Repeat Cesarean Delivery Research Articles

THE EFFECT OF PRIMARY AND REPEATED CESAREAN BIRTH ON BREASTFEEDING SUCCESS AND MATERNAL ATTACHMENT LEVEL IN POSTPARTUM: A CROSS-SECTIONAL AND COMPARATIVE STUDY

This research was conducted to determine the effect of primary and repeated cesarean births on breastfeeding success and maternal attachment level in postpartum women. The cross-sectional and comparative study sample consisted of 322 postpartum women who applied to a public hospital in eastern Turkey. Data were collected with the "Personal Information Form", "LATCH Breastfeeding Assessment Tool" and “Maternal Attachment Scale(MAS)". Descriptive statistics, independent group’s t-test, and Pearson correlation analysis were used to analyze the data. The average age of the puerperants with primary and repeat births was determined as 28.14±6.15, and 30.56±4.91, respectively. The mean LATCH and MAS total scores of postpartum women who had primary cesarean delivery were lower than those of postpartum women who had repeated cesarean delivery, and the difference between them was statistically significant(p=0.000). It was found that there was a weak, positive relationship between the MAS and LATCH score averages of women who had primary and repeated cesarean deliveries, and as breastfeeding success increased, the level of attachment also increased. It was concluded that breastfeeding success and attachment levels were lower in primary cesarean births compared to repeated cesarean births, and as the breastfeeding success achieved in both groups increased, the level of attachment increased.

The Impact of Indication for Cesarean on Blood Loss

BackgroundPostpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment at the time of cesarean delivery is a more accurate measure of blood loss than is simple estimation. Risk factors for postpartum hemorrhage are well described; however, contemporary, systematic investigations into the impact of the indication for cesarean delivery on quantitative blood loss are lacking. ObjectiveTo investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery. Study DesignA cohort of 4,881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 was identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into seven indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage ( > 1000 cc and >1500cc) were compared among the different indications. ResultsMean quantitative blood loss for primary, repeat and total cesarean deliveries was 886 cc, 697 cc and 792 cc, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was seen in cesareans performed for labor arrest, with blood loss exceeding 1500 cc in 18% and 13% of all cases. Blood loss exceeding 1500cc was seen in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean/hysterectomies for placenta accreta was < 400cc greater than primary cesareans performed for labor arrest (1442 cc vs. 1065 cc), despite the addition of an often-complex hysterectomy to the procedure. ConclusionsClinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in rates of serious postpartum hemorrhage (>1500cc) with negligible differences in mean quantitative blood loss suggests the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean and the possibility of such outliers, rather than the predicted “average blood loss for cesarean delivery” should be considered in determining risk and the degree of necessary pre-operative blood preparation. These data raise questions about whether current, traditional techniques of non-accreta related cesarean delivery can be justified in non-emergent cases when such procedures could be performed with significantly less blood loss using accreta-specific techniques.

Impact of high-order repeat cesarean deliveries on early maternal complications among major placenta previa patients in Southern Saudi Arabia.

To investigate the rates and odds ratios (ORs) of early maternal complications among patients with major placenta previa (PP) who have undergone high-order repeat cesarean deliveries (HOR-CDs) in comparison to those with low-order repeat cesarean deliveries (LOR-CDs). We carried out a retrospective review of all major PP patients (n=184) who delivered through second or subsequent repeat CDs, from January 2012 to December 2021 (Abha Maternity and Children's Hospital, Abha, Saudi Arabia). The patients were categorized into 2 groups: the LOR-CDs group (n=100), comprising individuals with their second and third CDs (CD2-CD3) and the HOR-CDs group (n=84), consisting of those undergoing their fourth to seventh CDs (CD4-CD7). In comparison to the LOR-CDs, the HOR-CDs group with major PP exhibited significantly higher rates and ORs of early maternal complications, including MRI-diagnosed placenta accreta spectrum (PAS, OR=2.67), transfusions of packed red blood cells (OR=2.71), moderate to severe intra-operative bleeding (OR=1.80), emergency hysterectomy (OR=2.96), urological injuries (OR=3.17), and length of post-operative hospital stay (OR=3.91). The major PP subgroup undergoing CD6-CD7 showed the highest rates and ORs for PAS diagnosis at 84.6% (OR=3.98) and emergency hysterectomy at 28.6% (OR=4.04). Among patients with major PP, undergoing more than 3 CDs is associated with a notable increase in both the rates and ORs of various early maternal complications. This trend of increasing many complications correlates directly with an ascending number of CDs.

Trial of labor following cesarean among patients with polyhydramnios: a multicenter retrospective study.

This study aimed to assess maternal and neonatal outcomes in patients with polyhydramnios attempting trial of labor after cesarean (TOLAC) compared to those undergoing planned repeat cesarean delivery (PRCD). A multi-center retrospective cohort study was conducted and included women with term singleton viable pregnancies following a single low-segment transverse cesarean delivery (CD) with a polyhydramnios diagnosis (maximal vertical pocket > 8cm and/or Amniotic Fluid Index > 24cm) within 14days before birth who delivered between the years 2017 and 2021. Maternal and neonatal outcomes were compared between those attempting TOLAC and those opting for PRCD. The primary outcome was composite adverse maternal. Univariate analysis was followed by multivariate analysis to control for potential confounders. Out of 358 included births with a previous CD, 208 (58.1%) attempted TOLAC, while 150 had PRCD (41.9%). The successful vaginal birth after cesarean (VBAC) rate was 82.2%, and no cases of uterine rupture, hysterectomy, or maternal intensive care unit admission occurred in either group. After controlling for potential confounders, no independent association between TOLAC and composite adverse maternal (adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.32-1.20, p = 0.16) and neonatal (aOR 0.89, 95% CI 0.51-1.53, p = 0.67) adverse outcomes was demonstrated. In patients with a term diagnosed polyhydramnios, TOLAC appears to be a reasonable alternative associated with favorable outcomes. Larger prospective studies are needed to refine management strategies and enhance maternal and neonatal outcomes in this context.

Social disparities in delivery choice among patients with history of cesarean

ObjectiveGiven the call to reduce rates of non-medically indicated cesarean deliveries (CDs) by encouraging trials of labor after cesarean (TOLAC), this study looks at social characteristics of patients choosing a TOLAC versus a scheduled repeat cesarean delivery (SRCD) to determine disparities regarding delivery method choice. MethodsThis was a retrospective cohort study of patients with a history of one CD between April 29, 2015–April 29, 2020. Patients were divided based on type of delivery chosen at admission. Chi-squared tests examined proportional differences between groups and logistic regression models examined odd ratios of choosing TOLAC versus SRCD according to socially dependent categories including race/ethnicity, health insurance, pre-pregnancy body mass index, and Social Vulnerability Index (SVI). Results1,983 patients were included. Multivariable logistic regression models revealed that patients with a high SVI (reference: low/medium SVI) (AOR 2.0, CI: 1.5, 2.5), self-identified as Black/ African American (AOR: 2.4, CI: 1.6, 3.6) or Hispanic/Latina (AOR: 2.0, CI: 1.4, 2.8) (reference: White), had public insurance (reference: private insurance) (AOR: 3.7, CI: 2.8, 5.0), and who had an obese BMI (reference: non-obese BMI) were more likely to opt for a TOLAC rather than SRCD. ConclusionThese findings demonstrate differences in delivery method preferences. Specifically, more disadvantaged patients are more likely to choose TOLAC, suggesting that social and economic factors may play a role in delivery preferences. These findings have implications for improving individualized counselling and engaging in shared decision-making around mode of delivery.

Postoperative analgesic consumption for primary versus first repeat Cesarean delivery: a historical cohort study.

It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compareopioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls. We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48hr, and opioid consumption at 24hr. We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51). In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.

Elective Repeated Cesarean Section (ERCS)

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

Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case-control study.

Intraoperative hemorrhage and peripartum hysterectomy are the main complications in patients presenting with a low-lying placenta or placenta previa undergoing repeat Cesarean delivery (CD). Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injury. The aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries. This was a retrospective case-control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior CD and diagnosed prenatally with an anterior low-lying placenta or placenta previa at 32-36 weeks' gestation. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examination within 48 h prior to delivery. Ultrasound anomalies of uterine contour and uteroplacental vascularity, and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery, were recorded using a standardized protocol, which included evaluation of the extent of uterine contour anomalies. The diagnosis of PAS was established when one or more placental lobules could not be separated digitally from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, and was confirmed by histopathology. Data were compared between cases complicated by intraoperative bladder injury and controls from the same cohort matched at a 1:3 ratio by parity and the number of prior CDs using conditional logistic regression. There were 16 (9.4%) patients with an intraoperative bladder injury in a cohort of 170 managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. There were 14 (87.5%) patients with a bladder injury that had histopathologic evidence of PAS at birth, including 11 (68.8%) cases described on microscopic examination as placenta increta and three (18.8%) as placenta creta. There was a significant (P = 0.03) difference between cases and controls in the distribution of intraoperative LUS vascularity, whereby the higher the number of enlarged vessels, the higher the odds of bladder injury. Multivariable regression analysis revealed that both gestational age at delivery and LUS remodeling on transabdominal ultrasound were associated with bladder injury. A higher gestational age was associated with a lower risk of injury. A higher LUS remodeling grade on transabdominal ultrasound was associated with an increased risk of bladder injury. Patients with Grade-3 remodeling (involving > 50% of the LUS) had 9-times higher odds of a bladder injury compared to patients with Grade-1 remodeling (involving < 30% of the LUS). Preoperative ultrasound examination is useful in the evaluation of the risk of intraoperative bladder injury in patients with a history of prior CD presenting with a low-lying placenta or placenta previa. The larger the remodeling of the LUS on transabdominal ultrasound, the higher the risk of adverse urologic events. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Maternal and neonatal outcomes associated with multiple repeat cesarean deliveries: A registry-based study from Qatar.

Cesarean delivery (CD) is associated with increased maternal and neonatal morbidity compared to vaginal delivery, particularly in cases classified as emergency procedures or when there are multiple CDs. This retrospective cohort study aims to examine the incidence of maternal and neonatal complications in women with multiple CDs. This study used data from a national perinatal database obtained from a single tertiary maternity care hospital. Women who delivered a singleton live birth after 24 weeks of gestation by CD were stratified into five groups based on the number of CDs, with the last group having five or more CDs. The women were divided into those with five or more CDs (Group 5) versus those with fewer than five (Groups 1 to 4). The maternal outcomes included intra-operative surgical complications, blood loss, and intensive care unit (ICU) admission. The neonatal outcomes included preterm birth, neonatal ICU (NICU) admission, respiratory distress syndrome (RDS), and perinatal death. Of the 6,316 women in the study, 2,608 (41.3%) had a primary CD. 30.3%, 17.5%, and 7.3% of the cohort had their second, third, and fourth CDs, respectively. Women undergoing the 5th CD and above formed the remaining 3.5% (227). Women in Group 5 had the highest risk of suffering a surgical complication (3.1%, p=0.015) and postpartum hemorrhage (7.5%, p=0.010). 24% of babies in Group 5 were born preterm (p<0.001). They also had a 3.5 times higher risk of having a surgical complication (RR=3.5, 95% CI 1.6-7.6, p=0.002), a 1.8 times higher risk of developing postpartum hemorrhage (RR=1.8, 95% CI 1.1-2.9, p=0.014), a 1.7 times higher risk of delivering between 32-37 weeks of gestation (RR=1.7, 95% CI 1.3-2.2, p<0.001), a higher risk of the baby getting admitted to NICU (RR=1.3, 95% CI 1.0-1.6, p=0.038), and developing RDS (RR=1.5, 95% CI 1.2-2.0, p=0.002) compared to Groups 1-4. The risks of neonatal outcomes such as NICU admission (RR 2.9, 95% CI 2.1-4.0) and RDS (RR 3.5, 95% CI 2.3-5.5) were much higher in elective CDs performed at term compared to preterm births (p<0.001 for both). Maternal morbidity significantly increases with the increasing number of CD. The increased risk of RDS and NICU admissions in the neonate with multiple CDs reflects lower gestational age and birthweight in these groups-consideration of preoperative steroids for lung maturation in these women to reduce neonatal morbidity warrants further discussion.

Exploring Effect of Patient Counseling on Mode of Delivery After Cesarean Section [ID 2683575

INTRODUCTION: Increasing vaginal birth after cesarean (VBAC) may help lower national cesarean delivery rates in the United States. This study aims to evaluate factors that affect counseling practices and trial of labor after cesarean (TOLAC). METHODS: All term repeat cesarean deliveries (rCDs) and VBACs from September 2018 to February 2020 were reviewed. Antepartum counseling on mode of delivery, demographic, and obstetrical data were collected. Patients who were not TOLAC candidates were excluded. This study was IRB approved. RESULTS: Six hundred thirty-five patients met inclusion criteria. 304 (47.72%) of these patients had rCD, 65 (10.20%) attempted TOLAC with subsequent rCD, and 268 (42.07%) had VBAC. Of the 635 patients, 470 (74.02%) patients had documentation of TOLAC counseling prior to admission for delivery, whereas 165 (25.98%) did not. TOLAC counseling documentation was not associated with age, race, ethnicity, body mass index (BMI), insurance type, or history of vaginal delivery (VD). Prior VBAC increased the odds of documented TOLAC counseling (odds ratio [OR] 2.36; 95% CI, 1.29–4.63). Medicaid insurance (OR 2.18; 95% CI, 1.29–3.73), history of VD (OR 2.28; 95% CI, 1.16–4.68), history of VBAC (OR 269.0; 95% CI, 50.2–5079), and documented TOLAC counseling (OR 21.12; 95% CI, 11.0–45.10) increased the odds of TOLAC. Increasing BMI decreased the odds of TOLAC (OR 0.91; 95% CI, 0.89–0.95). CONCLUSION: Documented TOLAC counseling increased the odds of attempting TOLAC. As only 74.02% of patients had documented counseling prior to admission for delivery, an effort to increase TOLAC counseling and documentation may increase TOLAC and subsequent VBAC rates, decreasing the cesarean delivery rate.

Management of Fetal Hemolytic Disease Due to Anti-Rh17 With the D−Phenotype [ID 2683500

INTRODUCTION: The rare blood D− haplotype produces multiple Rh antibodies against red blood cell antigens such as anti-Rh17 or anti-Hr0 antibodies if a patient is sensitized to Rh antigens. METHODS: This report discusses successful management of a pregnancy in a 28-year-old woman with high anti-Rh17 titers leading to hemolytic disease of the fetus (HDFN). The combination of a D− allele and the weak D 45 allele has not been reported previously, and it may be that the hybrid allele expresses D antigen epitopes such that the D antigen is not weakened. During the studied pregnancy, the patient received plasmapheresis and intravenous immunoglobulin (IVIG) infusions along with intrauterine transfusions (IUTs) when absolutely necessary. She underwent uncomplicated repeat cesarean delivery at 32 5/7 weeks of gestation resulting in a female infant weighing 2,020 g. Patient informed consent was obtained for this case report. CONCLUSION: This patient with the D−/D− blood phenotype leading to anti-Rh17 antibodies after her first pregnancy was managed successfully. Her baby with HDFN and several instances of hydrops fetalis, was successfully managed and treated. The patient’s blood donations for IUTs and maternal plasma exchange therapies promoted efficiency and favorable outcomes for the baby, but did put the mother in an anemic blood range.

Examining provider practice-level disparities in delivery outcomes among patients with a history of Cesarean Delivery

BackgroundChoosing whether to pursue a trial of labor after cesarean (TOLAC) or scheduled repeat cesarean delivery (SRCD) requires prenatal assessment of risks and benefits. Providers and patients play a central role in this process. However, the influence of provider-associated characteristics on delivery methods remains unclear. We hypothesized that different provider practice groups have different obstetric outcomes in patients with one prior cesarean delivery (CD).MethodsThis was a retrospective cohort study of deliveries between April 29, 2015 – April 29, 2020. Subjects were divided into three cohorts: SRCD, successful VBAC, and unsuccessful VBAC (patients who chose TOLAC but had a CD). Disparities were reviewed between five different obstetric provider practice groups, determined from a breakdown of different providers delivering at the study site during the study period. Proportional differences were examined using Chi-squared tests and logistic regression models.Results1,439 deliveries were included in the study. There were significant proportional disparities between patients in the different groups. Specifically, patients from Group D were significantly more likely to undergo successful VBAC, while patients seeing a provider from Group A were more likely to deliver by SRCD. In our multivariate analysis of successful versus unsuccessful VBAC, patients from Group D had greater odds ratios of successful VBAC compared to Group A. Patients delivered by Group E had a significantly lower odds ratio of successful VBAC.ConclusionThis study suggests an association between provider practice groups and delivery outcomes among patients with one prior CD. These data contribute to a growing body of literature around patient choice in pregnancy and the interplay of patients and providers. These findings help to guide future investigations to improve outcomes among patients with a history of CD.

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

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

Prediction of Intraperitoneal Adhesions in Repeated Cesarean Deliveries with Stria Gravidarum Scoring System: A Cross-sectional Study.

The preoperative prediction of intraperitoneal adhesion (IPA) before repeated cesarean deliveries (CD), which are becoming more prevalent, is crucial for maternal health. The aim of the study was to preoperatively predict IPA in repeated CD with the stria gravidarum (SG) scoring system. A total of 167 patients with at least one previous CD at or beyond 37 weeks of gestation were analyzed. Preoperative SG was calculated according to the Davey scoring system: 0-2 score were defined as mild SG (Group 1; n: 94, 56.2%), and 3-8 score were defined as severe SG (Group 2; n = 73, 43.8%). Preoperative previous cesarean incision features were evaluated according to the Vancouver scar scale. IPA was evaluated according to the Nair's and modified Nair's scoring systems. Parity, younger age at first pregnancy, higher body mass index, number of previous CDs, rate of scar symptoms, Nair's and the modified Nair's scores were statistically significant in Group 2 (P = 0.01; P = 0.04; P = 0.007; P = 0.004; P < 0.001; P = 0.007; P = 0.02, respectively). Davey score ≥3 and Vancouver score ≥4.5 were determined as the cut-off value to predict IPA (P = 0.1 and 0.07, respectively). According to multivariate analysis, both Davey and Vancouver scores are independent factors in predicting IPA (P = 0.02 and 0.04, respectively). Evaluating the SG score through the Davey score in women with a history of previous CD may assist in predicting IPA status before the planning of a subsequent surgery.

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

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

Timing of planned cesarean delivery among patients with two previous cesarean sections.

The timing of planned repeat cesarean delivery (CD) is debateful in clinical practice. Planned repeat CD is typically scheduled before the spontaneous onset of labor to minimize the risk of uterine rupture during labor and the associated risk for fetal compromise. This timing should be balanced with the potential risk of delivering an infant who could benefit from additional maturation in utero. We aim to study the influence of gestational age at the time of repeat CD on maternal and fetal complications. A population-based retrospective cohort study including all term singleton third CDs (≥ 37weeks of gestation), between February-2020 and January-2022 at a tertiary medical center was conducted. Maternal and neonatal adverse outcomes were compared by gestational age at the time of the CD. A logistic regression models were constructed to adjust forconfounders. The study population included624 third CDs. Among them, two study groups were defined: 199 were at 37 + 0 to 37 + 6weeks of gestation, and 44 were at ≥ 39weeks of gestation at the time of delivery. 381 were at 38 + 0 to 38 + 6weeks. Since our routine practice is to schedule elective CD at 38 + 0 to 38 + 6weeks of gestation, we defined this group as the comparison group. In a multivariate analysis, both study groups were associated with significantly higher rates of emergent CDs after adjusting for maternal age, parity, ethnicity, premature rapture of membranes, spontaneous onset of labor and birthweight. After adjusting also for emergent CDs, CDs at 37 + 0 to 37 + 6weeks of gestation were significantly associated with maternal and neonatal length of stay exceeding 4days. Additionally, CDs at 37 + 0 to 37 + 6weeks of gestation were also associated with composite of adverse neonatal and maternal outcomes. Our study demonstrated that scheduling third CD at 38 + 0 to 38 + 6weeks is associated with reduced risk of emergent CD, as well as beneficial maternal and neonatal outcomes.

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

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

Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study.

To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. Population-based cohort study. The Swedish Medical Birth registry. Women with their first and second singletons between 1982 and 2012. Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). Stillbirth (antepartum and intrapartum fetal death). Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

A randomized controlled trial reducing cesarean delivery rates in China by introducing trial of labor after cesarean and electrohysterography

Objective A cesarean delivery (CD) can affect health of both mother and child and future pregnancies. Since the abandonment of the one-child policy in China, obstetricians tend to perform a repeat CD rather than a trial of labor after cesarean (TOLAC). This study aims to reduce CD rates by increasing vaginal births after cesarean (VBAC) rates and introducing electrohysterography (EHG) for accurate monitoring. Methods In total, 82 women received counseling regarding TOLAC at the Shijiazhuang Sixth Hospital in China. Women opting for TOLAC were randomized for either external tocodynamometry (TOCO, i.e. standard care) or EHG. The primary outcome was the VBAC rate. Secondary outcomes were indications for CD, percentage of assisted vaginal deliveries, labor duration, maternal blood loss, complications and neonatal outcomes. Results After accounting for preterm delivery and dropouts, all counseled women opted for a TOLAC (100%). After randomization, 42 women were included in the TOCO-group and 37 in the EHG-group. Women did not receive pain medication and labor was not augmented with oxytocin. The VBAC rate was 71.4% in the TOCO-group, versus 78.4% in the EHG-group (p = .48). Birth was assisted with forceps in 11.9% of TOCO-group versus 2.7% of EHG-group (p = .21). One secondary CD (i.e. a shift from intended vaginal delivery to surgical delivery within the same labor) was performed because of a suspicion of uterine rupture (TOCO-group). Other indications for CD were: fetal distress, labor dystocia, fetal position, cephalopelvic disproportion. There were no significant differences in secondary study outcomes. No complications were reported. Conclusion This study showed an average VBAC rate of 75%, without any complications, in a hospital with no previous experience with TOLAC. The VBAC rate with EHG-monitoring was higher than TOCO, although this difference was not significant. To demonstrate a significant difference, larger clinical studies are necessary. Trial registration The Daily Board of the Medical Ethics Committee of The Maternal and Child Hospital of Shijiazhuang approved the study protocol (number 20171018, Dutch Trial Register NL8199).

230 Trial of labor or repeat caesarean delivery in women with morbid obesity

230 Trial of labor or repeat caesarean delivery in women with morbid obesity