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.     

A Critique of the Literature on Women’s Request for Cesarean Section

ABSTRACT: Background: The influence of women’s birth preferences on the rising cesarean section rates is uncertain and possibly changing. This review of publications relating to women’s request for cesarean delivery explores assumptions related to the social, cultural, and political‐economic contexts of maternity care and decision making. Method: A search of major databases was undertaken using the following terms: “c(a)esarean section” with “maternal request,”“decision‐making,”“patient participation,”“decision‐making‐patient,”“patient satisfaction,”“patient preference,”“maternal choice,”“on demand,” and “consumer demand.” Seventeen papers examining women’s preferred type of birth were retrieved. Results: No studies systematically examined information provided to women by health professionals to inform their decision. Some studies did not adequately acknowledge the influence of obstetric and psychological factors in relation to women’s request for a cesarean section. Other potential influences were poorly addressed, including whether or not the doctor advised a vaginal birth, women’s access to midwifery care in pregnancy, information provision, quality of care, and cultural issues. Discussion: The psychosocial context of obstetric care reveals a power imbalance in favor of physicians. Research into decision making about cesarean section that does not account for the way care is offered, observe interactions between women and practitioners, and analyze the context of care should be interpreted with caution. (BIRTH 34:4 December 2007)     

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)     

Childbirth Preferences after Cesarean Birth: A Review of the Evidence

Abstract: Background : Conflicting evidence on maternal and fetal safety of vaginal and cesarean childbirth after a previous cesarean makes patients and practitioners uncertain about pursuing a trial of labor or an elective repeat cesarean delivery. This review systematically evaluated and summarized the evidence related to women's preference for delivery. Methods : The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthSTAR, PsycINFO, and CINAHL databases were searched from 1980 to August 2002. We reviewed controlled trials, case‐control studies, and observational studies that contained original patient data on preference for women with a previous cesarean delivery and that were of “good” or “fair” quality. Results : Women with a previous vaginal delivery were more likely to select trial of labor than women who did not have one. The most commonly cited reason for selecting trial of labor was ease of recovery and desire to return quickly to caring for other children (reported in 6 of 7 studies). Safety for the mother and/or infant was cited as an important reason for delivery choice in 4 of 11 studies. Important ethnic differences were reported. Nonwhite women were more likely to identify their provider as an important influence (39% vs 19%), and perceived labor as something to be avoided if another option resulted in a healthy baby compared with white women, who perceived labor as a challenge and an experience not to be missed. Conclusions : A woman's choice for delivery was often based on family obligations, such as the need for a shorter recovery so that she could care for her infant and children at home, rather than the safety of herself or her infant. It remains unclear if education on vaginal birth after cesarean increases the proportion of women who choose trial of labor. Future studies should evaluate the impact of education and timing of education on patient preference. (BIRTH 31:1 March 2004)     

Planned vaginal delivery versus planned cesarean delivery in cases of low-lying placenta

Objective: To assess the applicability of trial of labor in cases of low-lying placenta.

Methods: In this observational cohort study, we collected data from the women with low-lying placenta delivered at our hospital between April 2012 and December 2015. Low-lying placenta was diagnosed when the length from the placental lowest edge to the internal cervical os (placenta-os distance) was 0–20?mm at 36 gestational weeks. Planned mode of delivery for each case was determined by patient’s preference. Maternal and neonatal outcomes were compared between the planned vaginal delivery group (N?=?11) and the planned cesarean delivery group (N?=?7).

Results: All the women in the planned cesarean delivery group underwent scheduled cesarean section at 37–38 gestational weeks. Three cases in the planned vaginal delivery group required emergency cesarean section for uncontrollable antepartum bleeding. The intrapartum blood loss was significantly smaller in the planned vaginal delivery group than in the planned cesarean delivery group (946?±?204?g vs. 1649?±?256?g, p?=?0.047). Umbilical arterial blood pH was similar between the two groups. All the women requiring emergency cesarean section were accompanied by marginal sinus.

Conclusions: Trial of labor can be offered to all the women with low-lying placenta except for those accompanied by marginal sinus.     

Neonatal Mortality for Primary Cesarean and Vaginal Births to Low‐Risk Women: Application of an “Intention‐to‐Treat” Model

ABSTRACT: Background: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an “intention‐to‐treat” methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low‐risk women. Methods: Low‐risk births were singleton, term (37–41 weeks’ gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention‐to‐treat methodology, a “planned vaginal delivery” category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a “planned cesarean delivery” category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. Results: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. (BIRTH 35:1 March 2008)     

Quantifying VBAC Risk: Muddying the Waters

The Landon et al and the Crowther et al papers are both prospective trials comparing planned vaginal birth after a previous cesarean section (VBAC) with elective cesarean section in women eligible for a trial of labor. With 33,000 women, the cohort studied by Landon et al in conjunction with the National Institute of Child Health and Human Development (NICHHD) spawned multiple publications, giving estimates of VBAC risks and success relevant to women in a wide variety of clinical situations. Data abstraction was careful and outcomes were hard and verified. With 2,300 women, the study by Crowther et al, was 6 percent the size of the Landon‐NICHHD study. Although it claimed “increased risk of both fetal death or liveborn infant death prior to discharge or serious infant outcome,” there were only 2 perinatal deaths—both stillbirths prior to 39 weeks' gestation and unrelated to mode of delivery. Of the 28 infants with “serious neonatal morbidity,” only three could have resulted from uterine rupture; prior experience with this outcome indicates all three will likely escape long‐term morbidity. Pseudorandomization and erroneous adherence to an intention‐to‐treat principle seriously hinder the study's internal validity, attributing outcomes for one quarter of women undergoing elective cesarean section to the planned VBAC group. The study by Landon and NICHHD is over 10 times larger and of much higher quality than the study by Crowther et al. The Landon‐NICHHD publications should be used to help women make decisions about planned mode of delivery after cesarean. (BIRTH 39:4 December 2012)     

Women's Request For a Cesarean Section: A Critique of the Literature

Background: The consistently high cesarean section rate in most developed Western countries has been attributed in part to maternal request. This controversial view demands critical analysis. This paper provides a critique of published research relating to women's request for cesarean delivery. Method: A search of the major databases was undertaken using the search term “cesarean section” with “maternal request,”“decision‐making,”“patient‐participation,”“decision‐making‐patient,”“patient‐satisfaction,”“patient‐preference,” and “maternal‐choice.” Ten research articles examining women's preferred mode of birth were retrieved, nine of which focused on women's preference for cesarean delivery. Results: The methodology of some studies may result in overreporting women's request for a cesarean delivery. The role of the woman's caregiver in the generation, collection, and entry of data, and the occurrence of post hoc rationalization, recall bias, and women's tendency to be less critical of their care immediately after birth are possible areas of concern. Due consideration is rarely given to the influence of obstetric risk for women who may be requesting a cesarean section or to the information women used in making their decision. Women's perceptions of their involvement in decision‐making regarding cesarean section are used to draw conclusions regarding women's request. Conclusions: Few women request a cesarean section in the absence of current or previous obstetric complications. The focus on women's request for cesarean section may divert attention away from physician‐led influences on the continuing high cesarean section rates.     

Making Choices for Childbirth: A Randomized Controlled Trial of a Decision‐aid for Informed Birth after Cesareana

ABSTRACT: Background: Decision‐making about mode of birth after a cesarean delivery presents challenges to women and their caregivers and requires a balance of risks and benefits according to individual circumstances. The study objective was to determine whether a decision‐aid for women who have experienced previous cesarean birth facilitates informed decision‐making about birth options during a subsequent pregnancy. Method: A prospective multicenter randomized controlled trial of 227 pregnant women was conducted within 3 prenatal clinics and 3 private obstetric practices in New South Wales, Australia. Women with 1 previous cesarean section and medically eligible for trial of vaginal birth were recruited at 12 to 18 weeks’ gestation; 115 were randomized to the intervention group and 112 to the control group. A decision‐aid booklet describing risks and benefits of elective repeat cesarean section and trial of labor was given to intervention group women at 28 weeks’ gestation. Main outcome measures included level of knowledge, decisional conflict score, women's preference for mode of birth, and recorded mode of birth. Results: Women who received the decision‐aid demonstrated a significantly greater increase in mean knowledge scores than the control group (increasing by 2.17 vs 0.42 points on a 15‐point scale)(p < 0.001, 95% CI for difference = 1.15–2.35). The intervention group demonstrated a reduction in decisional conflict score (p < 0.05). The decision‐aid did not significantly affect the rate of uptake of trial of labor or elective repeat cesarean section. Preferences expressed at 36 weeks were not consistent with actual birth outcomes for many women. Conclusion: A decision‐aid for women facing choices about birth after cesarean section is effective in improving knowledge and reducing decisional conflict. However, little evide nce suggested that this process led to an informed choice. Strategies are required to better equip organizations and practitioners to empower women so that they can translate informed preferences into practice. Further work needs to examine ways to enhance women's power in decision‐making within the doctor‐patient relationship. (BIRTH 32:4 December 2005)     

The Importance of Mode of Birth After Previous Cesarean: Success,Satisfaction, and Postnatal Health

Introduction: The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase women's opportunities to make informed choices about VBAC. This study aimed to expand knowledge of women's experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth‐after‐cesarean study. Methods: At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10‐point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. Results: Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F= 5.33; P= .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health‐related problems and were least likely to agree that they would make the same birth choice again. Discussion: Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance women's opportunities to achieve spontaneous vaginal birth during planned VBAC.     

IN THE LITERATURE:Combating Coercion: Breech Birth,Parturient Choice,and the Evolution of Evidence‐Based Maternity Care

ABSTRACT: In 2001 the term breech trial led the American and Royal Colleges of Obstetricians and Gynecologists (ACOG and RCOG) to issue black‐and‐white “cookbook” guidelines condemning vaginal breech birth. Since then, women have been coerced, both overtly and covertly, into having cesarean sections. New evidence and a better understanding of the limitations of the term breech trial have led both the ACOG and RCOG to replace their 2001 guidelines with new ones that re‐open the door for planned vaginal breech birth, acknowledge the evolving understanding of the nature of evidence, and emphasize the importance of external validity in the evaluation of complex phenomena. Parturient choice and clinical judgment are re‐introduced. (BIRTH 34:2 June 2007)     

“It's All the Rage These Days”: University Students' Attitudes Toward Vaginal and Cesarean Birth

Background: At 30 percent, British Columbia has the highest cesarean section rate in Canada. Little is known about the childbirth views and birthing preferences of college‐aged women and men. The objectives of this study were to document (a) the prevalence of cesarean versus vaginal delivery as the preferred mode of delivery among nonpregnant university students without a history of childbirth, (b) the reasons for reported childbirth preferences, and (c) confidence in vaginal birth as a predictor of childbirth preference. Methods: A cohort of 3,680 male and female university students without a history of childbirth participated in an online survey of childbirth preferences. The study used a mixed methods approach (quantitative thematic analysis and logistic regression modeling). Prevalence of, and reasons for, preferred mode of delivery were analyzed separately for male and female respondents. Results: Most men and women responded that they preferred vaginal delivery, with 9 percent stating a preference for cesarean delivery. Reasons for preferred mode of delivery were similar for men and women. For women, confidence in vaginal birth emerged as a significant predictor of childbirth preference. Conclusions: Results indicate that a preference for cesarean section is linked to fear of childbirth and driven by low confidence in vaginal birth. Educational strategies targeting university‐aged men and women may be helpful in alleviating fears of vaginal birth and providing evidence‐based information about different birth options.     

Please exit safely: maternal and twin pair neonatal outcomes according to delivery mode when twin A is vertex*

Objective: To investigate maternal and infant outcomes associated with delivery mode for twins with a cephalic presenting twin.

Methods: Linked birth certificate and ICD hospital discharge data were analyzed retrospectively for 5573 mothers and their respective twin pairs born live at 34–42 weeks’ gestation, with twin A vertex, in Washington State from 1997–2007. Relative risks (RR) and 95% confidence intervals of adverse maternal and twin pair outcomes were calculated for vaginal delivery or cesarean during labor in comparison to cesarean without labor.

Results: Vaginal delivery or cesarean during labor was associated with significantly elevated rates of maternal hemorrhage (RR?=?2.8 [2.2,3.7]), infection (RR?=?2.2 [1.5,3.3]), twin pair birth injury (RR?=?2.6 [1.2,5.4]) and low 5-min Apgar scores (RR?=?1.4 [1.1,1.8]) and with significantly lower rates of ventilation among preterm twin pairs only (RR?=?0.8 [0.7,0.9]). The lowest rate of combined poor short-term outcomes occurred in mothers and twin pairs delivered by cesarean without labor (23%) and the highest rates occurred in those with operative vaginal or cesarean during labor (39% and 34%, respectively). Among women in labor, 35% of nulliparas achieved spontaneous vaginal delivery of both twins compared to 63% of non-nulliparas.

Conclusion: For nulliparous women who carry twins to term, planned cesarean may improve outcomes.     

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)     

Women's Preference for a Cesarean Section: Incidence and Associated Factors

Background: Few studies have examined women's preferences for birth. The object of this study was to determine the incidence of women's preferred type of birth, and the reasons and factors associated with their preference. Methods: Three hundred and ten women between 36 and 40 weeks' gestation were recruited from the antenatal clinic of a major metropolitan teaching hospital and the consulting rooms of six private obstetricians in Brisbane, Australia. Participants completed a questionnaire asking about their preferred type of birth, reasons for their preference, preparation for childbirth, level of anxiety and concerns, and the influence of the primary caregiver. Results: Two hundred and ninety women (93.5%) preferred a spontaneous vaginal birth; 20 women (6.4%) preferred a cesarean section. Of the latter group, most had a current obstetric complication or experienced a previously complicated delivery (p <0.001); 1 woman (0.3%) preferred a cesarean section in the absence of any known current or previous obstetric complication. Women who preferred a cesarean section were more anxious, were generally poorly informed of the risks of this procedure, and/or overestimated the safety of the procedure. Conclusions: Women who preferred a cesarean section were more likely to have experienced this type of birth previously and to have negative feelings about it. To decrease women's preference for a cesarean section, practitioners should reduce the primary cesarean delivery rate and improve the quality of emotional care for women who require a cesarean section. Caregivers should engage in a sensitive discussion of the risks and benefits of various birth options, including a vaginal birth after cesarean, with women who have previously experienced a cesarean birth before they make decisions about mode of delivery in a subsequent pregnancy.     

Women’s Autonomy and Scheduled Cesarean Sections in Brazil: A Cautionary Tale

ABSTRACT: Background: In Brazil, one‐fourth of all women deliver in the private sector, where the rate of cesarean deliveries is extremely high (70%). Most (64%) private sector cesareans are scheduled, although many women would have preferred a vaginal delivery. The question this study addresses is whether childbearing women were induced to accept the procedure by their physicians, and if so, how? Methods: Three face‐to‐face structured interviews were conducted with 1,612 women (519 private sector and 1,093 public sector) early in pregnancy, approximately 1 month before their due date, and approximately 1 month postpartum. For all private sector patients having a scheduled cesarean section, women’s self‐reported reasons given for programming surgical delivery were classified into three groups according to obstetrical justification. Results: After loss to follow‐up (19.2% of private sector and 34.4% of public sector), our final sample included 1,136 women (419 private sector and 717 public sector). Compared with public sector participants in the final sample, on average, private sector participants were older by 3.4 years (28.7 vs 25.3 yr), had 0.4 fewer previous deliveries (0.6 vs 1.0), and had 3.4 more years of education (11.0 vs 7.6 yr). The final samples also differed slightly with respect to preference for vaginal delivery: 72.3 percent among those in the private sector and 79.6 percent in public sector. The cesarean section rate was 72 percent in the private sector and 31 percent in the public sector. Of the women with reports about the timing of the cesarean decision, 64.4 percent had a scheduled cesarean delivery in the private sector compared with 23.7 percent in the public sector. Many cesarean sections were scheduled for an “unjustified” medical reason, especially among women who, during pregnancy, had declared a preference for a vaginal delivery. Among 96 women in this latter group, the reason reported for the procedure was unjustified in 33 cases. On the other hand, more cesarean deliveries were scheduled for “no medical justification,” including physician’s or the woman’s convenience, among women who preferred to deliver by cesarean (35/65). The incidence of real medical reasons for a scheduled cesarean section diagnosed before the onset of labor among private sector patients who had no previous cesarean birth and who wanted a vaginal delivery was 13 percent (31/243). Conclusions: The data suggest that doctors frequently persuaded their patients to accept a scheduled cesarean section for conditions that either did not exist or did not justify this procedure. The problem identified in this paper may extend well beyond Brazil and should be of concern to those with responsibility for ethical behavior in obstetrics. (BIRTH 35:1 March 2008)     

The indication for induction of labor impacts the risk of cesarean delivery

Objective: The risk of cesarean delivery following labor induction has been clearly established. While numerous factors are known to impact this risk, the indication for induction has rarely been examined as a risk factor. This study aimed to examine the relationship between indication for induction and ultimate mode of delivery after labor induction.

Methods: A retrospective cohort study was conducted examining all cases of labor induction in a tertiary center university teaching hospital over a one-year period. The primary outcome measure was mode of delivery (vaginal delivery versus cesarean delivery) and its relationship to the indication for induction. Secondary outcome measures were: parity, maternal age, birth week, cervical maturity, use of epidural anesthesia, fetal birth weight and fetal sex.

Results: Seven hundred and ninety-six women met inclusion criteria, of which 17.1% ultimately underwent cesarean delivery. Using multivariate analysis, fetal indications for induction (including intra-uterine growth restriction, oligohydramnios, placental abruption, macrosomia and post-term pregnancy) were found to significantly increase the risk of cesarean delivery in nulliparous women. The other significant factor was birth after week 40?+?0.

Conclusions: The indication for labor induction impacts the risk of cesarean delivery. Specifically, induction of labor for fetal indications significantly increases the risk of cesarean delivery in nulliparous women.     

Ultrasound examination at term for predicting the outcome of delivery in women with a previous cesarean section

Objective: To evaluate if ultrasound variables at term are associated with the mode of delivery in women with previous cesarean section (PCS).

Methods: This was a prospective study of singleton pregnant women who planned a trial of vaginal birth after cesarean delivery. Cervical length, posterior cervical angle, head–perineum distance, and estimated fetal weight were measured at 37–39 weeks of gestation.

Results: One hundred forty-four pregnancies were examined and vaginal delivery was achieved in 98 women (73%). Logistic regression analysis identified cervical length, head–perineum distance, age, previous vaginal delivery, previous cesarean for dystocia, and Bishop score as predictors of vaginal delivery. Combining ultrasound and clinical parameters, two models for risk scoring that differ in the variable Bishop score or cervical length were constructed. The AUC of these models was 0.867 and 0.855, respectively.

Conclusions: In women with a PCS, measurement of cervical length and head–perineum distance at term is associated with the mode of delivery. A combination of clinical and sonographic parameters at term can predict the likelihood of vaginal delivery.     

Web-Based Education and Attitude to Delivery by Caesarean Section in Nulliparous Women

ObjectiveTo measure the effect of a web-based educational tool on baseline knowledge of the risks and benefits of delivery by Caesarean section in healthy nulliparous women.MethodsWe constructed a web-based educational tool to provide evidence-based information on the potential benefits and risks of CS for healthy nulliparous women in the second trimester. We included women with an uncomplicated singleton pregnancy who were receiving antenatal care at Mount Sinai Hospital. Eligible women logged into the website to undertake a pretest survey. After completing this survey, they received access to the educational tool, followed by a link to a second survey. The surveys collected baseline demographics and assessed participants’ knowledge of the perceived safety and risks of vaginal delivery and CS, their sources of information, and the influence of these sources on their views.ResultsSeventy-three participants completed both surveys. Participants had a high baseline preference (84%) for vaginal delivery. The mean score for knowledge about vaginal delivery and CS increased significantly between the surveys, from 47% to 76% (P < 0. 001). There was no significant change in preference for mode of delivery between the two surveys. In both surveys, more participants responded that they were a “little fearful” or “not fearful at all” of vaginal deliveries. In the second survey, significantly more responded that they were “very fearful” or “fearful” of CS (P < 0.05). Increased knowledge about specific risks of vaginal delivery did not deter participants from preferring a vaginal delivery. However, knowledge of risks associated with CS made them more likely to have “very favourable” or “somewhat favourable” views of vaginal delivery. Ethnicity and country of birth were not found to have a significant effect on preferred mode of delivery.ConclusionsWe demonstrated that a web-based educational tool significantly increased knowledge of the risks and benefits of vaginal delivery and CS. However, the educational intervention did not significantly change preferences.