Attempted vaginal birth after cesarean: assessment of morbidity and predictors of success / Parto tras cesárea anterior: análisis de la morbimortalidad materno-fetal

Objective: Determining the appropriate approach for delivery after previous cesarean is a very controversial issue. Our objective was to establish whether pregnant women with a previous cesarean have an increased maternal and fetal morbidity and mortality after attempting vaginal delivery as well as to determine which factors may influence the achievement of a vaginal birth after cesarean. Materials and methods: A retrospective observational cohort study including 390 patients (196 cesarean group and 194 nulliparous group) was carried out. We compared neonatal and maternal outcomes between groups. Afterward, a multivariate logistic regression was applied for our second objective. Results: There were higher rates of uterine rupture (2% vs. 0%, p: 0.045) and puerperal hemorrhage (9.7% vs. 3.1%, p: 0.008) in the cesarean group and lower vaginal delivery rate (58.2% vs. 77.8%, p < 0.0005). We found that the induced onset of labor (OR = 2.9) and new born weight (OR = 1.0001) were associated with an increased risk of cesarean section. Conclusions: Our findings stress the need for further investigations in this field, which might provide a basis for a better management of patients with a previous cesarean.

Objetivo: Determinar el abordaje adecuado del tipo de parto tras una cesárea previa es un tema muy controvertido. Nuestro objetivo fue establecer si las gestantes con cesárea previa presentan mayor morbimortalidad materna y fetal tras intentar parto vaginal, así como determinar qué factores pueden influir en conseguir un parto vaginal posterior a la cesárea. Material y métodos: Estudio observacional de cohortes retrospectivo incluyendo 390 pacientes (196 con cesárea previa, 194 nulíparas). Comparamos los datos sobre los resultados neonatales y maternos. Posteriormente se aplicó un modelo de regresión logística multivariante. Resultados: Hubo mayores tasas de ruptura uterina (2% vs. 0%; p = 0.045) y hemorragia puerperal (9.7% vs. 3.1%, p: 0.008) en el grupo de cesárea anterior, así como una tasa de parto vaginal mas baja (58.2% vs. 77.8%, p < 0.0005). La inducción del parto (OR = 2,9) y el peso del recién nacido (OR = 1.0001) se asociaron a un mayor riesgo de cesárea. Conclusión: La probabilidad de parto vaginal en estas pacientes disminuye cuanto mayor sea el peso del recién nacido y con partos inducidos.

Menor opción de parto en cesáreas repetidas: estudio de caracterización / Minor option for vaginal delivery in repeat cesarean sections: characterization study

Resumen OBJETIVO: Describir las características de las pacientes con cesárea por indicación de cesárea anterior. MATERIALES Y METODOS: Estudio cuantitativo, descriptivo, observacional y retrospectivo llevado a cabo en el Hospital Regional de Medicina Tropical Julio César Demarini Caro, Chanchamayo, Junín, Perú, entre enero de 2020 y junio de 2021. La información se recopiló de las historias clínicas completas y legibles de los sujetos de investigación y se reunió en una base de datos de Excel y se procesó en el programa SPSS versión 25. Se aplicaron estadística descriptiva, medidas de tendencia central y de frecuencias simples. RESULTADOS: La muestra estudiada fue de 200 mujeres que finalizaron el último embarazo por cesárea; la indicación fue, precisamente, cesárea previa. El 40% no tuvo otra indicación secundaria para la cesárea y 19% tuvo como indicación adicional el sufrimiento fetal agudo. Características obstétricas: multíparas (83.5%), con periodo intergenésico adecuado (62.5%), con atención prenatal adecuada (69%), y con pelvis ginecoide (84.5%). Complicaciones de las madres: anemia moderada y severa (64.5%), rotura uterina (10.5%) y atonía uterina (5%). Complicaciones perinatales: Apgar menor a 7 (15%), asfixia neonatal (11%) y síndrome de insuficiencia respiratoria (9%). CONCLUSIONES: Las indicaciones de las cesáreas previas fueron: sufrimiento fetal agudo, desproporción cefalopélvica, trastornos funiculares, trastornos hipertensivos, oligohidramnios severo y distocias de presentación. Las principales complicaciones materno-perinatales fueron: anemia moderada y severa, rotura uterina, atonía uterina, Apgar del recién nacido menor o igual a 7, asfixia neonatal, síndrome de insuficiencia respiratoria y recién nacido prematuro.

Abstract OBJECTIVE: To determine the main characteristics of patients with previous cesarean section. MATERIALS AND METHODS: Quantitative, descriptive, observational and retrospective study carried out at the Regional Hospital of Tropical Medicine Julio César Demarini Caro, Chanchamayo, Junín, Peru, between January 2020 and June 2021. The information was collected from the complete and legible medical records of the research subjects and was collected in an Excel database and processed in SPSS version 25. Descriptive statistics, measures of central tendency and simple frequencies were applied. RESULTS: The sample studied consisted of 200 women whose last gestation was terminated by cesarean section; the indication was, precisely, previous cesarean section. Forty percent had no other secondary indication for cesarean section and 19% had acute fetal distress as an additional indication. Obstetric characteristics: multiparous (83.5%), with adequate inter-gestational period (62.5%), with adequate prenatal care (69%), and with gynecoid pelvis (84.5%). Maternal complications: moderate and severe anemia (64.5%), uterine rupture (10.5%) and uterine atony (5%). Perinatal complications: Apgar less than 7 (15%), neonatal asphyxia (11%) and respiratory failure syndrome (9%). CONCLUSIONS: Indications for previous cesarean sections were acute fetal distress, cephalopelvic disproportion, funicular disorders, hypertensive disorders, severe oligohydramnios and presentation dystocias. The main maternal and perinatal complications were moderate and severe anemia, uterine rupture, uterine atony, newborn Apgar less than 7, neonatal asphyxia, respiratory distress syndrome and premature newborn.

Cesarean-section rates in Brazil from 2014 to 2016: cross-sectional Aanalysis using the robson classification / Taxas de cesariana no Brasil de 2014 a 2016: análise transversal utilizando a classificação de robson

Abstract Objective To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. Methods A descriptive epidemiological study using data from secondary birth records fromthe Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. Results The overall rate of CSwas of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. Conclusion Over half of the births in Brazil were cesarean sections. The Midwest had the highestCS rates,while theNorth had the lowest. The largestobstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

Resumo Objetivo Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. Métodos Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. Resultados Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais forammais frequentes nos grupos 1 (53,6%), 3(80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. Conclusão Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro- Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, amaior contribuição para a taxa geral de cesárea foi do grupo 5.

Uterine Scar Condition and Complications Associated with Repeat Caesarean Section: A study in a Tertiary Care Hospital

Introduction: Lower segment cesarean section is thecommonest surgical procedure in obstetrics. Repeating acesarean section in subsequent pregnancies is the usualmethod of termination which involves many complications.Our objective was to study these complications and difficultiesobserved in a repeat cesarean section.Material and methods: It was a prospective observationalstudy of 241 cases of repeat cesarean section from October2017 to September 2018 in department of obstetrics andgynecology of Hi-Tech medical college and hospital,Bhubaneswar, odisha.Results: In this study, total 1610 patients are taken. Amongthese most common indication for cesarean section is CPDi.e56 (23%).Most common incidence of intraoperativecomplication of previous cesarean section is adhesion i.e.124(51.61%).Conclusion: Maternal morbidity is a cause of concern in repeatcesarean section because of the intraoperative complicationsencountered during surgery and thereafter. Reduction inprimary caesarean rate can reduce the complications. Patientswith previous cesarean section are categorized as high riskand counselled for VBAC in suitable cases.

Assessment of maternal and fetal outcome in trial of labor after cesarean

Background: Nowadays, cesarean sections are increasing consistently. Repeat cesarean sections are performed for a large percentage and associated with a higher rate of surgical complications and Long-term morbidities. The trial of labor after cesarean offers an alternative choice. This study carried out to assess the maternal and fetal outcome and to evaluate various parameters as a predictor of success of TOLAC.Methods: This prospective observational study conducted on 150 pregnant women with one previous LSCS who delivered at Mahatma Gandhi hospital, from January 2017 to July 2018. Patient having a singleton pregnancy, cephalic presentation, adequate pelvis size with spontaneous onset of labor were included. Cases were monitored carefully during the labor. Emergency LSCS was done if any indication appeared.Results: 78% of cases delivered safely by the vaginal birth and 22% of cases had an emergency repeat cesarean section (EmRCS). Favorable Bishop Score, active stage of labor and prior vaginal delivery were associated with higher success rate. One (0.66%) case of uterine scar rupture and 2 (1.33%) cases of scar dehiscence noted. No maternal mortality observed. Perinatal mortality occurred in 2 cases (1.33%).Conclusions: Present study shows that appropriate clinical settings and the properly selected group of patients can make the TOLAC safe and effective.

Validation of a predictive model for successful vaginal birth after cesarean section / Validación de modelos predictivos para parto vaginal exitoso después de cesárea

Abstract Introduction: A strategy for reducing the number of cesarean sections is to allow vaginal delivery after cesarean section. Objective: To validate two predictive models, Metz and Grobman, for successful vaginal delivery after a cesarean section. Methods: Retrospective cohort study involving women with previous history of a previous segmental cesarean section, single pregnancy ≥37 weeks and cephalic presentation. The proportion of vaginal delivery in all pregnant women was determined, and it was compared with those (women) with successful delivery after cesarean section. Then, there were elaborated the models, and their predictive capacity was determined by curve-receiver-operator. Results: The proportion of successful delivery in pregnant women with a previous cesarean section and indication of vaginal delivery was 85.64%. The observed proportion of birth for each decile predicted in the Grobman model was less than 15%, except for the 91-100% decile, where it was 64.09%; the area under the curve was 0.95. For the Metz model, the actual successful delivery rate was lower than predicted in scores between 4 and 14, and within expected for a score between 15 and 23; the area under the curve was 0.94. Conclusions: The vaginal delivery rate after cesarean was lower than expected according to the predictive models of Grobman and Metz. The implementation of these models in a prospective way can lead to a higher rate of successful birth.

Resumen Introducción: Una estrategia de reducción del número de cesáreas es permitir el parto vaginal después de cesárea. Objetivo: Validar dos modelos predictivos, Metz y Grobman, para el parto vaginal exitoso después de una cesárea. Métodos: Estudio de cohorte retrospectivo con mujeres con antecedente de una cesárea segmentaria previa, embarazo único ≥37 semanas y presentación cefálica . Se determinó la proporción de parto vaginal en todas las gestantes y se comparó con aquellas con parto exitoso después de cesárea, se elaboró los modelos y se determinó la capacidad predictiva de ellos mediante curva-receptor-operador. Resultados: La proporción de parto exitoso en gestantes con cesárea previa e indicación de parto vaginal fue 85.64%. La proporción de parto observado para cada decil predicho en el modelo de Grobman fue inferior al 15%, excepto para el decil 91-100%, en el que fue 64.09%, el área bajo la curva fue 0.95. Para el modelo de Metz, la proporción de parto exitoso real fue menor a lo predicho en puntajes entre 4-14 y dentro de lo esperado para puntaje entre 15-23, con un área bajo la curva de 0.94. Conclusiones: La tasa de parto vaginal después de cesárea fue menor a lo esperado de acuerdo a los modelos predictivos de Grobman y Metz. La implementación de estos modelos en forma prospectiva puede llevar una mayor tasa de parto exitoso.

Are cesarean delivery rates and indications changing?

Background: There seems to be gradual raising trend in cesarean deliveries over decades with associated decrease in perinatal mortality rate. This study was undertaken to compare the caesarean delivery (CS) rates along with its indications over the last decade and to examine whether it is changing.Methods: The aim is to compare the rate and indications of CS in a retrospective manner from the data collected between January 1 and December 31 in the year 2006, 2011, and 2016 in a zonal hospital. The rates and indications of CS were analyzed to find whether they are changing if yes which are the factors contributing for the same. Categorical variables were compared using chi-square test.Results: The CS rate showed an increasing trend from 26 % in 2006 to 27.6 % in 2011 to 32.4 % in 2016. Of the total CS, repeat CS rate was significantly increased from 76 (6.61%) in 2006 to 106 (10.34%) in 2011 to 128 (13.72%). Primary CS percent remained more or less same during the study period. Post cesarean pregnancy (p=0.00001) and fetal distress (p=0.012) showed significant rise as an indication for CS which were major contributor for rise in last decade while failed induction decreased.Conclusions: Over the decade there is increase in the total CS rate mainly attributable to repeat CS while post CS pregnancies and foetal distress were leading cause for CS. There is need for reducing primary CS along with increase in trial of labor after cesarean in properly selected women.

Vesicouterine fistula (Youssef syndrome): case report and literature review / Fístula vesico-uterina (síndrome de Youssef): descrição de caso e revisão da literatura

Abstract Objective To describe a case of vesicouterine fistula and to review the literature related to this condition. Methods For the review, we accessed the MEDLINE, BIREME and LILACS databases; the references of the searched articles were also reviewed. Results A 38-year-old woman, in the 1st day after her 3rd cesarean, presented heavy hematuria, which was considered secondary to a difficult dissection of the bladder. A total of 6 months after delivery, she failed to resume her regular menstrual cycles and presented cyclic menouria and amenorrhea. At this time, she had two episodes of urethral obstruction by blood clots. She remained without a correct diagnosis until about two years postdelivery, when a vesicouterine fistula was confirmed through cystoscopy. A surgical correction through open abdominal route, coupled with hysterectomy, was performed. After the surgery, the symptoms disappeared. The review showed a tendency of change in the relative frequency of the different types of genitourinary fistulae. Vesicovaginal fistulae, usually caused by inadequate care during labor, are becoming less frequent than those secondary tomedical procedures, such as vesicouterine fistulae. The most common cause of this latter kind of fistula is cesarean section, especially repeated cesarean sections. The diagnosis is confirmed through one or more imaging exams, or through cystoscopy. The most common treatment is surgical, and the routes are: open abdominal, laparoscopic, vaginal or robotic. There are some reports of success with the conservative treatment. Conclusion Vesicouterine fistulae are becoming more common because of the increase in the performance of cesarean sections, and the condition must be considered a possible complication thereof.

Resumo Objetivo Apresentar um caso de fístula vesico-uterina e realizar revisão da literatura sobre esta condição. Métodos Revisão realizada consultando-se as bases MEDLINE, BIREME e LILACS, além das referências dos artigos consultados. Resultados Uma mulher de 38 anos, após sua terceira cesárea, no puerpério imediato, apresentou hematúria importante, que foi atribuída a uma dificuldade na dissecção da bexiga durante o procedimento. Seis meses pós-parto, emvez de retomar os ciclos menstruais regulares, apresentou menúria cíclica e amenorreia (síndrome de Youssef). A paciente chegou a apresentar obstrução uretral por coágulos, e permaneceu sem diagnóstico correto até cerca de anos pós-parto, quando este foi feito por cistoscopia. Ela foi então submetida a correção cirúrgica por via abdominal, associada a uma histerectomia, com desaparecimento dos sintomas. A revisão mostrou que tem havido mudança na frequência dos vários tipos de fístulas urogenitais. As fístulas vesicovaginais, normalmente secundárias à má assistência durante o parto, têm sido mais raras, enquanto aquelas secundárias a procedimentos médicos, como as vesicouterinas, têm sido mais frequentes. A causa mais comum deste tipo de fístula é a cesárea, especialmente a de repetição. A apresentação pode ser de amenorreia e menúria e/ou perda urinária. O diagnóstico é feito por um ou maismétodos de imagem ou cistoscopia. O tratamento mais comum é cirúrgico, por via abdominal aberta, laparoscópica, transvaginal ou robótica. Existem relatos de cura com tratamento conservador. Conclusão As fístulas vesicouterinas têm sido mais comuns devido ao aumento da proporção de cesáreas. Deve-se ter em mente a possibilidade deste diagnóstico e considerá-las uma das possíveis complicações da cesárea.

Clinical application of meditation training in postoperative rehabilitation of repeat cesarean section patients / 中国实用护理杂志

Objective To study the effect of postoperative rehabilitation of meditation training on repeat cesarean section patients. Methods A total of 86 cases of repeat cesarean section from October 1st, 2014 to October 1st, 2016 were collected. The patients were divided into the observation group (43 cases) and the control group (43 cases) by random digits table method. The observationgroup received meditation therapy by a well-trained nurse based on the routine treatment. The control group was treated with routine treatment. The two groups were compared by postoperative pain score, anxiety and depression scores, the first breastfeeding time, the first urination time and satisfaction. Results After intervention, the postoperative pain visual scores of the observation group and the control group were 3.21 ± 1.51 and 5.41±1.45 respectively, the difference was statistically significant (t=3.817, P6 h/failure:2.32%(1/43). While the data of the control group were 6 h/failure: 13.95%(6/43), the differences were statistically significant (t=6.114, P<0.05). The satisfaction of the observation group and the control group were 98.47% (42/43) and 91.69% (39/43) respectively, the difference was statistically significant. (χ2=7.679, P<0.01). ConclusionsMeditation can effectively reduce the postoperative pain, reduce the incidence of anxiety, shorten the first time of breastfeeding and urination, and improve patients′satisfaction.

Changing trends in Cesarean delivery.

The study conducted in retrospective manner in 150 bedded Government Victoria Hospital Maternity Hospital affiliated to Andhra Medical College, Visakhapatnam, Andhra Pradesh. The rates and indications of primary and repeat Cesarean section rate was compared with 2004 and 2009 Cesarean rates. In our study, the Cesarean section rate was 25.66%. There is an increase in the CS rate over last decade from 16.14% in 2004, 20.33% in 2009 to 25.66% in 2014. The main contribution to this rise in CS is due to increase in numbers of repeat sections. CS become increasingly the procedure of choice in high risk pregnancies to prevent perinatal morbidity and mortality. This has become possible due to improved patient care, availability of effective antibiotics, blood transfusion services safer anesthesia, improved surgical technique and sophisticated neonatal care services.