X-ray Pelvimetry Has No Impact on the Outcomes of Trial of Labor after Cesarean Delivery: A Retrospective Single-center Study.

Few studies have examined the relationship between pelvic size and the success or failure of trial of labor after cesarean delivery (TOLAC). Here we aimed to determine whether pelvic size and morphological data obtained from radiography contribute to the first successful TOLAC. This retrospective single-center observational study enrolled pregnant women who underwent TOLAC between 2010 and 2021. The results of X-ray pelvimetry data, including obstetric conjugate (OC), transverse diameter of the pelvic inlet (TD), anteroposterior diameter of the pelvic inlet (APD), shape of the pelvic inlet, and other obstetrical clinical data, were compared between the success and failure groups. Seventy-five patients in successful group after excluding 35 patients with previous successful TOLAC, and 21 patients in failure group were eligible. The failure group had a higher rate of previous cesarean sections due to failed labor trials (p = 0.042) and heavier newborns (p = 0.014). OC, TD, and APD on X-ray pelvimetry did not differ significantly between the two groups nor did the shape of the pelvic inlet affect the success rate for TOLAC. The generalized linear model identified a history of failed trials of labor as a significant predictor of failed TOLAC (odds ratio, 0.26; 95% confidence interval 0.071-0.923; p = 0.037), whereas no pelvimetric parameters were found. Pelvic size and morphological findings have no discernible impact on the outcomes of TOLAC. The universal application of X-ray pelvimetry in all women attempting TOLAC may not have significant clinical relevance.

The Novel Parallel Closure Technique Compared to Single-Layer Closure of the Uterus After Primary Cesarean Section Decreases the Incidence of Isthmocele Formation and Increases Residual Myometrial Thickness.

Background Isthmocele or a scar defect is a relatively common consequence of cesarean section resulting in menstrual disturbances and infertility and may compromise the myometrial integrity of the uterus in women contemplating subsequent vaginal birth. Several preventive measures have been suggested, including the modification of surgical techniques used for the closure of the uterine incision. The current study aimed to compare the incidence of isthmocele and assess residual myometrial thickness in women who underwent single versus parallel layered closure to approximate the endo-myometrial layer during cesarean section. Methodology This retrospective study evaluated data of women undergoing their first cesarean section under elective conditions (n = 497) where the uterine incision was closed using a single (n = 295) or a parallel layer (n = 202) technique. Patients were evaluated twice, at 3-6 months and 18 months postpartum, with a transvaginal ultrasound noting the presence or absence of an isthmocele and measurement of the residual myometrial thickness. Results Regardless of the closure technique, 64 (12.9%) women had an ultrasound-diagnosed isthmocele. Significantly fewer patients in the parallel-layer closure group presented with an isthmocele both at 3-6 (13.6 vs. 6.9%; p = 0.019) and 18 months (16.3 vs. 7.8%; p = 0.009) postpartum. Residual myometrium was significantly thicker in the parallel-layer closure group (8.0 vs. 13.2 mm at 3-6 months postpartum; p = 0.000 and 7.2 vs. 12.3 mm at 18 months postpartum; p = 0.004). For all patients, a retroverted position of the uterus at 3-6 months follow-up examination significantly increased the frequency of isthmocele (36/395 (9.1%) with an anteverted uterus and 18/102 (17.6%) with a retroverted uterus; p = 0.002). In patients with a single-layer closure, a retroverted uterus at the 3-6-month follow-up was associated with an isthmocele in 29.5% (18/61) of patients, while no isthmocele was recorded when the uterus was retroverted in the parallel-layer closure group (0/41) (p = 0.001). At 18 months postpartum, of the 64 patients with an isthmocele, 26 (40.6%) presented with abnormal uterine bleeding mainly in the form of postmenstrual spotting. Of the 26 patients with abnormal bleeding, 23 were in the single-layer and three were in the parallel-layer closure group. Conclusions The parallel-layer closure when compared to a single-layer closure of the uterine incision in patients undergoing primary cesarean section decreased the incidence of isthmocele formation and increased residual myometrial thickness. More patients in the single-layer closure group had menstrual cycle disturbances at 18 months postpartum.

Induction of labor vs expectant management among low-risk patients with 1 prior cesarean delivery.

BACKGROUND: Studies that have compared induction of labor in individuals with 1 prior cesarean delivery to expectant management have shown conflicting results. OBJECTIVE: To determine the association between clinical outcomes and induction of labor at 39 weeks in a national sample of otherwise low-risk patients with 1 prior cesarean delivery. STUDY DESIGN: This cross-sectional study analyzed 2016 to 2021 US Vital Statistics birth certificate data. Individuals with vertex, singleton pregnancies, and 1 prior cesarean delivery were included. Patients with prior vaginal deliveries, delivery before 39 weeks 0 days or after 42 weeks 6 days of gestation, and medical comorbidities were excluded. The primary exposure of interest was induction of labor at 39 weeks 0 days to 39 weeks 6 days compared to expectant management with delivery from 40 weeks 0 days to 42 weeks 6 days. The primary outcome was vaginal delivery. The main secondary outcomes were separate maternal and neonatal morbidity composites. The maternal morbidity composite included uterine rupture, operative vaginal delivery, peripartum hysterectomy, intensive care unit admission, and transfusion. The neonatal morbidity composite included neonatal intensive care unit admission, Apgar score less than 5 at 5 minutes, immediate ventilation, prolonged ventilation, and seizure or serious neurological dysfunction. Unadjusted and adjusted log binomial regression models accounting for demographic variables and the exposure of interest (induction vs expectant management) were performed. Results are presented as unadjusted and adjusted risk ratios with 95% confidence intervals. RESULTS: From 2016 to 2021, a total of 198,797 individuals with vertex, singleton pregnancies, and 1 prior cesarean were included in the primary analysis. Of these individuals, 25,915 (13.0%) underwent induction of labor from 39 weeks 0 days to 39 weeks 6 days and 172,882 (87.0%) were expectantly managed with deliveries between 40 weeks 0 days and 42 weeks 6 days. In adjusted analyses, patients induced at 39 weeks were more likely to have a vaginal delivery when compared to those expectantly managed (38.0% vs 31.8%; adjusted risk ratio 1.32, 95% confidence interval 1.28, 1.36). Among those who had vaginal deliveries, induction of labor was associated with increased likelihood of operative vaginal delivery (11.1% vs 10.0; adjusted risk ratio 1.15, 95% confidence interval 1.07, 1.24). The maternal morbidity composite occurred in 0.9% of individuals in both the induction and expectant management groups (adjusted risk ratio 0.92, 95% confidence interval 0.79, 1.06). The rates of uterine rupture (0.3%), peripartum hysterectomy (0.04% vs 0.05%), and intensive care unit admission (0.1% vs 0.2%) were all relatively low and did not differ significantly between groups. There was also no significant difference in the neonatal morbidity composite between the induction and expectant management groups (7.3% vs 6.7%; adjusted risk ratio 1.04, 95% confidence interval 0.98, 1.09). CONCLUSION: When compared to expectant management, elective induction of labor at 39 weeks in low-risk patients with 1 prior cesarean delivery was associated with a significantly higher likelihood of vaginal delivery with no difference in composite maternal and neonatal morbidity outcomes. Prospective studies are needed to better elucidate the risks and benefits of induction of labor in this patient population.

Delivery mode after cervical ripening among patients with no prior vaginal births.

PURPOSE: To compare mode of delivery and maternal and neonatal outcomes using cervical ripening balloon (CRB) for induction of labor (IOL) in nulliparous patients vs. those undergoing first trial of labor after cesarean (TOLAC). METHODS: Retrospective cohort study including data from two tertiary medical centers. Included were all patients with a singleton pregnancy and a gestational age > 37+0 weeks and no prior vaginal birth undergoing IOL with CRB. Nulliparous patients (nulliparous group) were compared to patients with one prior cesarean delivery (CD) and no prior vaginal delivery (TOLAC group). Patients who withdrew consent for trial of labor at any time in both groups were excluded. The primary outcome was mode of delivery. RESULTS: Overall, 161 patients were included in the TOLAC group and 1577 in the nulliparous group. The rate of CD was similar in both groups and remained similar after adjusting for confounders (29.8 % vs. 28.9 %, p = 0.86, OR 1.1, 95 %, CI 0.76-1.58). CD due to fetal distress was more common in the TOLAC group (75 % vs. 56 %, p = 0.014). Other maternal outcomes and neonatal outcomes were similar in the two groups. CONCLUSION: Comparable vaginal delivery rates may be achieved in patients with or without a previous CD attempting their first trial of labor, with a cervical ripening balloon for labor induction, without increasing adverse maternal or neonatal outcomes.

External cephalic version following prior cesarean delivery: A comparative cohort analysis.

OBJECTIVE: To analyze the success rate of external cephalic version (ECV) in pregnant women with a history of previous cesarean section, as well as to describe the rate of complications associated with the procedure. METHODS: A retrospective cohort study of women who were offered an ECV at "Virgen de la Arrixaca" Clinic University Hospital (Murcia, Spain) between January 2014 and December 2023. We collected data for previous cesarean delivery, obstetric history, fetal presentation, amniotic fluid volume, ECV success rate, complications related to ECV, mode of delivery, and neonatal outcomes. The study confidently performed ECV under sedation with propofol and tocolysis with ritodrine. Univariate and multivariate analyses were conducted to compare the success rate of ECV, ECV complications, and mode of delivery between women with and without previous cesarean sections. RESULTS: Of 1116 pregnant women who were offered ECV, 911 were included in the study, with 42 having a previous cesarean section. The success rate of ECV in pregnant women with a previous cesarean section was 78.6% (adjusted odds ratio 1.18; 95% confidence interval 0.49-2.86; P = 0.708), with a low complication rate of 9.5%, such as non-reassuring fetal heart rate (7.1%) or major vaginal bleeding (2.4%). Of the women who attempted a vaginal delivery after ECV, 80.8% were successful. CONCLUSIONS: These findings support that ECV is a safe and effective option for women with a previous cesarean section, with success rates comparable to those in women without a previous cesarean section.

Evaluating the performance of an AI-powered VBAC prediction system within a decision-aid birth choice platform for shared decision-making.

Background: Vaginal birth after cesarean (VBAC) is generally regarded as a safe and viable birthing option for most women with prior cesarean delivery. Nonetheless, concerns about heightened risks of adverse maternal and perinatal outcomes have often dissuaded women from considering VBAC. This study aimed to assess the performance of an artificial intelligence (AI)-powered VBAC prediction system integrated into a decision-aid birth choice platform for shared decision-making (SDM). Materials and Methods: Employing a retrospective design, we collected medical records from a regional hospital in northern Taiwan from January 2019 to May 2023. To explore a suitable model for tabular data, we compared two prevailing modeling approaches: tree-based models and logistic regression models. We subjected the tree-based algorithm, CatBoost, to binary classification. Results: Forty pregnant women with 347 records were included. The CatBoost model demonstrated a robust performance, boasting an accuracy rate of 0.91 (95% confidence interval (CI): 0.86-0.94) and an area under the curve of 0.89 (95% CI: 0.86-0.93), surpassing both regression models and other boosting techniques. CatBoost captured the data characteristics on the significant impact of gravidity and the positive influence of previous vaginal birth, reinforcing established clinical guidelines, as substantiated by the SHapley Additive exPlanations analysis. Conclusion: Using AI techniques offers a more accurate assessment of VBAC risks, boosting women's confidence in selecting VBAC as a viable birthing option. The seamless integration of AI prediction systems with SDM platforms holds a promising potential for enhancing the effectiveness of clinical applications in the domain of women's healthcare.

Is vaginal birth after cesarean section a risk factor for obstetric anal sphincter injury?

OBJECTIVE: To investigate whether women undergoing their first vaginal delivery after a previous cesarean section (secundiparous) are at increased risk for obstetric anal sphincter injury (OASI) compared with primiparous women. METHODS: A retrospective cohort study of 85 428 women who delivered vaginally over a 10-year period in a single tertiary medical center. Incidence of OASI, risk factors, and clinical characteristics were compared between primiparous women who delivered vaginally and secundiparous women who underwent their first vaginal birth after cesarean section (VBAC). A multivariable logistic regression analysis was used to study the association between VBAC and OASI. RESULTS: Overall, 36 250 primiparous and 1602 secundiparous women were enrolled, 309 of whom had OASI. The rates of OASI were similar among secundiparous women who had VBAC and primiparous women who underwent vaginal delivery (15 [0.94%] vs 294 [0.81%], P = 0.58). The proportions of third- and fourth-degree tears were also similar among secundiparous and primiparous women who experienced OASI (87% vs 91.5%, and 13% vs 8.5%, respectively, P = 0.68). Furthermore, the rates of OASI were similar in both study groups, although secundiparous women who underwent VBAC had higher rates of birth weights exceeding 3500 g (414 [25.8%] vs 8284 [22.8%], P = 0.016), and higher rates of vacuum-assisted deliveries (338 [21%] vs 6224 [17.2%], P < 0.001). A multivariate logistic regression analysis failed to establish a statistically significant association between VBAC and OASI (odds ratio 0.672, 95% confidence interval 0.281-1.61, P = 0.37). CONCLUSIONS: No increased risk for OASI was found in secundiparous women who underwent VBAC compared with primiparous women at their first vaginal birth.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review.

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

[Usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean: Literature review]. / Utilité de la mesure échographique du segment utérin inférieur avant accouchement parmi les femmes ayant un antécédent de césarienne : revue de la littérature.

Identifying women with a history of cesarean delivery and at real risk for uterine rupture is an important aim in obstetric care. It is with this objective that different authors have evaluated the interest of ultrasound for predicting the risk of a cesarean scar defect by measuring the thickness of the lower uterine segment. The literature is sparse and subject to numerous biases because they are mainly prospective cohort studies with small numbers. However, the results are concordant: Ultrasound measurements of lower uterine segment thickness are strongly correlated with the operative findings observed during cesarean delivery. Moreover, the thinner the lower uterine segment on ultrasound, the higher the likelihood of a uterine defect. Two randomized trials have recently been published. The PRISMA cluster randomized controlled trial evaluated a multifaceted intervention including an ultrasound estimation of the risk of uterine rupture by ultrasound measurement of the lower uterine segment thickness and aimed at helping women in their choice of mode of delivery after a previous cesarean delivery. This multifaceted intervention resulted in a significant reduction in the rates of major perinatal and maternal morbidity, without any increase in the rate of cesarean delivery or uterine rupture. However, due to its design, it is impossible to specifically specify the benefit of lower uterine segment measurement in reducing major maternal and perinatal morbidity since the trial combined several interventions. The LUSTrial randomized controlled trial evaluated the impact on maternal-fetal morbidity and mortality of proposing a mode of delivery based on ultrasound measurement of the lower uterine segment thickness compared to usual care among women with a history of cesarean delivery. Ultrasound measurement of lower uterine segment thickness was not associated with a statistically significant reduction in maternal-fetal morbidity and mortality compared to usual care. In this literature review, we will mainly detail and analyze the results of this trial.

Trial of labor after 2 previous cesareans: a multicenter study.

BACKGROUND: Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than trial of labor after cesarean after 1 previous cesarean delivery. OBJECTIVE: This study aimed to investigate the factors associated with failed trial of labor after cesarean among women with 2 previous cesarean deliveries. STUDY DESIGN: This was a multicenter retrospective cohort study, which included all women with singleton pregnancies attempting trial of labor after cesarean after 2 previous cesarean deliveries between 2003 and 2021. This study compared labor, maternal, and neonatal characteristics between women with failed trial of labor after cesarean and those with successful trial of labor after cesarean. Univariate analysis was initially performed, followed by multivariable analysis (adjusted odds ratios with 95% confidence intervals). RESULTS: The study included a total of 1181 women attempting trial of labor after cesarean after 2 previous cesarean deliveries. Among these cases, vaginal birth after cesarean was achieved in 973 women (82.4%). Women with failed trial of labor after cesarean had higher rates of maternal and neonatal morbidities. Several factors were found to be associated with failed trial of labor after cesarean, including longer interpregnancy and interdelivery intervals, lower gravidity and parity, lower rates of previous successful vaginal delivery, smoking, earlier gestational age at delivery (38.3±2.1 vs 39.5±1.3 weeks), late preterm delivery (34-37 weeks of gestation), lower cervical dilation on admission, no use of epidural, and smaller neonatal birthweight. Our multivariable model revealed that late preterm delivery (adjusted odds ratio, 3.79; 95% confidence interval, 1.37-10.47) and cervical dilation on admission for labor <3 cm (adjusted odds ratio, 2.58; 95% confidence interval, 1.47-4.54) were associated with higher odds of failed trial of labor after cesarean. CONCLUSION: In the investigated population of women with 2 previous cesarean deliveries undergoing trial of labor after cesarean, admission at the late preterm period with a cervical dilation of <3 cm, which reflects the latent phase, may elevate the risk of failed trial of labor after cesarean and a repeated intrapartum cesarean delivery.

Obstetric Violence in Italy: From Theoretical Premises to Court Judgments.

Introduction: Historical mistreatment and violence directed toward women's bodies extend to the field of medicine, and obstetric and gynecological practices are not immune to such misconduct. Obstetric violence (OV) refers to actions involving disrespectful, abusive, or coercive treatment directed at pregnant and birthing women. This includes institutional and personal attitudes that lead to the violation of women's autonomy, human rights, and sexual and reproductive health. Despite various international legislative initiatives and recommendations from the World Health Organization (WHO) addressing disrespectful and abusive treatment, OV is still poorly known to Italian public opinion. This study aims to investigate whether the concept of OV has been conversely assimilated in judicial decisions. Materials and methods: A retrospective analysis was conducted to scrutinize judgments in Italy until June 2023 related to OV. The Italian legal database 'De Jure Giuffrè', which collects sentences by various Courts, and the terms 'obstetric' and 'violence' as keywords were used for the research. Results: The full-text revision of the results (n. 41 sentences) al-lowed the selection of 5 eligible contributions covering the following issues: Informed Consent, Kristeller maneuver, Vaginal Birth After Cesarean (VBAC), Acceleration of childbirth without indication, and Episiotomy. The analysis of individual judgments was complemented by an examination of the key issues involved. Conclusions: The reviewed judgments frequently seemed to be grounded in technical aspects and inclined towards a predominant evaluation of childbirth outcomes. However, some encouraging aspects emerged, particularly in terms of attention to the female body, acknowledgment of consequences within the intimate-relational dimension, and a commitment to the principle of self-determination through the provision of free and informed consent. Ensuring the psychophysical well-being of women and unborn children, fostering positive interactions between pregnant women and medical staff, and actively working to reduce the grounds for litigation are among actual emerging priorities in healthcare. In this sense, fundamental elements include the implementation of continuous staff training and education as well as a focus on promoting the self-determination of women, leveraging new technologies for this purpose, and ensuring legal protection of their rights.

Decision-making experiences and the need for decision aids in women considering vaginal birth after cesarean: A qualitative meta-synthesis.

AIMS: This study aims to comprehensively explore the decision-making requirements of women contemplating vaginal birth after cesarean (VBAC). DESIGN & METHODS: A meta-synthesis approach was employed for this study. Using an integrative methodology, we conducted a systematic assessment of women's experiences and needs related to VBAC decision-making. A comprehensive search was conducted across The Cochrane Library, PubMed, EMBASE, Ovid Medline, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Wan Fang databases to identify pertinent studies between 2000 and 2022. Furthermore, the reference lists of the included studies were thoroughly examined. RESULTS: Fifteen studies were incorporated, from which seven themes emerged: emotional changes, preference for vaginal birth, unmet information needs, influences on decision-making, decision-making autonomy, aligning information provision with decision-support needs, and the requirement for support systems. Two primary syntheses were constructed on the decision-making process and the need for decision-making aids, respectively. CONCLUSION: Women opting for VBAC experienced emotional shifts during their decision-making process in pregnancy. There remains a need for an enhanced decision-making tool to guide them in their choice. Recommendations for implementation in VBAC decision aids include facilitating women's involvement in decision-making, satisfying their information needs, and delivering appropriate emotional support.

The association between obesity and the success of trial of labor after cesarean delivery (TOLAC) in women with past vaginal delivery.

OBJECTIVES: To evaluate the effect of overweight (body mass index; BMI 25.0-29.9 kg/m2), and obesity (BMI>30 kg/m2), on the success of trial of labor after cesarean delivery (TOLAC), with consideration of successful past vaginal birth. METHODS: This retrospective cohort study was performed using electronic database of obstetrics department at a university-affiliated tertiary medical center. All women admitted for TOLAC at 37-42 weeks of gestational age, carrying a singleton live fetus at cephalic presentation, with a single previous low segment transverse cesarean delivery between 1/2015 and 5/2021 were included. Primary outcome was the rate of cesarean delivery during labor, and subgroup analysis was performed for the presence of past vaginal birth. RESULTS: Of the 1200 TOLAC deliveries meeting the inclusion criteria, 61.9 % had BMI in the normal range, 24.6 % were overweight (BMI 25.0-29.9 kg/m2), and 13.4 % were obese (BMI of 30 kg/m2 and over). Using a multivariate analysis, BMI≥30 kg/m2 was associated with increased risk of cesarean delivery compared to normal weight. However, in the subgroup of 292 women with a history of successful vaginal birth BMI did not affect TOLAC success. CONCLUSIONS: BMI does not affect the success of TOLAC in women with previous vaginal birth. This information should be considered during patients counselling, in order to achieve a better selection of mode of delivery and higher patients' satisfaction.

Variations over time in mode of birth and perinatal outcomes in women with one previous cesarean in the Netherlands: A 20-year population-based study.

BACKGROUND: Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second-pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. METHODS: We conducted a nationwide, population-based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). RESULTS: Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. CONCLUSIONS: In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality.

Maternal and perinatal outcomes of women with vaginal birth after cesarean section compared to repeat cesarean birth in select South Asian and Latin American settings of the global network for women's and children's health research.

OBJECTIVE: Our objective was to analyze a prospective population-based registry including five sites in four low- and middle-income countries to observe characteristics associated with vaginal birth after cesarean versus repeat cesarean birth, as well as maternal and newborn outcomes associated with the mode of birth among women with a history of prior cesarean. HYPOTHESIS: Maternal and perinatal outcomes among vaginal birth after cesarean section will be similar to those among recurrent cesarean birth. METHODS: A prospective population-based study, including home and facility births among women enrolled from 2017 to 2020, was performed in communities in Guatemala, India (Belagavi and Nagpur), Pakistan, and Bangladesh. Women were enrolled during pregnancy, and delivery outcome data were collected within 42 days after birth. RESULTS: We analyzed 8267 women with a history of prior cesarean birth; 1389 (16.8%) experienced vaginal birth after cesarean, and 6878 (83.2%) delivered by a repeat cesarean birth. Having a repeat cesarean birth was negatively associated with a need for curettage (ARR 0.12 [0.06, 0.25]) but was positively associated with having a blood transfusion (ARR 3.74 [2.48, 5.63]). Having a repeat cesarean birth was negatively associated with stillbirth (ARR 0.24 [0.15, 0.49]) and, breast-feeding within an hour of birth (ARR 0.39 [0.30, 0.50]), but positively associated with use of antibiotics (ARR 1.51 [1.20, 1.91]). CONCLUSIONS: In select South Asian and Latin American low- and middle-income sites, women with a history of prior cesarean birth were 5 times more likely to deliver by cesarean birth in the hospital setting. Those who delivered vaginally had less complicated pregnancy and labor courses compared to those who delivered by repeat cesarean birth, but they had an increased risk of stillbirth. More large scale studies are needed in Low Income Country settings to give stronger recommendations. TRIAL REGISTRATION: NCT01073475, Registered February 21, 2010, https://clinicaltrials.gov/ct2/show/record/NCT01073475 .

Induction of labor after one previous cesarean: Predictors of vaginal birth.

Objective: To identify independent predictors for vaginal delivery after induction of labor after one cesarean (IOLAC). Study design: In this retrospective cohort study, the electronic medical record of 19064 women who delivered from January 2018-September 2022 in a university hospital in Malaysia were individually searched to identify cases of IOLAC. Preselected data points on characteristics and the outcome of mode of delivery were retrieved. Bivariate analysis was performed to identify predictor characteristics for the dichotomous outcomes of vaginal delivery vs unplanned cesarean delivery. Variables with crude p < 0.05 were incorporated into a multivariable binary logistic regression analysis to identify independent predictors of vaginal delivery after IOLAC. Results: 819 IOLAC cases were identified. There were 465/819 (56.5 %) unplanned cesareans deliveries. Of the 14 selected characteristics, eight had p < 0.05 on bivariate analysis. After adjustment, six characteristics, body mass index, height, ethnicity, parity, previous cesarean indication and Bishop score were independently predictive of vaginal birth but not maternal age or method of labor induction. Birthweight, labor induction indication, gestational age, haemoglobin level, diabetes and hypertension in pregnancy were not significant at the level of bivariate analysis. Conclusion: Obesity, short stature, no prior vaginal delivery, previous cesarean indicated by failure to progress, unfavorable Bishop score and ethnicity were independent predictors for unplanned cesarean after IOLAC. These predictors should help guide women and their care providers in their shared decision-making about IOLAC.

Construction and evaluation of nursing-sensitive quality indicators for vaginal birth after cesarean: A Delphi study based on Chinese population.

Aim: To develop scientific, systematic and clinically applicable nursing-sensitive quality indicators for vaginal birth after cesarean in obstetrics, which provide a theoretical and clinical basis for monitoring and improving the nursing quality of vaginal birth after cesarean in China. Methods: A modified Delphi-consensus technique was used in this study. Based on literature retrieval published between January 2012 and December 2022 and group discussion, the preliminary nursing-sensitive quality indicators were selected using a structural-process-outcome model. Then a questionnaire was designed on the preliminary indicators. The modified Delphi method was used to conduct two rounds of expert consultation among 26 hospitals in China. The survey data of experts' opinions were collected and analyzed to determine the final nursing-sensitive quality indicators. The importance of indicators, rationality of calculation formula and operability of data collection were analyzed and discussed. Results: A total of 33 nursing-sensitive quality indicators were determined. The indicators were composed of 3-level ones, including 3 first-level indicators (structural, process and outcome indicators), 9 s-level ones and 33 third-level ones. The positive coefficients in the two rounds of expert consultation were 95.56 % and 97.67 %, respectively, and the authoritative coefficients were 0.88 and 0.94. The coefficients of variation ranged from 0.05 to 0.28. Conclusion: The nursing-sensitive quality indicators were successfully developed using the modified Delphi method. The indicators are scientific, systematic and clinically operable, and play an important role in improving the nursing quality for pregnant women with vaginal birth after cesarean.

Influence of organizational factors on the offer and success rate of a trial of labor after cesarean section in Belgium: an ecological study.

BACKGROUND: Trial of Labor After Cesarean is an important strategy for reducing the overall rate of cesarean delivery. Offering the option of vaginal delivery to a woman with a history of cesarean section requires the ability to manage a potential uterine rupture quickly and effectively. This requires infrastructure and organization of the maternity unit so that the decision-to-delivery interval is as short as possible when uterine rupture is suspected. We hypothesize that the organizational characteristics of maternity units in Belgium have an impact on their proposal and success rates of trial of labour after cesarean section. METHODS: We collected data on the organizational characteristics of Belgian maternity units using an online questionnaire. Data on the frequency of cesarean section, trial of labor and vaginal birth after cesarean section were obtained from regional perinatal registries. We analyzed the determinants of the proposal and success of trial of labor after cesarean section and report the associations as mean proportions. RESULTS: Of the 101 maternity units contacted, 97 responded to the questionnaire and data from 95 was included in the analysis. Continuous on-site presence of a gynecologist and an anesthetist was associated with a higher proportion of trial of labor after cesarean section, compared to units where staff was on-call from home (51% versus 46%, p = 0.04). There is a non-significant trend towards more trial of labor after cesarean section in units with an operating room in or near the delivery unit and a shorter transfer time, in larger units (> 1500 deliveries/year) and in units with a neonatal intensive care unit. The proposal of trial of labor after cesarean section and its success was negatively correlated to the number of cesarean section in the maternity unit (Spearman' rho = 0.50 and 0.42, p value < 0.001). CONCLUSIONS: Organizational differences in maternity units appear to affect the proposal of trial of labor after cesarean section. Addressing these organizational factors may not be sufficient to change practice, given that general tendency to perform a cesarean section in the maternity unit is the main contributor to the percentage of trial of labor after cesarean.

Trial of labor following cesarean in patients with bicornuate uterus: a multicenter retrospective study.

OBJECTIVE: This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. METHODS: A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. RESULTS: Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. CONCLUSIONS: This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.