History Of Prior Cesarean Delivery Research Articles

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator.

To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors. We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts. Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC. Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

A unique placenta previa risk factor profile for pregnancies conceived with assisted reproductive technology

To define specific risk factors for placenta previa in pregnancies conceived with assisted reproductive technology (ART). Retrospective cohort. Fertility centers and inpatient obstetric units in Massachusetts. Patients conceiving with ART and delivering at 20 weeks gestation or later between 2011 and 2017 in Massachusetts. Patient demographic and medical factors and specific components of their cycles. Data were obtained by linking vital records of the State of Massachusetts to reproductive clinic data obtained from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System, and then supplementing this information with laboratory and obstetric data from 2 large academic hospitals. Associations were tested between multiple cycle- and patient-related factors and placenta previa or low-lying placenta at delivery. After testing for confounders, multivariate models were adjusted for maternal age, history of prior cesarean delivery and birth plurality, and are reported as adjusted relative risks (aRR). We included 18,939 pregnancies, with 553 (2.9%) having placenta previa at delivery. Advanced maternal age (aRR, 1.25; 95% confidence interval [CI], 1.06-1.48), endometriosis, (aRR, 2.22; 95% CI, 1.71-2.86), and controlled ovarian hyperstimulation (aRR, 1.33; 95% CI, 1.12-1.59) were associated with placenta previa, whereas multiple births (aRR, 0.63; 95% CI, 0.48-0.81) and a history of polycystic ovary syndrome or ovulation disorders (aRR, 0.59; 95% CI, 0.46-0.75) had negative associations. The endometriosis association was strong in nulliparas and the controlled ovarian hyperstimulation association was strong in parous patients in a stratified analysis. No association was seen with prior history of cesarean delivery. Patients conceiving with ART do not have the typical previa risk factors of prior cesarean delivery and multiple gestations, whereas endometriosis and fresh embryo transfers contributed moderate risk. The embryo transfer process itself may affect previa development in this population.

The association of timing of repeat cesarean with outcomes among a cohort of Guatemalan women with a history of prior cesarean birth

BackgroundThe objective of this analysis was to observe whether maternal and perinatal/neonatal outcomes of birth vary by timing of repeat cesarean among women with a history of one prior cesarean birth in a Guatemalan cohort.MethodsThis secondary analysis was conducted using data from a prospective study conducted in communities in Chimaltenango, Guatemala through the Global Network for Women’s and Children’s Health Research.ResultsBetween January 2017 and April 2020, 26,465 women delivered; 3,143 (11.9%) of those women had a singleton gestation and a history of prior cesarean delivery. 2,210 (79.9%) women with a history of prior cesarean birth had data available on mode of delivery and gave birth by repeat cesarean; 1312 (59.4%) were pre-labor cesareans while 896 (40.5%) were intrapartum cesarean births. Risk factors associated with an increased risk of intrapartum cesarean birth included hospital delivery as compared to “other” location (ARR 1.6 [1.2,2.1]) and dysfunctional labor (ARR 1.6 [1.4,1.9]). Variables associated with a reduced risk of intrapartum cesarean birth were hypertensive disease (ARR 0.7 [0.6,0.9]), schooling (ARR 0.9 [0.8,0.9]), and increasing age, which was associated with a very slight reduction in the outcome (ARR 0.99 [0.98,0.99]). Maternal and neonatal outcomes did not vary by type of cesarean birth.ConclusionOutcomes of cesarean birth do not seem to vary by timing of repeat cesarean birth, with hypertensive disease increasing the likelihood of pre-labor cesarean. This information might be useful in counseling women that outcomes after failed trial of labor do not appear worse than those after pre-labor cesarean birth.

846 Risk of stillbirth with history of prior cesarean deliveries

The rate of US births delivered by cesarean has increased significantly, even for women considered to be at low risk for cesarean delivery (CD). The relationship between previous CD and subsequent stillbirth is unclear. We aim to examine the influence of prior CD, and increasing numbers of prior CDs, on the risk of subsequent stillbirth. Population-based retrospective cohort of all live births and stillbirths in the US 2014-2016 using CDC Vital Statics. Rates of stillbirth of multiparous woman with singleton gestations with prior history of vaginal deliveries (referent) were compared to a similar cohort with prior history of CD, and stratified by number of CDs (one, two, three and ≥ four). Rates of stillbirth were also compared at term, stratified by week of gestational age (GA) with comparison groups of one and ≥ two prior CDs (exposure groups consolidated due to small sample size in some comparisons). Multivariate logistic regression quantified the relationship between history of prior CDs and risk of stillbirth risk after adjustment for coexisting risk factors. Of the 7,614,326 singleton births in parous women, 77.8% had no prior CD and 22.2% had at least one prior CD. The rate of stillbirth was 4.27 per 1,000 births in women without prior CD vs 4.51 per 1000 births with prior CD, p<0.01. As the number of prior CDs increased, the rate of stillbirth increased linearly from 4.17 with one prior to 7.96 per 1,000 with ≥4 prior CDs, p < 0.01, r=0.93. The adjusted relative risk (aRR) of stillbirth was not significantly increased with one or two prior CDs, but increased with higher number of prior CDs, highest with four or more prior (aRR 1.38, 95% 1.17-1.63). At term, the aRR of stillbirth was significantly increased with two or more prior CDs, 38 weeks GA (aRR 1.40, 95% 1.16-1.69), 40 weeks GA (aRR 2.27, 95% 1.49-3.45). Stillbirth rates increase linearly with increasing number of prior CDs. Prior CD is associated with increased risk of stillbirth in women with three or more prior cesareans. Stillbirth risk is most pronounced at term, with >2-fold risk at 40 weeks.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

767 Cesarean wound outcomes among super obese women

To evaluate the difference in wound outcomes among super obese (BMI >50 kg/m2) and obese (BMI 30-49.9 kg/m2) women undergoing cesarean delivery. This is a secondary analysis of a single site randomized clinical trial of women who underwent cesarean delivery between September 2013 and June 2016. Participants in the original study were randomized to a silver nylon dressing versus standard gauze dressing. Inclusion criteria included completion of > 36 gestational weeks, receipt of preoperative antibiotics, and scheduled or unscheduled cesarean delivery via Pfannenstiel incision. In this secondary analysis, patient characteristic of women with BMI >50 kg/m2 were compared to women with BMI 30-49.9 kg/m2 using chi-square, Students T-test, and logistic regression to generate adjusted odds ratios and 95% confidence intervals. P-value < 0.5 was considered significant. Among the 657 participants who underwent randomization, 470 were noted to have BMI >30 kg/m2. Within this cohort of obese women, 50 (10.6%) had a BMI >50 kg/m2. Sociodemographic data was similar among the groups. Women in the obese and super obese groups were similar with regard to labor prior to cesarean (30.8% vs 38.8%, p=0.255), smoking status in pregnancy (6.2% vs 0%, p=0.18), chorioamnionitis (3.3% vs 6.0%, p=0.34), and diabetes type 1 (2.1% vs 2.0%, p=0.947). Compared to women BMI 30-49.9 kg/m2, super obese women had higher rates of gestational diabetes (22% vs 8.1%, p< 0.001), diabetes type 2 (14% vs 5%, p=0.011), chronic hypertension (52% vs 15.7%, p< 0.001), and prior cesarean delivery (26.5% vs 12.6%, p=0.008). Women in the super obese category were more likely to have any wound infection (aOR 2.95 [1.14-7.62]). Composite outcome for wound complication was not statistically significantly increased for the super obese cohort (aOR 1.7 [0.73-4.09]). History of prior cesarean delivery was independently associated with increased risk of wound infection. Women with BMI > 50 kg/m2 undergoing cesarean delivery were more likely to have a wound infection compared to obese counterparts.

Influence of Race/Ethnicity on Cesarean Delivery by Year in the United States

Objective: Attempts have been made to reduce the rate of cesarean delivery in the United States. The intent of this study was to examine the trends of cesarean delivery rates over time by race/ethnicity in the United States, stratified by parity and history of prior cesarean delivery. Methods: A retrospective cohort study in the United States between 2011 and 2018 using linked vital statistics data derived from National Center for Health Statistics. Race/ethnicity was categorized into non-Hispanic white, non-Hispanic Black, Hispanic, Asian, and American Indian & Alaska Native (AIAN). Chi-square tests were used to compare rates of cesarean delivery between years among all racial/ethnic groups. Multivariable logistic regression analyses were used to examine the association of race/ethnicity with cesarean delivery, controlling for maternal age, BMI, parity, education, number of prenatal visits, insurance, diabetic disease and hypertensive disease. Our main outcomes were rates of cesarean delivery in each considered racial/ethnic group and year by parity and history of prior cesarean delivery. Results: Our cohort of 27,779,284 patients consisted of 14,982,866 (53.9%) white, 4,046,238 (14.6%) Black, 6,750,058 (24.3%) Hispanic, 1,773,798 (6.4%) Asian, and 226,324 (0.8%) AIAN individuals. When examining nulliparous parturients, the rates of cesarean delivery decreased for white, Asian, and AIAN nulliparas, but increased from 33.1% to 33.5% (p=0.01) for Black nulliparas between the years of 2011 to 2018. The rates of cesarean delivery in multiparous individuals decreased across all racial/ethnic groups. Conclusion: Rates of cesarean delivery increased in Black individuals but decreased in all other races/ethnicities over time among nulliparas. During a time when efforts were made to reduce the risk of cesarean delivery, rates both increased in Black individuals and health disparities increased. As these associations persisted even when controlling for confounders in multivariate analysis, investigation of structural contributors of these varied outcomes is needed. Funding: None to declare. Declaration of Interest: None to declare.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis

Background The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD). Objectives To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term. Study design A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34–41 weeks’ gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. Results In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%). Conclusion In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Robotic Resection and Revision of Uterine Scar Defect with Hysteroscopic Guidance

Study Objective To demonstrate the steps of a robotic-assisted resection and revision of a uterine scar defect with hysteroscopic guidance and review tips and trips for this rare surgical procedure. Design This video describes the step by step approach to a robotic resection and revision of a uterine scar defect using hysteroscopic guidance to identify the target anatomy. Additionally, we describe tips and tricks to utilize while performing this rare surgical procedure to facilitate identification of the uterine scar laparoscopically, resect the defect in its entirety, improve hemostasis, and place a supportive suture for revision. Setting The patient was placed in dorsal lithotomy position in preparation for both hysteroscopic and robotic access. Patients or Participants In this surgical video, we present a case of a women with secondary infertility and a uterine scar defect in the setting of a history of prior cesarean delivery. She was referred by an REI physician due to history of aborted embryo transfers with abnormal fluid collections in the uterine defect. Interventions Robotic-assisted resection and revision of the uterine scar defect with hysteroscopic guidance. Measurements and Main Results Complete resection and reapproximation of the defect was visualized both laparoscopically and hysteroscopically without evidence of leakage of hysteroscopic fluid through the incision. Conclusion A minimally invasive approach to uterine scar defects can utilize simultaneous robotic-assisted laparoscopy and hysteroscopic guidance to identify the defect for resection and revision in symptomatic women or for fertility indications.

Association of Prior Cesarean Delivery With Early Term Delivery and Neonatal Morbidity

To assess whether a history of prior cesarean delivery is associated with an increased risk of earlier delivery timing and resultant neonatal morbidity. We performed a population-based retrospective cohort study using U.S. birth certificate data, 2012-2016. The study population included women with one or more prior cesarean deliveries compared with a referent group of parous women without prior cesarean delivery. To enrich for a population with minimized risk factors for early delivery, we excluded women with history of preterm birth, pregnancies complicated by multifetal gestation, pregnancy-induced hypertension, anomaly, small for gestational age, or malpresentation. Analyses were limited to births from 35 to 42 weeks of gestation. Women with a vaginal birth after cesarean delivery were excluded. The primary outcome was the risk of birth at each week of gestational age. Secondary outcomes included adverse neonatal and maternal outcomes. Patients were stratified by number of prior cesarean deliveries (one, two, three, or four or more) compared with parous patients without prior cesarean delivery. The adjusted relative risk (aRR) of delivery at 35 weeks of gestation was highest in women with four or more prior cesarean deliveries (aRR 2.79, 95% CI 2.74-2.82). Prior cesarean delivery also had a significant influence on neonatal morbidity. As the number of prior cesarean deliveries increased, the risk of composite neonatal morbidity increased, from 8.0% (aRR 1.5, 95% CI 1.48-1.51) with one prior cesarean delivery up to 21.0% (aRR 4.9, 95% CI 4.76-5.04) with four or more prior cesarean deliveries compared with a baseline risk of 5.5% in parous women without prior cesarean delivery. Prior cesarean delivery is correlated with earlier delivery and increased neonatal morbidity. Advocating trial of labor after cesarean delivery may provide maternal and neonatal benefit.

A new methodologic approach for clinico-pathologic correlations in invasive placenta previa accreta

The development of new management strategies for women presenting with placenta accreta spectrum requires quality epidemiology data, which have so far been limited by the high variability in clinical and histopathologic data confirming the diagnosis at birth. To evaluate the role of a new methodologic approach for the correlation of clinical and pathological data for women with a history of prior cesarean delivery diagnosed prenatally with placenta previa accreta. A modified pathologic technique for gross examination of hysterectomy specimens with placenta in situ consisting of intraoperative examination, immediate postoperative examination, and guided histologic sampling was used prospectively in a cohort of 24 patients with singleton pregnancies complicated by placenta low-lying/placenta previa accreta. Maternal characteristics, detailed ultrasound findings, surgical outcomes, and histopathologic examination were compared with those of a group of 24 patients with similar clinical characteristics and in whom a standard pathologic examination method was used. The median reporting time for obtaining the complete histopathology results including the microscopic examination was significantly shorter (7 versus 15 days; P < .001) and the median number of samples taken for histologic examination significantly lower (4 versus 14 samples; P < .001) in the study group than in the controls. The number of histologic slides showing villous invasion was significantly higher (2 versus 1 slide; P= .002), and the ratio of the number of samples taken to the numbers of slides confirming villous invasion was significantly lower (2 versus 9; P < .001) in the study group than in the controls. In all cases in the study group, intraoperative examination identified a dense tangled bed of vessels or multiple vessels running laterally and cranio-caudally in the uterine serosa above the placental insertion that were no longer visible during immediate gross postoperative examination of the hysterectomy specimens. Immediate postoperative dissection enables the differential diagnosis between focal and large increta areas, and between abnormally adherent placenta and invasive placenta accreta. Valuable clinical information on the serosal vascularity, uterine dehiscence, and extension of the accreta area is added with the description of the macroscopic examination during the surgical procedure and immediate dissection of the specimen. This methodological approach is cost-effective and increases the quality of the histologic sampling. It thus provides more accurate correlations with the clinical data and more accurate epidemiologic data collection. Perinatal pathologists should be part of multidisciplinary teams involved the management placenta accreta spectrum disorders.

Mode of delivery in antepartum stillbirths

Stillbirth complicates 1 in 160 pregnancies in the United States. We sought to determine the rate of cesarean delivery in pregnancies complicated by antepartum stillbirth and to identify characteristics associated with cesarean delivery. This was a population-based retrospective cohort study of all stillbirths in the United States during the year of 2014. Frequency of cesarean delivery was stratified by week of gestation. Maternal, obstetric, and fetal characteristics were compared between women with antepartum stillbirth who underwent cesarean delivery compared with vaginal delivery. Multivariate logistic regression estimated the relative influence of maternal, obstetric, and fetal factors on the outcome of cesarean delivery. There were 16,160 nonlaboring women diagnosed with stillbirth during 2014 in the United States. Of the 16,160 stillbirths, 2449 (15.2%) underwent cesarean delivery. At 20-23, 24-27, 28-31, 32-36, and >36 weeks of gestation, the cesarean delivery rate was 4.0%, 16.2%, 23.7%, 30.8%, and 28.8%, respectively. Factors associated with cesarean delivery included gestational diabetes, preeclampsia, use of assisted reproductive technology, history of prior cesarean delivery, and increasing gestational age at delivery. Approximately 15% of women diagnosed with a stillbirth after 16 weeks of gestation underwent a cesarean delivery in 2014. The stillbirth cesarean delivery rate peaked during the third trimester, during which more than 1 in 4 women underwent a cesarean birth.

Multidisciplinary treatment of total placenta previa in a blood-refusal parturient for a religious reason.

Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta.The objective of the study was to evaluate the accuracy of ultrasound imaging in the prenatal diagnosis of placenta accreta and the impact of the depth of villous invasion on management in women presenting with placenta previa or low-lying placenta and with 1 or more prior cesarean deliveries.We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE for studies published between 1982 and November 2016.Criteria for the study were cohort studies that provided data on previous mode of delivery, placenta previa, or low-lying placenta on prenatal ultrasound imaging and pregnancy outcome. The initial search identified 171 records, of which 5 retrospective and 9 prospective cohort studies were eligible for inclusion in the quantitative analysis.The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool.The 14 cohort studies included 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries screened for placenta accreta. There were 328 cases of placenta previa accreta (8.4%), of which 298 (90.9%) were diagnosed prenatally by ultrasound. The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries. The pooled performance of ultrasound for the antenatal detection of placenta previa accreta was higher in prospective than retrospective studies, with a diagnostic odds ratios of 228.5 (95% confidence interval, 67.2–776.9) and 80.8 (95% confidence interval, 13.0–501.4), respectively. Only 2 studies provided detailed data on the relationship between the depth of villous invasion and the number of previous cesarean deliveries, independently of the depth of the villous invasion. A cesarean hysterectomy was performed in 208 of 232 cases (89.7%) for which detailed data on management were available. Positive correlations were found in the largest prospective studies between the cumulative rates of the more invasive forms of accreta placentation and the sensitivity and specificity of ultrasound imaging but not with diagnostic odds ratio values. We found no data on the ultrasound screening of placenta accreta at the routine midtrimester ultrasound examination from the nonexpert ultrasound units.Planning individual management for delivery is possible only with accurate evaluation of prenatal risk of accreta placentation in women presenting with a low-lying placenta/previa and a history of prior cesarean delivery. Ultrasound is highly sensitive and specific in the prenatal diagnosis of accreta placentation when performed by skilled operators. Developing a prenatal screening protocol is now essential to further improve the outcome of this increasingly more common major obstetric complication.

Route of Delivery in Women With Stillbirth: Results From the Stillbirth Collaborative Research Network.

To describe delivery management of singleton stillbirths in a population-based, multicenter case series. We conducted a retrospective chart review of 611 women with singleton stillbirths at 20 weeks of gestation or greater from March 2006 to September 2008. Medical and delivery information was abstracted from medical records. Both antepartum and intrapartum stillbirths were included; these were analyzed both together and separately. The primary outcome was mode of delivery. Secondary outcomes included induction of labor and indications for cesarean delivery. Indications for cesarean delivery were classified as obstetric (abnormal fetal heart tracing before intrapartum demise, abruption, coagulopathy, uterine rupture, placenta previa, or labor dystocia) or nonobstetric (patient request, repeat cesarean delivery, or not documented). Of the 611 total cases of stillbirth, 93 (15.2%) underwent cesarean delivery, including 43.0% (46/107) of women with prior cesarean delivery and 9.3% (47/504) of women without prior cesarean delivery. No documented obstetric indication was evident for 38.3% (18/47) of primary and 78.3% (36/46) of repeat cesarean deliveries. Labor induction resulted in vaginal delivery for 98.5% (321/326) of women without prior cesarean delivery and 91.1% (41/45) of women with a history of prior cesarean delivery, including two women who had uterine rupture. Among women with a history of prior cesarean delivery who had spontaneous labor, 74.1% (20/27) delivered vaginally, with no cases of uterine rupture. Women with stillbirth usually delivered vaginally regardless of whether labor was spontaneous or induced or whether they had a prior cesarean delivery. However, 15% underwent cesarean delivery, often without a documented obstetric indication.

Serious adverse neonatal outcomes such as 5-minute Apgar score of zero and seizures or severe neurologic dysfunction are increased in planned home births after cesarean delivery.

The United States is with 37,451 home births in 2014 the country with the largest absolute number of home births among all developed countries. The purpose of this study was to examine the occurrence and risks of a 5-minute Apgar score of zero and neonatal seizures or serious neurologic dysfunction in women with a history of prior cesarean delivery for planned home vaginal birth after cesarean (VBAC), compared to hospital VBAC and hospital birth cesarean deliveries for term normal weight infants in the United States from 2007–2014. We report in this study outcomes of women who had one or more prior cesarean deliveries and included women who had a successful vaginal birth after a trial of labor after cesarean (TOLAC) at home and in the hospital, and a repeat cesarean delivery in the hospital. We excluded preterm births (<37 weeks) and infants weighing under 2500 g. Hospital VBACS were the reference. Women with a planned home birth VBAC had an approximately 10-fold and higher increase in adverse neonatal outcomes when compared to hospital VBACS and hospital repeat cesarean deliveries, a significantly higher incidence and risk of a 5-minute Apgar score of 0 of 1 in 890 (11.24/10,000, relative risk 9.04, 95% confidence interval 4–20.39, p<.0001) and an incidence of neonatal seizures or severe neurologic dysfunction of 1 in 814 (Incidence: 12.27/10,000, relative risk 11.19, 95% confidence interval 5.13–24.29, p<.0001). Because of the significantly increased neonatal risks, obstetric providers should therefore not offer or perform planned home TOLACs and for those desiring a VBAC should strongly recommend a planned TOLAC in the appropriate hospital setting. We emphasize that this stance should be accompanied by effective efforts to make TOLAC available in the appropriate hospital setting.

The gravid uterus: MR imaging and reporting of abnormal placentation.

Appropriate placentation is critical to maternal and fetal outcomes. Abnormal placentation, including placenta previa and morbidly adherent placenta, is increasing in incidence and is associated with multiple risk factors including advanced maternal age and history of prior cesarean delivery. Magnetic resonance imaging (MRI) is increasingly used in assessing the type and extent of abnormal placentation, often leading to modifications in surgical approach. Here, we review the MRI features and appropriate reporting of placenta previa and the placenta accreta spectrum.

Impact of a prior cesarean delivery on embryo transfer: a prospective study

To determine whether a history of prior cesarean delivery (CD) makes ET more difficult and impacts pregnancy outcomes. Prospective cohort study. Tertiary care military facility. One hundred ninety-four patients with previous delivery undergoing IVF/intracytoplasmic sperm injection (ICSI)-ET. None. Live birth (primary), positive hCG, clinical pregnancy, and time to perform ET. There was no statistically significant difference between patients with a history of only vaginal deliveries versus those with a history of CD for live birth (39% vs. 32%), positive hCG (56% vs. 53%), or clinical pregnancy (49% vs. 41%). Embryo transfers took longer in the history of CD group (157 vs. 187seconds) and were more likely to have mucus (27% vs. 45%) or blood (8% vs. 21%) on the catheter. Embryo transfers performed on patients with a prior CD took 30seconds longer. They were also more likely to have blood or mucus on the catheter. Despite the apparently more difficult transfers, pregnancy outcomes were not different between the two groups.

Comparison of Cesarean Delivery Rates in Urban and Rural Hospitals [1

INTRODUCTION: Some studies have demonstrated hospital and geographic variation in cesarean delivery rates. Our objective is to compare primary cesarean delivery rates in urban and rural hospitals. METHODS: We examined all hospital admissions of women who delivered a singleton live-born neonate in the state of Hawaii from January 2010 to December 2011 using the Hawaii Health Information Corporation database. Women with a history of prior cesarean delivery were excluded. Hospitals were divided into two categories: rural and urban. Primary cesarean delivery rates as well as common reasons for primary cesarean deliveries were examined. RESULTS: Of the 30,647 women who met criteria for our study, 7,717 (25.3%) delivered in rural hospitals. Women who delivered at rural hospitals had fewer risk factors for cesarean delivery, including advanced maternal age, preterm delivery, pregestational diabetes, and hypertensive disease. However, rural hospitals had a higher primary cesarean delivery rate of 21.1% compared with 15.3% in the urban hospitals (P<.001). Even after adjusting for maternal risk factors and common indications for cesarean delivery, women who delivered at rural hospitals had a more than twofold risk for cesarean delivery (adjusted odds ratio 2.46, 95% confidence interval 2.26–2.70). CONCLUSION AND IMPLICATION: In a geographically isolated population, rates of cesarean delivery are significantly higher in rural hospitals. Because reasons for this finding are unclear, this disparity should be investigated further.

Cervical Insufficiency After Prior Term Delivery

OBJECTIVE: Our objective was to examine the relationship between obstetric and gynecologic procedures and the development of secondary cervical insufficiency, a term we coined for patient who had a history of birth(s) at term and developed cervical insufficiency in a subsequent pregnancy. The primary objective was to determine whether previous cesarean delivery increases the likelihood of secondary cervical insufficiency. Our secondary objective was to look at other obstetrics and gynecologic factors and the development of secondary cervical insufficiency. STUDY DESIGN: This was a case–control study. All deliveries occurring between 2011 and 2014 in our center were reviewed. Participants were defined as having clinical characteristics suggestive of cervical insufficiency and having had a history of at least delivery at term, before the index pregnancy. Parity-matched participants for the control group were selected as the next patient who had a term delivery immediately after the case. The obstetric and gynecologic characteristics of the participants in the case and control groups were compared. RESULTS: Thirty-seven patients had clinical characteristics suggesting of secondary cervical insufficiency. Women in the case group delivered at a mean gestational age of 24.3 weeks compared with 39.0 weeks of gestation for women in the control group. Women in the case group were not more likely to have had a history of prior cesarean delivery(s) than those in the control group, eight of 37 (22%) compared with 11 of 37 (30%). However, women in the case group were more likely to have had an interpregnancy dilatation and curettage (D&C) (nine of 37 compared with one of 37, P=.01) and to have multiple prior D&C procedures (seven of 37 compared with one of 37, P=.03). CONCLUSION: There does not seem to be an association between cesarean delivery and the subsequent development of secondary cervical insufficiency. However, there was an association between secondary cervical insufficiency and history of multiple D&Cs and interpregnancy D&Cs.

The public health threat of anti-abortion legislation

The public health threat of anti-abortion legislation

Hysteroscopic removal of cesarean scar pregnancy after methotrexate treatment failure

Abstract A 35-year-old woman with persistent vaginal bleeding and a history of prior cesarean delivery was diagnosed with cesarean scar pregnancy (CSP) by transvaginal ultrasonography at 7 weeks of gestation. The patient was initially treated with a single dose of systemic methotrexate (MTX) injection. However, both follow-up β-hCG levels and transvaginal ultrasonography had shown evidence of ongoing pregnancy. Finally, she was treated with hysteroscopic resectoscope, by which the gestational tissue was removed completely. No intra-operative or post-operative complication occurred. Serum β-hCG level returned to normal limit four weeks after the surgery. In our experience, systemic MTX injection provides an alternative choice of treatment for carefully selected women with CSP, and hysteroscopic removal of CSP, which offers good prognosis, can serve both as the initial treatment and as the rescue management after a failed MTX treatment attempt.