartum care records, and from a follow‐up survey conducted 2 to 4 years after the birth in question. Results: Fear of birth was accompanied by extensive psychosocial problems in most women. Ninety percent had experienced anxiety or depression, 43 percent had eating disturbances, and 63 percent had been subjected to abuse. Twenty‐four percent of those with psychiatric conditions had previously been in treatment. After the intervention, 86 percent changed their original request for cesarean section and were prepared to give birth vaginally. The follow‐up survey confirmed long‐term satisfaction with having changed their request for a cesarean delivery. Of these, 69 percent gave birth vaginally and 31 percent were delivered by cesarean for obstetrical indications. Conclusions: Impending birth activates previous traumatic experiences, abuse, and psychiatric disorders that may give rise to fear of vaginal birth. When women were referred to a specialist service for fear of birth and request for cesarean, they became conscious of, and to some degree worked through, the causes of their fear, and most preferred vaginal birth. They remained pleased with their choice later. (BIRTH 33:3 September 2006)     

Decision Making in Patient-Initiated Elective Cesarean Delivery: The Influence of Birth Stories

Patient‐initiated elective cesarean delivery is emerging as an urgent issue for practitioners, hospitals, and policy makers and for pregnant women. This exploratory qualitative study looks at the birth stories and cultural knowledge that women use to inform the decision about an elective cesarean without medical indication. Data collection consisted of exploratory qualitative in‐depth interviews with 17 primiparous women in British Columbia, Canada. Interviews revealed the influence of socially circulated birth stories and cultural narratives on their attitudes towards mode of delivery. Participants included in their decision making process both medical information and informal birth stories that were technologically inclined and confirmed their preference for cesarean delivery. Results indicate that women who participated in this study drew heavily from social and cultural knowledge in forming their decision to give birth by patient‐initiated elective cesarean delivery. Although the numbers of women who request a cesarean delivery for social reasons is still small, the persuasive influence on parturient women of positive cesarean stories and negative vaginal stories must be considered. Care providers and childbirth educators need to become familiar with the social influences impacting women's decisions for mode of delivery so that truly informed choice discussions can be undertaken.     

The safety of a trial of labor after cesarean section in a grandmultiparous population

Background The rate of vaginal birth after a cesarean (VBAC) delivery in the multiparous population has decreased largely in recent years because of maternal and neonatal complications. The clinical management of grand multiparous (GMP) women (>5 births) with a prior cesarean delivery is even less clear. The purpose of the present study was to assess the risks of maternal and neonatal complications associated with VBAC compared to that of repeated elective cesarean section (CS) in the GMP population. Methods A retrospective study of 1,102 GMP women with a singleton gestation and a prior single CS was conducted. Data were retrieved from the database of the Department of Obstetrics and Gynecology at the Soroka University Medical Center, Beer Sheva, Israel. Maternal and neonatal outcomes were compared between women who underwent a successful VBAC attempt, women who had failed in a trial of labor and women who had an elective repeated CS. Results Six hundred and nineteen women (56%) underwent a successful VBAC, 155 (14%) underwent a trail of labor and 328 (30%) had an elective repeated CS. Women who had a successful VBAC required less blood transfusion, and had less puerperal fever diseases (P < 0.001). Induction or augmentation of labor was associated with failure of VBAC (P < 0.001). No significant differences in neonatal complications were observed between the groups. No significant difference in uterine dehiscence, uterine rupture, amnionitis, postpartum hemorrhage, hysterectomy, puerperal fever and thromboembolic diseases was observed between the groups. Conclusions A successful VBAC in the GMP population was not associated with a higher risk of maternal complications in comparison with a repeated elective CS. This work is in satisfaction of E. Kugler M.D. requirements     

Repeat cesarean section and primary elective cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions

OBJECTIVE: This study was undertaken to determine opinions of obstetrician-gynecologists regarding vaginal birth after cesarean (VBAC) section and elective cesarean section. STUDY DESIGN: A questionnaire was administered to obstetrician-gynecologists attending 2 review courses. RESULTS: Of 500 obstetrician-gynecologists, 304 completed the survey for a response rate of 61%. Most (92%) counseled VBAC candidates differently, and 84% quoted differential VBAC completion rates on the basis of the indication for prior cesarean section. Uterine rupture was virtually always discussed (99%). Pelvic floor risks were infrequently discussed with urinary incontinence, pelvic organ prolapse, and fecal incontinence discussed by less than one third of obstetricians (30%, 28%, and 25%, respectively). Fifty-nine percent of physicians would perform a primary elective cesarean section, and 67% would perform a primary elective cesarean section specifically to prevent pelvic floor disorders. CONCLUSION: Two thirds of recent graduates are willing to perform an elective cesarean section to prevent pelvic floor injury. Most offer VBAC; however, less than a third include risk of pelvic floor injury in their informed consent discussions.     

Association between prior vaginal birth after cesarean and subsequent labor outcome

Objective: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean.

Methods: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007–2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes.

Results: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p?=?.036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p?p?=?.04).

Conclusions: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.     

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.