Vaginal birth after cesarean section—The world trend and local experience in Taiwan

Objective

The trend of increasing cesarean section rates had evoked worldwide attention. Many approaches were introduced to diminish cesarean section rates. Vaginal birth after cesarean section (VBAC) is a route of delivery with diverse agreements. In this study, we try to reveal the world trend in VBAC and our experience of a 10-year period in a medical center in northern Taiwan.

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.     

Prior cesarean section—An acceptable risk for vaginal delivery at free-standing midwife-led birth centers? Results of the analysis of vaginal birth after cesarean section (VBAC) in German birth centers

Objectives

Is out-of-hospital vaginal birth at a birth center safe for women with a previous cesarean section? Do their maternal or neonatal outcomes vary significantly from those of a “non-cesarean” control group?

Study design

Retrospective evaluation of prospectively collected data on documented singleton births (cephalic presentation, >34/0 weeks of gestation), all of which were second births, occurring between 2000 and 2004 in 1 of 80 German birth centers. Births that occurred in the birth center or when labor had started in the birth center prior to transfer were included for analysis.

Results

Three hundred and sixty four women (5.3%) had a previous cesarean. The control group included 6448 parae II with no previous cesarean. Significant differences (p < 0.05) between these two groups included: the transfer rate of mothers from a birth center to a hospital clinic during labor, the number of emergency transfers, the method of delivery (repeat cesarean), and the Apgar score at 5 min ≤7.

Conclusions

At best, vaginal birth after cesarean (VBAC) is possible at a birth center if good cooperation exists with an emergency birth clinic near the birth center, allowing for a responsible and timely transfer to this hospital. Because serious maternal and neonatal complications are rare, further continuous observational studies with larger sets of data are necessary to determine safety of free-standing birth center care for women having VBAC.     

Deciding on route of delivery for obese women with a prior cesarean delivery

OBJECTIVES: This study was undertaken to estimate the vaginal birth after cesarean (VBAC) success rate, compare rates of infections in women attempting VBAC and those undergoing planned repeat cesarean, and compare the cost of these two plans of care for obese women.STUDY DESIGN: We performed a historical cohort analysis of singleton deliveries at ≥36 weeks' gestation in women with a body mass index 40 or greater and one prior cesarean delivery. Outcomes included rates of VBAC success and puerperal infections and mean cost of care.RESULTS: The cohort consisted of 122 mother-infant pairs, 61 each in the VBAC and cesarean groups. In the VBAC group, 57% (95% CI 45-70) of women were delivered vaginally. The VBAC group had higher rates of chorioamnionitis (13.1% vs 1.6%, P = .02), endometritis (6.6% vs 0%, P = .06), and composite puerperal infection (24.6% vs 8.2%, P = .01). Mean cost of care was similar for mothers ($4439 vs $4427, P = .95), infants ($1241 vs $1422, P = .49), and mother-infant pairs ($5680 vs $5851, P = .64).CONCLUSION: Compared with planned cesarean delivery, VBAC trials in obese women are three times as likely to be complicated by infection and do not result in reduced costs.     

Are Women’s and Obstetricians,Views on Mode of Delivery Following a Previous Cesarean Section Really OCEANS Apart?

Purpose

Most women with one previous cesarean section (CS) are suitable for either a vaginal birth after CS (VBAC) or an elective repeat CS. Previously, nurse-led prenatal education and support groups have failed to have an impact on the mode of delivery, which women opted for after one CS. A novel one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) has been developed to inform and empower women in their decision-making following one previous CS. The objective of our study was to evaluate how OCEANS influences the mode of delivery for women who have previously had one CS.

Study Design

Two-hundred and sixty-six women who had a single previous lower segment CS were invited to attend OCEANS, which is a 1-h discussion group of women between 5 and 15 in number, facilitated by an experienced obstetrician. Data were collected prospectively on women who were invited to attend OCEANS over a 12-month period commencing on the 1st January 2012.

Results

188 (71 %) attended the group, while 20 (8 %) canceled their appointment and 58 (22 %) did not keep their appointment. Those who attended OCEANS were 38 % more likely to opt for a VBAC than those who did not attend. There was no difference in the rates of successful vaginal delivery between women who attended OCEANS and those who did not (56 vs. 61 %, p = 0.55).

Conclusions

While nurse-led prenatal education and support groups have no impact on mode of delivery after one CS, a dedicated obstetrician-led clinic increases the rate of those opting for VBAC by 38 %. Such clinics may be a useful tool helping in empowering women in their decision-making and reduce the rate of CSs.     

Are There Differences between Women who Choose Elective Repeat Caesarean Versus Trial of Labour in St. John's,NL?

Objectives

To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL).

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery

Objective

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women.

Study design

This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data.

Results

The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P < 0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups.

Conclusion

Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation.     

Prediction of vaginal birth after one ceasarean delivery for non-progressive labor

Purpose

A model exists that predicts the probability of vaginal birth after cesarean (VBAC). That model is not stratified by indication at first cesarean. The aim of the study was to identify factors that may predict successful VBAC in patients operated for arrest of dilatation or descent at their first cesarean.

Methods

Retrospective analysis of all women with trials of labor after one cesarean (TOLAC) for non-progressive labor between November 2008 and October 2015 was performed (n = 231). A multivariate logistic regression analysis was carried out to generate a prediction model for VBAC at hospital admission for planned TOLAC.

Results

During the study period, we had 231 parturient women who chose to undergo TOLAC following one previous cesarean delivery for non-progressive labor. Successful VBAC occurred in 155 (67.0%) parturient women. A model consisting of previous successful VBAC, lower head station on decision at previous cesarean delivery, lower newborn weight at previous cesarean delivery and larger cervical effacement on admission at delivery planned for TOLAC correctly classified 75.3% of cases (R ² = 0.324, AUC 0.80, 95% CI 0.70–0.89, p < 0.001).

Conclusion

A predictive model, which incorporates four variables available at hospital admission for the planned TOLAC, has been developed that allows the determination of likelihood of successful VBAC following one cesarean delivery for non-progressive labor.

     

Complicated primary cesarean delivery increases the risk for uterine rupture at subsequent trial of labor after cesarean

Purpose

To evaluate whether cesarean delivery (CD) indication, labor status, and other primary CD characteristics affect the risk for uterine rupture in subsequent deliveries.

Methods

A case–control study of women attempting trial of labor after cesarean (TOLAC) in a single, tertiary, university-affiliated medical center (2007–2016). Deliveries complicated by uterine rupture were matched to successful vaginal birth after cesarean (VBAC) deliveries in a 1:3 ratio. Indication, labor status and post-partum complications (postpartum hemorrhage and postpartum infection) at primary CD were compared between study and control group.

Results

During study period, there were 75,682 deliveries, of them, 3937 (5.2%) were TOLAC. Study group included 53 cases of uterine rupture at TOLAC and 159 women with successful VBAC. Women in study group had significantly lower rates of previous VBAC (15.1 vs. 28.9%, p?=?0.047). Rate of postpartum complications at primary CD was significantly higher in women with TOLAC complicated by uterine rupture (7.5 vs. 1.9%, respectively, p?=?0.042). Utilizing the multivariate logistic regression analysis, postpartum complications remained an independent risk factor for uterine rupture in the following TOLAC (aOR 4.07, 95% CI 1.14–14.58, p?=?0.031).

Conclusion

Postpartum hemorrhage and infection, in primary CD, seem to be associated with increased risk for uterine rupture during subsequent TOLAC.

     

Audit of cesarean delivery in Burkina Faso

Objective

To assess the level and determinants of unnecessary cesarean delivery.

Methods

In a retrospective study, the medical charts were reviewed for 300 low-risk women who underwent intrapartum cesarean delivery at 10 referral hospitals in Burkina Faso between May 2009 and April 2010. In this context, cesarean deliveries were delegated to clinical officers who have less training than doctors.

Results

Among the 300 study patients, 223 women (74.3%) were referred from primary healthcare facilities. The reason for referral was not medically justified for 35 women. Cesarean was performed by a gynecologist–obstetrician (46.0%), a trained doctor (35.0%), or a clinical officer (19.0%). Acute fetal distress and fetopelvic disproportion were the main indications recorded for intrapartum cesarean delivery. These diagnoses were not confirmed by an obstetrician–gynecologist in 12.0% of cases. Clinical officers were associated with a higher risk of unnecessary cesarean delivery compared with gynecologist–obstetricians by multivariate analysis (odds ratio, 4.46; 95% confidence interval, 1.44–13.77; P = 0.009).

Conclusion

Verification of cesarean indications by highly qualified personnel (i.e. second opinion), in-service training, and supervision of health workers in primary healthcare facilities might improve the performance of the referral system and help to reduce unnecessary cesarean deliveries in Burkina Faso.     

Maternal obesity and rate of cesarean delivery in Djibouti

Objective

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti.

Methods

In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity.

Results

Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07–4.82; P = 0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae.

Conclusion

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.     

Mechanical induction of labor and ecbolic-less vaginal birth after cesarean section: A cohort study

Objective

During delivery counseling, some women with previous uncomplicated cesarean section (CS) wish mechanical induction of labor (IOL) but they are not accepting the added risk of using ecbolics to induce and/or augment labor. The objective of the study was to assess the safety and efficacy of the isolated use of transcervical Foley's catheter balloon as a mean of mechanical cervical ripening (CR)/IOL and successful ecbolic-less vaginal birth after cesarean section (VBAC).

Route of delivery following successful external cephalic version

Objective

To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV).

Methods

A retrospective matched case–control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status.

Results

Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63).

Conclusion

Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.     

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3).     

Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems

Background

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective

To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods

Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results

A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion

Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

     

Vaginal birth after a cesarean delivery for arrest of descent*

Objective: The objective of this study is to determine vaginal birth after cesarean (VBAC) success rates for patients with a prior cesarean delivery (CD) for arrest of descent, as well as determine any predictors for success.

Study design: This was a retrospective cohort study of all patients delivered by a single MFM practice from 2005 to 2017 with a singleton pregnancy and one prior CD for arrest of descent. We estimated the rate and associated risk factors for successful VBAC.

Results: We included 208 patients with one prior CD for arrest of descent, 100 (48.1%) of whom attempted a trial of labor after cesarean (TOLAC) with a VBAC success rate was 84/100 (84%, 95% CI 76–90%). Among the women who attempted TOLAC, women with a prior vaginal delivery >24 weeks’ had a significantly higher VBAC success rate (91.8% versus 71.8%, p?=?.01). Maternal age, body mass index, estimated fetal weight, induction of labor, and cervical dilation were not associated with a higher VBAC success rate.

Conclusions: For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.     

A randomized comparative trial of early initiation of oral maternal feeding versus conventional oral feeding after cesarean delivery

Objective

To compare the effects of two maternal feeding policies—early versus conventional oral feeding—after cesarean delivery.

Methods

This prospective multicenter randomized comparative trial was conducted at tertiary care hospitals in Sindh, Pakistan, from 2010 to 2012. Women with an uncomplicated cesarean delivery under spinal anesthesia were allocated to an intervention of early (after 2 hours) or conventional (after 18 hours) initiation of oral feeding. Outcomes included maternal ambulation, maternal satisfaction, gastrointestinal functions, and length of hospital stay.

Results

In total, 1174 women (n = 587 per group) were included in the final analysis. Gastrointestinal complications were not significantly different between the two groups. Lower intensities of thirst and hunger and a higher rate of maternal satisfaction were observed in the early feeding group (P < 0.05), and 53.8% of women in this group were able to ambulate within 15 hours of surgery, compared with 27.9% of women in the conventional feeding group. The frequencies of readmission, febrile morbidity, and wound infection were insignificant.

Conclusion

Early oral dietary initiation after cesarean delivery resulted in early ambulation, greater maternal satisfaction, and reduced length of hospital stay, with no detrimental outcomes, making this practice cost-effective. Hence, day-care cesarean delivery might be an option in resource-constrained settings.Trial Registration number: ChiCTR-TRC-13003651, http://www.chictr.org     

The consequences of previous uterine scar dehiscence and cesarean delivery on subsequent births

Objective

To determine whether women with a previous uterine scar dehiscence are at increased risk of adverse perinatal outcomes in the following delivery.

Methods

A retrospective cohort study was conducted of all subsequent singleton cesarean deliveries performed at the Soroka University Medical Center, Beer-Sheva, Israel, between January 1, 1988, and December 31, 2011. Clinical and demographic characteristics, maternal obstetric complications, and fetal complications were evaluated among women with or without a previous documented uterine scar dehiscence.

Results

Of the 5635 pregnancies associated with at least two previous cesarean deliveries, 180 (3.2%) occurred among women with a previous uterine scar dehiscence. Women with this condition in a prior pregnancy were more likely than those without previous uterine scar dehiscence to experience subsequent preterm delivery (86 [47.8%] vs 1350 [24.7%]; P < 0.001), low birth weight (47 [26.1%] vs 861 [15.8%]; P < 0.001), and peripartum hysterectomy (5 [2.8%] vs 20 [0.4%]; P < 0.001). Nevertheless, previous uterine scar dehiscence did not increase the risk of uterine rupture, placenta accreta, or adverse perinatal outcomes, such as low Apgar scores at 5 minutes and perinatal mortality.

Conclusion

Uterine scar dehiscence in a previous pregnancy is a potential risk factor for preterm delivery, low birth weight, and peripartum hysterectomy in the following pregnancy.     

Trial of labor following one previous cesarean delivery: the effect of gestational age

Purpose

To stratify maternal and neonatal outcomes of trials of labor after previous cesarean delivery (TOLAC) by gestational age.

Methods

Retrospective cohort study of all singleton pregnancies with one previous cesarean delivery in TOLAC at term between 2007 and 2014. We compared outcomes of delivery at an index gestational week, with outcomes of women who remained undelivered at this index gestational week (ongoing pregnancy). Odds ratios and 95% confidence intervals were adjusted for maternal age, previous vaginal delivery, induction of labor, epidural use, presence of meconium, and birth weight > 4000 g.

Results

Overall, 2849 women were eligible for analysis. Of those, 2584 (90.7%) had a successful TOLAC and 16 women (0.56%) had uterine rupture. Those rates did not differ significantly for any gestational age (GA) group. Following adjustment for possible confounders, GA was not found to be independently associated with adverse maternal or neonatal outcomes.

Conclusion

Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.

     

剖宫产术后再次妊娠阴道分娩的安全性及影响因素分析

目的探讨剖宫产术后再次妊娠阴道分娩的安全性及其影响因素。 方法回顾性分析2017年1月至2018年10月在佛山市妇幼保健院住院分娩的剖宫产术后再次妊娠阴道试产孕妇的临床资料。按照是否成功经阴道分娩分成剖宫产后阴道分娩(vaginal birth after cesarean section, VBAC)组和剖宫产后阴道试产(trial of labor after cesarean,TOLAC)失败组,比较VBAC组和TOLAC失败组患者的妊娠结局,采用多因素Logistic回归分析方法分析VBAC的影响因素。 结果(1)2017年1月至2018年10月共纳入TOLAC研究的孕妇共323例,其中VBAC率为80.2%(259/323),TOLAC失败率为19.8%(64/323);子宫破裂发生率为0.62%(2/323),均为TOLAC失败组;两组患者均无子宫切除。(2)VBAC组和TOLAC失败组比较,VBAC组头盆评分(7.77±1.15)分,高于TOLAC失败组(7.16±0.70)分,(t＝4.891,P<0.001);TOLAC失败组产前阴道出血率6.3%(4/64),高于VBAC组1.2%(3/259),P＝0.033;两组的Bishop评分、羊水指数、羊水最深均没有统计学差异(P>0.05)。(3)TOLAC失败组产后出血≥500 ml的比例为51.6%(33/64),高于VBAC组的2.8%(7/259),( χ²＝105.500,P<0.001);TOLAC失败组子宫破裂率3.2%(2/64),高于VBAC组(0/259),( χ²＝8.144,P＝0.017);但两组间产后出血≥1000 ml的比例、输血率没有统计学差异(P>0.05)。(4)VBAC组的分娩孕周、新生儿出生体重、身长、头围和胸围均低于TOLAC失败组,1 min Apgar评分高于TOLAC失败组且具有统计学意义(P<0.05)。(5)多因素分析显示,孕妇的头盆评分(OR＝0.610, 95%CI：0.420～0.887,P＝0.010)、新生儿出生体重3500～3999 g(OR＝4.783, 95%CI：1.431～15.989,P＝0.011)和新生儿出生体重≥4000 g(OR＝16.042, 95%CI：1.306～196.983,P＝0.030)是VBAC的独立影响因素。 结论在严格的纳入排除标准、系统的产前评估和严密的产程管理下,TOLAC是安全可行的,VBAC成功率也较高。多因素分析显示,头盆评分和胎儿出生体重是VBAC的独立影响因素。