Analytical Study on Trial of Scar using Flamm and Geiger Admission Scoring System for VBAC

Introduction: The strength of the uterine scar and its capacityto withstand the stress of subsequent pregnancy and laborcannot be completely assessed or guaranteed in advance.Hence the present study was undertaken to analyse factorsstated by Flamm and Geiger admission scoring system andother plausible factors for successful TOLAC.Material and methods: A total of 265 cases of a previous CSwere selected. Booked cases were regularly followed up inthe antenatal clinic and the unbooked patients, who reporteddirectly for labor, were then assessed for a trial of vaginaldelivery.Result: A total of 265 cases were eligible for trial of scar usingFlamm and Geiger Admission scoring system. 135 had VBACwhereas in 130 cases trial was terminated and had ERCS.Out of 130 ERCS, 73.4% were because of scar tenderness,whereas 16.4% had non reassuring fetal heart rate. Remaininghad unsuccessful progress of labor.Conclusion: Flamm and Geiger admission scoring systemcan be used to successfully predict the likelihood of vaginaldelivery after a trial of scar, thereby reducing maternal andfetal morbidity and rate of caesarean section. Decisionregarding trial should also include factors like eventfulprevious pregnancy, interpregnancy interval, gestational ageand estimated fetal weight. Successful trial can be increasedby regular antenatal visits, general health promotion, earlydetection and management of high risk factors. Adequate interpregnancy interval should be encouraged by promoting andoffering contraception.

Classification of births according to Robson 10 group classification: an emerging concept to audit the increasing caesarean section rate

Background: High caesarean birth rates are an issue of international public health concern. Worries over such increases have led the WHO to advice that caesarean section rate should not be more than 15%. WHO proposes that the health care facilities to use the Robson’s 10 group classification system to audit their CS rates. Our aim was to investigate the CS rates in a period of 6 months using Robso’s 10 group classification.Methods: This was a cross sectional study conducted for a period of 6 months from July 2018 to December 2018 in Department of Obstetrics and Gynecology, Siddhartha medical college which is a tertiary care center .All women delivered during this period in labour ward were included. All relevant obstetric information (parity, mode of previous deliveries, previous CS and indications, gestational age, onset of labor) was entered on a questionnaire and classified into Robson’s 10 classes and percentages were calculated.Results: Total number of deliveries in 6 months is 4719 out of which C-sections are 1816 which accounts for 38.48%. Highest contribution was by group 5 and group 2. Together these two groups contribute to 62.4% of the total caesarean sections. Group 6 and group 9 by themselves did not contribute much but within their groups had 100% C-section rates.Conclusions: Robson’s 10 group classification provides easy way in collecting information about caesarean section rate which obtains good insight into certain birth groups. Number of women who attempt VBAC has declined over recent years due to fear of uterine rupture. Reducing primary C-section rates, adequate counseling and changing norms for non-reassuring fetal status could reduce contribution of Robson’s groups towards absolute C-section rates.

Vaginal birth after cesarean

Background: A heightened awareness must be present among the clinicians while taking the decision to perform the first cesarean section, as it decides the future obstetric career of the women. Because of the rise in cesarean section rate in recent decades, the question of how to manage the subsequent deliveries becomes important. Vaginal birth after cesarean (VBAC) has long been proposed as an alternative measure to reduce repeat cesarean rate. Our present study aims to assess the predictive factors of successful VBAC and study the risks and benefits involved.Methods: A prospective observational study was conducted to assess the success of VBAC and its outcome in GMERS Medical College and Hospital, Ahmedabad. A total of 100 pregnant women with history of previous one cesarean section who fulfilled the criteria for vaginal delivery were recruited for study and the outcome was analyzed.Results: The success rate of VBAC was 58% while failed TOLAC which ended up in emergency repeat cesarean section was 42%. Vaginal delivery either before or after the history of previous cesarean section, neonatal birth weight between 2.5-3kg, and admission during active phase of  labour were associated with successful VBAC. There were 2 cases of partial scar rupture diagnosed peroperatively. The commonest indication of repeat cesarean section was non progress of labour (45.2%) followed by fetal distress (16.7%). The neonatal morbidity rate was similar in both groups due to limited prolonged unsuccessful trial in our study. There was no maternal and neonatal mortality.Conclusions: To reduce the escalating rate of total cesarean section worldwide, VBAC is an alternative option which should be encouraged in carefully selected patients. However, it should be carried out in a well equipped institute with close fetal monitoring and availability of blood and trained personnel. Thus “once a cesarean section, always a hospital delivery” and not, “once a cesarean section, always a cesarean section”.

Perinatal outcome in cases of severe oligohydramnios

Background: Oligohydramnios is defined as when on ultrasonography the single largest pocket in horizontal and vertical diameter is less than 2cm or amniotic fluid index is less than 5cm. Normal amniotic fluid index is 5-25cm. The overall incidence is 0.5 to more than 5%. However, the incidence increases in post dated pregnancies as many as 11%. It is increasing these days because of changes in lifestyle and also reduced maternal fluid intake.Methods: A prospective randomized study was done in Dept of Obstetrics and Gynaecology, MGMMC and MYH, Indore during the period of 6 months from 1st July 2017 to 31st December 2017. It included 200 cases from all the antenatal patients attending Antenatal OPD in routine and emergency and who are admitted in MYH beyond 28 weeks of pregnancy.Results: Most of the perinatal cases nearly 64% of babies were handover, 26% were IUDs (intra uterine devices) and rest 10% requiring neonatal care in nursery. The color Doppler changes showed normal flow in 54% in cases with 26% showing early fetal hypoxia and 14% showing uteroplacental insufficiency. Rest of the 6% cases were IUD. Incidence of IUGR was 50% in babies most commonly being constitutionally small. About 8% cases were found to be associated with abruption and 24% cases were found to be associated with pregnancy induced hypertension. Most common mode of delivery was vaginal delivery in 68% cases. However, 32% cases underwent LSCS.Conclusions: There has been reported cases of sudden IUD in severe oligohydramnios presenting with loss of fetal movements.

Caesarean section audit in a tertiary hospital of North India using Robson’s classification

Background: In view of upsurging Caesarean section (CS) rate worldwide WHO conducted two multicountry surveys to diagnose the driving determinants. In two WHO surveys increased overall CS rate was observed from 26.4% to 31.2% worldwide except Japan. Both WHO 2014 and FIGO 2016 recommend Robson ten- group classification for monitoring caesarean rate over time because of its clarity, tenacity, resilience and pliability. Our Aim is to classify women delivered in our Hospital as per Robson ten –group classification and access the factor driving caesarean rate in each group.Methods: This is a retrospective study 1671 caesarean section conducted in tertiary hospital over 6 months (July- December) 2018. All the delivering women were classified according to Robson ten-group classification and data was analyzed using Microsoft excel and SPSS 23 software.Results: During the study period there were 5917 deliveries. Of these 1671 deliveries were CS accounting for CS rate of 28.24% . The major contributor to CS rate were women in group 5 followed by primigravida’s in group 1 and 2. Increasing  CS rate was observed in group 1 ,2, 3 and 5. Most common indication for caesarean section was fetal distress , failed induction , previous caesarean , breech and Antepartum hemorrhage.Conclusions: Increasing trend in CS rate is observed in group 1,2 ,3 and 5. In order to reduce CS rate among group 2 better patient selection is required for induction of labour based on Bishop score. In order to reduce CS rate in group 5 promotion of  VBAC deliveries should be encouraged. By classifying women according to Robson group 10 classification  helps in identification of women likely to deliver by caesarean  and to identify effective strategies to optimize the CS rate.

Labor patterns in women undergoing vaginal birth after cesarean delivery / 中国实用妇科与产科杂志

OBJECTIVE:To describe labor patterns in women undergoing vaginal birth after cesarean(VBAC)and to ex⁃amine whether the labor pattern differed due to the different time of the previous cesarean.METHODS:In a retrospective observational study at Shengjing Hospital from January 2015 to July 2017,we compared the labor duration of latent、ac⁃tive phase and second stage among 50 women undergoing VBAC,51 nulliparous women and 51 multiparous women. Ac⁃cording to whether they had an elective cesarean(20)or a cesarean after a trial of labor(27)(data of 3 women was not available)in the previous pregnancy,the VBAC women were divided into two groups and compared the labor durations.RESULTS:There was no significant difference in median labor duration of latent phase among the groups(P>0.05). The median length of the active phase was 140,170 and 80 minutes in the VBAC,nulliparous and multiparous groups,re⁃spectively,and the VBAC was significantly longer than the multiparous(P<0.001).The median length of second stage for VBAC was 23 minutes which was significantly shorter than that of nulliparous(38 minutes,P<0.001)and longer than that of multiparous(9 min,P<0.001).Between subgroups within the VBAC according to whether they had an elective cesarean or a cesarean after a trial of labor in the previous pregnancy,there were no significant differences in the median labor duration of each stage.CONCLUSION:The labor patterns of first stage in women undergoing VBAC is similar to that of nulliparous,regardless of the indication for the previous cesarean,and labor curve shows a gradual smooth transition.The labor was faster for VBAC compared to nulliparous women in second stage.These findings on labor progress in VBAC should help obstetricians to manage labor,which improves the success rate of VBAC.

Application of Doula delivery combined with delivery ball midwifery in VBAC patients / 中国实用护理杂志

Objective To discuss the application value of Doula delivery combined with delivery ball (vaginal birth after in cesarean, VBAC) in patients. Methods 80 cases of successful VBAC delivery in our hospital are randomly selected from January to September, 2017 as observation group, with patients who are given Doula delivery combined with delivery ball midwifery and continued monitoring of fetal heart rate; Another 80 cases of successful VBAC delivery in our hospital are randomly selected from January to December, 2016 as comparison group, with patients who are given free position delivery and continued monitoring of fetal heart rate. Results The incidence of gradeⅡpain in the two groups was 81.25% (65/80), which was higher than that of the control group (56.25% (45/80) ); The incidence of gradeⅢ pain was 16.25% (13/80), which was lower than that of the control group(37.50% (30/80) ). The difference between the 2 groups was statistically significant (χ2=11.64, 9.19, P<0.01). In the first stage of labor, the observation group was (290.02 ± 181.41) min, and the control group was (510.15 ± 91.22) min, and the 2 groups were statistically significant (t=-9.696, P<0.01). There was no significant difference in the amount of bleeding, neonatal score and neonatal asphyxia rate at the second, third stage of labor (P>0.05). Conclusions Doula delivery combined with birthing midwifery can be used in the delivery of VBAC. It can relieve pain and shorten the first stage of labor, which is worthy of promotion.

Effective factor of vaginal birth after cesarean / 대한산부인과학회지

OBJECTIVE: The aim of this study is to determine prognostic factor affecting the mode of delivery in women with one previous low transverse cesarean section by comparing success group with failure group in Vaginal birth after cesarean (VBAC). METHODS: In this retrospective study, 79 patients with one previous low transverse cesarean section who attempted vaginal birth at Jeon-Ju Jesus Presbyterian hospital from January 1, 1997 to December 31, 2007. Information was collected and analyzed to see if there is significant difference between success group and failure group in VBAC. and the significance was set at P<0.05. RESULTS: The VBAC success rate turned out to 88.6%. There was one case of uterine rupture which was associated with hypoxic -ischemic encephalopathy in neonate. But, there was no case of the fetal death or mother death. There were significant difference between two groups in gestational age, expected fetal body weight, cervical dilation, Bishop score, thickness of lower uterine segment. CONCLUSION: The prognostic factors on success of VBAC can be aid in deciding the mode of delivery after cesarean section. Patient being chosen under strict indication, can enhance the VBAC trial and success rate.

Effect of weight gain during the pregnancy on success of vaginal birth after cesarean delivery (VBAC) / 대한주산의학회잡지

PURPOSE: To examine the relationship between weight gain and the success of VBAC by using body mass index (BMI). To examine the relationship between weight gain and the success of VBAC by using body mass index (BMI). METHODS: The study compared clinical features taken from 112 patients who tried VBAC at our institute from January 2001 through December 2006. There were divided into two GROUPS: 92 patients for the success (82.1%) and 20 patients for the failure group (17.9%). Excluding 36 patients with no BMI data, we constructed Receive-operating characteristics (ROC) curve to make the optimum BMI value for the prediction of success of VBAC. Based on the BMI 26 or more, two groups of patient were surveyed the interrelation between weight gain and success of VBAC. RESULTS: Between success and failure group, the weight gain during pregnancy showed significant differences which are 11.2+/-4 kg of the success group and 13.2+/-5 kg of the other one (p<0.05) A survey on the availability of the BMI date to estimate success of VBAC, the criteria with the standard BMI 26 is not statistically valuable (p=0.837). By comparing normal weight and overweight based on BMI 26, some factors showed statistically significant discrepancies: number of prenatal visit, maternal weight gain, maternal weight at the time of delivery, use of oxytocin and birth weight. CONCLUSION: BMI value of 26 has limitations in using as an estimate criteria on success of VBAC. Patients, however, who had relatively small scale of weight gain, showed significant clinical factors to increased success rate of VBAC.

Evaluation of the factors affecting the success of the trial of vaginal birth and duration of labor in women with previous cesarean section / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to determine which factors influence the likelihood of successful trial of labor, to evaluate the risks of VBAC and to evaluate the criteria of dystocia and the safety of VBAC. METHODS: This retrospective study was peformed based on 61 pregnant women who succeeded VBAC, 37 VBAC failure women, 100 nulliparas and 100 multiparas. RESULTS: In clinical characteristics, the parity, the number of previous cesarean section, gestational age, estimated fetal body weight by ultrasonography, and neonatal body weight had notable differences between the success and the failure group. In obstetric and historical factors, cervical effacement, dilation, and Bishop score at admission, spontaneous labor and method of induction of labor had differences. Among these factors, estimated fetal body weight by ultrasonography, cervical effacement and augmentation of labor using oxytocin were the most prognostic factors affecting the success of VBAC. In VBAC group, the duration of active-phase, second phase and total duration of labor were 313.5, 36.4 and 350.2 minutes, which were significantly shorter than nulliparas, but longer than multiparas. CONCLUSION: The trial of labor after cesarean section will decrease repeat operation, if it is performed under exact understanding of successful prognostic factors and the unique time length of labor. It will contribute to increase advantages for mother and economic benefits.

A Study of the Causes and the Predictive Factors in Failed Vaginal Birth After Cesarean Section / 대한주산의학회잡지

OBJECTIVE:The purpose of this study was to determine the factors associated with successful vaginal birth after cesarean section (VBAC), and to analyze the causes of failed VBAC. METHODS:This study was performed based on 193 pregnant women who tried vaginal delivery after cesarean section in Chungbuk National University Hospital from January 1997 to December 2005. Maternal age, gestational age, cervical dilatation at admisson, maternal body mass index (BMI), neonatal bodyweight, history of prior vaginal delivery, and indication of prior cesarean section were retrospectively analyzed between the successful group and the failed group of women who tried labor. The causes of the failed trial were analyzed. RESULTS:Seventy nine percent (153/193) was successful in the trial of VBAC and 21% (40/193) failed. There were no difference in maternal age or gestational age between two groups. The success rate was significantly higher when cervical dilatation at admission was more extended, BMI of pregnant women before pregnancy and birth was lower, and birthweight of newborn was lower. Maternal request was the major cause of failure (47.5%), and others were failure to progress, non-reassuring fetal monitoring and failed induction. CONCLUSION:The factors that had significant differences in this study can be used as predictor of successful VBAC. And failed trial of VBAC due to maternal request can be decreased by adequate explanation regarding the complication of emergency operation, and enough pain control during labor.

Two Cases of Vesicouterine Fistula after Delivery in Women with Previous Cesarean Section / 대한산부인과학회지

Vesicouterine fistula, a fistula between bladder and uterus, is one of the rarest urogenital fistula. Most cases are associated with repeat Cesarean section and with vaginal birth after Cesarean section (VBAC). During Cesarean section, it is important to dissect and move the bladder away from uterus carefully, especially in case of adherent bladder to the anterior vaginal wall or lower segment wall and it is necessary to explain the possibility of vesicouterine fistula development in case of VBAC. Patients usually present with urinary incontinence in the early postoperative period or present months or years later with cyclic hematuria, amenorrhea, vaginal leakage of urine, urinary tract infection and secondary infertility. The diagnosis is made by cystoscopic visualization of the fistula orifice in the bladder and outlining the fistula tract on cystogram, hysterosalpingogram or transvaginal ultrasonogram. There have been varied approaches to the treatment of vesicouterine fistula with conservative therapy or surgical therapy. We experienced two cases of vesicouterine fistulas in women with previous Cesarean section, the one is delivered with repeat Cesarean section after trying VBAC, the other is delivered with vacuum assisted VBAC, and treated with surgical repair.

The Impact of Previous Cervical Dilatation on the Duration of Vaginal Birth after Cesarean Delivery / 대한주산의학회잡지

OBJECTIVE: This study examined the effect of a maximal cervical dilatation prior to their primary cesarean birth on the time length of labor in women attempting vaginal birth after cesarean section (VBAC). METHODS: From January 2000 to Jun 2005, a total of 526 patients with VBAC were entered into the study. Patients were classified into 4 groups according to the maximal cervical dilatation on the prior cesarean birth: Group 1 (0~3 cm), Group 2 (4~7 cm), Group 3 (8~9 cm), and Group 4 (10 cm). RESULTS: An analysis of the duration of labor showed that the time length of active phase was significantly shorter in each of Group 3 (147.3+/-103.9 minutes) and 4 (155.2+/-104.2 minutes) than in Group 1 (192.9+/-126.0 minutes) or 2 (195.1+/-148.2 minutes) (p or =8 cm than those without. Study results indicate that prior cervical dilatation may affect the labor time of subsequent VBAC. The proper understanding of the association between prior cervical dilatation and labor time on a subsequent VBAC may be useful for better management or further intervention in the setting of VABC.

The length of active labor in women with vaginal birth after cesarean section compared with nulliparas and multiparas / 대한산부인과학회지

OBJECTIVE: Despite the general information of vaginal birth after cesarean section (VBAC), little is known about the duration of active labor in women attempting VBAC. The aim of this study was to compare the time length of active labor in women attempting VBAC compared with nulliparas or multiparas, and then, provide further insight for better management of labor. METHODS: From January 1999 to December 2003, a total of 444 patients with VBAC were entered into the study. Women with two or more history of caesarean section or previous vaginal delivery were all excluded from the study. Time length of active labor in these patients was compared with 335 nulliparas and 218 multiparas consecutively visiting our unit for delivery in 2003. RESULTS: For patients with VBAC, the duration of active and second phase were 184.8+/-115.7, and 25.1+/-15.2 minutes, which was significantly shorter than nulliparas (p<0.05), but longer than multiparas (p<0.05). To eliminate confounding factors affecting the duration, 374 women without use of vacuum, oxytocin, or epidural anesthesia were selected for analysis. Consistently, the time length of active and second phase in women with VBAC was significantly shorter than in nulliparas, but longer than in multiparas (p<0.001) except for active phase compared with nulliparas (p=0.295). CONCLUSION: With regard to the time length of active labor, women attempting VBAC were in the intermediate group when compared with nulliparas or multiparas. Understanding of this unique time interval in women attempting VBAC may help in allowing an appropriate management for labor process.

A Study of Successful Prognostic Factors in Vaginal Birth after Cesarean Sections / 대한산부인과학회잡지

OBJECTIVE: Recently, with rising rates of repeat cesarean sections, enormous amount of the studies about trial of labor after cesarean section have been reported to decrease the rate of cesarean section. The purpose of this study is to provide data regarding the safety and the successful prognostic factors of VBAC (vaginal birth after cesarean section). METHODS: This retrospective study was performed based on 194 pregnant women who tried vaginal delivery after cesarean section at Eulji University Hospital from March 1997 to February 2002. The age of mother, gestational age, estimated fetal body weight by ultrasonography, neonatal body weight, cervical effacement, cervical dilatation, Bishop score, the number of previous vaginal delivery, and spontaneous labor were analyzed between successful group (177 patients) and failure group (17 patients) with trial of labor. Student T-test and Chi-square test were used for statistical analysis. RESULTS: 177 cases (91.24%) in 194 cases succeeded in VBAC and 17 cases (8.76%) failed. There was no maternal death or uterine rupture in the cases of trial of labor. The gestational age, estimated fetal body weight by ultrasonography, neonatal body weight, cervical effacement, cervical dilatation, Bishop score, the number of previous vaginal delivery, spontaneous labor had notable differences between the successful group and the failure group. But, There was no significant difference in maternal age. CONCLUSION: The trial of labor after cesarean section is relatively safe method of delivery if it is performed under strict indication. Above findings can be used as possible prognostic factors for the success of VBAC and may reduce the risk and complication of VBAC. The following studies with large populations and performed by multi-centers will be needed for the evaluation of safety and successful prognostic factors of VBAC.

Vaginal birth after cesarean section: A 10-years study / 대한산부인과학회잡지

OBJECTIVE: Recently, enormous amount of the studies about trial of labor after cesarean section has been reported to decrease the rate of cesarean section. This study focused on analyzing multiple variables and results to acknowledge the safety and complications of VBAC (vaginal birth after cesarean section). METHODS AND MATERIALS: This study was performed based on 97 pregnant women who were tried vaginal delivery after cesarean section at Hanyang University Hospital from January 1990 to December 1999. The age of mother, gestational age, estimated fetal body weight by ultrasonography, neonatal body weight, cervical dilatation, cervical effacement, Bishop score, the number of previous vaginal delivery, complications of mother, and complications of fetus were analyzed between successful group (82 patients) and failure group (15 patients) with trial of labor. Student T-test and Chi-square test were used for statistical analysis. RESULTS: In the 97 cases with trial of labor after cesarean, the success rate was 84.5% and failure rate was 15.5%. The estimated fetal body weight by ultrasonography, cervical dilatation and effacement, Bishop score, Apgar score had notable differences between successful group and failure group, while the other factors had not. There was no maternal death or uterine rupture in the cases of trial of labor. CONCLUSION: Trial of labor after cesarean section is relatively safe method of delivery if it is performed under strict indication. It could be suggested that VBAC has relatively little complication in both mother and fetus. The studies with large populations and performed by multi-centers will be needed for the evaluating safety of VBAC and developing safe protocols to decrease the risk of complications.

A Clinical Study of Comparison with Success Group and Failure Group in Vaginal Birth after Cesarean Delivery / 대한산부인과학회잡지

OBJECTIVES: Vaginal birth or trial of labor after previous cesarean section has become one of the most remarkable changes in obstetric practice. The safety and efficacy of a trial of labor and vaginal birth after previous cesarean are well documented. The purpose of this report is to predict the likelihood of vaginal birth in patients undergoing a trial of labor after previous cesarean delivery using factors known at the time of hospital admission. METHOD: In this retrospective study, 120 women who attempted vaginal birth at Kyung-Hee University Hospital from March 1997 to March 1999. An attempt to identify possible prognostic factors for success of such a trial was made and we evaluated the variables of significant predictive value and the patients' characteristics in the success group and failure group of women who attempted VBAC. RESULT: 87 cases(72.5%) in 120 cases succeeded in VBAC and 33 cases(27.5%) failed. In this comparative groups in VBAC, there was significant difference in CPD index(cephalopelvic disproportion index) and Bishop score, but no significant difference in gestational age, the estimated fetal weight by sonography and newborn birth weight. CONCLUSION: In this study, Bishop score and CPD index and age may be useful and valid predictor of success in VBAC and this information could be particularly valuable. The CPD index may prove most important in determining if a vaginal birth should occur after a cesarean section because it can clearly identify some patients who need a repeat cesarean section.