Prior Vaginal Delivery Research Articles

Ultrasound-guided staging and reversal of female genital mutilation.

FGM/C is common, effecting over 200 million women worldwide and has substantial associated morbidity. We seek improving the reversal procedure using ultrasound imaging. The use of peri- and intraoperative ultrasound imaging for reconstructive surgery following FGM/C for staging and surgical planning, with focus on the clitoral structures and blood flow. This is a case series of patients with FGM/C who were evaluated and underwent reconstructive surgical management at a single institution between 2018 and 2022. Ultrasound examination with Doppler imaging was performed. The electronic medical record was queried for data regarding patient characteristics, examination and ultrasound findings, and surgical and postoperative course. Seven patients are described in this case series who sustained the FGM/C with classifications ranging from Ia to IIIb. The primary complaints were dyspareunia or apareunia. Six of seven (86%) reported anorgasmia. Four of seven (57%) had prior vaginal deliveries, and one of seven (14%) was delivered only by cesarean sections, two of seven (29%) have not been able to have intercourse. Ultrasound examination was utilized to facilitate recognition of the anatomic structures during the reconstruction, and Doppler was used to evaluate the clitoral blood flow. Doppler was useful to delineate clitoral tissues from a closely involved periclitoral inclusion cyst, aiding in surgical excision while minimizing clitoral vascular or nerve injury. Postoperative anatomical restoration, sexual function, and alleviation of dyspareunia were excellent. None of the patients reported decreased sexual pleasure postoperatively. Ultrasound imaging with Doppler can be utilized to facilitate personalized approaches to optimize both anatomical and functional results in cases of genital reconstruction.

Association between interpregnancy interval and the labor curve

Both short and long interpregnancy intervals are associated with adverse pregnancy outcomes; however, the impact of interpregnancy intervals on labor progression is unknown. We examined the impact of interpregnancy intervals on the labor curve, hypothesizing that those with a longer interpregnancy intervals would have slower labor progression. This is a retrospective cohort study of patients with a history of one prior vaginal delivery admitted for induction of labor or spontaneous labor with a singleton gestation ≥37 weeks at an academic medical center between 2004 and 2015. Repeated measures regression was used to construct labor curves, which were compared between patients with short interpregnancy intervals, defined as <3 years since the last delivery, and long interpregnancy intervals, defined as >3 years since the last delivery. We chose this interval as it approximates the median birth interval in the United States. Interval-censored regression was used to estimate the median duration of labor after 4 centimeters of dilation, stratified by type of labor (spontaneous vs induced). Multivariate analysis was used to adjust for potential confounders. Of the 1331 patients who were included in the analysis, 544 (41%) had a long interpregnancy interval. Among the entire cohort, there were no significant differences in first or second-stage progression between short and long interpregnancy interval groups. In the stratified analysis, first-stage progression varied between groups on the basis of labor type: long interpregnancy interval was associated with a slower active phase among those being induced and a quicker active phase among those in spontaneous labor. The second-stage duration was similar between cohorts regardless of labor type. Multiparas with an interpregnancy interval >3 years may have a slower active phase than those with a shorter interpregnancy interval when undergoing induction of labor. Interpregnancy interval does not demonstrate an effect on the length of the second stage.

Short stature and vaginal dinoprostone as independent predictors of composite maternal-newborn adverse outcomes in induction of labor after one previous cesarean: a retrospective cohort study

BackgroundThe rates of labor induction and cesarean delivery is rising worldwide. With the confluence of these trends, the labor induction rate in trials of labor after cesarean can be as high as 27-32.7%. Induction of labor after one previous cesarean (IOLAC) is a high-risk procedure mainly due to the higher risk of uterine rupture. Nevertheless, the American College of Obstetricians and Gynecologists considers IOLAC as an option in motivated and informed women in the appropriate care setting. We sought to identify predictors of a composite of maternal and newborn adverse outcomes following IOLAC.MethodsThe electronic medical records of women who delivered between January 2018 to September 2022 in a Malaysian university hospital were screened to identify cases of IOLAC. A case is classified as a composite adverse outcome if at least one of these 11 adverse outcomes of delivery blood loss ≥ 1000 ml, uterine scar complications, cord prolapse or presentation, placenta abruption, maternal fever (≥ 38 0C), chorioamnionitis, intensive care unit (ICU) admission, Apgar score < 7 at 5 min, umbilical artery cord artery blood pH < 7.1 or base excess ≤-12 mmol/l, and neonatal ICU admission was present. An unplanned cesarean delivery was not considered an adverse outcome as the practical management alternative for a clinically indicated IOLAC was a planned cesarean. Bivariate analysis of participants’ characteristics was performed to identify predictors of their association with composite adverse outcome. Characteristics with crude p < 0.10 on bivariate analysis were incorporated into a multivariable binary logistic regression analysis model.ResultsElectronic medical records of 19,064 women were screened. 819 IOLAC cases and 98 cases with composite adverse outcomes were identified. Maternal height, ethnicity, previous vaginal delivery, indication of previous cesarean, indication for IOLAC, and method of IOLAC had p < 0.10 on bivariate analysis and were incorporated into a multivariable binary logistic regression analysis. After adjustment, only maternal height and IOLAC by vaginal dinoprostone compared to Foley balloon remained significant at p < 0.05. Post hoc adjusted analysis that included all unplanned cesarean as an added qualifier for composite adverse outcome showed higher body mass index, short stature (< 157 cm), not of Chinese ethnicity, no prior vaginal delivery, prior cesarean indicated by labor dystocia, and less favorable Bishop score (< 6) were independent predictors of the expanded composite adverse outcome.ConclusionShorter women and IOLAC by vaginal dinoprostone compared to Foley balloon were independently predictive of composite of adverse outcome.

Severe Pre-Eclamptia Resulting In Abruptio Placentae, Stillbirth and Disseminated Intravascular Coagulopathy in Antenatal Clinic Defauter Woman in Calabar, South-South Nigeria

This case report examines a poignant instance of severe preeclampsia in a 26 year old with a history of recurrent pregnancy loss and however, a prior vaginal delivery. The patient presented at 29 weeks gestation with acute lower abdominal pain with associated abruptio placentae, resulting in a stillbirth and disseminated intravascular coagulopathy (DIC). The intricate interplay of obstetric history and clinical management reveals the challenges in navigating such complex scenarios. The patient's obstetric history of recurrent miscarriages and a vaginal delivery with perineal tear signals a predisposition to adverse outcomes. The acute presentation of abruptio placentae underscores the imperative for heightened vigilance in pregnant women even in the absence of antenatal complaints. Successful resuscitation involved correcting shock, transfusing three units of blood and addressing hemorrhagic DIC. Tranexamic acid, pentazocine, normal saline, misoprostol and oxytocin were employed to stabilize the patient, highlighting the necessity of a comprehensive and multidisciplinary approach. This case serves as a stark reminder of the unpredictable nature of severe preeclampsia and emphasizes on the critical importance of early detection and intervention. Future research endeavors should focus on refining risk stratification models and exploring innovative interventions to enhance maternal and fetal outcomes in high-risk pregnancies.

Delivery mode after cervical ripening among patients with no prior vaginal births

PurposeTo compare mode of delivery and maternal and neonatal outcomes using cervical ripening balloon (CRB) for induction of labor (IOL) in nulliparous patients vs. those undergoing first trial of labor after cesarean (TOLAC). MethodsRetrospective cohort study including data from two tertiary medical centers. Included were all patients with a singleton pregnancy and a gestational age > 37+0 weeks and no prior vaginal birth undergoing IOL with CRB. Nulliparous patients (nulliparous group) were compared to patients with one prior cesarean delivery (CD) and no prior vaginal delivery (TOLAC group). Patients who withdrew consent for trial of labor at any time in both groups were excluded. The primary outcome was mode of delivery. ResultsOverall, 161 patients were included in the TOLAC group and 1577 in the nulliparous group. The rate of CD was similar in both groups and remained similar after adjusting for confounders (29.8 % vs. 28.9 %, p = 0.86, OR 1.1, 95 %, CI 0.76–1.58). CD due to fetal distress was more common in the TOLAC group (75 % vs. 56 %, p = 0.014). Other maternal outcomes and neonatal outcomes were similar in the two groups. ConclusionComparable vaginal delivery rates may be achieved in patients with or without a previous CD attempting their first trial of labor, with a cervical ripening balloon for labor induction, without increasing adverse maternal or neonatal outcomes.

Induction of labor vs expectant management among low-risk patients with 1 prior cesarean delivery

Studies that have compared induction of labor in individuals with 1 prior cesarean delivery to expectant management have shown conflicting results. To determine the association between clinical outcomes and induction of labor at 39weeks in a national sample of otherwise low-risk patients with 1 prior cesarean delivery. This cross-sectional study analyzed 2016 to 2021 US Vital Statistics birth certificate data. Individuals with vertex, singleton pregnancies, and 1 prior cesarean delivery were included. Patients with prior vaginal deliveries, delivery before 39 weeks 0 days or after 42weeks 6days of gestation, and medical comorbidities were excluded. The primary exposure of interest was induction of labor at 39weeks 0days to 39weeks 6days compared to expectant management with delivery from 40weeks 0days to 42weeks 6days. The primary outcome was vaginal delivery. The main secondary outcomes were separate maternal and neonatal morbidity composites. The maternal morbidity composite included uterine rupture, operative vaginal delivery, peripartum hysterectomy, intensive care unit admission, and transfusion. The neonatal morbidity composite included neonatal intensive care unit admission, Apgar score less than 5 at 5minutes, immediate ventilation, prolonged ventilation, and seizure or serious neurological dysfunction. Unadjusted and adjusted log binomial regression models accounting for demographic variables and the exposure of interest (induction vs expectant management) were performed. Results are presented as unadjusted and adjusted risk ratios with 95% confidence intervals. From 2016 to 2021, a total of 198,797 individuals with vertex, singleton pregnancies, and 1 prior cesarean were included in the primary analysis. Of these individuals, 25,915 (13.0%) underwent induction of labor from 39weeks 0days to 39weeks 6days and 172,882 (87.0%) were expectantly managed with deliveries between 40weeks 0days and 42weeks 6days. In adjusted analyses, patients induced at 39weeks were more likely to have a vaginal delivery when compared to those expectantly managed (38.0% vs 31.8%; adjusted risk ratio 1.32, 95% confidence interval 1.28, 1.36). Among those who had vaginal deliveries, induction of labor was associated with increased likelihood of operative vaginal delivery (11.1% vs 10.0; adjusted risk ratio 1.15, 95% confidence interval 1.07, 1.24). The maternal morbidity composite occurred in 0.9% of individuals in both the induction and expectant management groups (adjusted risk ratio 0.92, 95% confidence interval 0.79, 1.06). The rates of uterine rupture (0.3%), peripartum hysterectomy (0.04% vs 0.05%), and intensive care unit admission (0.1% vs 0.2%) were all relatively low and did not differ significantly between groups. There was also no significant difference in the neonatal morbidity composite between the induction and expectant management groups (7.3% vs 6.7%; adjusted risk ratio 1.04, 95% confidence interval 0.98, 1.09). When compared to expectant management, elective induction of labor at 39weeks in low-risk patients with 1 prior cesarean delivery was associated with a significantly higher likelihood of vaginal delivery with no difference in composite maternal and neonatal morbidity outcomes. Prospective studies are needed to better elucidate the risks and benefits of induction of labor in this patient population.

Exploring Vaginal Birth After Cesarean: Success Rates and Cultural Decisions in the United Arab Emirates.

This study explores the success rates and cultural influences on the decision-making process for vaginal birth after cesarean (VBAC) in the United Arab Emirates (UAE). An observational cohort study was conducted at a hospital in the UAE accredited by Joint Commission International, enrolling 263 women eligible for VBAC from March 1, 2018, to February 28, 2019. The study focused on maternal-fetal outcomes, the proportions of women opting for trial of labor after cesarean (TOLAC) versus elective repeat cesarean section (ERCS), and the impact of cultural backgrounds on these decisions. The study found significant cultural variations in VBAC acceptance and success rates. Among local Emirati/Omani women, 86% (152 out of 177) opted for TOLAC, with an 83% success rate (126 out of 152). In contrast, lower TOLAC uptake and success rates were observed among other nationalities, such as Egyptian and other Arab women. The study also noted higher VBAC success rates in women with prior vaginal deliveries and those who experienced spontaneous labor. NICU admissions and maternal readmissions were lower in the TOLAC group (1% NICU admissions and 2% maternal readmissions) compared to the ERCS group (8.2% NICU admissions). The study underscores the influence of cultural factors in VBAC decision-making and outcomes, highlighting the need for culturally tailored counseling and care. It also confirms the safety and efficacy of VBAC in appropriately selected cases, advocating for more research into counseling practices and long-term outcomes in culturally diverse populations. Impact statement: This research adds to the understanding of how cultural and ethnic backgrounds influence VBAC decisions and outcomes, offering critical insights for clinical practice, especially in multicultural societies like the UAE. It emphasizes the role of tailored counseling and suggests avenues for future research in this domain.

Successful postcoital testing of Ovaprene: An investigational non-hormonal monthly vaginal contraceptive

ObjectiveEvaluate reduction in progressively motile sperm per high power field (HPF) in midcycle cervical mucus after intercourse with Ovaprene: an investigational monthly non-hormonal vaginal contraceptive consisting of a vaginal ring and mechanical barrier, releasing spermiostatic ferrous gluconate. Study designOpen-label, multicenter study enrolling heterosexually-active women with previous permanent contraception. Participants underwent a baseline postcoital test cycle with no device to confirm the presence of sperm, followed by one diaphragm postcoital test cycle, one Ovaprene safety cycle, and two Ovaprene postcoital test cycles. In each postcoital test cycle, participants underwent a midcycle cervical mucus evaluation to confirm an Insler score ≥10 and absence of sperm, and then returned two to four hours after vaginal intercourse for repeat cervical mucus evaluation. We considered <5 progressively motile sperm/HPF indicative of preliminary contraceptive effectiveness. ResultsWe enrolled 38 participants; 23 completed the study. All participants had ≥5 progressively motile sperm/HPF in the baseline cycle and <5 progressively motile sperm/HPF in all 49 Ovaprene cycles and all 35 diaphragm cycles, meeting the definition of a successful postcoital test. This was true regardless of examiner blinding, prior vaginal delivery or vaginal ring use, body mass index, or dislodgements noted by the participant or investigator. The mean of 27.2 (±17.9) progressively motile sperm/HPF in baseline postcoital test cycles was reduced to 0.5 (±1.1) and 0.5 (±1.3) progressively motile sperm/HPF in the first and second Ovaprene cycles, respectively. Ovaprene fit all participants and all could insert, position, and remove it. ConclusionUse of Ovaprene resulted in meeting the prespecified criterion for contraceptive effect by all participants during all postcoital test cycles. ImplicationsThe finding that use of Ovaprene, an investigational monthly non-hormonal vaginal contraceptive, resulted in postcoital testing of cervical mucus that met the pre-specified definition of success (<5 progressively motile sperm/HPF) supports further evaluation of contraceptive efficacy of the device in users at risk for pregnancy.

Intrauterine Device Placement Success for Adolescents and Young Adults at Community-Based Reproductive Health Clinics

BackgroundDespite the endorsement of intrauterine device (IUD) use in adolescents and young adults (AYA) by leading professional organizations and demonstrated acceptance and desirability by AYA, clinicians may worry about procedural difficulty of IUD device placement in younger patients. ObjectiveThe aim of this study was to evaluate the clinical outcomes of first-attempt IUD placement in an AYA population by vaginal delivery (VD) history. Study DesignWe performed a retrospective cohort study of patients <25 years at reproductive health clinics with an IUD placement attempt between January 1-August 31, 2017. We abstracted sociodemographic characteristics, pregnancy history, and procedural characteristics including complications. Bivariate analyses compared successful first attempt IUD placement by VD history. We also assessed frequency of secondary clinical outcomes including ancillary measures used, provider type, symptoms reported during the procedure, and complications. ResultsWe included 1,325 participants (median age=21.3 years) including 42 (3.2%) with a prior VD. Nearly all IUD placements were successful at first attempt (n=1,301, 98.2%) and performed by advanced practice clinicians (n=1,314, 99.2%). First-attempt IUD placement success was similar in those participants with and without VD (p>0.999). Ancillary measures other than NSAIDS were used infrequently (n=16, 3.6%.) .(Among participants with an unsuccessful placement, 66.7% returned, and all had a successful IUD placement on the second attempt. Documented complications within six months of placement were rare (n=29) and mostly comprised of expulsions (n=27, 93.1%). ConclusionIUD placement success among AYA at community-based reproductive health clinics is very high and is not associated with a history of prior vaginal delivery.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation

ObjectivesThis study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting. Study designIn this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group. ResultsWe enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6–0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels. ConclusionsFear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks. ImplicationsReliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

The relationship between cesarean delivery and fecundability: a population-based cohort study

BackgroundPrevious studies have found that women with caesarean delivery have fewer pregnancies. Caesarean delivery is also more common among women with lower fecundability. The potential role of caesarean delivery on reduced fecundability is not known. ObjectiveTo assess the bidirectional relationship between caesarean delivery and fecundability. Study DesignThis is a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥ 12 months) according to mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a caesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,025 women. ResultsThe proportion of women with infertility was 6.2% (2711/43936) among women with prior vaginal delivery, and 8.6% (518/6036) among women with a prior caesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval: 1.10 to 1.33). Women with previous caesarean delivery also had lower fecundability ratio (0.90, 95% confidence interval 0.88 to 0.93), compared to women with prior vaginal delivery. When assessing the reverse association between fecundability and caesarean delivery, we found that women who did not conceive within 12 or more cycles had higher risk of caesarean delivery (adjusted relative risk 1.55, 95% confidence interval 1.46 to 1.64) compared to women who conceived within the first two cycles. Associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups. ConclusionAmong women with more than one child, those who had caesarean delivery had subsequent lower fecundability ratio and increased infertility risk compared to those who had vaginal delivery. However, women who needed longer time to conceive were also more prone to be delivered by caesarean delivery. We therefore found evidence of a bidirectional relationship between caesarean delivery and fecundability. This could be due to a common underlying explanatory mechanism, and the surgical procedure itself may not directly influence fecundability.

Induction of labor after one previous cesarean: Predictors of vaginal birth

ObjectiveTo identify independent predictors for vaginal delivery after induction of labor after one cesarean (IOLAC). Study designIn this retrospective cohort study, the electronic medical record of 19064 women who delivered from January 2018–September 2022 in a university hospital in Malaysia were individually searched to identify cases of IOLAC. Preselected data points on characteristics and the outcome of mode of delivery were retrieved. Bivariate analysis was performed to identify predictor characteristics for the dichotomous outcomes of vaginal delivery vs unplanned cesarean delivery. Variables with crude p < 0.05 were incorporated into a multivariable binary logistic regression analysis to identify independent predictors of vaginal delivery after IOLAC. Results819 IOLAC cases were identified. There were 465/819 (56.5 %) unplanned cesareans deliveries. Of the 14 selected characteristics, eight had p < 0.05 on bivariate analysis. After adjustment, six characteristics, body mass index, height, ethnicity, parity, previous cesarean indication and Bishop score were independently predictive of vaginal birth but not maternal age or method of labor induction. Birthweight, labor induction indication, gestational age, haemoglobin level, diabetes and hypertension in pregnancy were not significant at the level of bivariate analysis. ConclusionObesity, short stature, no prior vaginal delivery, previous cesarean indicated by failure to progress, unfavorable Bishop score and ethnicity were independent predictors for unplanned cesarean after IOLAC. These predictors should help guide women and their care providers in their shared decision-making about IOLAC.

Transvaginal Ultrasound Evaluation Of Cesarean Section Niche Scar During Pregnancy: A Prospective Longitudinal Study

Background and Objectives: To determine the prevalence of a CS scar niche during pregnancy using transvaginal ultrasound imaging, and to determine the relationship between the evolution of the CS scar niche and the ultimate pregnancy result. Materials and Methods: Transvaginal sonography was used in this prospective observational research to look at the uterine scars of 100 women at 11+0-13+6, 18+0-20+6 and 32+0-35+6 weeks of pregnancy. When the region of hypoechogenic myometrial discontinuity of the lower uterine section was discovered, a scar was discernible while pregnant. An indentation at the location of the CS scar with a depth of at least 2 mm in the sagittal axis was designated as the CS scar niche (or "defect"). Myometrial thickness next to the niche and the remaining myometrial thickness were used to quantify the hypoechogenic portion of the CS niche in two dimensions. (RMT). The entire lower uterine segment (LUS) thickness and the myometrial layer thickness were measured during the second and third trimesters of pregnancy at the thinnest portion of the scar area. In a non-selected subset of patients (n=20), CS scars were measured by two separate examiners. Scar visibility was evaluated using descriptive analysis, and the intraclass correlation coefficient (ICC) was computed to demonstrate the degree of absolute agreement between two observers for measuring scars. Maternal age, BMI, smoking status, prior vaginal deliveries, obstetric complications, and a history of uterine curettage were among the factors looked into as potential contributors to the CS scar niche. The hospital's computerized medical database provided clinical statistics on pregnancy outcomes and complications. Results: 80.9% of the ladies could see the scar. A CS scar niche was prevalent in 53.6% of people with a noticeable CS scar. Excellent intra- and interobserver agreement was observed for CS scar niche readings. There was no statistically significant correlation between maternal age, BMI, gestational diabetes, smoking status, previous vaginal delivery after CS, and niche development when subgroups of women were compared in terms of CS scar niche and non-niche. In contrast to 34.4 % of the women who did not have uterine curettage, 56.3% of the women who had done uterine curettage had uterine scar niches. Conclusions: The CS scar niche could be reproducibly measured by a transvaginal scan in half of the cases with a visible CS scar at the first trimester of pregnancy, according to an ultrasonography evaluation. An increased chance of uterine niche formation in a subsequent pregnancy was linked to prior uterine curettage. The CS scar area may be connected to uterine scar dehiscence.

The Feasibility of a Trial of Labor after Two Cesarean Deliveries: Outcomes and Prognostic Factors for Success.

This study aimed to determine whether a trial of labor after two cesarean deliveries (TOLAC2) increases the risk of adverse maternal and neonatal outcomes and identify prognostic factors for TOLAC2 success. A retrospective cohort study was conducted at a single medical center. The study group was comprised of women with a history of TOLAC2. Outcomes were compared with women undergoing trial of labor after one previous cesarean delivery (TOLAC1). The primary outcome was trial of labor after cesarean delivery (TOLAC) success. Secondary outcomes included mode of delivery, uterine rupture, and combined adverse outcome (CAO; uterine rupture, postpartum hemorrhage, 5-minute Apgar score < 7, pH < 7.1). Logistic regression was used for the multivariate analysis to identify prognostic factors for TOLAC2 success. A total of 381 women who underwent TOLAC2 were compared with 3,635 women who underwent TOLAC1. Women attempting TOLAC2 were less likely to achieve vaginal births after cesarean delivery (VBAC; 80.8 and 92.5%; odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.26-0.47; p < 0.001) and more likely to experience uterine rupture (0.8 vs. 0.2%; OR: 4.1; 95% CI: 1.1-15.9; p = 0.02) but not CAO (4.2 vs. 4.8%; OR: 0.88; 95% CI: 0.5-1.5; p = 0.3). TOLAC2 women with no previous vaginal deliveries had a lower chance of VBAC and a higher risk of uterine rupture compared with TOLAC1 women without a prior vaginal delivery (45.2 vs. 86.3%; OR: 0.13; 95% CI: 0.07-0.25; p < 0.001; 2.3 vs. 0%) and TOLAC2 women with a prior vaginal delivery (45.2 vs. 85.3%; OR: 0.14; 95% CI: 0.1-0.3; p < 0.0001; 2.4 vs. 0.6%; OR: 4.1; 95% CI: 0.4-46.3; p = 0.3). Multivariate analysis revealed that a history of vaginal delivery is an independent predictor of TOLAC2 success. Women attempting TOLAC2 are less likely to achieve VBAC and are at greater risk of uterine rupture compared with those attempting TOLAC1. Despite these risks, the overall success rates remain very high, and the absolute risk of adverse outcomes is still very low. Prior vaginal delivery seems to have a protective effect on TOLAC outcomes. These data should be used to counsel women and assist in decision-making when considering the mode of delivery in women with two previous cesarean sections. · TOLAC2 has a lower chance of success and higher rate of uterine rupture compared with TOLAC1.. · Previous vaginal delivery is an independent predictor of TOLAC2 success.. · Overall TOLAC2 outcomes are associated with high chances of success and low risk of uterine rupture..

A comparative study for feto-maternal outcome of trial of labour after caesarean: spontaneous versus induction

Objective The purpose of this study was to compare the foeto-maternal outcome of trial of labour after previous one lower segment caesarean section in spontaneous and induced labour and to ascertain the success rate of VBAC.(Vaginal birth after cesarean section) Methods It was a prospective study conducted from May2019-November2020.The pregnant women admitted in BPSGMC (BPS Government Medical College), labour ward who had previous one caesarean section undergoing trial of labour after either spontaneous onset or induction of labour, were included in the study. Results Total patients were 130, [65 each, in group I(spontaneous) and group II (induced)]. Successful TOLAC (Trial of labour after cesarean section) happened in 80% in spontaneous labour (gp I) patients and 66.2 % women in induced patients (group II), (p value-0.075). There was no significant difference in age, parity and gestational age (p value &gt;0.05), APGAR score and NICU (Neonatal intensive care unit) admissions in both spontaneous labour(gp I) and induced patients (gp II). There incidence of fetal distress was not statistically significant in spontaneous (group I) and induced patients (group II), (p value-0.744). Indication of primary LSCS (Lower segment cesarean section) showed no significant effect on outcome of TOLAC in spontaneous and induced group patients. History of prior vaginal delivery had more chances of VBAC. Hospital stay and PPH was more in induced patients(group II). The dfference of scar dehiscence in group I(spontaneous) and II (induced) were not statistically significant (p value=0.721). There were no cases of scar rupture in both the groups. Conclusion Induction of labour and spontaneous labour both have almost similar VBAC success rates. Also with fewer scar dehiscence and no rupture, IOL (Induction of labour) is a good option in previous one cesarean patients.

Second stage duration and delivery outcomes among women laboring after cesarean with no prior vaginal delivery.

We aimed to evaluate the association of the duration of the second stage with labor after cesarean (LAC) success and other outcomes among women with one prior cesarean delivery (CD) and no prior vaginal births. All women undergoing LAC that reached the second stage of labor from March 2011 to March 2020 were included in this retrospective cohort study. The primary outcome was the mode of delivery by second stage duration. The secondary outcomes included adverse maternal and neonatal outcomes. We allocated the study cohort into five groups of second stage duration. Further analysis compared <3 to ≥3 h of second stage based on prior studies. LAC success rates were compared. Composite maternal outcome was defined as the presence of uterine rupture/dehiscence, postpartum hemorrhage, or intrapartum/postpartum fever. One thousand three hundred ninety seven deliveries were included. Vaginal birth after cesarean (VBAC) rates decreased as the second stage length time interval increased: 96.4% at <1 h, 94.9% at 1 to <2 h, 94.6% at 2 to <3 h, 92.1% at 3 to <4 h and 79.5% at ≥4 h (p < 0.001). Operative vaginal and CDs were significantly more likely as second stage duration time interval increased (p < 0.001). The composite maternal outcome was comparable among groups (p = 0.226). When comparing the outcomes of deliveries at <3 h versus ≥3 h, the composite maternal outcome and neonatal seizure rates were lower in the <3 h group (p = 0.041 and p = 0.047, respectively). Vaginal birth after cesarean rates decreased as second stage time interval length increased. Even with prolonged second stage, VBAC rates remained relatively high. Increased risk of composite adverse maternal outcomes and neonatal seizures were observed when the second stage lasted 3 h or more.

Women Who Avoid or Stop Exercise Due to Lower Urinary Tract Symptoms: Prevalence, Symptom Profile, and Associated Factors

To determine the prevalence of women who report avoiding exercise or stopping a workout due to lower urinary tract symptoms (LUTS) in a community population, characterize symptoms in these women, and identify clinical and demographic factors associated with exercise cessation due to LUTS. A cross-sectional online survey was administered to community-based women. The prevalence of having avoided exercise or stopped a workout due to LUTS was calculated. Clinical and demographic variables along with comprehensive urinary symptoms assessed by the Lower Urinary Tract Research Network-Symptom Index (LURN-SI 29) were compared between women with and without the outcome. Multivariable logistic regression and random forest models were used to identify variables associated with the outcome. Out of 1707 women who completed the survey, 18.9% reported avoiding exercising or stopping a workout due to LUTS. For these women, multiple domains of LUTS were noted, including incontinence, pain, voiding difficulty, urgency, and nocturia. Multivariable logistic regression identified LURN SI-29 score, White race, and prior vaginal delivery as significantly associated with the outcome, while the random forest model identified LURN SI-29 score, age, and body mass index (BMI) as most important. In a population-based study, 1 in 5 women reported avoiding exercise or stopping a workout due to LUTS. Their reported LUTS span multiple symptom domains, and factors associated with stopping exercise include symptom severity, older age, higher BMI, White race, and prior vaginal delivery. Addressing LUTS may improve the resumption and continuation of exercise in women.

Prevalence and risk factors for urinary incontinence up to 2 years postpartum: a cross-sectional population-based study.

Urinary incontinence (UI) is common in the postpartum period; however, most studies focus on the early postpartum period and assess prevalence at only one or two time points. We hypothesized that UI would be prevalent across the first 2 years postpartum. Our secondary objective was to evaluate risk factors for postpartum UI among a nationally representative, contemporary sample. This cross-sectional, population-based study used National Health and Nutrition Examination Survey (2011-2018) data for parous women within 24months following delivery. Prevalence of UI, UI subtypes, and severity were estimated. Multivariate logistic regression was used to estimate adjusted odds (aOR) of UI for exposures of interest. Among 560 postpartum women, prevalence of any UI was 43.5%. Stress UI was most common (28.7%), and most women (82.8%) experienced mild symptoms. There was no significant change in prevalence of UI across the 24months following delivery (R2 = 0.004). Individuals with postpartum UI tended to be older (30.3 ± 0.5 versus 28.8 ± 0.5years) and had higher BMI (31.1 ± 0.6 versus 28.9 ± 0.6). In multivariate analysis, odds of postpartum UI were higher for women who had had a prior vaginal delivery (aOR 2.0, 95% CI: 1.3-3.3), prior delivery of a baby weighing 9 lb (4 kg) or more (aOR 2.5, 95% CI: 1.3-4.8), or who reported current smoking (aOR 1.5, 95% CI: 1.0-2.3). During the first 2 years postpartum 43.5% of women report UI, with relatively stable prevalence over this period. This high prevalence supports screening for UI after delivery regardless of risk factors.

MATERNAL AND FETAL OUTCOMES IN PATIENTS WITH PREVIOUS CAESAREAN SECTION UNDERGOING TRIAL OF VAGINAL BIRTH

Background: Vaginal birth after cesarean section (VBAC) is one of the strategies developed to control the rising rate of cesarean sections (CSs). It is a trial of vaginal delivery in selected cases of a previous CS in a well-equipped hospital. In 1916, Cragin popularized the dictum, once a caesarean section, always a caesarean section. That was the era of the classical CS. In the present era of lower segment caesarean section (LSCS), cesarean-related morbidity and mortality are significantly reduced. The dictum now is once a caesarean section, always an institutional delivery in a well-equipped hospital. The reasons which led to the reversal of the old dictum are based upon the newer concepts of the assessment of scar integrity, fetal well-being, and improved facilities of emergency Cesarean Section. Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation.Nevertheless, a previous CS does cast a shadow over the outcome of future pregnancies. With present techniques and skill, the incidence of cesarean scar rupture in subsequent pregnancies is very low. The strength of the uterine scar and its capacity to withstand the stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in advance. These cases require the assessment and supervision of a senior obstetrician during labor. Hence, the present study is undertaken to assess the success and safety of VBAC in selected cases of one previous LSCS and to evaluate the maternal and fetal outcome in these cases. Methods:This prospective observational study was conducted over a period of 18 months from 1st August 2019 to 28th February 2021 at the department of obstetrics and Gynaecology, tertiary care hospital Pune, Maharashtra, India. After achieving ethic committee approval, informed consent of patients enrolled for the study taken, a thorough history and physical examination was done as per proforma. Cases were evaluated thoroughly to collect maternal age, gestational age at admission, association of success rate of VBAC and Parity, Mode of delivery, whether instrumentation was required, indication of previous LSCS, indication of caesarean section in repeat emergency caesarean section, history of prior vaginal delivery, interpregnancy interval. Maternal and fetal outcomes in both successful VBAC and emergency caesarean section were observed.Data collected in structured pro-forma, entered in Microsoft Office Excel format, and statistical analysis was performed using SPSS software. The data so collected was presented with graphical representation. Results: Out of 65 patients undergoing TOLAC, a total of 51 patients had successful vaginal birth and for 14 patients emergency caesarean section was needed. Therefore, the success rate of VBAC in this study in 78%. The most common indication of failed TOLAC was fetal distress. Factors affecting success of TOLAC seen in the study were inter-pregnancy interval, fetal weight and previous caesarean section done for non-recurrent indications. No significant fetal or maternal morbidity was observed in this study. There was no fetal and maternal mortality. Conclusion:Trial of labor after one caesarean section should be undertaken in selected patients in well-equipped hospitals where facilities to deal with emergencies are available.Despite the risks, trial of labor after caesarean remains safer option for many patients as there are fewer complications with less maternal morbidity and will lead to a successful outcome in a high percentage of cases.

Prediction of Success Rates of Vaginal Birth after Cesarean Delivery According to the Previous Indication for Cesarean Delivery

Background: Trial of labor after cesarean delivery (TOLAC) has long been accepted as a safe option for women with previous cesarean delivery. Previous efforts have been exerted in trials to predict the success rates of TOLAC according to specific parameters related to previous cesarean section and before TOLAC. We aimed to investigate the different indications of previous cesarean delivery as independent predictors for successful vaginal birth. Methods: A retrospective study was conducted in Armed Forces Hospitals of the Southern Region between December 15, 2019, and July 1, 2020. The included 566 patients with previous cesarean section who were willing to undergo a trial of labor were divided into two groups according to the success of vaginal birth (VBAC). Results: The nonrecurring indications for previous cesarean delivery were higher in the successful group (fetal distress 54.7% vs 41.1%, malpresentation 26% vs 21.4%, multifetal pregnancy 3.8% vs 2.7%). Additionally, the successful VBAC group had a significantly higher percentage of previous successful VBAC (47.7% vs 21.9%) and prior vaginal deliveries (58.5% vs 44.2%) and less coincidence of medical disorders and meconium-stained liquor (18.1% vs 26.3% and 3.2% vs 8.2%, respectively) than the unsuccessful group. Conclusion: During counseling regarding trial of labor after cesarean section, indications for previous cesarean section not related to arrest of labor can predict higher success of VBAC. Moreover, previous successful vaginal delivery or VBAC improves the success rates.