Trial of labor after cesarean delivery in grand multiparous women: maternal and neonatal outcomes

To determine the rate, delivery outcome and safety of attempted vaginal birth after cesarean section (VBAC) in grand multiparous women (para 6 or more). This is a retrospective case-control study, performed at King Abdulaziz university hospital, the charts of 405 grand multiparous women with previous caesarean section were reviewed to determine rate and delivery outcome of attempted VBAC. The outcome of 217 VBAC in grand multiparous women was compared to the outcome of 217 VBAC in multiparous women (para 2-5) during the same period. The rate of VBAC in grand multiparous women was 53.6%. One hundred-seventy five (80.7%) grand multiparous women were delivered vaginally compared to 170 (78.3%) in multiparous women, this was not statistically significant difference. Sixteen (7.4%) grand multiparous women need labor augmentation with oxytocin, while 34 (16%) in multiparous women, this was statistically significant difference (P value 0.005). The labor duration was 6.4+/-3.5 h in grand multiparous women compared to 9.0+/-4.3 h in multiparous women, and was also statistically significant difference (P value 0.001). The fetal weight, Apgar scores, postpartum hemorrhage, fever and number of hospital days in the two groups, were not statistically significant differences. In the control multiparous women there was one uterine rupture, two uterine dehiscence, and one stillbirth due to placental abruption. VBAC in grand multiparous women is common practice, safe and efficacious. High parity in association with vaginal deliveries is good prognostic factor and also can predict successful VBAC outcome. However, further studies are needed to confirm our findings.

Caesarean delivery: truths and consequences.

973: Trial of labor after a previous single cesarean delivery in grand multiparous women

The use of a strict protocol in the trial of labor following two previous cesarean deliveries: Maternal and neonatal results

Grand multiparous women in poor and under-privileged settings run a high risk of uterine rupture at labor induction. The purpose was to elucidate whether vaginal misoprostol medication is a safe and cost-effective alternative induction method in grand multiparous women, in whom, under prevailing circumstances, induction by oxytocin is associated with high risk of adverse maternal outcome of pregnancy. One hundred and sixty-five grand multiparous parturient women with five or more previous deliveries were divided into two groups. The first group (n=134) had the fetus alive and the second (n=31) had late intrauterine fetal death. Both groups were subject to induction of labor by use of vaginal misoprostol in a dose of 50 microg (live fetus) and 100 microg (intrauterine fetal death). No additional oxytocin was utilised. Labor induction by vaginal misoprostol was successful in grand multiparous women. The proportion of women requiring a Cesarean section was 6.0%, which is less than one third of the average Cesarean section rate in the setting studied. Women with fetus alive had significantly shorter application-to-expulsion interval (AEI) than women with fetal death (10.1 versus 15.4 hours; p=0.039). Significantly shorter AEI was recorded in women with prelabor rupture of membranes (9.1 hours) than in women with intact membranes (12.9 hours) (p=0.01). With Bishop's score > or = 5 and < 5 AEI was 8.7 hours and 14.4 hours, respectively (p=0.001). No significantly adverse neonatal or maternal outcomes of pregnancy were registered and it was specifically noted that no uterine rupture occurred among the 165 grand multiparous women induced. Induction of under-privileged grand multiparous women with live fetus or with fetal death can be performed safely and cost-effectively by vaginal misoprostol.

Vaginal Birth After Caesarean Section in Grand Multiparous Women

Caesarean sections constitute major surgery, and are associated with immediate maternal and perinatal risks with implications on future pregnancies. After a caesarean delivery, the World Health Organization (WHO) recommends an Inter-pregnancy Interval (IPI) of at least 24 months to lower the risk of adverse maternal and perinatal outcomes in the subsequent pregnancy. However, whether the recommendation confers obstetric benefits is unclear as there’s paucity of data in low- and medium-income countries (LMIC). The objective was to determine the association between IPI length and maternal and neonatal outcomes in women with one previous caesarian section undergoing a repeat caesarian delivery at term in Pumwani Maternity Hospital between 1st January 2014 and 31st December 2018. A cross-sectional study was done where patients who had delivered via repeat caesarean section at term between 1st January 2014 and 31st December 2018 were evaluated. The files of 625 patients were retrieved and IPI was determined from the time interval between a previous caesarean section delivery and the beginning of the subsequent pregnancy, established from the date of the last normal menstrual period as recorded or extrapolated from an early trimester obstetric scan. The files were allotted to study groups as follows: = 170), 24 - 29 months/intermediate IPI (n = 384), and 60+ months/long IPI (n = 121) and data on sociodemographic/reproductive characteristics and maternal and neonatal outcomes abstracted and uploaded to SPSS (version 21) worksheet. Descriptive, bivariate, and multivariate logistic regression analyses were done and a p-value of 0.05 was considered statistically significant. The demographic and reproductive characteristics were comparable across the three IPI groups. Maternal outcomes such as uterine rupture, post-partum haemorrhage (PPH), blood transfusions, preeclampsia, and maternal mortality were comparable across short, intermediate, and long IPI. Some neonatal outcomes, however, showed evidence of an association with IPI. These were prematurity (p = 0.03) and developing congenital malformations (p = 0.01). Other neonatal outcomes (birth outcomes, birth weight, Apgar at 5, and NBU admission) were similar. In conclusion, maternal outcomes are comparable when the IPI after a repeat caesarean section at term is short, intermediate, and long. Congenital anomalies and premature births should be anticipated when the IPI is long (more than 59 months).

BackgroundTrial of labor after cesarean (TOLAC) is often recommended as an alternative to elective repeat cesarean section (ERCS) in women with a single prior cesarean section. This retrospective cohort study aimed to compare obstetrical outcomes between TOLAC and ERCS in a French hospital setting.MethodsWomen with a single prior cesarean delivery, cephalic presentation, and term pregnancies (≥ 37 weeks) between 2019 and 2024 were included. Women were analyzed according to their initially intended mode of delivery (TOLAC or ERCS), irrespective of the final delivery route, to reflect a real-world, decision-based clinical approach. Primary outcomes were uterine rupture, severe postpartum hemorrhage (PPH), and neonatal intensive care unit (NICU) admission. Statistical methods included chi-square tests, Student’s t-tests, and Firth’s penalized logistic regression for rare events.ResultsIn total, 2,424 women were included, with 2,146 undergoing TOLAC and 278 undergoing ERCS. Severe PPH occurred less frequently in the TOLAC group (5.6%) than in the ERCS group (10.4%, p = 0.002), with adjusted analysis confirming a significant reduction in risk (adjusted OR: 0.45, 95% CI: 0.31–0.69, p < 0.001). NICU admissions were also lower in the TOLAC group (6.5% vs. 13.3%, p < 0.001; adjusted OR: 0.45, 95% CI: 0.31–0.69, p < 0.001). Uterine rupture rates were low and showed no significant difference in unadjusted analysis (1.7% TOLAC vs. 1.1% ERCS, p = 0.622), though adjusted models indicated an increased risk with TOLAC (adjusted OR: 2.08, 95% CI: 1.24–3.58, p = 0.005).ConclusionThe findings suggest that obstetrical practice concerning TOLAC, in a French tertiary care maternity unit, is associated with lower rates of severe PPH and NICU admission compared to ERCS, with a slightly increased risk of uterine rupture. These results support offering TOLAC as a safe and beneficial option for eligible women.

Objective The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units Network (MFMU) helps to identify the likelihood of VBAC. We sought to compare adverse maternal and neonatal outcomes of trial of labor after cesarean (TOLAC) to those of elective cesarean delivery after stratifying by VBAC likelihood. Study design This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton term delivery with vertex presentation occurred at an academic center from January 2009 to June 2018. Only data from the second pregnancy were analyzed. The final analysis included 835 women. The MFMU VBAC calculator was used to assess the likelihood of VBAC. The two primary outcomes were composite adverse maternal (death or severe maternal complications) and neonatal outcomes (perinatal death or severe neonatal complications). The analyses were stratified based on the VBAC likelihood (less than 60% and 60–100%). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates. Results Among women with VBAC likelihood less than 60%, TOLAC compared with elective cesarean was associated with increased odds of the primary adverse maternal outcome (16.4% vs. 4.2%; adjusted OR 4.60 [95%CI 1.48–14.35]) and the primary adverse neonatal outcome (17.8% vs. 6.3%; adjusted OR 3.93 [95%CI 1.31–11.75]). Among women with VBAC likelihood of 60–100%, TOLAC compared with elective cesarean was associated with decreased odds of the primary adverse maternal outcome (6.4% vs. 11%; adjusted OR 0.47 [95%CI 0.25–0.89]) and similar odds of the primary adverse neonatal outcome (6.7% vs. 8.3%; adjusted OR 0.98 [95%CI 0.52–1.84]). Conclusions Among women with a history of a primary low transverse cesarean delivery, those who underwent TOLAC compared to those who had elective cesarean had increased odds of adverse maternal and neonatal outcomes when VBAC likelihood was less than 60%.

The rate of vaginal birth after a cesarean (VBAC) delivery in the multiparous population has decreased largely in recent years because of maternal and neonatal complications. The clinical management of grand multiparous (GMP) women (>5 births) with a prior cesarean delivery is even less clear. The purpose of the present study was to assess the risks of maternal and neonatal complications associated with VBAC compared to that of repeated elective cesarean section (CS) in the GMP population. A retrospective study of 1,102 GMP women with a singleton gestation and a prior single CS was conducted. Data were retrieved from the database of the Department of Obstetrics and Gynecology at the Soroka University Medical Center, Beer Sheva, Israel. Maternal and neonatal outcomes were compared between women who underwent a successful VBAC attempt, women who had failed in a trial of labor and women who had an elective repeated CS. Six hundred and nineteen women (56%) underwent a successful VBAC, 155 (14%) underwent a trail of labor and 328 (30%) had an elective repeated CS. Women who had a successful VBAC required less blood transfusion, and had less puerperal fever diseases (P < 0.001). Induction or augmentation of labor was associated with failure of VBAC (P < 0.001). No significant differences in neonatal complications were observed between the groups. No significant difference in uterine dehiscence, uterine rupture, amnionitis, postpartum hemorrhage, hysterectomy, puerperal fever and thromboembolic diseases was observed between the groups. A successful VBAC in the GMP population was not associated with a higher risk of maternal complications in comparison with a repeated elective CS.

To compare pregnancy outcomes in grand-multiparous (GMP) women with and without one previous cesarean delivery (CD), and to evaluate the number of previous successful vaginal deliveries after a CD needed to reduce the complication rate of trials of labor after a previous CD. This is a retrospective cohort study of women with singleton pregnancy at term who had a trial of vaginal delivery between 2007 and 2014 at a tertiary medical center. We compared pregnancy outcomes in GMP women with and without one previous cesarean delivery. The primary outcome was mode of delivery and secondary outcomes were uterine rupture and composite maternal and neonatal morbidity. For the secondary objective, we compared pregnancy outcomes in women in TOLAC, stratified by the number of previous vaginal deliveries. Overall, 2815 GMP women met the study criteria, of which 310 (11%) had a previous cesarean delivery. The rate of a successful vaginal deliveries (VBAC) was similar, regardless of the presence of a previous cesarean delivery. No other differences in outcomes were found between the groups. In a secondary analysis, it was found that the presence of a single previous VBAC (compared to no previous VBACs) increased the odds of achieving a vaginal delivery in the next trial of labor after cesarean delivery (TOLAC) (aOR 5.66; 95% CI 3.73-8.60), and decreased the risk of maternal or neonatal adverse outcomes (aOR 0.62; 95% CI 0.39-0.97, and aOR 0.49; 95% CI 0.25-0.97, respectively). Multiple prior VBACs (as compared to a single prior VBAC) did not increase the odds of achieving another VBAC. Grand-multiparous women with and without previous uterine scar have comparable pregnancy outcomes. Additionally, after the first VBAC, additional successful VBACs do not improve the success rate in the next TOLAC.

Objective: To investigate the impact of the number of cesarean deliveries on adverse maternal and neonatal outcomes. Methods: A retrospective analysis was conducted on 11 904 singleton pregnant women who underwent cesarean delivery at the Third Affiliated Hospital of Guangzhou Medical University from January 1st, 2019 to December 31st, 2023. The women were grouped according to the number of cesarean deliveries: those undergoing their first cesarean delivery (1CD group, 7 231 cases), those undergoing their second cesarean delivery (2CD group, 3 749 cases), those undergoing their third cesarean delivery (3CD group, 841 cases), and those undergoing their fourth or more cesarean deliveries (4CD group, 83 cases). Differences in clinical characteristics, related surgical procedures, and adverse maternal and neonatal outcomes among the groups were compared. Binary logistic regression analysis was used to assess the impact of the number of cesarean deliveries on related surgical procedures and adverse maternal and neonatal outcomes. Results: (1) During the 5-year period, the total number of women undergoing cesarean delivery in our hospital showed a slight downward trend, while the proportion of women undergoing three or more cesarean deliveries increased. (2) Compared with women undergoing their first cesarean delivery, women in each repeat cesarean delivery group were older, had higher proportions of advanced maternal age and pre-pregnancy body mass index, and had more pregnancies, deliveries, and induced abortions; the incidence of placenta previa, placental implantation, antepartum hemorrhage, gestational hyperglycemia, and failed trial of labor requiring conversion to surgery was higher, while the incidence of premature rupture of membranes was lower; the proportions of ureteral stent placement, adhesiolysis of the pelvic and abdominal cavities, uterine rupture, uterine reconstruction, uterine artery ligation, hysterectomy, postpartum hemorrhage, and postoperative intestinal obstruction were higher, and the amount of postpartum hemorrhage was greater; the gestational age at delivery of neonates was earlier, but the rates of preterm birth at 28-31+6 and 32-33+6 weeks of gestation were lower; the differences were statistically significant (P<0.05) for all comparisons. (3) The number of cesarean deliveries was not an independent risk factor for the dose-dependent occurrence of placenta previa (aOR=0.99, 95%CI: 0.98-1.01; P=0.261). In women without placenta previa, the number of cesarean deliveries was not a risk factor for placental implantation (aOR=1.12, 95%CI: 0.90-1.39; P=0.320). However, in women with placenta previa, the number of cesarean deliveries was a risk factor for placental implantation (aOR=4.01, 95%CI: 3.08-5.22; P<0.001). In the overall population, the number of cesarean deliveries was a risk factor for ureteral stent placement, adhesiolysis of the pelvic and abdominal cavities, bladder rupture repair, uterine rupture, uterine reconstruction, uterine artery ligation, hysterectomy, postpartum hemorrhage, and preterm birth (all P<0.05). However, the number of cesarean deliveries was not a risk factor for postoperative intestinal obstruction, admission to the intensive care unit, neonatal asphyxia, admission to the neonatal intensive care unit, or neonatal death (all P<0.05). Conclusions: The number of cesarean deliveries could lead to adverse maternal and neonatal outcomes, but the relationship is not simply dose-dependent. It is speculated that the occurrence of severe adverse maternal and neonatal outcomes is more closely related to maternal complications and comorbidities, as well as whether multidisciplinary comprehensive management was received.

769: What is the best type of skin incision for multiple prior cesarean deliveries?

829: Timing of cesarean delivery in women with more than one previous cesarean delivery

To evaluate the rates of vaginal birth after cesarean (VBAC) among parturients attempting preterm trial of labor following a cesarean delivery (TOLAC) vs. term TOLAC. A multicenter historic cohort study was conducted at two university-affiliated centers between August 2005 and March 2021. Parturients in their second delivery, attempting TOLAC after a single low segment transverse cesarean delivery were included. We retrospectively examined computerized medical records of all preterm (< 37weeks) and term (37-42weeks) births. Multifetal gestations and postterm deliveries (≥ 42weeks) were excluded. A univariate analysis was conducted, followed by a multivariate analysis. 4865second deliveries following previous cesarean were identified: 212 (4.4%) preterm and 4653 (95.6%) term. Hypertensive disorders, diabetes and fertility treatments were significantly more prevalent in the preterm group. VBAC rate was significantly lower in preterm group (57.5 vs 79.7%., p < 0.01), including both spontaneous and vaginal-assisted deliveries. In multivariate analysis, preterm TOLAC was independently associated with TOLAC failure [adjusted odds ratio 2.24, [95% confidence interval 1.62-3.09]. Overall, maternal outcomes were favorable. Rates of uterine rupture, re-laparotomy and postpartum hemorrhage were comparable between groups. Neonatal outcomes were less favorable among the preterm group; however, preterm vs. term TOLAC was not associated with low 5min Apgar score (aOR 1.76, 95% CI 0.92-3.40). In our study, VBAC rates were lower in preterm compared to term deliveries. Maternal outcomes were comparable. Neonatal outcomes were less favorable in the preterm group, more likely due to prematurity than delivery mode.