Maternal and neonatal outcomes in the following delivery after previous preterm caesarean breech birth: a national cohort study

Management of Breech Presentation: Green-top Guideline No. 20b.

Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. Cohort study. University Hospital. All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011). Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. Incidence of uterine rupture. Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.

To determine the optimum mode of delivery of the early preterm fetus in breech presentation. Retrospective comparison of two cohorts of preterm breech fetus. Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section. All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded. Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis. There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6-3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation. A policy of caesarean section for early preterm (26-31 weeks) breech delivery is not associated with increased survival without disability or handicap.

Objective. To compare the risk of uterine rupture between a cohort of women with previous low-transverse cesarean section (CS) and a cohort with intact uterus.Methods. All women with a singleton pregnancy and previous low-transverse CS requiring induction of labor from January 1, 1992 to December 30, 2001 (n = 310) were compared with a cohort of women with intact uterus undergoing induction of labor during the same study period (n = 5420). Protocols of induction using prostaglandin E2 gel and oxytocin infusion were consistent within groups, but differed between the previous CS and the intact uterus group.Results. Uterine rupture occurred in 0.3% in the previous CS group vs. 0.03% in the intact uterus group (p = 0.37). Logistic regression analysis showed no significant difference in rate of uterine rupture between the previous CS vs. intact uterus group (p = 0.16) after controlling for maternal age, parity, gestational age at delivery, Bishop score on admission, use of prostaglandin and oxytocin, and birth weight. Our study had adequate power to detect a 0.38% difference in rate of uterine rupture between the two groups (α = 0.05, β = 0.80).Conclusion. Induction of labor is not associated with significantly higher rates of uterine rupture among women with previous low-transverse CS compared with women with intact uterus provided a consistent protocol with strict intervention criteria is adopted.

Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review

To compare the fetal outcome of preterm breech infants delivered vaginally (VD) or by cesarean section (CS). A monocentric, retrospective consecutive case series of preterm breech deliveries between 24-37 gestational weeks over 10 years from 1/2000 to 12/2009 was performed in a perinatal care center (Level 1) at the University Clinic of Salzburg, Austria. Data from hospital database were statistically analyzed and compared regarding birth weight, head circumference, parity, transfer rate to neonatal intensive care unit (NICU), arterial and venous cord blood pH and base excess (BE), arterial cord blood pH ≤ 7.10 and BE ≤ -11. Special focus was on fetal outcome of elective CS preterm breech deliveries with a non-urgent medical indication compared to VD. Among 22.115 deliveries, there were 346 live-born preterm singletons and twins in breech presentation (1.56 %), born between 24 + 0 and 37 + 0 gestational weeks. 180 CS and 36 vaginally delivered preterm breech infants were statistically evaluated. On comparing CS vs. VD for premature breech singletons, arterial cord blood pH and BE were lower in the VD group. VD twins had a lower arterial cord blood pH than CS twins. All other parameters were comparable. In preterm breech singletons with non-urgent CS, a statistical analysis was not possible due to small numbers. The VD twin group revealed lower values in birth weight, head circumference, arterial cord blood pH and BE, but no significant difference in venous cord blood pH and BE and transfer rate to NICU. Although general recommendations regarding a superior mode of delivery for improved fetal outcome of preterm breech infants cannot be given, these data do not support a policy of routine CS.

Guidelines for Vaginal Birth After Previous Caesarean Birth

Guidelines for vaginal birth after previous caesarean birth

Guidelines for Vaginal Birth after Previous Caesarean Birth

Objective: Rates of vaginal breech delivery at term have fallen significantly. We sought to examine rates of preterm vaginal breech delivery and outcomes associated with delivery route.Methods: This retrospective cohort study was carried out at a large tertiary referral center serving an urban population, from 2001 to 2011. The primary objective was to compare outcomes of breech presenting preterm infants according to mode of delivery. The incidence of preterm breech delivery was examined as well as maternal and neonatal outcomes associated with vaginal and abdominal delivery of preterm breech infants.Results: A total of 15% (413/2759) of breech presenting infants delivered prior to 37-week gestation. In extreme prematurity (<28 weeks) the majority (88%; 37/42) of those who presented in labor delivered vaginally, this rate fell to 47% (63/134) after 28 weeks. Infants delivered vaginally after 28 weeks were more likely to have an Apgar <7 at 5 min, than those who had a cesarean delivery (22.5% [16/71] versus 9% [25/278], p = .002; numbers needed to treat (NNT) = 4). Maternal blood loss >500 ml was more likely in those patients delivered by cesarean section (24.2% [74/305] versus 3.7% [4/108]; p < .0001; NNT =2).Conclusion: These results demonstrate that vaginal delivery of a preterm breech – presenting infant is a necessary skill for all birth attendants in contemporary practice, particularly prior to 28-week gestation.

PurposeTo assess the risk factors for adverse outcomes in attempted vaginal preterm breech deliveries.MethodsA retrospective case–control study, including 2312 preterm breech deliveries (24 + 0 to 36 + 6 gestational weeks) from 2004 to 2018 in Finland. The preterm breech fetuses with adverse outcomes born vaginally or by emergency cesarean section were compared with the fetuses without adverse outcomes with the same gestational age. A multivariable logistic regression analysis was used to calculate the risk factors for adverse outcomes (umbilical arterial pH below 7, 5-min Apgar score below 4, intrapartum stillbirth and neonatal death < 28 days of age).ResultsAdverse outcome in vaginal preterm breech delivery was associated with maternal obesity (aOR 32.19, CI 2.97–348.65), smoking (aOR 2.29, CI 1.12–4.72), congenital anomalies (aOR 4.50, 1.56–12.96), preterm premature rupture of membranes (aOR 1.87, CI 1.00–3.49), oligohydramnios (28–32 weeks of gestation: aOR 6.50, CI 2.00–21.11, 33–36 weeks of gestation: aOR 19.06, CI 7.15–50.85), epidural anesthesia in vaginal birth (aOR 2.44, CI 1.19–5.01), and fetal growth below the second standard deviation (28–32 weeks of gestation: aOR 5.89, CI 1.00–34.74, 33–36 weeks of gestation: aOR 12.27, CI 2.81–53.66).ConclusionThe study shows that for each subcategory of preterm birth, there are different risk factors for adverse neonatal outcomes in planned vaginal breech delivery. Due to the extraordinary increased risk of adverse outcomes, we would recommend a planned cesarean section in very preterm breech presentation (28 + 0 to 32 + 6 weeks) with severe maternal obesity, oligohydramnios, or fetal growth restriction and in moderate to late preterm breech presentation (33 + 0 to 36 + 6 weeks) with oligohydramnios or fetal growth restriction.

IntroductionCesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor.Material and MethodsThis retrospective cohort study of the four largest delivery units in Stockholm during 2012–2015 included 1150 women with one previous cesarean section with induction of labor. Inclusion criteria: women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. Primary outcome: mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). Secondary outcomes: induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0.ResultsOur study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64–17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women.ConclusionsOur study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased.

Mortality and morbidity in early preterm breech singletons: impact of a policy of planned vaginal delivery

Rates of Caesarean Section (CS) have been increasing worldwide with varying rates of [5] percent in Sub-Saharan Africa to 43 percent in Latin America and the Caribbean [1]. In Australia too rates have increased from 32 percent in 2011 to 38 percent in 20212. Attempts have been made to seek ways at slowing the rise in rates of CS but with little success [3]. Women who have had a previous CS may elect to have a Elective Repeat CS (ERCS) or have an attempt at a Vaginal Birth (VBAC) in their subsequent pregnancy. A planned VBAC, considering the woman’s individual history and needs, is viewed as a safe option for many women with a single previous lower segment caesarean section [4]. Studies have shown that a Trial of Labour (TOL) ending in a VBAC is most favourable for the mother, newborn, and the health service [5,6]. Likelihood of success rates are reported to be between 60 and 80 percent [7]. A recent meta-analysis [8] noted successful vaginal birth rates of 74.3 percent if labour was spontaneous and 60.7 percent if induced. Achieving successful VBAC has also been reported to be less expensive and more effective than undergoing an ERCS [9,10]. There has recently been an international multi-centre trial that aims to increase the proportion of women having VBAC by increasing woman-centred care and facilitating women’s empowerment in their choice of birth in three countries – Germany, Ireland and Italy [1]. An attempt at vaginal birth is also supported by various colleges across countries [4,7,12]. One of the reasons for the preference of ERCS may be a concern of a failed trial at vaginal birth resulting in an emergency CS. In one study of 29 352 women who attempted a vaginal birth after CS compared to 169 377 women without previous CS, Odds Ratio (OR) for emergency CS was 3.65 (CI: 3.26-4.08) higher when compared to women without previous CS [13]. The scibasejournals.org aim of this retrospective study however was to use a large dataset with a specific objective to report on the success and failure rate and to identify any specific predictors of a successful or an unsuccessful vaginal birth in women who are pregnant after one previous CS.

BackgroundEvidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC.MethodsA comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database’s inception to March 16, 2018. Observational studies, identifying women with a trial of labor after one previous low-transverse cesarean section were included. Two reviewers independently abstracted the data. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale.ResultsWe included 94 eligible observational studies (239,006 pregnant women with 163,502 VBAC). Factors were associated with successful VBAC with the following odds ratios (OR;95%CI): age (0.92;0.86–0.98), obesity (0.50;0.39–0.64), diabetes (0.50;0.42–0.60), hypertensive disorders complicating pregnancy (HDCP) (0.54;0.44–0.67), Bishop score (3.77;2.17–6.53), labor induction (0.58;0.50–0.67), macrosomia (0.56;0.50–0.64), white race (1.39;1.26–1.54), previous vaginal birth before cesarean section (3.14;2.62–3.77), previous VBAC (4.71;4.33–5.12), the indications for the previous cesarean section (cephalopelvic disproportion (0.54;0.36–0.80), dystocia or failure to progress (0.54;0.41–0.70), failed induction (0.56;0.37–0.85), and fetal malpresentation (1.66;1.38–2.01)). Adjusted ORs were similar.ConclusionsDiabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC.