Elective Repeat Research Articles

Effect of China's Universal Two-child Policy on the Rate of Cesarean Delivery: A Case Study of a Big Childbirth Center in China.

China's universal two-child policy was released in October of 2015. How would this new policy influence the rate of overall cesarean delivery (CD) in China? The objective of this paper is to investigate the trend of overall CD rate with the increase of number of multiparous women based on a big childbirth center of China (a tertiary hospital) in 2016. In this study, 22 530 cases from the medical record department of a big childbirth center of China from January 1 to December 31 in 2016 were enrolled as research objects. Electronic health records of these selected objects were retrieved. According to the history of childbirth, the selected cases were divided into primiparous group containing 16 340 cases and multiparous group containing 6190 cases. Chi-square test was carried out to compare the rate of CD, neuraxial labor analgesia, maternity insurance between the two groups; t-test was performed to compare the in-hospital days and gestational age at birth between the two groups. Pearson correlation coefficient was used to evaluate the relationship among observed monthly rate of multiparas, overall CD rate, and Elective Repeat Cesarean Delivery (ERCD) rate. The results showed that the CD rate in multiparous group was 55.46%, which was higher than that in primiparous group (34.66%, P<0.05). The rate of neuraxial labor analgesia in multiparas group was 9.29%, which was lower than that in primiparas group (35.94%, P<0.05). However, the rate of maternity insurance was higher in multiparas group (57.00%) than that in primiparas group (41.08%, P<0.05). The hospital cost and in-hospital days in multiparas group were higher, and the gestational age at birth in multiparas group was lower than in primiparas group (P<0.05). The overall CD rate slightly dropped in the first 4 months of the year (P<0.05), then increased from 36.27% (April) to 43.21% (December) (P<0.05). The rate of multiparas women and ERCD had the same trend (P<0.05). There were linear correlations among the rate of overall CD, the rate of multiparas women and the rate of ERCD rate (P<0.05). With the opening of China's two-child policy, the increasing rate of overall CD is directly related with the high rate of ERCD. Trials of Labor After Cesarean Section (TOLAC) in safe mode to reduce overall CD rate are warranted in the future.

Risk of negative birth experience in trial of labor after cesarean delivery: A population-based cohort study.

To improve care for women going through trial of labor after cesarean (TOLAC), we need to understand their birth experience better. We investigated the association between mode of delivery on birth experience in second birth among women with a first cesarean. A population-based cohort study based on the Swedish Pregnancy Register with 808 women with a first cesarean and eligible for TOLAC in 2014-2017. Outcomes were mean birth experience measured by visual analogue scale (VAS) score from 1-10 and having a negative birth experience defined as VAS score ≤5. Linear and logistic regression analyses were performed with β-estimates and odds ratios (OR) with 95% confidence intervals (CI). Mean VAS score among women with an elective repeat cesarean (n = 251 (31%)), vaginal birth (n = 388 (48%)) or unplanned repeat cesarean (n = 169 (21%)) in second birth were 8.8 (standard deviation SD 1.4), 8.0 (SD 2.0) and 7.6 (SD 2.1), respectively. Compared to women having an elective repeat cesarean, women having an unplanned repeat cesarean delivery had five-fold higher odds of negative birth experience (adjusted OR 5.0, 95% CI 1.5-16.5). Women having a first elective cesarean and a subsequent unplanned repeat cesarean delivery had the highest odds of negative birth experience (crude OR 7.3, 95% CI 1.5-35.5). Most women with a first cesarean scored their second birth experience as positive irrespective of mode of delivery. However, the odds of a negative birth experience increased among women having an unplanned repeat cesarean delivery, especially when the first cesarean delivery was elective.

OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section

BackgroundDespite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries.MethodsOptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women.ResultsThe OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000.ConclusionsChanging clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances.Trial registrationThe OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Trial of Labor After Cesarean Delivery in Twin Gestations: Systemic Review and Meta-Analysis

(Am J Obst Gynecol. 2019;220:336–347) While twin gestation pregnancy rates have increased, multiple gestation pregnancies are considered a high-risk condition with significant maternal and perinatal risks. For patients with twin pregnancy and history of previous cesarean delivery, adequate data to guide informed decision-making for planned, elective repeat cesarean delivery (RCD) or planned vaginal delivery are lacking. The aim of this study was to assess maternal and neonatal morbidity associated with trial of labor (TOL) after cesarean delivery in twin pregnancy.

Incidence and outcome of vaginal birth after cesarean among women receiving counseling at El Manial University Hospital

Background Repeated cesarean section (CS) is the most significant factor contributing to overall increased CS rates. The primary indicator of repeated CS is a prior CS. Vaginal birth after cesarean (VBAC) is a trial to reduce CS rates. Aim The aim of study was to examine the effect of counseling on the incidence, maternal, and neonatal outcomes of VBAC. Design A quasi-experimental one-group posttest-only design was adopted for this study. Setting The study was conducted at the Outpatient Clinic and Casualty Department at Manial University Hospital affiliated to Cairo University. Sample A purposive sample of pregnant women was recruited through a period of 6 months from July to December 2019 based on certain criteria; the most important one is to have a previous CS. Tool A structured interviewing tool, labor progress record (Partograph), and neonatal Apgar score were used to collect the data. Results A total of 90 participants were enrolled into study. A total of 79 (87.8%) women agreed to have VBAC after counseling compared with only 11 (12.2%), who refused to have VBAC and chose CS. The trial of labor after cesarean (TOLAC) rate was 40.5%. The rate of VBAC was 31.6%. Success rate of TOLAC was 78.1%, whereas failed TOLAC was 21.9% owing to lack of labor progress and fetal distress. Overall, 68.4% had CSs lower segment cesarean section (LSCS). Among them, 37% had elective LSCS and 63% had emergency LSCS. Physician decision without any medical indication for CS was the most common indications of elective repeat CS, with a rate of 85%. Oligohydramnios was the most common cause for emergency CS delivery, with a rate of 44.5%. All women who delivered VBAC had normal progress of labor and their babies had normal Apgar score (8–10). No cases that underwent VBAC had any morbidity or mortality. Conclusion Counseling is needed for the selection of VBAC as a mode of delivery. Successful VBAC is associated with better fetomaternal and neonatal outcomes, so most women with one previous cesarean delivery with a low-transverse incision should be counseled and encouraged to undergo a trial of labor in her recurrent pregnancy. Recommendations A qualitative research study should be conducted to assess the satisfaction of women from VBAC and compare it with CS.

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

To evaluate maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean (TOLAC) using a more contemporary data set. This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study from 2002 to 2008. Women met inclusion criteria for our study if they had a history of any prior cesarean delivery (CD). Perinatal outcomes such as uterine rupture, uterine dehiscence, blood transfusion, hemorrhage, hysterectomy, endometritis, maternal death, neonatal intensive care unit (NICU) admission, neonatal respiratory distress syndrome, neonatal seizure, and neonatal death were evaluated based on desired delivery mode (planned elective CD or TOLAC). Multivariate logistic regression was used to describe the association between TOLAC and markers of maternal and neonatal morbidity and mortality. Of 9,858 patients who had a prior CD, our study population had 4,400 patients (44.6%) who desired TOLAC and 5,458 patients (55.4%) who underwent elective repeat CD. Of 4,400 patients who desired trial of labor, 3,162 (72%) achieved a vaginal birth. Women who attempted TOLAC compared to those who had an elective CD were more likely to have uterine rupture (OR 3.11; 95% CI 1.21 – 8.02), hemorrhage (OR 2.24; 95% CI 1.86 – 2.70), and blood transfusion (OR 2.33; 95% CI 1.70 – 3.19) (Table 1). Rate of uterine rupture was higher in patients undergoing TOLAC (0.34%), however it was still described in patients undergoing elective CD (0.11%). Rate of NICU admission was higher in patients undergoing TOLAC compared to elective CD, 12.9% and 11.3% respectively (OR 1.17; 95% CI 1.03 – 1.32). Patients undergoing TOLAC are two-times more likely to have a hemorrhage or require blood transfusion compared to women with elective repeat cesarean delivery. Compared to the Cesarean Registry data, women have half the rate of uterine rupture and a 30% higher risk for blood transfusion.

340: Subsequent pregnancy outcomes after failed vacuum assisted delivery: A retrospective study

Failed attempted vacuum assisted vaginal delivery (VAD) is not uncommon, occurring in 5-10% of cases. However, little is known regarding subsequent pregnancy outcomes in this setting. We aimed to examine women's preferences for mode of delivery and trial of labor after cesarean (TOLAC) success rates and their associated factors among women with previous failed VAD A retrospective cohort study. The study group comprised all women with prior failed VAD who subsequently delivered during a-10 year period at a university hospital. Overall, 166 women with prior history of failed VAD delivered during study period, with a median inter-delivery of 28 [21-36] months. Of them, 53 (31.9%) women had an elective repeat cesarean delivery (ERCD) and 113 (68.1%) had a TOLAC. Women who elected to undergo ERCD were of older age (p=0.008) and had higher rates of gestational hypertensive disorders at both the first (p< 0.001) and subsequent deliveries (p=0.01). Of the 113 women undergoing TOLAC in the subsequent pregnancy, the overall success rate was 67.3%, with gestational diabetes mellitus associated with failed TOLAC (p=0.04). Neonatal 1- and 5- minutes Apgar scores were lower in those who experienced failed TOLAC attempt as compared to those undergoing ERCD and those with successful TOLAC (p=0.01). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among those undergoing TOLAC. TOLAC in those with previous failed VAD appears to be safe and associated with high success rates. These data should improve patients counseling and provide reassurance for those who wish to deliver vaginally in this setting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

593: Neonatal outcomes of trial of labor after cesarean delivery compared with elective cesarean

The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units (MFMU) Network helps to predict the likelihood of VBAC. It is not clear whether the decision of undergoing a trial of labor after cesarean (TOLAC) is associated with adverse neonatal outcomes when the VBAC likelihood is low. We sought to compare neonatal outcomes of TOLAC to those of elective repeat cesarean after stratifying by VBAC likelihood. This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton delivery occurred at our academic center. Only data from the second pregnancy were analyzed. Women with preterm delivery prior to 37 weeks’ gestation, multiple gestation, malpresentation, abnormal placentation, fetal anomaly, and stillbirth were excluded. The MFMU VBAC calculator was used to assess the likelihood of VBAC. Women were categorized into two groups based on the VBAC likelihood (less than 60% and 60-100%). The primary outcome was a composite of perinatal death or severe neonatal complications. Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates. Of 843 women, 625 (74%) and 218 (26%) had VBAC likelihood of 60-100% and less than 60%, respectively. In women with VBAC likelihood of 60-100%, women who underwent TOLAC compared with those who had elective cesarean had a similar rate of the primary outcome (7.0% vs. 8.5%; adjusted OR 0.95 [95%CI 0.51-1.75]). In women with VBAC likelihood less than 60%, women who underwent TOLAC compared with those who had elective cesarean had increased odds of the primary outcome (17.8% vs. 6.2%; adjusted OR 3.89 [95%CI 1.42-10.63]). Among women with a history of a primary low transverse segment cesarean delivery, women who underwent TOLAC compared to those who had elective cesarean had increased odds of neonatal complications when VBAC likelihood was less than 60%.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Can recurrent cesarean section due to arrest of descent be predicted by newborn weight difference?

ObjectiveTo evaluate if newborn weight difference is associated with the mode of delivery in women with a previous cesarean section due to arrest of descent. Study DesignThis retrospective cohort analysis included all women admitted to the delivery room of Carmel Medical Center with a singleton fetus at vertex presentation and a prior cesarean section for arrest of descent. A comparison was made between women who had a subsequent successful vaginal birth after cesarean delivery vs. a repeat cesarean section for arrest of descent. The primary outcome was newborn weight difference between the previous cesarean section and the present delivery. Secondary outcomes were gestational age, gravidity, age, induction of labor, previous vaginal birth and epidural analgesia. ResultsOf 179 women with a prior cesarean section due to arrest of descent, 55 women (30.7 %) underwent an elective repeat cesarean section. Of the remaining 124 women, 95 women (76.6 %) achieved a vaginal delivery. Out of the 29 cases who underwent a repeat cesarean section, 18 women had a cesarean section for arrest of descent. Women who achieved vaginal delivery were more likely to be with higher gravidity, a previous vaginal delivery and a lower rate of epidural anesthesia. Following multivariate logistic regression, the women who required a cesarean section due to arrest of descent, had significantly higher birth weight in the current than in the previous pregnancy, compared to women achieving vaginal delivery (Odds Ratio 4.7, CI 95 % 1.4–15.7, P = 0.012). ConclusionCurrent birth weight higher than the previous newborn weight in a cesarean section for arrest of descent is associated with lower likelihood of successful vaginal birth after cesarean delivery and therefore should be taken in consideration during fetal weight estimation and the decision on the mode of delivery. This issue should be explored in future prospective large-cohort studies.

Hospital Variation in Utilization and Success of Trial of Labor After a Prior Cesarean

(Am J Obstet Gynecol. 2019;220:98.e1–98.e14) Although elective repeat cesarean is commonly performed to prevent uterine rupture during labor and other complications, cesarean delivery carries risks for mother and fetus, including increased risk of maternal and neonatal morbidity. Trial of labor after cesarean (TOLAC) delivery is recommended by the American College of Obstetricians and Gynecologists for women with no contraindications. The practice of TOLAC can be influenced by factors such as provider litigation concerns, patient preference and hospital support. The aim of this study was to understand varying utilization of TOLAC in California hospitals and how this affected patient outcomes. In addition, institutional characteristics associated with varying TOLAC utilization and success rates were analyzed.

Blood Transfusion Following Intended Vaginal Birth After Cesarean Versus Elective Repeat Cesarean Section in Women With a Prior Primary Cesarean: A Population‐based Record Linkage Study

(Acta Obstet Gynecol Scand. 2019;98:382–389) For parturients with a previous cesarean delivery, counseling and decision-making needs to be made regarding whether to attempt a vaginal birth after cesarean (VBAC) or undergo elective repeat cesarean section (ERCS). Many factors should be considered during the decision-making process including the likelihood of requiring blood transfusion due to postpartum hemorrhage (PPH). This is an important factor because blood transfusions after PPH have been associated with longer hospital stay, and increased risk of infection, morbidity, and mortality. This study was undertaken to ascertain blood transfusion and PPH rates related to chosen delivery method (VBAC or ERCS) for women with a prior cesarean delivery, as well as to determine the effect of the number of prior cesarean deliveries on transfusion rates.

Subsequent Pregnancy Outcomes After Failed Vacuum-Assisted Delivery.

To examine trial of labor after cesarean delivery (TOLAC) success rates and its associated factors among women with a previous failed vacuum-assisted vaginal delivery. We conducted a retrospective cohort study. The study group comprised all women with a prior failed vacuum-assisted vaginal delivery who subsequently delivered from 2008 to 2017 at a university hospital. Overall, 166 women with prior history of failed vacuum-assisted vaginal delivery delivered during the study period, with a median interdelivery interval of 28 (21-36) months. Of them, 53 (32%) had an elective repeat cesarean delivery, and 113 (68%) had a TOLAC. Although there were small statistical differences in the predelivery characteristics of the two groups, there were not clinically significant differences. Of the 113 women who underwent TOLAC in the subsequent pregnancy, the overall success rate was 67%. Neonatal 1- and 5-minute Apgar scores were lower among neonates born to women who experienced a failed TOLAC attempt compared with those who underwent successful TOLAC: 1-minute Apgar score less than 7 (6 [16%] vs 2 [3%], odds ratio [OR] 7.16, 95% CI 1.36-37.45, P=.01), 5-minute Apgar score less than 8 (3 [8%] vs 0 [0%], OR 15.5, 95% CI 1.78-308.7, P=.03). No events of obstetric anal sphincter injury, postpartum hemorrhage and uterine rupture were encountered among women who underwent TOLAC. Trial of labor after cesarean delivery in women with a previous failed vacuum-assisted vaginal delivery appears to be associated with an acceptable success rate. These data should improve patient counseling and provide reassurance for those who wish to deliver vaginally after a previous failed vacuum-assisted vaginal delivery.

The effect of maternal health conditions on maternal morbidity in women with a prior cesarean: the role of elective repeat cesarean delivery

Background: We evaluated women with a prior cesarean delivery (CD) who were eligible for elective repeat CD or trial of labor to test whether the risk of severe maternal morbidity (SMM) was: 1) directly associated with important pre-existing and gestational conditions or 2) indirectly associated (significantly increased or decreased) with the decision to undergo elective repeat CD.Methods: Women with a prior CD who had inborn, liveborn, term, singleton, vertex deliveries were identified in California 2010-2011 hospital discharge datasets. Using discharge codes, this population was stratified into two groups: attempted labor and elective repeat CD. A mediation model (stratified by younger vs. older women [&gt;35 years]) was built for each of the following maternal conditions (exposure): chronic/gestational diabetes mellitus (DM), chronic/gestational hypertension, heart disease, obesity, and mental health diagnoses. Elective repeat CD was the mediator and SMM was the outcome.Results: Of 141,535 eligible deliveries, 72.7% had an elective repeat CD; 2.3% had SMM, which occurred in 2.2% of younger vs. 2.6% of older women. For younger and older women respectively, the modeled total effect odds ratios (95% CI) for heart disease were: 10.7 (8.5, 13.5) and 8.8 (6.4, 12.2); for hypertension: 1.7 (1.4, 1.9) and 2.0 (1.6, 2.4); and for mental health diagnoses: 1.9 (1.6, 2.3) and 1.7 (1.3, 2.3). Neither DM nor obesity demonstrated a direct effect. Odds ratios for indirect effects were negligible for all models.Conclusion: Among women with a prior CD, in the presence of important health conditions, the increased risk of SMM mediated by an elective repeat CD was negligible.

The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study.

ObjectiveAfter one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women’s rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers’ fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates.MethodsWe performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion.ResultsThere was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69–1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18–2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40–0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001).ConclusionsImplementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

Establishment and validation of a prediction model for vaginal delivery after cesarean and its pregnancy outcomes—Based on a prospective study

ObjectiveTo explore factors that can be used to predict successful vaginal births after cesarean (VBAC) and its outcome. MethodsThis is a prospective study involving women with a previous low-segment cesarean section, singleton pregnancy and cephalic presentation who desire for vaginal trial delivery. Delivery modes were observed and the pregnancy outcomes were followed up. The data were analyzed to identify the factors associated with the success of vaginal births after cesarean (VBAC). Then, there were elaborated the models, and their predictive capacity was determined by receiver-operator curve (ROC). ResultsThe multivariate logistic regression showed Bishop’s score and spontaneous labour independently influenced vaginal births after cesarean (VBAC) success. The prediction model is established and validated. The fitting degree and prediction accuracy of the model is good. The vaginal births after cesarean (VBAC) group had less postpartum hemorrhage (Median 270 ml vs. 300 ml, P < 0.05), a lower puerperal infection rate (1.62% vs 5.88%, P < 0.01), and shorter postpartum hospitalization (Median 2 days vs. 3 days, P < 0.01) than the trial of labor after cesarean (TOLAC)-failure groups. It also had less postpartum hemorrhage (Median 270 ml vs. 320 ml, P < 0.01), a lower puerperal infection rate (1.62% vs 6.23%, P < 0.05), and shorter postpartum hospitalization (Median 2 days vs. 3 days, P < 0.01) than the elective repeat cesarean section (ERCS) groups. The use of labor analgesia in the vaginal births after cesarean (VBAC) group had no effect on pregnancy outcomes. ConclusionThe predictive factors are conducive to making rational choices about delivery mode and should improve pregnancy outcomes.

Preference of birth mode and postnatal health related quality of life after one previous caesarean section in three European countries

ObjectivesWomen who have had a caesarean section may have a preference for birth mode during their subsequent pregnancy, either ‘vaginal birth after caesarean’ (VBAC) or ‘elective repeat caesarean section’ (ERCS). A mismatch between the preferred and actual birth mode may result in an impaired postnatal Health Related Quality of Life (HRQoL). This study examined the associations between antenatal birth mode preferences, the actual birth mode and postnatal HRQoL in women with one previous caesarean section in three European countries. DesignProspective longitudinal survey, as a part of a cluster randomised trial (OptiBIRTH) SettingFifteen maternity units in three European countries: Germany (5), Ireland (5) and Italy (5). ParticipantsWomen (≥ aged 18 years) living in Germany, Ireland and Italy with one previous caesarean section. The sample consisted of 862 women with complete antenatal and postpartum data. MeasurementsWomen's preference for birth mode after one previous caesarean section was assessed at inclusion to the trial, and HRQoL was assessed antenatally and at three months postpartum using the Short-Form Six-Dimension health survey. Based on women's preferences and actual birth mode six groups were determined: “match VBAC-VBAC” (preference for vaginal birth, actual mode of birth vaginal birth), “match ERCS-ERCS” (preference for caesarean section, actual mode of birth elective repeat caesarean section), “match ERCS-EMCS” (preference for caesarean section, actual mode of birth emergency repeat caesarean section), “mismatch VBAC-ERCS” (preference for vaginal birth, actual mode of birth elective repeat caesarean section), “mismatch VBAC-EMCS” (preference for vaginal birth, actual mode of birth emergency repeat caesarean section) and “no preference”. Associations between the preferred and actual birth mode were examined using univariate and multivariate analyses. FindingsWomen with preference for vaginal birth but who gave birth by elective repeat caesarean section (mismatch VBAC-ERCS) had a lower postnatal HRQoL compared to women with a preference for vaginal birth who actually had a birth vaginally (match VBAC-VBAC, p = 0.02). Poor antenatal HRQoL scores (p < 0.01) and maternal readmission postpartum (p = 0.03) are cofounding factors for poorer postnatal HRQoL scores. Key conclusionsThe results show that women with a preference for a vaginal birth who gave birth by an elective repeat caesarean section had a significantly lower HRQoL at three months postnatal. The long-term consequences and psychological health of women who do not achieve a vaginal birth after caesarean require further consideration and research. Implications for practiceAttention should be given to the long-term impact of a mismatch in preferred and actual mode on the psychological health of women.

Risk of Repeat Cesarean Delivery in Women Undergoing Trial of Labor: A Population-based Cohort Study

(Acta Obstet Gynecol Scand. 2018;97:1524–1529) As the rate of cesarean delivery (CD) has increased worldwide, trial of labor after one cesarean delivery (TOLAC) is often recommended for limiting the incidence of CD. Both elective repeat cesarean delivery (ERCD) and TOLAC carry maternal and neonatal risks. Compared with ERCD, cesarean delivery following TOLAC is associated with increased risks of blood transfusion, hysterectomy, and endometritis. TOLAC itself is associated with a low but increased risk of uterine rupture. Previous studies have estimated the likelihood of successful VBAC after TOLAC in relation to maternal characteristics. These studies, though, have yielded contradictory results and study sizes have been limited. This study aimed to investigate the risk of TOLAC resulting in CD based on cervical dilation during labor for the first CD as well as the indication for the first CD.

Socio-cultural and clinician determinants in the maternal decision-making process in the choice for trial of labor vs. elective repeated cesarean section: a questionnaire comparison between Italian settings.

Objective To identify socio-cultural and clinician determinants in the decision-making process in the choice for trial of labor after cesarean (TOLAC) or elective repeat cesarean section (ERCS) in delivering women. Methods A tailored questionnaire focused on epidemiological, socio-cultural and obstetric data was administered to 133 patients; of these, 95 were admitted for assistance at birth at Fondazione Policlinico Universitario "A. Gemelli" (FPG) IRCCS, Rome, and 38 at S. Chiara Hospital (SCH), Trento, Italy. Descriptive analysis and logistic regression modeling were performed. Results Vaginal birth after cesarean (VBAC) rates were higher at SCH than at FPG (68.4% vs. 23.2%; P < 0.05). Maternal age in the TOLAC/VBAC group was significantly higher at SCH than at FPG (37.1 vs. 34.9 years, P < 0.05). High levels of education and no-working condition corresponded to a lower rate of VBAC. Proposal on delivery mode after a previous CS was missed in the majority of cases. Participation in prenatal course was significantly less among women in the ERCS groups. Using logistic regression, the following determinants were found to be statistically significant in the decision-making process: maternal age [odds ratio (OR) = 0.968 (95% confidence interval [CI] 0.941-0.999); P = 0.019], education level [OR = 0.618 (95% CI 0.419-0.995); P = 0.043], information received after the previous CS [OR = 0.401 (95% CI 0.195-1.252); P = 0.029], participation in antenatal courses [OR = 0.534 (95% CI 0.407-1.223); P = 0.045] and self-determination in attempting TOLAC [OR = 0.756 (95% CI 0.522-1.077); P = 0.037]. Conclusion In the attempt to promote person-centered care, increases in TOLAC/VBAC rates could be achieved by focusing on individual maternal needs. An ad hoc strategy for making birth safer should begin from accurate information at the time of the previous CS.

Double balloon catheter for labour induction at term after previous cesarean: a retrospective clinical research

Objective To determine the safety and effectiveness of double balloon catheter for labor induction in women with previous cesarean section. Methods This was a retrospective case-control study. Data from Shenzhen maternal and child healthcare hospital and Shenzhen Longgang District Maternal and Child Healthcare Hospital between 2015.01.01 to 2018.12.31 were used. A total of 156 term pregnant women, with previous one low segment cesarean section (CS) and balloon catheter for labour induction were included as case group. A total of 156 term pregnant women with previous one low segment CS and spontaneous onset of labor were included as control group. The vaginal delivery rate and maternal and infant outcomes were compared between the two groups. Results There was no significant difference in CS rate, vaginal assisted rate and vaginal spontaneous rate between the two groups (20.51% vs 15.38%, 8.97% vs 5.77%, 70.51% vs 78.85% respectively, P>0.05). And there were no significant difference in the rates of intrauterine infection, uterine rupture, postpartum hemorrhage, blood transfusion, maternal and infant mortality and neonatal transfer between the two groups. Conclusions Our study indicates that induction of labor with double balloon catheter is effective and safe in term pregnant women with previous one low segment CS. Women with previous CS and indications for labour induction should be informed about vaginal birth success rates and the alternative of elective repeat CS needs to be discussed. Key words: Labor, induced; Vaginal birth after cesarean; Catheterization

Clinical analysis of delivery mode of 576 cases of re-pregnancy after cesarean section

Objective To explore the choice of re-pregnancy delivery mode after cesarean section. Methods From January 2015 to December 2017, a retrospective study was performed on 576 pregnant women who received re-pregnancy after cesarean section in National Nuclear Corporation 416 Hospital and randomly selected 40 cases of vaginal birth after cesarean delivery(VBAC), 40 cases of cesarean section after trial of labor after cesarean delivery(TOLAC) and 40 cases of elective repeat cesarean delivery(ERCD) for comparative analysis.The postpartum hemorrhage, neonatal Apgar score, hospitalization time, hospitalization expenses and complication were compared. Results All the 159 pregnant women chose transvaginal trials and 112 had successful vaginal delivery.The success rate of delivery was 70.4%.Compared with the other two groups, the VBAC group had less postpartum hemorrhage [(172.50±59.86)mL, (281.25±192.05)mL, (260.00±125.68)mL], less average hospital stay [(3.9±0.9)d, (5.7±1.5)d, (4.6±0.7)d] and lower medical expenses [(6 491.79±1 104.78), (11 871.96±1 784.30), (10 724.69±1 843.63)], and the differences were statistically significant (F=7.086, 26.243, 123.488; P=0.001, 0.000, 0.000). The neonatal Apgar score, incidence rates of complications (incomplete uterine rupture, postpartum hemorrhage, urinary retention, thrombotic disease and neonatal conversion) had no statistically significant differences between the two groups (all P>0.05). The TOLAC failed to change to the cesarean section group compared with the ERCD group, the average hospitalization cost was more [(11 871.96±1 784.30)CNY, (10 724.69±1 843.63)CNY], the average hospitalization days was longer [(5.7±1.5)d, (4.6±0.7)d], the difference was statistically significant (P=0.000, 0.005). The postpartum hemorrhage volume, neonatal Apgar score, complications had no statistically significant differences between the two groups(all P>0.05). Conclusion It is safe and feasible to perform vaginal trials under close monitoring without vaginal trials.It is safe and feasible to perform vaginal trials under strict monitoring.Even if the vaginal trial fails to change to cesarean section, it will not increase the occurrence of serious complications.Infant outcomes are good. Key words: Cesarean section; Pregnancy; Mode of delivery