Validation of the Grobman model for successful vaginal birth after cesarean section in Jordanian women.

BACKGROUND: To validate both models of Grobman nomogram (The antenatal and the intrapartum model) for predicting successful intended Vaginal Birth After Caesarean delivery (VBAC) in a Jordanian population. METHODS: A retrospective study has identified all live, singleton, term, cephalic pregnancies with a previous lower segment cesarean section who opted for a Trial Of Labour After Caesarean Section (TOLAC) between January 2014 to December 2020. Five variables were used for the antenatal model, while ten variables were used for the intrapartum model. Two sets of patients were created: one for the antenatal model and the other for the intrapartum model. The predicted probability for each woman was calculated and compared with the successful VBAC for each category. The predictive ability was assessed with a receiver operating characteristic, and the area under the curve (AUC) was determined. RESULTS: There were seven hundred and fourteen complete cases for the antenatal model and six hundred ninety-seven for the intrapartum model. Our population's overall number of VBAC is 83.89% for the antenatal group and 82.92% for the intrapartum group. The mean predicted probability for a successful intended VBAC using the antenatal and intrapartum models were 79.53 ± 13.47 and 78.64 ± 14.03, respectively. The antenatal and intrapartum predictive models ROC had an AUC of 65% (95% CI: 60%-71%) and 64% (95% CI: 58%-69%), respectively. CONCLUSIONS: Both models are validated in the Jordanian population. Adapting the antenatal model as supporting evidence can lead to a higher rate of TOLAC.

Outcome of Induction of Labor with Foley's Catheter in Women with Previous One Cesarean Section with Unfavorable Cervix: An Experience From a Tertiary Care Institute in South India.

BACKGROUND: Induction of labor in women with previous cesarean section is associated by the fear of scar rupture, resulting in high rates of repeat scheduled cesarean section. Mechanical methods are being advocated as a safe method. We present our experience of vaginal birth rates and safety profile with single-balloon Foley's catheter for induction of labor in women with previous one cesarean section. METHODS: We studied 96 women admitted in Women and Children Hospital JIPMER, India, with a previous cesarean section at term having unfavorable cervix and undergoing induction of labor. Foley's catheter inflated to 60 ml was used for cervical ripening for 24 h followed by strict oxytocin infusion protocol. RESULTS: The mean Bishop score before induction of labor was 3.3 ± 0.88. Ripening with Foley's catheter resulted in mean improvement in the Bishop score by 2.56 ± 0.67. Forty-seven percent women spontaneously expelled the Foley's catheter, and 53.1% achieved contractions spontaneously. The successful vaginal birth rate was 40%. Emergency caesarean section was more likely in women with poor post ripening Bishop score, meconium stained liquor and abnormal fetal heart rate pattern during labour. There was one scar dehiscence, one neonate with low Apgar score. There was no rupture uterus. CONCLUSION: Induction of labor with Foley's catheter resulted in a 40% successful vaginal birth rate and was found to be safe with only one scar dehiscence and no perinatal or maternal mortality. There was no perinatal or maternal mortality.

Health Care Practitioners' Attitudes and Knowledge Regarding Trial of Labour After Cesarean Delivery (TOLAC): A Survey of Canadian Obstetrical Care Providers.

OBJECTIVES: To understand current attitudes and practice patterns of obstetrical care providers regarding trial of labour after cesarean (TOLAC) and to assess misconceptions regarding eligibility for and risks associated with TOLAC. METHODS: A survey was developed based on published literature, validated by a statistician, and piloted with Canadian obstetricians. French and English versions were distributed via the mailing list of the Society of Obstetricians and Gynaecologists of Canada and social media. Practising obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics and correlational and multiple regression analyses. RESULTS: A total of 381 people responded, with representation from every Canadian province and territory. Obstetrician-gynaecologists (239, 63%), family physicians (100, 26%), and midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although most respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin induction compared with cervical foley or amniotomy (P < 0.001) and offering TOLAC to patients with an unknown uterine scar (P < 0.001). Providers in western Canada reported more comfort offering TOLAC to patients with more than 1 previous cesarean delivery compared with other regions. Two hundred nine participants (62%) reported that they had had at least 1 patient with a uterine rupture, with the minority of cases (13, 6%) resulting in litigation. CONCLUSIONS: This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Efficacy of butorphanol mixed with different doses of hydromorphone in improving PCIA after secondary cesarean section / 中华麻醉学杂志

Objective:To evalaute the efficacy of butorphanol mixed with different doses of hydromorphone in improving patient-controlled intravenous analgesia (PCIA) after secondary cesarean section.Methods:Two hundred American Society of Anesthesiologists physical status Ⅱsingleton pregnant parturients, aged 18-45 yr, at 37-42 week gestation, with body mass index≤30 kg/m 2, undergoing elective secondary cesarean section under combined spinal-epidural anesthesia, were allocated to one of 4 groups ( n=50 each) using a random number table method: butorphanol (group B) and butorphanol mixed with different doses of hydromorphone groups (group BH 1, group BH 2 and group BH 3). Flurbiprofen 50 mg, butorphanol 1 mg and granisetron 3 mg were intravenously injected after delivery during operation.The analgesic pump was connected and turned on at the end of operation.The PCIA solution contained butorphanol 0.24 mg/kg and granisetron 6 mg in group B, butorphanol 0.24 mg/kg and hydromorphone 0.06 mg/kg and granisetron 6 mg in group BH 1, butorphanol 0.24 mg/kg and hydromorphone 0.09 mg/kg and granisetron 6 mg in group BH 2, butorphanol 0.24 mg/kg and hydromorphone 0.12 mg/kg and granisetron 6 mg in group BH 3.The PCIA solution was diluted with normal saline to 150 ml, and the patient-controlled analgesia (PCA) pump was set up to deliver a 3.0 ml bolus dose with a 15-min lockout interval and background infusion at 2.5 ml/h in all the four groups.The degree of pain was evaluated using the VAS score.When the VAS score>5 points after pressuring analgesia pump at rest, flurbiprofen axetil 50 mg was intravenously injected for rescue analgesia.VAS scores during movement, at rest and during uterine contraction and observer′s assessment of alertness/sedation scale score were recorded at 3, 6, 24 and 48 h after operation.The requirement for rescue analgesia, effective pressing times of PCA, overall satisfaction score, OAA/S score<5, adverse reactions and time to the first flatus were recorded within 48 h after operation. Results:Compared with group B, VAS scores in different states were significantly decreased after operation, the effective pressing times of PCA were decreased within 48 h after surgery, and the overall satisfaction score was increased in BH 1, BH 2 and BH 3 groups ( P<0.05). Compared with group BH 1, no significant change was found in VAS score in different states after operation in group BH 2 ( P>0.05), and VAS score was significantly decreased at rest after operation in group BH 3 ( P<0.05). There was no significant difference in VAS scores between group BH 2 and group BH 3 ( P>0.05). There were no significant differences in the requirement for rescue analgesia, effective pressing times of PCA and overall satisfaction of the puerperae among BH 1, BH 2 and BH 3 groups ( P>0.05). There was no significant difference in the time to the first flatus after operation, requirement for rescue analgesia and incidence of observe′s assessment of alterness/sedation scale score<5 and adverse reactions among the four groups ( P>0.05). Conclusions:Compared with butorphanol alone, butorphanol mixed with hydromorphone is helpful in reducing maternal pain and improving the overall satisfaction, with fewer adverse reactions.Butorphanol 0.24 mg/kg mixed with hydromorphone 0.09 mg/kg is recommended.

Cesarean rates according to the Robson classification: analysis in a municipal maternity in São Paulo

ABSTRACT Objective To investigate the distribution of parturients at Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho according to the Robson classification, identify the cesarean rate in each Robson Group, and understand which group contributes more to the prevalence of Cesarean sections. Methods This is a retrospective observational cross-sectional study conducted through the analysis of medical records of parturients admitted to Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho from October 2016 to August 2019. Results A total of 9,794 births were recorded, and 31% were by Cesarean section. The most prevalent Robson Groups were Group 3 (25.7%-2,519), 1 (22.8%-2,234), and 5 (20.5%-2,006). The relative contribution of Cesarean sections was greatest in Groups 5 (39%), 2 (18%), and 1 (12.5%). Conclusion This study demonstrated the Robson classification is useful to lead to a more critical view, identifying the groups that deserve more attention, since they are the major contributors to cesarean rates; hence, the management protocols could be modified aim to reduce cesarean rates.

Revisiting the Care Pathway for Trial of Labour After Cesarean: The Decision-to-Delivery Interval Is Key.

Centres providing maternity care and offering a trial of labour after cesarean must develop and use maternal educational and consent processes that emphasize choice and autonomy related to options for and decisions surrounding vaginal birth after cesarean and elective repeat cesarean delivery. These centres should have administrative systems and processes that take into account local resources for cesarean delivery services, including team-based complex maternity risk support and an urgency consensus on the fetal, maternal, and maternal-fetal indications for a surgical delivery to ensure an appropriate decision-to-delivery interval.

Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle.

OBJECTIVE: To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle-a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). METHODS: A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician-patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. RESULTS: The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. CONCLUSIONS: A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

[Influencing factors and antenatal assessment of the vaginal birth after cesarean section].

Objective: To explore the influencing factors of the vaginal birth after cesarean section (VBAC), and establish a model for predicting the risk of trial of the trial of labor after cesarean section (TOLAC). Methods: From January 2016 to December 2018, total 694 pregnant women who underwent TOLAC in Northwest Women's and Children's Hospital were retrospectively analyzed. Those cases were divided into two groups according to the mode of delivery: the VBAC group and the failed TOLAC group. At the same time, 700 cases in the elective repeat cesarean section (ERCS) group were randomly selected as control group. The influencing factors of VBAC were analyzed by univariate and multivariate logistic regression, and the pregnancy outcomes between the three groups were compared. Results: (1) The VBAC rate was 76.1% (528/694) and 166 women underwent the failed TOLAC (23.9%, 166/694). (2) Univariate analysis found that, the pre-pregnancy body mass index (BMI) [(22.0±3.0), (23.3±2.7) kg/m(2)], the previous vaginal delivery history [10.4%(55/528), 3.6%(6/166)], the cervical score (5.2±1.9,4.3±1.6) and the neonatal birth weight [(3 315±468), (3 484±274) g] of the VBAC group were significantly different from the failed TOLAC group (P<0.05). (3) The comparison of pregnancy outcomes: the neonatal birth weight was (3 315±468) g, and the intrapartum hemorrhage volume was (255±121) ml in the VBAC group, which were significantly lower than those in the failed TOLAC group [intrapartum hemorrhage (325±173) ml] and the ERCS group [(3 572±344) g, (281±125) ml], there were statistically significant differences in the comparison among the three groups (all P<0.05). Two cases of bladder injury occurred during cesarean section in the TOLAC failure group (1.2%,2/166). The rates of the blood transfusion, puerperal infection, 5-minute Apgar score and neonatal ICU admission among the three groups were no statistically significantly different (all P>0.05). There was no maternal or perinatal death. (4) Multivariate logistic regression analysis showed that the delivery age of pregnant women (OR=0.92, 95%CI: 0.87-0.98), pre-pregnancy BMI (OR=0.92, 95%CI:0.86-0.98), vaginal delivery history (OR=3.31, 95%CI: 1.35-8.01), cervical score (OR=1.29, 95%CI: 1.13-1.42) and the birth weight of the neonates <3 300 g (OR=3.15, 95%CI: 2.02-4.90) were independent influencing factors for VBAC. The area under curve of the receiver operating characteristic curve was 0.74. Conclusions: The influencing factors of VBAC are delivery age, pre-pregnancy BMI, vaginal delivery history, cervical score and neonatal birth weight <3 300 g. The adequate individualized management and assessment of the TOLAC may be helpful to improve the VBAC rate.

Effect of the abdominal aortic balloon occlusion applied to caesarean section for pernicious placenta previa and previa accreta / 中国介入影像与治疗学

Objective: To investigate the clinical curative effect of the abdominal aortic balloon occlusion in caesarean section for pernicious placenta previa and previa accreta. Methods: Data of 18 puerperants with pernicious placenta previa and previa accreta who underwent the abdominal aortic balloon occlusion in caesarean section were retrospectively analyzed. The amount of intraoperation blood loss and transfusion, the effective rate of balloon occlusion, the occlusion time, hysterectomy and complications were recorded. Results: All the 18 puerperants underwent the abdominal aortic balloon occlusion in caesarean section successly, with the technical success rate was 100% (18/18). The mean amount of blood loss was (1 276.11±761.59)ml during the caesarean section. And the mean amount of leukoreduced red blood cells transfusion was (2.86±1.51)U. No puerperant was dead of bleeding. The effectiveness of the abdominal aortic balloon occlusion was 100% (18/18), with the occlusion time was (24.06±26.19)min. Four (4/18, 22.2%) puerperants were underwent the hysterectomy due to serious placenta implantation, which even extensively invaded the cervix, bladder and intestine. No serious complications related to the abdominal aortic balloon occlusion and the interventional embolization were occured during the caesarean section. Conclusion: For the puerperants with pernicious placenta previa and previa accreta, the abdominal aortic balloon can effectively block blood flow, reduce the amount of blood loss and transfusion during caesarean section, and reduce the rate of hysterectomy and the risk of the operation.

Influencing factors and antenatal assessment of the vaginal birth after cesarean section / 中华妇产科杂志

Objective To explore the influencing factors of the vaginal birth after cesarean section (VBAC), and establish a model for predicting the risk of trial of the trial of labor after cesarean section (TOLAC). Methods From January 2016 to December 2018, total 694 pregnant women who underwent TOLAC in Northwest Women's and Children's Hospital were retrospectively analyzed. Those cases were divided into two groups according to the mode of delivery: the VBAC group and the failed TOLAC group. At the same time, 700 cases in the elective repeat cesarean section (ERCS) group were randomly selected as control group. The influencing factors of VBAC were analyzed by univariate and multivariate logistic regression, and the pregnancy outcomes between the three groups were compared. Results (1) The VBAC rate was 76.1% (528/694) and 166 women underwent the failed TOLAC (23.9%, 166/694). (2) Univariate analysis found that, the pre-pregnancy body mass index (BMI) [(22.0±3.0),(23.3±2.7) kg/m2], the previous vaginal delivery history [10.4%(55/528),3.6%(6/166)], the cervical score (5.2±1.9,4.3±1.6) and the neonatal birth weight [(3 315 ± 468), (3 484 ± 274) g] of the VBAC group were significantly different from the failed TOLAC group (P<0.05). (3) The comparison of pregnancy outcomes: the neonatal birth weight was (3 315± 468) g, and the intrapartum hemorrhage volume was (255 ± 121) ml in the VBAC group, which were significantly lower than those in the failed TOLAC group [intrapartum hemorrhage (325 ± 173) ml] and the ERCS group [(3 572±344) g, (281±125) ml], there were statistically significant differences in the comparison among the three groups (all P<0.05). Two cases of bladder injury occurred during cesarean section in the TOLAC failure group (1.2%,2/166). The rates of the blood transfusion, puerperal infection, 5-minute Apgar score and neonatal ICU admission among the three groups were no statistically significantly different (all P>0.05). There was no maternal or perinatal death. (4) Multivariate logistic regression analysis showed that the delivery age of pregnant women ( OR=0.92, 95% CI : 0.87-0.98), pre-pregnancy BMI ( OR=0.92, 95% CI :0.86-0.98), vaginal delivery history ( OR=3.31, 95% CI : 1.35-8.01), cervical score ( OR=1.29, 95% CI :1.13-1.42) and the birth weight of the neonates <3 300 g ( OR=3.15, 95% CI : 2.02-4.90) were independent influencing factors for VBAC. The area under curve of the receiver operating characteristic curve was 0.74. Conclusions The influencing factors of VBAC are delivery age, pre-pregnancy BMI, vaginal delivery history, cervical score and neonatal birth weight <3 300 g. The adequate individualized management and assessment of the TOLAC may be helpful to improve the VBAC rate.

The significance of previous uterine scar excision during the second cesarean section on prevention of previous cesarean scar diverticulum by previous uterine scar excision during the second cesarean section / 中国医师进修杂志

Objective To investigate the significance of previous uterine scar excision during the second cesarean section on prevention of previous cesarean scar diverticulum (PCSD). Methods One hundred and seventy-eight cases of multipara women who underwent the second cesarean section were included from January 2012 to January 2017. And they were divided into the control group and the observation group by random digital table, with 89 cases in each group. In the control group, the uterine incision was directly closed by double-layer continuous suture without any treatment to the previous scar, and in the observation group, the previous uterine cesarean scar of the patients were removed, and then the uterine incision was closed by double-layer continuous suture. The surgical related indexes of the two groups were recorded and statistically analyzed. All patients were followed up for 1 year, and the abnormal vaginal bleeding, PCSD, the residual musculocutaneous thickness of diverticulum and the volume of diverticulum were statistically analyzed in those two groups. Results There were no statistical difference between observation group and control group in operation time, intraoperative blood loss, evacuation time, the duration of postoperation bloody lochia and hospitalization time (P>0.05). However, the abnormal vaginal bleeding [5.6% (5/89) vs. 14.6% (13/89)], the incidence of PCSD: 3.4%(3/89) vs. 12.4%(11/89), and the residual musculocutaneous thickness of diverticulum: (7.36 ± 1.66) mm vs. (4.86 ± 1.38) mm, and the volume of diverticulum: (0.37 ± 0.16) ml vs. (0.54 ± 0.15) ml in the observation group were decreased respectively, the differences were statistically significant (P<0.05). Conclusions Excision of previous uterine scar during the second cesarean section is more beneficial for uterine section healing. It will reduce the frequency of PCSD formation, and alleviate the severity of PCSD.

The safety observation of transverse incision of the lower part of the upper uterus in the application of scar uterus / 中国基层医药

Objective@#To investigate the effect of the transverse incision of the lower segment of the upper uterus in the treatment of scar uterine redelivery, and to analyze the safety of the surgical method.@*Methods@#88 patients with scar uterus who received cesarean section were randomly selected as research subjects, aged 24-37 years old, weight 53.3-76.9kg.According to the method of random numbers, they were divided into observation group and the control group, 44 cases in each group.The observation group received transverse incision of the lower segment of the uterus.The control group received conventional cesarean section.The operation time, intraoperative conditions, surgical incision healing, overall hospitalization time and neonatal Apgar score were statistically observed.@*Results@#The intraoperative blood loss of the observation group[(50.1± 3.2) mL]was significantly higher than (48.9±1.7)mL of the control group, and the difference between the two groups was statistically significant(t=2.099, P<0.05). The fetal delivery time, postoperative ventilation time in the observation group were (9.5±3.3)min, (331±97)min, respectively which were significantly shorter than those in the control group, and the differences between the two groups were statistically significant(t=3.018, 4.733, all P<0.05). The neonatal Apgar score of the observation group (9.3±1.2) was significantly higher than (8.8±2.4) of the control group(t=4.800, P<0.05). In the observation group, newborn hypoxia 0 cases, 1 case of aspiration pneumonia, maternal postpartum hemorrhage in 2 cases.There was no statistically significant difference in incidence of complications between the two groups (χ2=1.03, P>0.05). In the observation group, maternal incision healing class A in 40 cases, scar clearly generated in 7 cases, which in the control group were 37 cases, 11 cases, respectively, the difference between the two groups was statistically significant(t=4.200, P<0.05).@*Conclusion@#Transverse incision of the lower segment of the uterus complied with the tension of skin line, is beneficial to maternal postpartum incision healing, and to some extent can relieve pain, promote parturient recovery, further promote the puerpera restoration, significantly improve the clinical outcome of neonatal birth, postoperative complications and reduce cesarean section, it is worthy of clinical promotion.

Study on the way of pregnancy delivery after cesarean section / 中国基层医药

Objective@#To explore the choice of the best mode of delivery after cesarean section.@*Methods@#From January 2015 to December 2016, the clinical data of 2 526 pregnant women admitted in the Eighth People's Hospital of Taiyuan were retrospectively analyzed.A total of 971 cases were cesarean section, among them, the second cesarean section in 367 cases(control group B), cesarean section vaginal delivery in 604 cases(observation group). At the same period, another 186 cases with non-scar uterine pregnancy by vaginal delivery were selected as control group A. The maternal and child outcomes were compared among the three groups.@*Results@#The time of labor, postpartum hemorrhage, hospital stay, the incidence of neonatal asphyxia in the control group A were (6.30±3.03)h, (288.67±220.67)mL, (1.37±0.72)d, 3.76%, respectively, which in the control group B were (6.30±3.03)h, (415.87±356.20)mL, (4.32±0.83)d, 3.54%, respectively, which in the observation group were (5.98±2.87)h, (276.44±211.84)mL, (1.42±0.65)d, 3.48%, respectively.The postpartum hemorrhage of the control group B was significantly higher than that of the observation group[(415.87±356.20)mL vs.(276.44±211.84)mL], the difference was statistically significant(t=11.271, P<0.05). The length of hospital stay of the control group B was also longer than that of the observation group[(4.32±0.83)d vs.(1.42±0.65)d], the difference was statistically significant(t=18.034, P<0.05).@*Conclusion@#In the condition of emergency intercourse with cesarean section, it is safe and feasible to give the vagina trial to the pregnancy of cesarean section which meets the conditions of vaginal delivery.

Secular trends in caesarean section rates over 20 years in a regional obstetric unit in Hong Kong.

INTRODUCTION: Although caesarean section rates have been increasing over the years in both public and private sectors in Hong Kong, there has been a paucity of formal surveys on local trends in such rates. This study aimed to examine the trends in caesarean section rates over a 20-year period at a public regional obstetric unit in Hong Kong using the Robson's Ten-group Classification System. METHODS: All deliveries in a single obstetric unit during a 20-year period (1995-2014) were classified into 10 subgroups according to the Robson's classification. The annual caesarean section rate for each subgroup was calculated and then stratified into 5-year intervals to analyse any significant trends. RESULTS: The caesarean section rates in a total of 86 262 births with complete data were analysed. The overall caesarean section rate increased modestly from 15.4% to 24.6% during the study period. There was an obvious increasing trend for caesarean section in those with previous caesarean section (Robson's category 5), breech presentation at delivery (category 6 and 7), multiple pregnancy (category 8), and preterm labour (category 10). A gradual fall in caesarean section rate from 14.4% to 10.8% was seen in primiparous women with term spontaneous labour (category 1). Statistically significant differences (P<0.001) in these trends were confirmed when the data were stratified into 5-year intervals for comparison. CONCLUSION: The rising caesarean section rate may be associated with clinical management policies that allow women with relative risk factors (such as breech, previous caesarean section, or multiple pregnancy) to opt for caesarean section. This rise was counterbalanced by a decrease in primary caesarean section rate in primiparous women with spontaneous labour. The trend for caesarean section was more in line with patient expectations rather than evidence-based practice.

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.

Effect of Fu Qingzhu's Shenghua decoction on uterine involution after repeat cesarean section / 国际中医中药杂志

Objective To observe the effect of modified Fu Qingzhu's Shenghua decoction on uterine involution after repeat cesarean section.Methods Randomized and parallel design was adopted in the study.A total of 112 cases were recruited into an observation group and a control group.56 cases in the observation group were treated with oral Fu Qingzhu's Shenghua decoction for 5 days,while 56 cases in control group were treated without any herbs.The follow-up was 42 days.Duration of lochia,hemoglobin concentration,and abnormalities of uterine ultrasound were observed.Results Duration of lochia rubra (5.1 ± 1.2 d vs.5.8 ± 1.3 d;t=-2.734,P=0.007) and the duration of lochia rubra and lochia serosa in the observation group 25.0 (21.0,29.8) d vs.29.0 (26.0,33.8) d;Z=3.873,P＜0.001) were all lower than the control group.The lochia complete ration in 42 days (94.9％ vs.82.1％,x2=4.264),the average hemoglobin concentration (115.43 ± 10.68 g/L vs.104.29 ± 9.90 g/L,F=4.159) and sum of the three uterine diameters (14.2 ± 1.0 cm vs.14.8 ± 1.3 cm,t=-2.686,P=0.008) in the observation group were all higher than the control group.The incidence of uterine cavity hydrops (3.57％ vs.17.85％,P=0.015) in the observation group was lower than the control group.Conclusion Fu Qingzhu's Shenghua decoction has promotive effects on uterine involution after repeat cesarean section.

Application of uterine incision suture in multiple segment shrinkage in cesarean section / 中国基层医药

Objective To explore the application value of uterine incision suture in multiple segment shrinkage in cesarean section.Methods 85 pregnants with uterine scar who taken cesarean section were selected.In the single month,the pregnants were included in the observation group(43 cases):after pruning scars,uterine lower segment weak muscle tissue by wrinkling suture to reinforce the thickness of the lower segment again from both sides of the suture,intermediate knotted suture the uterine incision.In the bimonth,the pregnants were included in the control group(42 cases):after pruning scars by conventional suture incision of lower uterine segment.The duration of vaginal bleeding time after operation ,postoperative 42 days ,3 months ultrasonography of uterine incision healing were observed.Results The postoperative vaginal bleeding volume of the observation group was less than that of the control group[(480.55 ±53.75)mL vs.(550.14 ±50.45)mL],the bleeding time was less than that of the control group[(21.31 ±6.78)d vs.(30.45 ±5.16)d],the differences were statistically significant(t =3.65,2.28,all P <0.05).March B -ultrasonography uterine incision after surgery,the good healing rate of the observation group was 95.35%,which of the control group was 78.57%,the difference was statistically significant(χ2 =4.35,P <0.05). Conclusion Incision under section shrinkage joint is conducive to the incision structure and muscle layer mechanical recovery and can reduce the amount of vaginal bleeding and time and defect healing of incision morphology.

Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong.

OBJECTIVES: To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. SETTING: A regional obstetric unit in Hong Kong. PATIENTS: Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. RESULTS: A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. CONCLUSION: Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.

Analysis of the postoperative complications of pregnant women with two caesarean section / 中国基层医药

Objective To investigate the postoperative complications of pregnant women with two cesarean section.Methods Clinical data of 543 cases of pregnant women with two cesarean section (group A) were retrospective analyzed,and at the same period two spontaneous vaginal delivery in 963 cases(group B),225 cases of pregnant women with the first cesarean delivery add second vaginal delivery(group C) were analyed in contrast.The postoperative close,long-term complications of three different delivery way were censused.Results (1) Postoperative complications:141 cases(26％) in group A,29 cases(3％) ingroup B,27 cases (12％)in group C,and three complications occurrence rate had significant difference (x2 =182.711,29.712,43.040,all P ＜ 0.05).(2) The complications of postpartum bleeding,pelvic adhesions in group A were significantly higher than those of C group(all P ＜0.05) ;And the close complications of postpartum hemorrhage,infection of incision,postpartum fever and the long-term complications of chronic pelvic inflammation,pelvic adhesion in group A,C were significantly higher than those in group B (all P ＜ 0.05).Conclusion The cesarean section is traumatic,which can significantly increase maternal intraoperative,postoperative complications.Clinicians should avoid no indications of cesarean section,reduce the cesarean section rate;For secondary pregnancy after cesarean section,vaginal delivery can be given under the strict observation.

Clinical analysis of extraperitoneal cesarean section plus forceps in repeated cesarean section / 中国基层医药

Objective To observe the clinical application of extraperitoneal cesarean section(ECS) plus forceps vs transperitoneal cesarean sections(TCS) in repeated cesarean section.Methods 98 multiparous women with scar uterus for elective repeated cesarean sections were recruited retrospectively,47 cases for ECS plus forceps(group A),and 51 cases for TCS(group B).The multiparous women with hyperglycemia not controlled,severe preeclampsia,heart disease,placenta previa,premature rupture of membrane,a history of ＞ 1 cesarean section,myoma and/or ovarian neoplasm were excluded.Results Skin incision to baby delivery time and total operation time of group A were (7.7 ± 2.8) min and (42.8 ± 9.7) min,respectively,which were significantly shorter than (9.3 ± 3.2) min and (47.6 ± 9.4) min of group B,(t =2.700,2.497,P =0.008,0.014).There was significant difference in blood loss volume during the operation and postoperative 2 hours,which was (310.4 ± 106.3) mL,(365.3 ± 142.8) mL respectively(t =2.142,P =0.035).The Visual Analog Scale for pain (VAS pain) was (2.8 ± 1.8) in group A and (4.1 ± 1.9) in group B,respectively (t =3.252,P =0.002).The gastrointestinal function recovery mean time of group A was significantly shorter than that of group B (12.5 h versus 16.0h,t =2.771,P =0.007).And the postoperative febrile morbidity was significantly lower in group A than in group B(8.5％ versus 25.5％ ;x2 =4.918,P =0.033).The patients with chronic pelvic pain followed up after operation was 3 versus 12,and the difference was significant (x2 =5.143,P =0.026).There were no differences in neonatal Apgar score at 1 minute,birth asphyxia and wound healing rates.Conclusion ECS plus forceps can be safely used for repeated cesarean section,with the advantages of less operation time,less bleeding volume,lower postoperative morbidity,and fewer complications than TCS.