Prior Cesarean Research Articles

Comparison between a prenatal sonographic scoring system and a clinical grading at delivery for Placenta Accreta Spectrum disorders

Objective Placenta Accreta Spectrum (PAS) disorders have become a major iatrogenic obstetric complication worldwide. Data on the accuracy of ultrasound examination diagnosis are limited by incomplete confirmation and variability in the description of the different grades of PAS at delivery. The aim of this study was to compare our prenatal routine sonographic screening and diagnostic scoring system with a standardized clinical grading system at birth in patient at risk of PAS Study design This is a retrospective cohort study of 607 pregnant patients with at least one prior cesarean delivery between December 2013 and December 2018. All patients were assessed for PAS using our institutional prenatal sonographic scoring system and the corresponding ultrasound findings were compared with those of a standardized clinical intra-operative macroscopic grading system of the degree of accreta placentation at vaginal birth or laparotomy. Results PAS was diagnosed clinically at birth in 50 (8.2%) cases, 17 of which were confirmed by histopathology. A low (score ≤ 5), medium (score 6-7), high (score ≥ 8) probability for PAS was reported in 502, 61 and 44 cases, respectively. The probability score increased significantly (p < .001) in women ≥2 prior cesarean deliveries, with an anterior low-lying/placenta previa, with absent clear space, increased in retroplacental vascularity and with the size and numbers of lacunae. The number of cases classified clinically as grade 1 (non-PAS) and 3 (adherent PAS) was significantly (p < .001) lower in women with a high probability score whereas the rates of the other grades was significantly (p < .001) higher. The widest discrepancy between ultrasound probability score and clinical grade was found for grade 2 which, describes a partial placental adherence and grades 4 and 5 which, refer to placental percreta which describes tissue having invade trough the uterine serosa and beyond. Conclusions Both ends of the spectrum of accreta placentation remain difficult to diagnose antenatal and clinically at birth, in particular when no histopathologic confirmation is available. There is a need to develop ultrasound accuracy score systems that can differentiate between the different grades of PAS and which are validated by standardized clinical and pathology protocols.

Potentially Preventable Primary Cesarean Sections in Future Placenta Accreta Spectrum.

Prior cesarean delivery is a well-known risk factor for placenta accreta spectrum disorders. While primary cesarean section is unavoidable in some patients, in others it may not be clearly indicated. The aim of the study is to determine the proportion of patients with placenta accreta spectrum who had a potentially preventable primary cesarean section and to identify factors associated with preventable placenta accreta spectrum. This was a single-center retrospective cohort study of women with pathology-confirmed placenta accreta spectrum from 2007 to 2019. Primary cesarean sections were categorized as potentially preventable or unpreventable based on practice consistent with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine "Safe Prevention of the Primary Cesarean Delivery" recommendations. Fisher's exact test and Mann-Whitney U-test were used for comparison with p <0.05 considered statistically significant. Seventy-two patients had pathology-confirmed placenta accreta spectrum over the course of the study period, 15 (20.8%) of whom required a cesarean hysterectomy at the time of primary cesarean section. Fifty-seven patients had placenta accreta spectrum in a pregnancy following their primary cesarean section. Of these, 29 (50.9%) were considered potentially preventable. Most were performed without clear medical indication (37.9%) or for fetal malpresentation without attempted external cephalic version (37.9%). The remainder were due to arrest of labor not meeting criteria (17.2%) and abnormal or indeterminate fetal heart patterns with documented recovery (6.9%). Of the 11 patients without clear medical indication for primary cesarean section, eight (72.7%) were patient-choice cesarean sections and three (27.3%) were for suspected fetal macrosomia with estimated fetal weights not meeting criteria for cesarean delivery. There was no difference in the incidence of potentially preventable primary cesarean sections before and after the ACOG-SMFM "Safe Prevention of the Primary Cesarean Delivery" publication (48.8 vs. 57.1%, p = 0.59). Privately insured patients were more likely to have a potentially preventable primary cesarean section than those with Medicaid (62.5 vs. 23.5%, p = 0.008) and were more likely to have a primary cesarean section without clear medical indication (81.8 vs. 18.2%, p = 0.004). Many patients with placenta accreta spectrum had a potentially preventable primary cesarean section. Most were performed without clear medical indication or for malpresentation without attempted external cephalic version, suggesting that at least a subset of placenta accreta spectrum cases may be preventable. This was particularly true for privately insured patients. These findings call for continued investigation of potentially preventable primary cesarean sections with initiatives to address concerns at the patient, provider, and hospital level. · Many patients with placenta accreta spectrum have potentially preventable primary cesarean sections.. · Privately insured patients are more likely to have potentially preventable primary cesarean sections.. · Our findings suggest that at least a subset of placenta accreta spectrum cases may be preventable..

Maternal and neonatal adverse outcomes in individuals with a prior cesarean birth who undergo induction at 39 weeks

ObjectiveTo compare the maternal and neonatal adverse outcomes among individuals with one or two prior cesarean deliveries who are induced at 39 weeks gestational age versus those that are expectantly managed. MethodsThis was a population-based cross-sectional study using U.S. National Vital Statistics 2014–2018 period linked birth and infant death data. Cohorts were individuals with one or two prior cesarean deliveries who were induced at 39.0 to 39.6 weeks gestation or underwent delivery from 40.0 to 41.6 weeks gestational age from either spontaneous labor or induction. The primary outcome was a composite of maternal adverse outcomes: admission to the intensive care unit, transfusion, uterine rupture, or unplanned hysterectomy. The secondary outcome was a composite of neonatal adverse outcomes, including: 5-minute Apgar score <5, assisted ventilation for >6 h, neonatal seizures, or neonatal mortality (death within 27 days of birth). ResultsOf 263,489 women who met the inclusion criteria 21,951 (8.3%) underwent induction at 39 weeks. The composite maternal adverse outcome was significantly higher in women who delivered at 40–41 weeks gestation when compared to the 39 week gestation induction of labor cohort (8.1 versus 9.4 per 1,000 births; aRR 1.18; 95% CI 1.01–1.39). The overall rate of composite neonatal adverse outcome was 10.4 per 1,000 live births. The composite neonatal adverse outcome was also significantly elevated among deliveries at 40–41 weeks gestation as well (8.6 vs. 10.8 per 1,000 live births; aRR 1.31; 95%CI 1.12–1.53). ConclusionIn women undergoing trial of labor after cesarean, induction of labor at 39 weeks gestation was associated with fewer maternal and neonatal adverse outcomes when compared to delivery at 40–41 weeks gestation.

Common Combinations of Pregestational Diagnosis and Pregnancy Complications.

ObjectiveSingle pregestational diagnoses have been demonstrated to be associated with pregnancy-related complications. But, the effect of multiple diagnoses is understudied. The objective of this study is to determine the most common combinations of pregestational diagnoses and to determine if specific combinations increase the risk of pregnancy-related complications.Study designWe performed a cross-sectional study of the 2016 Healthcare Cost and Utilization Project’s National Inpatient Sample (HCUP NIS) database. Inclusion criteria were: Diagnosis-related groups assumed to be associated with delivery, and three or fewer International Classification of Diseases, Tenth Revision (ICD-10), clinical modification codes with a prevalence greater than or equal to 0.5%, or clinically important risk factors in Bateman’s co-morbidity index. Chi-squared analysis of combinations of pregestational diagnoses was performed to assess the relative risk of pregnancy-related complications.ResultsThe 2016 database included 255,233 delivered pregnancies. The most common combinations of pregestational diagnoses involved advanced maternal age, prior cesarean delivery, obesity, and tobacco use. Most combinations did not demonstrate an increased risk for complications greater than the risk with a single diagnosis. In those with statistically significant risk, all were 3-fold or less except we noted a 4.4-fold higher risk (95% CI: 3.16-6.15) of preeclampsia in obese patients of advanced maternal age compared to patients who were only of advanced maternal age.ConclusionOur results revealed that common combinations of pregestational diagnoses, in general, do not increase the risk for common pregnancy-related complications greater than the risk with a single diagnosis. This is reassuring, given that women entering pregnancy with multiple co-morbidities are becoming more common.

African American Women's Experiences with Birth After a Prior Cesarean Section.

Women who have had a cesarean section (C-section) and become pregnant again may choose to have a planned repeat cesarean delivery (RCD) or vaginal birth after a cesarean (VBAC). This study aimed to characterize the pregnancy and birth experiences of African American (AA) women who had a successful VBAC, failed VBAC, or RCD. Eligible participants (N = 25) self-identified as AA, had a C-section and a subsequent birth(s) in the past 12years, and were educated past high school. Each participant was individually interviewed via phone call. The Sort and Sift, Think and Shift method was used to evaluate interview transcripts to minimize researcher bias and emphasize the voices of the participants. The resulting themes included the impact of providers on pregnancy and childbirth satisfaction, the value of autonomy in maternal health decision-making, and the role that racism plays in AA women's birth experiences. Although some participants recalled a positive experience, the presence of limited autonomy, lack of support, and negative experiences with providers indicate that birth after a prior C-section for AA women can be improved. Providers should address their own racial biases and utilize the shared decision-making approach when their patients decide between a VBAC and RCD to improve patient satisfaction.

Trial of labor after cesarean in primiparous women with fetal macrosomia.

Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus. Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia. A retrospective cohort study conducted during 2005-2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome). Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P < 0.001), epidural anesthesia (aOR [95% CI] 2.38 (1.35, 4.20), P = 0.003) and history of cesarean delivery due to non-arrest disorder (aOR [95% CI] 2.25 (1.32, 3.85), P = 0.003) were the only independent factors associated with TOLAC success. Successful TOLAC was achieved in 82.0% (82/100) in the presence of all three favorable factors, 61.3% (65/106) in the presence of two factors and 38.6% (27/70) in the presence of one or less of these three factors (P < 0.001). Spontaneous onset of labor, epidural anesthesia and prior cesarean delivery due to non-arrest disorders were independently associated with higher vaginal birth after cesarean rate among women with fetal macrosomia, with an overall favorable success rate in the presence of these factors. These findings should be implemented in patient counseling in those contemplating a vaginal birth in this setting.

Cesarean delivery rates by hospital type among nulliparous and multiparous patients

Background Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital. Objective The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California. Methods We performed a retrospective study of singleton, non-anomalous, term (37–42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200–2399 deliveries/year), and medium-high-volume (2400–3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models. Results In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0–1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96–0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06–1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25–1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93–0.96; aOR: 0.93; 95% CI: 0.91–0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10–1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05–1.10; aOR: 0.96; 95% CI: 0.94–0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13–1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals. Conclusion Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.

The Intraoperative Median Effective Dose of Oxytocin for Preventing Uterine Atony in Parturients with a Prior History of Caesarean Delivery.

While oxytocin is commonly used for the prevention of uterine atony, its pharmacology may be affected by a prior history of caesarean delivery. The objective of this study was to determine the 50% effective dose (ED50) of bolus oxytocin after caesarean delivery in parturients with and without prior caesarean delivery. This was a parallel-group, double-blind, dose-response study using Dixon's up-and-down sequential allocation method to estimate the ED50 of bolus-administered oxytocin in parturients having caesarean delivery under combined spinal-epidural anaesthesia (CSE). Twenty-seven parturients with a history of prior caesarean delivery (With-PCD group) and 26 parturients with no such history (Without-PCD group) were enrolled. Oxytocin was administered as an intravenous bolus at a starting dose of 0.5 units, which was then increased or decreased by 0.25 units at a time. Uterine tone was assessed by the obstetrician as either 'adequate' or 'inadequate' 3 min after delivery of the fetus. Adverse effects, administration of additional uterotonic agents, and estimated blood loss were recorded. The ED50 of oxytocin was greater in the With-PCD group than in the Without-PCD group (0.95 units [95% CI 0.82-1.08] vs. 0.55 units [95% CI 0.38-0.73], P < 0.001). The overall incidence of adverse effects was higher in the With-PCD group than in the Without-PCD group (33.3% vs. 7.7%, P = 0.02). The initial bolus dose of oxytocin needed to prevent uterine atony was higher in parturients with prior caesarean delivery than in parturients without prior caesarean delivery. Uterine scarring may contribute to the increased oxytocin requirements of the former group. ChiCTR1900023474; investigator: Wei CN; date of registration: 30 May 2019.

Hysteroscopic Resection of an Endocervical Cesarean Scar Fibroid

<h3>Study Objective</h3> To present a case of a hysteroscopic resection of an endocervical fibroid from within a Cesarean scar defect (CSD), also known as an isthmocele. <h3>Design</h3> Video case presentation. <h3>Setting</h3> Operative hysteroscopic procedure performed at an urban, academic surgical center. <h3>Patients or Participants</h3> 37-year-old G4P3013 with a history of 3 prior Cesareans, a hysteroscopic and abdominal myomectomy. For 3 months following a spontaneous abortion, she experienced abnormal uterine bleeding. Saline infusion sonogram and MRI revealed a 2.9 cm anterior endocervical fibroid. Options for management were reviewed. Following a short course of progestins that resulted in persistent intermenstrual spotting, and considering desire for future pregnancy, hysteroscopic resection was subsequently decided. <h3>Interventions</h3> Hysteroscopic myomectomy of CSD myoma. <h3>Measurements and Main Results</h3> Successful hysteroscopic resection and techniques to limit intraoperative and postoperative bleeding are described. Postoperatively, the patient had heavy bleeding in PACU with a quantitative blood loss of 700 mL. <h3>Conclusion</h3> Preoperative, intraoperative, and postoperative considerations for this case are reviewed. Preoperative considerations include adequate counseling, imaging such as MRI, thorough discussion of the risks and understanding of the patient's desires in the event of possible hysterectomy. Intraoperatively, primary prevention of bleeding can be attempted with the use of vasoconstrictive agents for both parametrial and intra-myoma instillation to reduce blood flow to the uterus and fibroid. Minimizing the use of electrosurgery may be preferable given the high risk of perforation. Postoperatively, uterotonics are often ineffective at controlling CSD bleeding given the minimal residual myometrium, but antifibrinolytics such as tranexamic acid may be more helpful. If not placed in the operating room under hysteroscopic or ultrasound guidance, an intrauterine Foley balloon can also be inserted postoperatively for tamponade.

Prediction of vaginal birth after cesarean for labor dystocia by sonographic estimated fetal weight.

To estimate the association of the weight difference between the index trial of labor after cesarean (TOLAC) sonographic estimated fetal weight (sEFW) and prior delivery birth weight with TOLAC success rate among women with previous labor dystocia and no prior vaginal delivery. A retrospective cohort study including all women with prior cesarean for labor dystocia and no prior vaginal delivery undergoing TOLAC during between March 2011 and June 2020 with a sEFW within 1week from delivery. Overall, 168 women were included, of those 107 (63.7%) successfully delivered vaginally. The mean sEFW and mean birth weight were lower in the TOLAC success group (P=0.010 and P=0.013, respectively). The rate of higher sEFW in the current delivery compared with the previous delivery did not differ between study groups. The rate of higher TOLAC birth weight was lower in the TOLAC success group (odds ratio 0.30; 95% confidence interval 0.15-0.58). In multivariable regression analysis, maternal age older than 30years, induction of labor, and higher birth weight were independently negatively associated with TOLAC success (adjusted odds ratio [95% confidence interval]: 0.27 [0.10-0.70], 0.27 [0.08-0.90], and 0.43 [0.19-0.94]; P=0.008, P=0.034, and P=0.035, respectively). sEFW characteristics did not predict the success or failure of TOLAC among women with prior labor dystocia and no previous vaginal delivery.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Anterior Entry in Patients with Prior Cesarean Section

Study Objective The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Design Case report. Setting Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patients or Participants Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. Interventions vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Measurements and Main Results Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. Conclusion vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible. The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Case report. Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible.

The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study.

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD.Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates.Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS.Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

Fundal partial placenta percreta complicated with postpartum hemoperitoneum: A case report.

IntroductionThe fundus of the uterus is a rare location for abnormally invasive placenta compared with the common site of abnormally invasive placenta in the lower segment of the uterus.Presentation of caseWe report a case of a 38-year-old multipara woman who had a fundal partial placenta percreta with no prior cesarean sections, which presented as a retained placenta after preterm labor, and complicated with hemorrhagic shock due to postpartum hemoperitoneum, thus it was diagnosed after surgery and managed by subtotal hysterectomy.DiscussionWe discuss the most common risk factors for abnormally invasive placenta and its diagnosis and management. We compare the possibility of leading to invasive placenta resulting from curettage trauma and cesarean delivery scars.ConclusionHistory of uterine surgical procedures without prior cesarean delivery must raise suspicion of abnormally invasive placenta regardless of its localization, especially when associates with preterm labor or retained placenta.

Conducción del trabajo de parto en gestantes con cesárea previa en el Hospital Central Universitario Dr. Jesús María Casal Ramos. Acarigua-Estado Portuguesa.

Objective: To estimate the safety of vaginal delivery in pregnant women at term in spontaneous labor with previous cesarean section who attended the Obstetric Emergency Service of the Dr. Jesús María Casal Ramos University Hospital, in the period January-June 2018. Methods: A prospective, descriptive, cross-sectional and non-causal correlational study was conducted in pregnant women at term with a previous caesarean section in labour. The medical records of full-term pregnant women who entered into spontaneous labor and who underwent conduction of labor were reviewed if the indication for cesarean section did not persist, recording maternal, fetal and neonatal complications. Results: We attended 245 pregnant women, with previous cesarean section, 108 patients were included of which 99 (92 %) did not present complications and of the remaining nine, 4 (44 %) presented grade I tear, 4 (44 %) grade II tear and only 1 (12 %) grade III tear. The most frequent anatomical location was vaginal in 6 (67 %), cervical in 3 (33 %); the size of the same was not described; the grade III vaginal tear was sutured, did not require blood transfusion and the product weighed 4000 kg. There were no maternal deaths or fetal complications or fetal deaths. Conclusions: Spontaneously initiated vaginal delivery in pregnant women with previous caesarean section is 92% safe. Keywords: Vaginal Birth, Prior caesarean, Interpartum interval, Labor conduction.

Patient decision aid for trial of labor after cesarean (TOLAC) versus planned repeat cesarean delivery: a quasi-experimental pre-post study

ObjectiveTo assess the impact of a web-based decision aid on patient-centered decision making outcomes among women considering a trial of labor after cesarean (TOLAC) versus planned repeat cesarean delivery.MethodsThe Birth Decision Aid Study (B-READY) was a quasi-experimental pre-post study of two sequential cohorts. From June 18, 2018 to July 31, 2019, 50 women were enrolled in routine care, followed by 50 women who were enrolled in the decision aid group. Inclusion criteria were singleton pregnancies between 19/0 to 36/6 weeks, ≤2 prior cesareans, and no contraindications to TOLAC. The decision aid group viewed the online Healthwise® “Pregnancy: Birth Options After Cesarean” program. Both groups received the same birth options counseling and completed the same online assessment. Primary patient-centered outcomes were knowledge about birth options and shared decision making at online assessment, and informed, patient-centered decision making about her preferred mode of delivery at delivery admission.ResultsAmong 100 women participated in this study (50 per group), the mean gestational age at enrollment was 31 weeks, and 71% or 63/89 women who consented to delivery data abstraction had a cesarean delivery. Women in the patient decision aid group gained more knowledge (defined as score ≥ 75%) about birth options compared to those in the routine care group (72% vs. 32%; adjusted odds ratio, AOR: 6.15 [95% CI: 2.34 to 16.14]), and were more likely to make an informed, patient-centered decision (60% vs. 26%; AOR: 3.30 [95% CI: 1.20 to 9.04]. Women in both groups reported similar involvement in shared decision making, as well as satisfaction and values. More than 90% of decision aid users reported it was a useful tool and would recommend it to other TOLAC-eligible women.ConclusionsA web-based birth options patient-centered decision aid for TOLAC eligible women can be integrated into prenatal Telehealth and may improve the quality of decision making about mode of delivery.Trial registrationThe study was registered with ClinincalTrials.gov and the ID# was NCT04053413. Registered 12 August 2019 – Retrospectively registered.

618Is mode of first birth a risk factor for subsequent preterm birth?

Abstract Background Previous preterm birth is a strong predictor of subsequent preterm birth but less is known about the causes of preterm birth following a full-term pregnancy. Recent research highlighted previous caesarean as a potential risk factor and we aimed to further explore this risk. Methods This population-based record linkage study included all women in NSW, Australia who had a live singleton first birth at ≥ 37 weeks gestation, followed by a singleton second birth between 2005–2017. Relative risk (RR) and 95%CI of having a subsequent preterm birth, spontaneous preterm birth or preterm pre-labour caesarean was calculated using individual modified Poisson regression models, with mode of first birth as the exposure. Results Women who had an intrapartum (RR:1.26, 95%CI 1.19–1.32) or prelabour caesarean (RR:1.26,95%CI 1.18–1.35) first birth had a higher risk of subsequent preterm birth, than those who birthed vaginally. Those who had a pre-labour caesarean (RR:0.74, 95%CI 0.67–0.82) had a lower risk of subsequent spontaneous preterm birth. However, prior pre-labour caesarean also greatly increased the risk of subsequent preterm prelabour caesarean (RR:5.25, 95%CI 4.65–5.93). Conclusions Pre-labour and intrapartum caesareans have differing effects on the risk of subsequent spontaneous preterm birth and preterm pre-labour caesarean. Key messages The risk of subsequent preterm birth following a first birth caesarean depends on whether the caesarean occurred before or after the onset of labour and whether the subsequent preterm birth is spontaneous or a pre-labour caesarean.

Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean delivery: a randomized trial

The main reason to avoid trial of labor after cesarean delivery is the possibility of uterine rupture. Identifying women at risk is thus an important aim, for it would enable women at low risk to proceed with a secure planned vaginal birth. To evaluate the impact of proposing mode of delivery based on the ultrasound measurement of the lower uterine segment thickness on a composite outcome of maternal-fetal mortality and morbidity, compared with usual management, among pregnant women with a previous cesarean delivery. This multicenter, randomized, controlled, parallel-group, unmasked trial was conducted at 8 referral university hospitals with a neonatal intensive care unit and enrolled 2948 women at 36 weeks 0 days to 38 weeks 6 days of gestation with 1 previous low transverse cesarean delivery and no contraindication to trial of labor. Women in the study group had their lower uterine segment thickness measured by ultrasound. Those with measurements >3.5 mm, were encouraged to choose a planned vaginal delivery, and those with measurements ≤3.5 mm, were encouraged to choose a planned repeat cesarean delivery. This measurement was not taken in the control group; their mode of delivery was decided according to standard management. The primary outcome was a composite criterion comprising maternal mortality, uterine rupture, uterine dehiscence, hysterectomy, thromboembolic disease, transfusion, endometritis, perinatal death, or neonatal encephalopathy. Prespecified secondary outcomes were repeat cesarean deliveries, elective or after trial of labor. The study group included 1472 women, and the control group included 1476 women. These groups were similar at baseline. The primary outcome occurred in 3.4% of the study group and 4.3% of the control group (relative risk, 0.78; 95% confidence interval, 0.54-1.13: risk difference,-1.0%; 95% confidence interval,-2.4 to 0.5). The uterine rupture rate in the study group was 0.4% and in the control group 0.9% (relative risk, 0.43; 95% confidence interval, 0.15-1.19). The planned cesarean delivery rate was 16.4% in the study group and 13.7% in the control group (relative risk, 1.21; 95% confidence interval, 1.00-1.47), whereas the rates of cesarean delivery during labor were 25.1% and 25.0% (relative risk, 1.01; 95% confidence interval, 0.89-1.14) in the study and control groups, respectively. Ultrasound measurements of lower uterine segment thickness did not result in a statistically significant lower frequency of maternal and perinatal adverse outcomes than standard management. However, because this study was underpowered, further research should be encouraged.

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.

Intrapartum cesarean delivery and the risk of perinatal complications in women with and without a single prior cesarean delivery.

To determine maternal and neonatal complications associated with an intrapartum cesarean delivery (CD) with and without a history of a previous CD. A retrospective cohort study of all women who underwent an unplanned intrapartum CD following a trial of labor in a university-affiliated tertiary hospital, between 2009 and 2016. Perinatal outcomes of women with and without a history of a previous CD were compared. Composite adverse maternal outcome included one or more of the following: postpartum hemorrhage, need for blood transfusion, or cesarean hysterectomy. Composite adverse neonatal outcome included one or more of the following: 5-min Apgar score <7, neonatal seizure, need for intubation, meconium-aspiration-syndrome, or hypoxic-ischemic encephalopathy. During the study period, 42275 women attempted vaginal delivery. Of them, 2229 (5.3%) women underwent an unplanned intrapartum CD and met inclusion criteria: 337 (15.1%) with (study group) and 1892 (84.9%) without (control group) a previous CD. Women without a previous CD were younger and were characterized by higher rates of nulliparity and induction of labor compared with women with a previous CD. Other demographic and obstetrical characteristics did not differ between the groups. Indications for CD were also comparable between the groups. Uterine rupture complicated 2.3% of trials of labor among women with a previous CD. Adverse maternal (2.7% vs 2.9%, P=1.0) and neonatal (3.9% vs 4.3%, P=0.88) outcomes were comparable between the groups. After adjusting for potential confounders, a previous CD was not associated independently with adverse maternal outcomes (adjusted odds ratio [aOR] 0.86, 95% confidence interval [CI] 0.31-2.38; P=0.78) or neonatal outcomes (aOR 0.79, 95% CI 0.36-1.75; P=0.56). Our study provides evidence that perinatal outcomes of intrapartum CD delivery among women with a previous CD do not differ from those in women without a previous CD. These findings might improve the consultation and informed decision-making process for couples considering a trial of labor after CD.

Opioid prescription-use after cesarean delivery: an observational cohort study.

To evaluate current opioid prescription practices following a cesarean delivery. Women were asked to participate in a prospective observational cohort study following a cesarean delivery. Participants were asked about their opioid use after discharge, amount leftover, subjective pain score, and satisfaction. A total of 344 women had cesarean deliveries during the study period, 242 were approached, 171 met eligibility criteria, and 109 were included in the analysis. Women in our study were predominantly African American (66.1%), high school graduates (32.1%), publicly insured (65.1%), single (55%) working mothers (68.8%). Most had been previously prescribed opioids (70.6%), of which 58.4% had a prior cesarean delivery. Only 78.8% of study participants took their opioid prescriptions, and 89.6% had an average of 17 pills leftover. The number of pills taken correlated with those prescribed in the study. Improved satisfaction in pain control with opioid and non-opioid alternatives was associated with a decrease in opioids used. Similarly, the participants' perception of their abundant prescription quantity was associated with a decrease in prescription taken. Women were prescribed excess opioids. Excess opioids accounted for 63.3% of all pills filled, a total of 1670 pills leftover, most of which were stored in an unlocked location (75.6%). Our data showed a discrepancy of pills prescribed (24) compared to those used (10), which was also perceived as enough or too many by our participants. Our study demonstrates that women would benefit from fewer opioid pills and a discussion based on their pain perception.