Elective Repeat Cesarean Delivery Research Articles

Elective Repeated Cesarean Section (ERCS)

Objective: To investigate the timing of elective repeat cesarean deliveries at Al-Batool Teaching Hospital in Diyala, Iraq. Methods: A retrospective analysis was conducted of 100 women who underwent elective repeat cesarean delivery at 37-40 weeks gestation at Al-Batool Teaching Hospital. Emergency cesarean deliveries were excluded. Results: The majority of elective repeat cesarean deliveries (78%) were performed at 37 weeks gestation. Cesarean deliveries at 38, 39, and 40 weeks accounted for 4%, 2%, and 16% of the sample, respectively. Conclusions: In this cohort, most elective repeat cesarean deliveries were conducted at 37 weeks gestation, rather than the recommended 40 weeks. Delivering earlier than 39-40 weeks in the absence of medical indications reduces the chances of successful vaginal birth after cesarean. These findings suggest that evidence-based protocols were not consistently followed for timing of elective repeat cesarean sections at this institution. Further research is needed to identify barriers to adhering to delivery guidelines and implement quality improvement initiatives to optimize cesarean delivery timing when clinically appropriate.

Trial of Labor versus Repeat Cesarean Delivery in Individuals with Morbid Obesity after Previous Cesarean Delivery.

This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m2) and the presence of previous vaginal delivery (VD). This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates. Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m2, 1,108,278 had BMI 30 to 39.9 kg/m2, and 320,031 had BMI 40 to 69.9 kg/m2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m2 (5.0 vs. 6.5%; aRR = 1.33 [1.30-1.36]), BMI 30 to 39.9 kg/m2 (6.1 vs. 7.8%; aRR = 1.29 [1.24-1.34]), and BMI 40 to 69.9 kg/m2 (8.2 vs. 9.0%; aRR = 1.15 [1.07-1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m2 (6.2 vs. 5.8%; aRR = 0.98 [0.96-1.00]), BMI 30 to 39.9 kg/m2 (7.4 vs. 7.1%; aRR = 0.99 [0.95-1.02]), and BMI 40 to 69.9 kg/m2 (9.4 vs. 8.7%; aRR = 0.96 [0.91-1.02]). TOLAC among obese individuals could be offered in selected cases. · TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it.. · Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC.. · Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications..

Predictors and Risks of Vaginal Birth after Cesarean Section: Insights from a Regional Referral Hospital in Uganda

Vaginal birth after cesarean section (VBAC) remains a topic of significant interest due to its potential benefits and associated risks. This retrospective cohort study aimed to identify predictors and risks associated with VBAC compared to elective repeat cesarean section (ERCD) among women delivering at Jinja Regional Referral Hospital in Uganda. We analyzed data from 384 women who had a previous cesareansection and delivered at the hospital between 2022 and 2023. Socio-demographic, obstetric, and medical characteristics were assessed for their association with successful VBAC using logistic regression. Risks of maternal morbidities between VBAC and ERCD groups were compared using Chi-square tests. The study found that BMI &lt;35 kg/m², birth weight &lt;3500g, spontaneous onset of labor, previous safe vaginal birth, and absence of diabetes mellitus were significant predictors of successful VBAC. Women undergoing TOLAC had a higher incidence of uterine rupture (p = 0.030), thromboembolism (p &lt; 0.001), and blood transfusion requirement (p &lt; 0.001) compared to ERCD. However, hysterectomy, hemorrhage, viscus injury, and pelvic floor trauma did not significantly differ between the two groups. Our findings highlight important predictors and risks associated with VBAC compared to ERCD in a regional referral hospital setting. Understanding these factors can aid clinicians in counseling women on their delivery options and managing potential risks associated with VBAC. Further research is warranted to explore strategies for optimizing VBAC outcomes while minimizing associated morbidities. Keywords: Maternal, Morbidity, Labor, Cesarean Section, Elective Repeat Cesarean Delivery, Jinja, Hospital

Trial of labor after cesarean: Maternal and neonatal outcomes from the Consortium on Safe Labor.

The aim of our study is to describe maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean from the Consortium on Safe Labor. This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study over a 7 year study period. Maternal and neonatal outcomes were evaluated based on desired delivery mode: planned elective repeat cesarean delivery or trial of labor after cesarean. Of 9858 patients in our analysis, our study population had 4400 patients (45%) who desired trial of labor after cesarean and 5458 patients (55%) who desired elective repeat cesarean delivery. Women who attempted trial of labor after cesarean compared to those who had an elective repeat cesarean delivery were more likely to have an obstetric hemorrhage (adjusted odds ratio 1.6; 95% CI 1.3 -2.0) and blood transfusion (adjusted odds ratio 2.3; 95% CI 1.6 -3.2). Maternal morbidity in women undergoing trial of labor after cesarean was predominantly hemorrhage-related.

Outcome of subsequent pregnancies in women with prior uterine rupture

ObjectiveTo report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture. MethodsThe records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study. ResultsThe cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy. ConclusionWomen with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

Maternal Morbidity Following a Trial of Labor After Cesarean Section vs. Elective Repeat Cesarean Delivery at KIU Teaching Hospital

This study aimed to determine maternal morbidity and predictors of successful vaginal birth control (VBAC) among women at KIU Teaching Hospital. A retrospective cohort study was used, with 384 files of women who delivered between 2014 and 2018 selected. Descriptive statistics were used to determine the incidence of maternal morbidities. Univariate analysis and bivariate logistic regression were performed using STATA version 14.0 to identify predictors of successful VBAC. The mean age of the study participants was 25.62 years, with 63.54% of them elective repeat caesarean sections (ERCD) and 36.46% trial of labor after caesarean sections (TOLAC). Morbidities included uterine rupture, thromboembolism, transfusion requirement, and endometritis. Risks of TOLAC versus ERCD included uterine rupture, thromboembolism, and blood transfusion requirement. BMI, birth weight, spontaneous onset of labor, previous safe vaginal birth, and non-diabetic status were found to be predictors of successful VBAC. Delivering women with previous cesarean sections is a complex process that involves the physician's knowledge, experience, and fear of litigation, as well as the previous maternal experience and knowledge. Any decision made will affect the present pregnancy's outcome, future obstetric performance, and fertility of the patient. Keywords: Maternal Mortality Rate, Cesarean delivery, Women, pregnancy, Labour.

Morbidity of Repeat Cesarean Delivery after a Trial of Labor as Compared with Elective Repeat Cesarean Delivery.

This study aimed to evaluate if a secondary repeat cesarean after a trial of labor (TOLAC) without uterine rupture is associated with increased morbidity as compared with a scheduled elective repeat cesarean delivery (ERCD). This was a retrospective cohort study of repeat cesarean delivery (CD) in a single obstetrical practice between 2005 and 2022. Patients were included if they had a singleton pregnancy at term with one prior CD and had a repeat CD this pregnancy resulting in live birth. Patients were excluded if they had a prior myomectomy, more than one prior CD, uterine rupture in a prior or current pregnancy, or placenta previa in this pregnancy. We compared baseline characteristics and outcomes between patients who had a repeat cesarean after TOLAC and ERCD. The primary outcome was a composite of maternal morbidity that included hysterectomy, blood transfusion, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, or maternal mortality. A total of 930 women met inclusion criteria. A total of 176 (18.9%) patients intended to labor and 754 (81.1%) planned an ERCD. There was no difference in the primary outcome between patients with a repeat cesarean after TOLAC compared with patients with ERCD (2.8 vs. 1.2%, p = 0.158). Patients with repeat cesarean after labor had significantly more 1-minute Apgar scores less than 7, but no difference in 5-minute Apgar scores. We were powered to detect a difference in the primary outcome from 1.2% in the ERCD group to 3.3% in the repeat cesarean after labor group. Results did not differ when we analyzed patients who intended to TOLAC versus patients who actually labored prior CD. For women with one prior CD the morbidity of repeat cesarean after labor is not more than the morbidity of planned repeat CD. Our study can be helpful in delivery planning counseling for patients with one prior CD. · Uterine rupture is a known risk of TOLAC.. · This study aimed to understand morbidity associated with labor.. · No added morbidity of repeat cesarean after labor is inferred in this study..

Outcome of pregnancy in previous cesarean section comparing elective versus trial of labor (VBAC) at KRL Hospital, Islamabad.

Objective: To determine feto maternal outcome in patients with cesarean section and comparing outcome following TOLAC and elective repeat cesarean delivery. Study Design: Descriptive, Cross-sectional study. Setting: Department of Obstetrics &amp; Gynecology, Kahuta Research Laboratory (KRL) Hospital, Islamabad. Period: 10th September 2019 to 9th March 2020. Material &amp; Methods: 93 pregnant women of gestational age 37-42 weeks with previous transverse cesarean section were included. Patients with a history of multiple pregnancies, ruptured uterus, placenta previa, polyhydramnios or oligohydramnios, and fetal malpresentation were excluded. In each patient, the labor trial was done; if not possible, then a cesarean section was done on the elective list. Each case was done by the researcher herself in the presence of a consultant gynecologist and the mode of delivery (vaginal/cesarean), was noted. After this fetal outcome i.e. live birth (yes/no), NICU admission (yes/no), and Apgar score &gt;6 at 5 minutes (yes/no) was noted. Results: Maternal outcomes in a previous cesarean section was found to be a cesarean section in 60 (64.52%) and VBAC in 33 (35.48%), an APGAR score &gt;6 at 5 minutes after VBAC was seen in 100.0% and after elective cesarean delivery in 81.67% of neonates. NICU admission is 0.0% in TOLAC compared to 20.0% with elective repeat LSCS. Live birth after emergency cesarean delivery was seen in 93.33% and 100% after VBAC. Conclusion: This study concluded that the maternal outcome in a previous cesarean section was found to be a cesarean section in 64.52% and VBAC in 35.48% of women and fetomaternal outcome following TOLAC is better.

Maternal and Neonatal Outcomes of Trial of Labor Compared With Elective Cesarean Delivery According to Predicted Likelihood of Vaginal Delivery

(Abstracted from J Matern Fetal Neonatal Med 2022;35(26):10487–10493 In 2007, the Maternal-Fetal Medicine Unit (MFMU) Network developed the vaginal birth after cesarean (VBAC) calculator to help optimize the likelihood of a successful vaginal delivery. One study found that the risk of maternal and neonatal morbidity is no greater than that of elective repeat cesarean delivery (CD)—specifically when the likelihood of successful VBAC is &gt;70%.

MODE OF DELIVERY IN THE SECOND PREGNANCY OF MOTHER WITH HIGH MYOPIA AND HISTORY OF SECTIO CESAREAN: A CASE REPORT

Background: Pregnant women with a history of cesarean section have problems choosing the delivery method for their next pregnancy. Sometimes there are still other risk factors, one of which is high myopia, which adds to the problem of choosing an effective delivery method with the advantages and disadvantages of each. Continuity of care in midwifery is very important in providing patients insight, knowledge, and support to make decisions about appropriate and safe delivery methods. Case report: A 29-year-old woman G2P1A0 with high myopia (minus 8) and cesarean scar three years ago for indications of high myopia (minus 10). In this second pregnancy, the mother underwent another SC because of high myopia minus 8, and the mother has not had a retinal laser until the present. Patients receive referrals from a primary health center for antenatal care and preparation for delivery at referral health facilities with high-risk pregnancies. Mothers are faced with two choices: TOLAC (Trial Of Labor After Cesarean Delivery) and ERCD (Elective Repeat Cesarean Delivery). The mother was consulted by an eye specialist at the referral hospital. The condition of the eye’s retina is good from the results of an eye specialist examination. However, it is still necessary to do a retinal laser process as prophylaxis if the mother wants to have a vaginal delivery. In the end, cesarean delivery is the mother's choice. Conclusion: Pregnancies with high myopia and cesarean scars need to receive full support from midwives and families to carry out comprehensive COC care to improve the health of mothers and children by assisting mothers in selecting delivery methods that are effective and safe for both mother and baby.&#x0D;

Retrospective evaluation of outcomes of vaginal birth after caesarean section in a tertiary center: a single-center study from Türkiye.

The aim of this study was to evaluate the trial of labor after caesarean (TOLAC) outcomes and determine its reliability by comparing it with elective repeat caesarean delivery (ERCD) and vaginal delivery. For this purpose, the outcomes of patients aged 18-40 years who had 57 TOLACs, 72 vaginal deliveries, and 60 elective caesarean sections in Ankara Koru Hospital between January 1, 2019, and January 1, 2022 were compared. Gestational age was lower in the normal vaginal delivery (NVD) group than in the elective caesarean section and vaginal birth after caesarean delivery (VBAC) groups (p < 0.0005). The birth weight was statistically significantly lower in the NVD group than in the elective caesarean section and VBAC groups (p < 0.0002). No statistically significant correlation was found between the BMI values in all three groups (p < 0.586). There was no statistically significant difference between the groups in terms of pre- and post-natal haemoglobin and APGAR scores (p < 0.575) (p < 0.690) (p < 0.747). The rate of epidural and oxytocin use was higher in the NVD group than in the VBAC group (p < 0.001) (p < 0.037). There was no statistically significant correlation between the birth weights of the infants in the TOLAC group and failed VBAC (p < 0.078). No statistically significant correlation was observed between the use of oxytocin for induction and failed VBAC (p < 0.842). There was no statistically significant correlation between epidural anaesthesia and failed VBAC (p < 0.586). A statistically significant correlation was found between gestational age and caesarean section as a result of a failed VBAC (p < 0.020). The main reason for not preferring TOLAC continues to be uterine rupture. It can be recommended to eligible patients in tertiary centers. Because even when the factors increasing the success of VBAC were excluded, the rate of successful VBAC remained high.

An innovative web-based decision-aid about birth after cesarean for shared decision making in Taiwan: study protocol for a randomized control trial

BackgroundTaiwan has a high national caesarean rate coupled with a low vaginal birth after caesarean (VBAC) rate. This study aims to develop and evaluate a web-based decision-aid with communication support tools, to increase shared decision making (SDM) about birth after caesarean.MethodsA quantitative approach will be adopted using a randomized pre-test and post-test experimental design in a medical centre in northern Taiwan. The web-based decision aid consists of five sections. Section 1 provides a two-part video to introduce SDM and how to participate in SDM. Section 2 presents an overview of functions and features of the birth decision-aid. Section 3 presents relevant VBAC information, including definitions, benefits and risks, and an artificial intelligence (AI) calculator for rate and likelihood of VBAC success. Section 4 presents the information regarding elective repeat caesarean delivery (ERCD), involving definitions, benefits, and risks. Section 5 comprises four steps of decision making to meet women’s values and preferences. Pregnant women who have had one previous caesarean and are eligible for VBAC, will be recruited at 14–16 weeks. Participants will complete a baseline survey prior to random allocation to either the control group (usual care) or intervention group (usual care plus an AI-decision aid). A follow up survey at 35–38 weeks will measure change in decisional conflict, knowledge, birth mode preference, and decision-aid acceptability. Actual birth outcomes and satisfaction will be assessed one month after birth.DiscussionThe innovative web-based decision-aid with support tools will help to promote pregnant women’s decision-making engagement and communication with their providers and improve opportunities for supportive communication about VBAC SDM in Taiwan. Linking web-based AI data analysis into the medical record will also be assessed for feasibility during implementation in clinical practice.Trial registrationClinicalTrials.gov identifier (NCT05091944), Registered on October 24, 2021.

Pregnancy and Outcomes After Prolapse Surgery: A Case Series.

There are limited data on whether pelvic organ prolapse (POP) surgery is durable after subsequent delivery. The aims of this study were to evaluate the safety and durability of POP surgery after delivery and to describe the medical decision-making and clinical outcomes of patients who gave birth after POP surgery. This study is a retrospective case series of patients who underwent surgery for symptomatic POP between 2007 and 2017, and subsequently had a live birth. Twenty patients were identified. Seventeen patients underwent posterior colporrhaphy, 10 anterior colporrhaphy, and 5 apical suspensions. The mean interval between POP surgery and the first delivery was 28.6 months. One patient endorsed recurrent POP symptoms before pregnancy, and none of the remaining 19 patients reported recurrent POP symptoms before or during pregnancy. There were no pregnancy complications related to the POP surgery. Nine patients underwent cesarean delivery (CD). Four patients were counseled to have a CD due to their prior POP surgery, 3 patients had an elective primary CD due to the POP surgery, 1 patient chose an elective repeat CD, and 1 patient had a CD due to obstructed labor. Urogynecologists were consulted for delivery recommendations for 6 patients and recommended CD for 3 of them. Eleven patients had spontaneous vaginal delivery. Three patients reported recurrent POP symptoms after delivery. Our findings corroborate previous case series demonstrating the safety and durability of POP surgery during and after pregnancy. More than 75% of patients gave birth by CD, which was due to physician or patient concerns regarding the prior POP surgery.

To Try or Not to Try: A Questionnaire Study among Women with Previous Lower Segment Cesarean Section.

The recent increase in the cesarean section (CS) rate worldwide has led to global concerns and vaginal birth after CS (VBAC) as an effective way to reduce the CS rate. In this study, our main aim was to know about various factors that help women make their preferred mode of delivery following a previous CS. This was a questionnaire-based study conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Jodhpur, among 200 women with previous one lower segment CS (LSCS). Elective repeat cesarean delivery (ERCD) was found to be more among uneducated women and those who had complications in their previous babies. The most common reason for opting for ERCD was fear of labor pains. Women who were counseled by senior doctors were more likely to opt for a trial of labor after cesarean section (TOLAC). Improving the education levels of mothers, counseling about advantages associated with vaginal birth, counseling by senior obstetrician, and information regarding labor analgesia can decrease CS rates.

Risk of uterine rupture among women in a trial of labor after prior cesarean delivery

Uterine rupture during a trial of labor after prior cesarean (TOLAC) delivery is an obstetrical emergency with potentially severe adverse outcomes. The aim of this study was to assess the incidence of uterine rupture and adverse maternal and perinatal outcomes. We conducted a population-based, retrospective cohort analysis with data from all women who gave birth after one prior cesarean delivery at a single tertiary center from 2009 through 2019. Maternal and perinatal outcomes were compared between women who underwent a successful or failed TOLAC and elective repeated cesarean delivery (ERCD) without labor. Out of 95,552 deliveries, TOLAC was attempted by 5,619 (63.35%), while 3,250 (36.64%) women underwent ERCD. The rate of successful TOLAC - vaginal birth after cesarean (VBAC) was 81.92%. Symptomatic uterine rupture occurred in 55 (0.98%) women who underwent TOLAC and asymptomatic rupture in five (0.153%) who underwent ERCD. Compared with women with spontaneous onset of labor, a greater risk, albeit not significant, for uterine rupture was observed among women with induction of labor using prostaglandins (OR 2.44; CI 0.86-6.92), oxytocin (OR 2.16 CI 0.84-5.54), and lower when external amniotic balloon was used (OR 0.52; CI 0.07-3.86). Women who failed in TOLAC needed more blood transfusions (OR 6.06; CI 3.61-10.16, p< 0.011). Neonatal hypoxic–ischemic encephalopathy occurred in a single case of successful TOLAC but in none of the other groups. There were no cases of cesarean hysterectomy, maternal or neonatal death in any group. Our data confirm the relatively small risk of uterine rupture during TOLAC. In a tertiary well-trained center, with close maternal and fetal monitoring, uterine rupture is rare and does not result in severe maternal and neonatal morbidity or mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Timing of Elective Repeat Cesarean Delivery at 38 Weeks versus 39 Weeks: Rate of Spontaneous Onset of Labor before Planned Cesarean Section and Impact on Maternal Outcome: A Retrospective Cohort Study

Background: The timing of elective repeat cesarean delivery at 38 weeks versus 39 weeks is still a debatable subject, both regarding maternal and neonatal outcomes. In the Saudi context, there is lack of local data to aid decision-making regarding the timing of elective repeat cesarean delivery. Objectives: To estimate the rate of spontaneous onset of labor before the planned gestational age for repeat cesarean section in women who were booked at gestational age of (39 0/7 - 39 6/7) weeks (W39) versus (38 0/7 - 38 6/7) weeks (W38) and to compare the rate of maternal composite outcome between these groups. Design: Retrospective cohort. Setting: This study was conducted at King Abdulaziz Medical City, Jeddah, KSA. Method: Delivery registry books were reviewed to identify all deliveries from 1 January 2014 to 31 December 2016 (3 years). All low-risk pregnant women who had 2 or more cesarean deliveries and who met the inclusion criteria were included. Results: A total of 440 women were included of whom 318 (72.3%) were planned for elective cesarean section at W38 gestational age and 122 women at W39 gestational age. Mothers planned at W39 had higher rate of emergency cesarean deliveries versus those planned at W38 (18.0% versus 10.4%, p = 0.030; RR = 13.06), most frequently due to early onset of contractions (16.4% versus 8.2%, p = 0.012; RR = 12.17) or cervical dilatation (11.6% versus 5.4%, p = 0.024, RR = 16.15). No difference in the incidence of individual or composite maternal complications was noted between the two groups. Mother’s age (OR 0.93, p = 0.018) and schedule date at W39 (OR = 1.94, p = 0.028) were independently associated with spontaneous onset of labor before the scheduled gestational age, while no association was found with parity, previous number of spontaneous vaginal deliveries, number of previous cesarean deliveries or interval from last cesarean delivery. Conclusion: Elective cesarean section scheduled at 39 weeks of gestation or beyond carries a higher risk of emergency cesarean section, with no significant increase in maternal complications. The identification of factors associated with spontaneous onset of labor before the planned gestational age should be carefully identified to determine the optimal timing.

Factors Associated with Failed Trial of Labor after Cesarean, among Women with Twin Gestation-A Multicenter Retrospective Cohort Study.

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40–0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36–19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65–1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01–20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery.

Trial of labor after two cesarean sections: A retrospective case-control study.

The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N=82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N=1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

Feeding Practices, Maternal and Neonatal Outcomes in Vaginal Birth after Cesarean and Elective Repeat Cesarean Delivery.

Cesarean section rates are constantly rising, and the number of women with a prior cesarean considering a delivery mode for their next labor is increasing. We aimed to compare maternal and neonatal outcomes and feeding method in women undergoing vaginal birth after cesarean (VBAC) versus elective repeat cesarean delivery (ERCD). This was a retrospective cohort study of women with one prior cesarean delivery (CD) and no previous vaginal births, delivering vaginally or by a CD in a single institution between 2016 and 2018. 355 live singleton spontaneous vaginal and cesarean deliveries were included. 121 women delivered vaginally and 234 had a CD. Neonates born by a CD were more likely to have higher birth weight (p < 0.001), higher weight at discharge (p < 0.001), macrosomia (p = 0.030), lose >10% of their body mass (p = 0.001), be mixed-fed (p < 0.001), and be hospitalized longer (p < 0.001). Children born vaginally were more likely to be exclusively breastfed (p < 0.001). Women undergoing VBAC were more likely to deliver preterm (p = 0.006) and post-term (p < 0.001), present with PROM (p < 0.001), have greater PROM latency period (p < 0.001), and experience intrahepatic cholestasis of pregnancy (p = 0.029), postpartum anemia (p < 0.001), and peripartum blood loss >1 L (p = 0.049). The incidence of anemia during pregnancy was higher in the ERCD cohort (p = 0.047). Women undergoing VBAC are more likely to breastfeed their children, perhaps for the same reason they choose the vaginal method of delivery, as vaginal delivery and breastfeeding along with antibiotic use, are the most important factors decreasing the risk for future diseases in their offspring.

Risk factors and outcomes associated with type of uterine rupture

PurposeTo identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn.MethodsBetween 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared.Results92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017).ConclusionTOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.