Trial of vaginal delivery for twins – is it safe? a single center experience

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL.

Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL.

Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p?Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.     

Previous caesarean or vaginal delivery: Which mode is a greater risk of perinatal death at the second delivery?

OBJECTIVE: To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean. STUDY DESIGN: Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history. RESULTS: A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p<0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason. CONCLUSION: Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.     

Failed vaginal birth after a cesarean section: How risky is it?: I. Maternal morbidity

OBJECTIVE: Our purpose was to determine the maternal risks associated with failed attempt at vaginal birth after cesarean compared with elective repeat cesarean delivery or successful vaginal birth after cesarean. STUDY DESIGN: From 1989 to 1998 all patients attempting vaginal birth after cesarean and all patients undergoing repeat cesarean deliveries were reviewed. Data were extracted from a computerized obstetric database and from medical charts. The following three groups were defined: women who had successful vaginal birth after cesarean, women who had failed vaginal birth after cesarean, and women who underwent elective repeat cesarean. Criteria for the elective repeat cesarean group included no more than two previous low transverse or vertical incisions, fetus in cephalic or breech presentation, no previous uterine surgery, no active herpes, and adequate pelvis. Predictor variables included age, parity, type and number of previous incisions, reasons for repeat cesarean delivery, gestational age, and infant weight. Outcome variables included uterine rupture or dehiscence, hemorrhage >1000 mL, hemorrhage >2000 mL, need for transfusion, chorioamnionitis, endometritis, and length of hospital stay. The Student t test and the chi(2) test were used to compare categoric variables and means; maternal complications and factors associated with successful vaginal birth after cesarean were analyzed with multivariate logistic regression, allowing odds ratios, adjusted odds ratios, 95% confidence intervals, and P values to be calculated. RESULTS: A total of 29,255 patients were delivered during the study period, with 2450 having previously had cesarean delivery. Repeat cesarean deliveries were performed in 1461 women (5.0%), and 989 successful vaginal births after cesarean delivery occurred (3.4%). Charts were reviewed for 97.6% of all women who underwent repeat cesarean delivery and for 93% of all women who had vaginal birth after cesarean. Vaginal birth after cesarean was attempted by 1344 patients or 75% of all appropriate candidates. Vaginal birth after cesarean was successful in 921 women (69%) and unsuccessful in 424 women. Four hundred fifty-one patients undergoing cesarean delivery were deemed appropriate for vaginal birth after cesarean. Multiple gestations were excluded from analysis. Final groups included 431 repeat cesarean deliveries and 1324 attempted vaginal births after cesarean; in the latter group 908 were successful and 416 failed. The overall rate of uterine disruption was 1.1% of all women attempting labor; the rate of true rupture was 0.8%; and the rate of hysterectomy was 0.5%. Blood loss was lower (odds ratio, 0.5%; 95% confidence interval, 0.3-0.9) and chorioamnionitis was higher (odds ratio, 3.8%; 95% confidence interval, 2.3-6.4) in women who attempted vaginal births after cesarean. Compared with women who had successful vaginal births after cesarean, women who experienced failed vaginal births after cesarean had a rate of uterine rupture that was 8.9% (95% confidence interval, 1.9-42) higher, a rate of transfusion that was 3.9% (95% confidence interval, 1.1-13.3) higher, a rate of chorioamnionitis that was 1.5% (95% confidence interval, 1.1-2.1) higher, and a rate of endometritis that was 6.4% (95% confidence interval, 4.1-9.8) higher. CONCLUSION: Patients who experience failed vaginal birth after cesarean have higher risks of uterine disruption and infectious morbidity compared with patients who have successful vaginal birth after cesarean or elective repeat cesarean delivery. Because actual numbers of morbid events are small, caution should be exercised in interpreting results and counseling patients. More accurate prediction for safe, successful vaginal birth after cesarean delivery is needed.     

Assisted vaginal birth: what is best practice?

Assisted vaginal birth (AVB) is the vaginal birth of a baby performed with the help of a medical device. In the United Kingdom, 10–15% of birthing people will have an AVB for maternal and/or fetal indications. Devices for AVB most commonly include forceps and vacuum, with differing risks and benefits. However, complications can include maternal and fetal morbidity. The decision-making in AVB is complex and multi-factorial to ensure a safe AVB is achieved. Technical and non-technical skills including: communication, situational awareness and human factors, are crucial for holistic care. Safety considerations comprised of a thorough assessment, intrapartum care and postnatal aspects of management. Training needs to cover all aspects of a competent AVB, including understanding the different devices and evaluating which to use in varied clinical settings. With rising rates of second-stage caesarean AVB continues to be an essential skill in obstetric care.     

Operative vaginal delivery – An historical perspective

This chapter will cover the evolution of forceps and vacuum-assisted delivery of the foetus in cephalic presentation. The options available before the development of obstetric forceps are briefly reviewed. The invention of the forceps in the early 17th century was followed by their evolution over four centuries with the introduction of the pelvic curve, axis-traction and rotational forceps. The phase of prophylactic forceps delivery will be discussed. The development of vacuum-assisted delivery has evolved over the past 150 years. However, in practical terms, the modern era of vacuum-assisted delivery began with Tage Malmström's vacuum extractor in the early 1950s. The evolution of the modern vacuum extractor with metal, soft and hard plastic cups will be reviewed.     

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.     

Postpartum stress urinary incontinence,is it related to vaginal delivery?

A postpartum stress urinary incontinence is highly prevalent in Chinese women. Both pregnancy and delivery can damage muscular, fascial, and neural mechanisms of urinary continence. Elective cesarean section (CS) is not completely protective against postpartum stress urinary incontinence.     

Sequential use of instruments at operative vaginal delivery: Is it safe?

Objective: Our purpose was to examine maternal and neonatal outcomes in a cohort of women who underwent delivery with the sequential use of instruments. Study Design: This retrospective case-control study included deliveries from May 1996 through March 1998. Charts of women who underwent delivery with the sequential use of instruments (vacuum first, then forceps, or vice versa) were identified. Two control groups (1 forceps group, 1 vacuum group) were randomly selected and matched for each case. Maternal and neonatal outcomes were abstracted and compared. Results: There were 34 patients in each group. There were no significant demographic differences. The vacuum group had lower rates of episiotomy (P = .01) and deep perineal lacerations (P = .014), whereas these outcomes were similar in the sequential and forceps groups. All other maternal outcomes were equivalent. There were no differences in any neonatal parameter except for superficial scalp trauma, which was more common in the vacuum group (P = .002). Conclusion: We conclude that the prudent use of sequential instruments at operative vaginal delivery did not engender higher rates of maternal or neonatal morbidity. (Am J Obstet Gynecol 1999;180:1446-9.)     

Can a vaginal birth after cesarean delivery be a normal labor and birth? Lessons from midwifery applied to trial of labor after a previous cesarean delivery

Women who undergo a trial of labor after a previous cesarean delivery (TOLAC) have special needs prenatally and during the intrapartum period. Counseling about the choice of TOLAC versus an elective repeat cesarean delivery involves complex statistical concepts. Prenatal counseling that is patient centered, individualized, and presented in a way that addresses the health literacy and health numeracy of the recipient encompasses best practices that support patient decision making. Evidence-based practices during labor that support vaginal birth and increase patient satisfaction are of special value for this population.     

Normal birth or spontaneous vertex delivery?

The declining normal birth rate and increasing Caesarean Section (CS) rates have been a worldwide cause for concern and debate for two decades. In the United Kingdom (UK) normal birth rates have fallen from 70 per cent in the 1970s to 46.7 per cent in 2009 (Birth Choice UK 2011). As normal birth rates continue to fall, researchers and advocates of normality are focusing on the midwife's role in response to this decline. The language and definitions used to classify normality and normal birth are contentious issues leading to confusion for midwives and women. This paper seeks to contribute to the debates around defining and promoting normality.     

Breech presenting twin A: is vaginal delivery safe?

The aim of our study was to compare the neonatal outcome of vaginally delivered breech-presenting twins (VD) to those delivered by cesarean (CS). Maternal and neonatal charts of all live, non-anomalous twins delivered at > or =25 weeks of gestation, in a single tertiary care center, over an 11-year period were reviewed. Of 517 twins delivered, 130 breech-presenting twins were analyzed. Thirty-five (26.9%) were delivered vaginally and 95 (73.1%) by cesarean. More patients presented in labor with advanced cervical dilation in the VD compared to the CS group. There was no difference in the incidence of respiratory distress syndrome, intraventricular hemorrhage, need for mechanical ventilation, length of nursery stay or neonatal mortality rate when twin A was compared in the two groups. However, one breech-presenting twin in the VD group had a traumatic delivery at 32 weeks of gestation that caused a spine fracture followed by immediate neonatal death. Although there seems to be no compromise in the immediate neonatal outcome of breech-presenting twins delivered vaginally compared to those delivered by cesarean, the case of head entrapment that led to intrapartum death is quite alarming. Based on our study, we cannot advocate normal vaginal delivery when twin A is non-vertex: cesarean seems to be a safer route of delivery.     

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.     

Anal sphincter disruption at vaginal delivery: is recurrence predictable?

Objectives: To evaluate the efficacy of clindamycin vaginal cream 2% once daily for 7 days in prolonging pregnancy. Study design: Randomised clinical trial of 112 women between 14 and 25 weeks of gestation with diagnosis of asymptomatic bacterial vaginosis were enrolled in a multicenter randomised trial and assigned to active or no treatment. A total of 55 women were assigned to clindamycin and 57 to no treatment. Main outcome measure: frequency of pre-term delivery. Results: The rates of pre-term delivery was 12.2% in the clindamycin group and 15.7% in the no treatment group (P=0.78). Birth weight was <2500 g in three and seven babies, respectively, in the two groups (P=0.32). Mean gestational ages at birth were 38.9 and 39.2 (P=0.52), respectively, in the clindamycin and no treatment groups. Conclusions: The results of this study suggest that treating asymptomatic bacterial vaginosis does neither markedly prolong pregnancy nor increase birthweight.