Factores predictores del éxito del parto vaginal posterior a cesárea

Objetivo : Determinar los predictores del éxito del parto vaginal posterior a cesárea segmentaria transversal primaria por causa no recurrente. Diseño : Estudio de casos y controles. Institución: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Métodos : Gestantes con inicio espontáneo del trabajo de parto y antecedentes de cesárea con incisión transversal en el segmento inferior por causa no iterativa. La prueba de parto fue considerada exitosa si terminaba en parto vaginal. Principales medidas de estudio : Edad materna, paridad, frecuencia de trabajo de parto previo a la cesárea anterior, edad gestacional al momento del parto, estación de la presentación cefálica fetal al ingreso y peso fetal. Resultados : Se seleccionó 126 gestantes, de las cuales 85 (67,4%) tuvieron pruebas exitosas (parto vaginal), mientras que 41 (32,5%) tuvieron prueba fallida. No se encontraron diferencias en las características generales entre los grupos (p = ns). El análisis univariante mostró que el peso fetal igual o menor de 3,500 gramos, la estación de la presentación cefálica fetal fija o encajada y la edad gestacional menor de 40 semanas fueron predictores significativos del resultado exitoso de la prueba de parto (p < 0,05). El análisis de regresión logística demostró que el peso fetal igual o mayor de 3,500 gramos (p = 0,04) y la estación de la presentación cefálica fetal flotante insinuada (p = 0,03) conservaron importancia como predictores. Conclusión : Los predictores para una prueba exitosa de parto vaginal posterior a cesárea fueron peso fetal menor o igual a 3,500 gramos y la estación de la presentación cefálica fetal fija o encajada.

Objective : To determine predictors of successful vaginal delivery following primary transverse segmental cesarean section for non-recurring cause. Design : Casecontrol study. Institution: Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Methods : Pregnant women with spontaneous onset of labor and history of cesarean section with transverse incision in the lower segment for non-recurrent cause. The trial of labor was considered successful if it ended in vaginal delivery. Main study measures : Maternal age, parity, frequency of labor prior to previous cesarean section, gestational age at delivery, station of fetal cephalic presentation at admission, and fetal weight. Results : A total of 126 pregnant women were selected, of whom 85 (67.4%) had successful trials (vaginal delivery), while 41 (32.5%) had a failed trial. No differences in general characteristics were found between groups (p = ns). Univariate analysis showed that fetal weight equal to or less than 3,500 grams, station of fixed or engaged fetal cephalic presentation, and gestational age less than 40 weeks were significant predictors of successful trial of labor outcome (p < 0.05). Logistic regression analysis showed that fetal weight equal to or greater than 3,500 grams (p = 0.04) and station of floating insinuated fetal cephalic presentation (p = 0.03) retained significance as predictors. Conclusion : Predictors for a successful trial of vaginal delivery following cesarean section were fetal weight less than or equal to 3,500 grams and station of fixed or engaged fetal cephalic presentation.

Study of success rate of vaginal birth after cesarean section in relation to FLAMM score

Background: Globally, there is an increased trend of cesarean section (CS). Repeat CS is associated with various complications. Successful vaginal birth after caesarean section (VBAC) helps to decrease CS rate and its associated morbidities. Practice of protocol of applying FLAMM score and monitoring by partogram reduces the rate of cesarean section in the previous one lower segment cesarean section patient. Aims and Objectives: The present study is conducted to evaluate the impact of FLAMM scoring for vaginal birth after CS on obstetrics and perinatal outcome in case of the previous one lower segment CS delivery. Materials and Methods: The prospective and observational study was conducted in Obstetrics and Gynaecology department of one of the teaching institutes of Ahmedabad over a period of 1 year. Total 100 pregnant women from labour room with history of the previous one CS, who gave consent for trial of labor after the previous cesarean (TOLAC) were selected and FLAMM score applied on them. Study participants were divided in two groups according to outcome. Group A: Successful TOLAC and Group B: Failed TOLAC. Maternal and neonatal outcome was measured in both groups. Results: Out of 98 patients <40 years, 74.48% had VBAC and 25% had failed TOLAC and two patients were >40 years of age had VBAC. Out of 94 patients with favorable FLAMM’s score, 79% (n = 75) had VBAC and 100% (n = 6) with unfavorable FLAMM had CS. Conclusion: Careful patient selection for TOLAC is of utmost priority to increase success rate and decrease complications. FLAMM scoring system is a very efficient guiding tool for this. By applying FLAMM score, we increase success rate of TOLAC and thereby decrease CS rate in case of previous CS.

Establish and application of scoring scale for trial of labor after cesarean section / 中华妇产科杂志

Objective:To establish a scoring scale for trial of labor after cesarean section (TOLAC), to explore the evaluation ability of this scoring scale for vaginal delivery after cesarean section (VBAC), and to improve the success rate of TOLAC.Methods:The delivery information of 661 TOLAC pregnant women admitted to Zhengzhou Central Hospital Affiliated to Zhengzhou University from 2014 to 2017 was retrospectively analyzed, and the TOLAC scoring scale was established by referring to relevant literatures. A prospective cohort study of pregnant women with TOLAC from January 2018 to December 2019 in Zhengzhou Central Hospital was conducted, including 440 pregnant women who were excluded from contraindications in trial labor. According to TOLAC scoring scale, pregnant women were divided into 3 groups, 0-6 group (94 cases), 7-9 group (234 cases) and 10-15 group (112 cases). The success rate of trial labor, failure reasons and incidence of maternal and neonatal complications were compared among the three groups.Results:(1) The overall success rate of TOLAC in 440 pregnant women was 75.0% (330/440). The success rates of 0-6, 7-9 and 10-15 groups were 53.2% (50/94), 76.9% (180/234) and 89.3% (100/112), respectively. The success rate of 10-15 group were significantly higher than those of 0-6 and 7-9 groups (all P<0.05). (2) Among the causes of trial labor failure, there were statistically significant differences between the three groups in terms of threatened uterine rupture and maternal abandonment (all P<0.05). Pairings showed that the incidences of threatened uterine rupture and maternal abandonment in 0-6 group was lower than those in 7-9 and 10-15 groups, and the differences were statistically significant (all P<0.05). (3) Maternal and neonatal complications mainly included postpartum hemorrhage and neonatal asphyxia, but there were no significant difference in the incidence of TOLAC success or failure among the three groups (all P>0.05). There was no uterine rupture in all groups. (4) The main factors affecting TOLAC score of pregnant women in the three groups included natural labor, estimated weight of the fetus at this time, Bishop score of the cervix at admission and gestational age, and the scores of the above indexes in 10-15 group were significantly higher than those in 0-6 group and 7-9 group (all P<0.05). Conclusions:TOLAC scoring scale has more accurate evaluation ability for VBAC, which could improve the success rate of TOLAC and maternal and child safety. The score of 0-6 is not recommended for vaginal trial labor, the score of 7-9 is recommended for vaginal trial labor, and the score of 10-15 is strongly recommended for vaginal trial labor.

Factors associated with failure of trial of labor in primiparae with preeclampsia and establishment of risk prediction model / 中华围产医学杂志

Objective:To investigate the risk factors associated with failure of trial of labor in primiparous women with preeclampsia (PE) and to establish a risk prediction model.Methods:Primiparae with PE who underwent trial of labor in the Department of Obstetrics of Suzhou Ninth People's Hospital from February 2018 to July 2020 were retrospectively selected as the modeling set, and divided into two groups: the success group and the failure group. Various parameters were compared between the two groups and those data with statistically significant difference were analyzed with multivariate logistic regression analysis. Those factors related to vaginal delivery failure in primiparous women with PE were identified. Based on the results, a risk prediction model was established using R language. Its performance was assessed with receiver operating characteristic (ROC) curve and goodness-of-fit test. This study also retrospectively enrolled primiparae with PE who underwent trial of labor in the same hospital from August 2020 to December 2021 as the validation set. Bootstrap method was used for verification and a calibration chart was created.Results:A total of 312 PE patients were selected as the modeling set with 89 in the failure group and 223 in the success group. Another 146 primiparae with PE were selected as the validation set. Logistic regression analysis showed that older age ( OR=1.609, 95% CI: 1.251-2.483), higher body fat rate in early pregnancy ( OR=1.456, 95% CI: 1.209-2.159) and higher ratio of umbilical artery systolic to diastolic flow velocity within a week before delivery ( OR=1.799, 95% CI: 1.372-2.794) were risk factors for vaginal delivery failure in primiparae with PE, while more maternal education during pregnancy ( OR=0.233, 95% CI: 0.054-0.672) and higher Bishop score ( OR=0.395, 95% CI: 0.258-0.756) were protective factors. A nomogram model to predict the risks of vaginal delivery failure was constructed based on the above five factors. The area under the ROC curve (AUC) of the modeling set was 0.921 (95% CI: 0.847-0.963) with the cut-off value of 0.213, and the corresponding sensitivity and specificity were 0.871 and 0.852, respectively;goodness-of-fit test showed that the observed values matched with those expected ( χ2=7.69, P=0.464); and the calibration curve indicated that the consistency of the prediction model was good. The AUC of the validation set was 0.903 (95% CI: 0.835-0.942) with the sensitivity and specificity of 0.892 and 0.796, respectively; the discrepancy between the observed values and those expected was not significant as indicated by goodness-of-fit test ( χ2=6.82, P=0.512); calibration curve of the validation set showed that the predicted values of the model was consistent with the actual values. Conclusions:The failure of vaginal delivery in primiparae with PE is associated with maternal age, prenatal body fat percentage, ratio of fetal umbilical artery systolic to diastolic flow velocity within a week before delivery, maternal education during pregnancy and Bishop score. The nomogram model based on these five risk factors for prediction of vaginal delivery failure performs well.

Assessing Success Of Vaginal Birth After Cesarean By FLAMM Model In A Retrospective Observational Design

Background: After year 2000 cesareanrates have increased from 15% to 30-50% worldwide. Practice of Trial of labor after cesarean has decreased from last two decades of 20thcentury. Predictors of vaginal birth after cesarean are not uniform and not suitable equally for all populations. FLAMM model was tested in this study for its predictability for a successful vaginal birth after previous one cesarean. Material And Methods:For an observational, retrospective study 72 patient files admitted in 2018 in Obstetric Department of C R Gardi Hospital were included which fulfille d criteria of having second pregnancy after cesarean for non recurrent indications like fataldistress, failure of induction of labor, pre-eclampsia, eclampsia, twins and others. Indication of contracted pelvis, rupture uterus, previous classical cesarean section; and multiple pregnancy, medical complications and obstetric complications in this pregnancywere excluded. FLAMM scoreparameters; cervical dilatation, effacement, presence of previous vaginal birth before cesarean, indication of it and age of woman wereused. Observations of successful and failed trial were done by scoring system. Chi square test was used to compare data. Study variables were success of trial in various FLAMM parameters. Result:Higher scores in cervical dilatation (p<0.001), effacement (p<0.001) and prior vaginal delivery (p=0.03) were significantly associated with a successful outcome. Higher theaggregate FLAMM score, higher were chances of successful trial. A non-recurrent indication other than non-progress of labor for previous cesarean had no statistical association with success of trial. Aggregate score of 6 and more has 100 % predictability for a successful vaginal birth. Conclusion:Prediction by FLAMM model resulted in 62. 5%successful trial. FLAMM model maybe used for near to accurate prediction of successful trial of labor after cesarean.

Analysis on the outcome of vaginal trial delivery in singleton full-term pregnancy with low-lying placenta / 中华妇产科杂志

Objective:To analyze the outcome of vaginal trial labor of pregnant women with low-lying placenta detected by translabial ultrasonography, and to explore the influencing factors of vaginal trial delivery and the risk factors of postpartum hemorrhage (PPH).Methods:A total of 80 pregnant women who were diagnosed by translabial ultrasonography with low-lying placenta and underwent vaginal trial delivery in Women′s Hospital, School of Medicine Zhejiang University were collected. Based on the distance of placenta lower edge to cervical internal os (IOD) 1 cm, and the general characteristics and pregnancy outcomes of pregnant women with IOD≤1 cm and 1-2 cm were compared and the related factors of PPH were analyzed by binary logistic regression analysis.Results:Among the 80 pregnant women with low-lying placenta, 41 cases with IOD≤1 cm and 39 cases with IOD 1-2 cm, respectively. The rate of cesarean section in the two groups were 15% (6/41) and 15% (6/39), respectively. The birth weight of newborns were (3 334±360) and (3 460±365) g, respectively. PPH rates were 24% (10/41) and 26% (10/39), respectively, and the differences were not statistically significant (all P>0.05). Among the 80 pregnant women with low-lying placenta, 60 cases did not have PPH, and 20 cases did. The rates of placenta manual removal were 2% (1/60) and 20% (4/20), respectively. The birth weight of newborns were (3 330±368) and (3 591±284) g, respectively. The differences were statistically significant (all P<0.05). Binary logistic regression analysis suggested that placenta manual removal was a risk factor for PPH in pregnant women with low-lying placenta ( OR=30.448, P=0.029). Conclusions:The results of vaginal trial labor in women with IOD≤1 cm and 1-2 cm are comparable, and vaginal trial labor could be attempted in those without contraindications of vaginal delivery. The main adverse complication of vaginal trial labor is PPH, and those with placenta manual removal need to make corresponding plans.

Effectiveness of modified mattress suture closing technique over conventional lower segment caesarean section closing technique

Background: The objective of this study was to compare the thickness of the scar and relative thinning of the uterinewall following conventional LSCS closing technique versus new closing technique (modified mattress Suture) and any additional surgical procedure in each group.Methods: A total of sixty patients undergoing primary caesarean for obstetric indications and who were willing for the study were included. In 30 patients uterus was closed by conventional double layer technique (the first layer is suturing with absorbable suture in a continuous running fashion. After first layer is complete, a second continuous stitch is used to invert the first layer, inverting stitch may be horizontal or vertical using same suturing material) and in 30 patient uterus was closed by new modified mattress technique. In both groups same suture material (vicryl 1-0) was used. Measurement of the thickness of scar site and corresponding posterior wall thickness was done following 6 months of caesarean section.Results: The possible parameters of better technique i.e., the mean scar thickness is more and relative as well as percentage thinning is less with this new technique of uterine closure although statistically not significant. Conclusions: Modified mattress suture technique is a single step procedure and gives the feel of double layer uterine closure. Hence the time taken, material. Used and the cost involved will be less along with excellent hemostasis.

A prospective observational study of role of epidural in trial of labour after cesarean section in view of maternal and neonatal outcome in a tertiary care hospital

Background: In a well-equipped hospital, trial of vaginal delivery is done in selected cases of previous C-section (CS). Epidural analgesia administration has been proved to be good adjunct in trial of labor after caesarean (TOLAC).Methods: This study is a prospective observational study done in a tertiary care institution in Tamil Nadu from May 2019 to July 2019. 50 cases with previous history of one CS were selected. Single ton pregnancy, previous transverse lower segment cesarean section admitted cases with adequate pelvis with no other co-morbidities were selected. Epidural analgesia was administered once mother was in established labor. TOLAC was continued till satisfactory progress and emergency repeat caesarean was taken in case of Suspected scar dehiscence (SSD) or abnormal fetal heart rate tracings. Quantitative data was expressed in mean and standard deviation. For qualitative data percentage was used.Results: In 50 cases observed the mean age of the cases was 26±3.64 years. TOLAC was successful in 41 (82%) mothers out of 50. The mode of delivery in 41 TOLAC mothers was found to be forceps in 18 cases (36%) and ventouse delivery 18 cases (36%). Only 9 cases had needed emergency CS (18%). The major indication for CS in TOLAC was found to be fetal distress in 4 number of cases (8%). 43 babies delivered were healthy, 6 babies (12%) admitted in NICU.Conclusions: With the application of epidural analgesia on attempted vaginal delivery in previous cesarean, vaginal delivery was 82% cases.

A study of correlation of antenatal uterine scar thickness by transabdominal ultrasound with intraoperative lower uterine segment scar grading in elective repeat cesarean delivery

Background: Caesarean section (CS) is the most common obstetric surgery performed world-wide. The objective of this study was to correlate the antenatal sonographic lower uterine segment (LUS) scar thickness in women with previous one cesarean section with intra operative LUS scar grading.Methods: A Prospective observational study was conducted from December 2014 to November 2015. In a tertiary care center. 200 pregnant women from ANC clinic with previous one LSCS were recruited. Transabdominal USG done between 36-38 weeks. LUS thickness was measured from bladder wall-myometrium interphase and myometrium-chorioamniotic membrane inter phase. Intraoperative grading of LUS scar was done. Based on grading of scar participants were assigned into scar dehiscence group (grade III and IV LUS scar) and non-dehiscence group (Grade I and II LUS scar).Results: Mean LUS thickness was 3.41±0.623 mm (range: 2-7 mm). Mean LUS thickness in the scar dehiscence group and non-dehiscence group was 2.98±0.55 mm and 3.48±0.60 mm (P value < 0.05) respectively. A cut off value of 3.5 mm was derived from ROC with sensitivity, specificity, positive and negative predictive value of 92.6%, 54.3%, 24.0%, 97.8%, respectively. The present study reported 27 (13.5%) cases of scar dehiscence.Conclusions: Ultra-sonographic evaluation of LUS thickness correlated significantly with intraoperative LUS appearance. USG evaluation of LUS can be used as a screening test to predict the LUS scar integrity. Risk of dehiscence is increased in women with thin LUS i.e. sonographic LUS thickness of < 3.5 mm and needs to be further evaluated. Women with previous one LSCS with thick LUS i.e. sonographic LUS thickness of > 3.5 mm, can be counselled regarding TOLAC if not contraindicated.

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.

Outcomes of induction in trial of labor after cesarean delivery

Background: The objective of this study is to evaluate the outcomes of induction of labor in women attempting trial of labor after cesarean delivery and to compare maternal and neonatal morbidity and mortality in women who were induced to those delivering spontaneously.Methods: The prospective study was carried out in the Department of Obstetrics and Gynecology in collaboration with the Neonatal Section, Department of Pediatrics at J.N. Medical College and Hospital, AMU Aligarh. The sample included 280 women with one previous cesarean section, of whom 130 women underwent induction of labor (study group) and 150 were admitted with spontaneous onset of labor. Prostaglandin gel and intracervical Foley’s were used for cervical ripening in the study group. Indication of cesarean section, mode of delivery, maternal and neonatal outcome were studied in between groups.Results: Overall rate of vaginal delivery after cesarean section was 45.3% and 56% in both study and control group respectively. The rate of cesarean section were higher in women who were induced and having unfavorable cervix. Maternal and neonatal morbidity were not significantly higher as compared in both groups, however one case of scar rupture was found in study group.Conclusions: Induction of labor in women with previous cesarean section had higher rates of cesarean section however it does not adversely affect neonatal and maternal morbidity. Overall vaginal birth is safe and effective in women with previous cesarean section by prostaglandin gel or intracervical Foley’s. Authors cautiously suggest, induction of labor should be considered in preselected patient with strict monitoring.

Anesthesia for cesarean section after failed labor under combined spinal and epidural analgesia: analysis of 58 cases / 中华围产医学杂志

Objective To summarize the experience in anesthesia management for cesarean section(CS) after failed labor in women with combined spinal and epidural analgesia and to provide evidence for more effective and safer clinical practice.Methods We included 58 singleton pregnant women who received spinal and epidural analgesia during labor but converted to CS at Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from October 2017 to October 2018.When CS was indicated,10 ml of 0.125％ ropivacaine was given through the epidural catheter immediately,and 5 ml of 1％ lidocaine was given when arriving at the operating room.Five minutes later,10 ml of 1％ ropivacaine was administered.General anesthesia would be required when epidural anesthesia was considered to be failed 10 min after the usage of ropivacaine.Clinical datas were retrospectively reviewed.The management and effects of anesthesia for CS,maternal and neonatal outcomes were described.Results Of the 58 patients when CS was indicated during labor,5.2％(3/58) received general anesthesia immediately.Among the other 94.8％ (55/58) who received epidural anesthesia,3.6％(2/55) converted to general anesthesia later.Adverse effects of epidural anesthesia included reduced mean artery pressure (8/53,15.1％),nausea and vomiting (3/53,5.7％).For the neonatal Apgar score at 1 min,one out of the 58 babies (1.7％) was between 0 and 3,ten (17.2％) between 4 and 7,and 47 (81.0％) between 8 and 10.The two babies (3.4％) with Apgar score between 4 and 7 at 5 min were both referred to the department of Neonatology,and the rest 56 neonates (96.6％) scored 8-10.Conclusions Spinal and epidural analgesia in labor can be safely and effectively adjusted to anesthesia for CS.

Ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes based on Robson classifications / 中华妇产科杂志

Objective To investigate the ratio of transfer cesarean section after trial of labor and maternal-fetal outcomes based on Robson classifications.Methods The delivery data by cesarean section in Third Affiliated Hospital of Guangzhou Medical University from January 1st,2009 to December 31st,2015 (gestational age ＞28 weeks and newborn birth weight ＞1 000 g) were retrospectively collected.The ratio of transfer cesarean section after trial of labor and maternal-fetal adverse outcomes were analyzed by weighted adverse outcome score in different Robson classifications.Results (1) The highest ratio of transfer cesarean section after trial of labor was classification 9 (all abnormal lies,including previous cesarean section and breech were excluded) reached 47.31％ (431/911),followed by classification 2 (nulliparous women with a single cephalic pregnancy,＞37 weeks gestation who had labour induced) accounted for 44.90％(409/911).(2)The tops of weighted adverse outcome score of transfer cesarean section after trial of labor were classification 10 (single cephalic pregnancy at ＜37 weeks gestation,including women with previous cesarean delivery) 24.55,classification 5 (single cephalic pregnancy multiparous women,with at least one previous cesarean delivery,＞37weeks gestation) 3.64.Conclusion Carefully evaluating the delivery mode and emphasizing the intrapartum management in nulliparous women with a single cephalic pregnancy,at ＞ 37 weeks gestation who had labour induced and trial of labor after cesarean section is essential to reduce the risk of adverse outcomes in transfer cesarean section after trial of labor.

Effect of induced labor on delivery outcome of pregnant women undergoing vaginal trial of labor after cesarean section / 中华妇产科杂志

Objective@#To explore the effect of induced labor on delivery outcome of pregnant women undergoing vaginal trial of labor after cesarean section.@*Methods@#Totally, 173 pregnant women undergoing vaginal trial of labor after cesarean from April 1st, 2016 to October 31st, 2017 were involved. According to whether or not induced labor, pregnant women were divided into induced labor group (n=47) and natural labor group (n=126). The two groups of the general situation, the situation of delivery and delivery outcome were compared. Further more, the induced labor group were divided into cesarean section patients (n=20) and vaginal delivery patients (n=27) based on pregnancy outcomes, induction situation and delivery situation were analyzed.@*Results@#(1) The gestational weeks was 39.2±1.1 in induced labor group, 38.7±1.0 in natural labor group. The 1-minute Apgar score was 9.98±0.15 in induced labor group, and 9.87±0.60 in natural labor group. The neonatal weight was (3 497±426) g in induced labor group, and (3 288±350) g in natural labor group. The thickness of lower uterine segment at 36-39 weeks of pregnancy was (2.4±0.6) mm in induced labor group, (2.1±0.6) mm in natural labor group. There were obviously differences in the gestational week, the 1-minute Apgar score, the neonatal weight and the thickness of lower uterine segment at 36-39 weeks of pregnancy between the two groups (all P<0.05). There were no significant differences in 5-minute Apgar score, the interval between previous cesarean delivery, postpartum hemorrhage, fetal distress, and intrauterine infection, secondary uterine inertia, placental abruption and uterine ruption between the two groups (all P>0.05). (2) In induced labor group, the cervical score of cesarean section patients was 3.8±1.7, while the cervical score of vaginal delivery patients was 5.2±1.7. The induced labor days of cesarean section patients was (1.6±0.9) days, while the induced labor days of vaginal delivery patients was (1.2±0.4) days. There were obviously differences in the cervical score and the induced labor days among the two subgroup patients (all P<0.05). There were no significiant differences in Apgar score, neonatal weight, the thickness of lower uterine segment at 36-39 gestational weeks and the interval times of previous cesarean delivery between the two subgroup patients (P>0.05).@*Conclusion@#Induction of labor does not reduce neonatal Apgar score, and does not increase the incidence of postpartum complications, and eliminats the increase of cesarean section rate caused by increased gestational weeks and fetal enlargement, and increases the vaginal delivery rate of pregnant women undergoing vaginal trail of labor after cesarean section.

Outcomes of ‘one-day trial of vaginal delivery of twins’ at 36–37 weeks' gestation in Japan

OBJECTIVE: The lack of obstetricians in Japan has prevented the implementation of a 24–hour delivery monitoring system for high-risk deliveries such as twin vaginal delivery at many obstetric facilities. To examine the outcomes of a 1-day trial of the vaginal delivery of twins at 36–37 weeks' gestation. METHODS: We induced the vaginal delivery of twins at 36–37 weeks' gestation of 256 women who provided consent between January 2007 and December 2016 using the following protocol: 1) administration of 0.5 mg oral prostaglandin E2 every 1 hour (maximum: 1.5 mg) in the morning; 2) intravenous administration of oxytocin and amniotomy in the afternoon; and 3) selection of caesarean delivery when vaginal delivery was not expected by evening. We examined their perinatal outcomes in a chart review. RESULTS: The completion rates of vaginal delivery in total, nulliparous, and multiparous women were 79%, 72%, and 84%, respectively. There were no cases of neonatal asphyxia. The total incidence of neonatal respiratory disorders was 2.1%, but there were no cases of persistent pulmonary hypertension. The total incidence of postpartum hemorrhage requiring transfusion was 2.7%. CONCLUSION: The 1-day planned vaginal delivery of twins at 36–37 weeks' gestation appears valid and safe, and our findings suggest that it can be an option for the delivery of twins.

Associated factors and pregnancy outcomes of trial of labor after cesarean: a prospective cohort study / 中华围产医学杂志

Objective To investigate the safety of trial of labor after cesarean (TOLAC) and clinical factors associated with successful TOLAC and to compare TOLAC with elective repeat caesarean section (ERCS) in terms of obstetric and neonatal outcomes.Methods A prospective cohort study was conducted among gravidas who had a history of lower segment cesarean section and were hospitalized in the Department of Obstetrics and Gynecology,the Affiliated Drum Tower Hospital of Medical School of Nanjing University from January to December 2014.Exclusion criteria included indications for caesarean section (such as placenta previa,placenta accreta,twin pregnancy,breech presentation and severe preeclampsia),serious maternal complications after cesarean section,lower uterine segment thinner than 3 mm and poor healing of uterine incision.Totally,287 gravidas were enrolled.Among them,142 chose TOLAC and the other 145 requested ERCS.Clinical data of those gravidas were collected and statistically analyzed by t-test,Log-rank test,Chi-square or Fisher's exact test.Results (1) The success rate of TOLAC was 90.8％ (129/142).There was no significant difference in maternal age,gestational age,thickness of lower uterine segment,interval between the two deliveries and neonatal birth weight and asphyxia rate between the successful (n=129) and unsuccessful (n=13) groups (all P＞0.05).Although the two groups had no significant difference in postpartum hemorrhage (PPH) rate,the gravidas who failed in TOLAC lost more blood than those who succeeded [425 (195-675) vs 200 (50-1 400) ml,P＜0.05].Moreover,higher amniotic fluid contamination rate was observed in the unsuccessful group [6/13 vs 17.1％ (22/129),P＜0.05].In the TOLAC group,99.3％ (141/142) were under continuous fetal heart rate monitoring.Incomplete uterine rupture occurred in one women without serious maternal or neonatal outcomes.The reasons for 13 failed TOLAC cases were unbearable pain during labor,abnormal labor,fetal distress and threatened rupture of uterus.(2) Compared with the ERCS group,the TOLAC group showed shorter interval from last cesarean section to the indexed delivery[5 (2-18) vs 6 (2-19) years],younger maternal age [(31±4) vs (33 ±4) years old] and less blood loss [200 (50-1 400) vs 300 (100-1 500) ml] (all P＜0.05).Conclusion Our study shows that,those who preferred TOLAC were younger,or had shorter pregnancy interval from last cesarean section.The success rate of TOLAC is high for women undergoing systematic prenatal assessment and close management during labor with less blood loss and non-serious maternal and neonatal complications compared with ERCS.

Establishment and evaluation of a standardization management model for pregnant women after caesarean sections / 中国实用护理杂志

Objective To establish a midwife-obstetrician collaboration-based management model for pregnant women after caesarean sections and to evaluate its effectiveness on women′s childbirth outcomes. Methods A panel of experts including obstetricians and midwives was established. A revised management scheme for women after cesarean sections was finally formed through multiple expert consultation method. A historical control method was implemented in our study. Women giving birth before the implementation of collaboration-based management scheme between 2011 and 2013 were recruited in the control group;and women giving birth afterwards between 2014 and 2016 were recruited in the intervention group. Childbirth outcomes such as the mode of delivery, rate of trial of labor after cesarean sections, and vaginal birth rate after cesareans were compared between the two groups. Results A total of 3326 women in intervention group, of those women 281 (8.4%) under trial of labor after cesarean, of the women who under trial of labor 264(94.0%) had successful vaginal birth. A total of 1625 women in control group, of those women 28(1.7%) under trial of labor after cesarean, of the women who under trial of labor 22(78.6%) had successful vaginal birth. The trial of labor after cesarean sections rate and the vaginal birth rate after cesareans rate was significantly higher in intervention group than that in control group (P<0.01). Conclusions The midwife-obstetrician collaboration-based management model can promote vaginal birth for women after cesarean sections, and has no adverse effect on other childbirth outcomes, which is worthy of being implemented more widely in China.

Establishment and evaluation of a standardization management model for pregnant women after caesarean sections / 中国实用护理杂志

Objective To establish a midwife-obstetrician collaboration-based management model for pregnant women after caesarean sections and to evaluate its effectiveness on women′s childbirth outcomes. Methods A panel of experts including obstetricians and midwives was established. A revised management scheme for women after cesarean sections was finally formed through multiple expert consultation method. A historical control method was implemented in our study. Women giving birth before the implementation of collaboration-based management scheme between 2011 and 2013 were recruited in the control group;and women giving birth afterwards between 2014 and 2016 were recruited in the intervention group. Childbirth outcomes such as the mode of delivery, rate of trial of labor after cesarean sections, and vaginal birth rate after cesareans were compared between the two groups. Results A total of 3326 women in intervention group, of those women 281 (8.4%) under trial of labor after cesarean, of the women who under trial of labor 264(94.0%) had successful vaginal birth. A total of 1625 women in control group, of those women 28(1.7%) under trial of labor after cesarean, of the women who under trial of labor 22(78.6%) had successful vaginal birth. The trial of labor after cesarean sections rate and the vaginal birth rate after cesareans rate was significantly higher in intervention group than that in control group (P<0.01). Conclusions The midwife-obstetrician collaboration-based management model can promote vaginal birth for women after cesarean sections, and has no adverse effect on other childbirth outcomes, which is worthy of being implemented more widely in China.

Delivery modes and their influencing factors of pregnant women with previous cesarean section: a retrospective study of 474 gravidas / 中华围产医学杂志

Objective To investigate the safety of vaginal delivery in gravidas with previous cesarean section and its influencing factors.Methods Four hundred and seventy-four full-term gravidas who received cesarean section at the Department of Obstetrics and Gynecology of Peking University First Hospital from January 1,2012 to August 31,2014 were enrolled in this study.Among those subjects,38 who underwent successful vaginal delivery were grouped into vaginal birth after cesarean (VBAC) group,and the other 436 accepting repeated cesarean section were grouped into cesarean group.Delivery outcomes and maternal/neonatal complications of the two groups were retrospectively analyzed with two-sample t-test and Chi-square test.Results Among the 45 patients (9.5％) who attempted VBAC,seven underwent cesarean section for suspected fetal distress and the other 38 (84.4％) succeeded in vaginal birth without uterine rupture.The amount of postpartum hemorrhage in patients of cesarean group was more than that of VBAC group [(330.8±94.8) vs (257.7± 199.7) ml,t=2.021,P＜0.01] after exclusion of three patients with dangerous placenta previa,and the postpartum hospital stay was shorter than that of cesarean group [(2.5± 1.4) vs (4.5± 1.3) d,t=7.952,P＜0.01].There were three newborns with neonatal asphyxia,twelve with neonatal infections and forty transferred to the Pediatrics Department following cesarean section.Besides,complications of headache and urinary retention occurred in 20 and 32 mothers after cesarean section,respectively.However,no complication occurred in VBAC group.Sixty-three cesarean sections were indicated as thin lower uterine segment and among them,fourteen (22.2％) had muscular rupture.Among the six patients who complained of tenderness in lower uterine segment,three were found having muscular rupture during cesarean section.Conclusion VBAC is an option for gravidas with history of cesarean section only if they meet the criteria for VBAC attempt.VBAC could lower the cesarean section rate without increase the incidence of complications.The rate of trial of labor after cesarean was low,patients education should be strengthened to increase it.