Rate Of Repeat Caesarean Section Research Articles

Frequency Of Vaginal Birth After Caesarean Section And Its Fetomaternal Outcome.

Vaginal birth after caesarean section (VBAC) is associated with reduced blood loss and transfusions, fewer infections, and fewer thromboembolic events as compared to caesarean delivery. The current rate of repeat caesarean after one previous caesarean is above the WHO standard of 15%. We aimed to determine the occurrence of VBAC and to determine the occurrence of feto-maternal outcomes in successful VBAC cases so that trials of VBAC can be given to carefully selected patients to reduce the rate of repeat caesarean section. The Combined Military Hospital (CMH) Rawalpindi's Obstetrics and Gynaecology department conducted this cross-sectional study from March 20 to September 19, 2021. After obtaining ethical committee approval, data was collected using a non-probability, consecutive sampling technique from 150 patients on a self-developed structured proforma. Patients between the age range of 20-35 years with a history of previous lower segment caesarean section, having gestational age between 37-41 weeks and who presented in spontaneous labour were included in this study. After taking informed consent, all women were given a trial of labour and the outcome of the trial was noted. Women were followed for the feto-maternal outcomes. The gathered information was analysed using SPSS version 25.0. Post-stratification, a p-value of 0.05 or lower on the chi-square test was deemed statistically significant. Following a C-section, 28.67% of patients experienced successful vaginal births. PPH was found in 2.32%, scar dehiscence in 0.0%, low birth weight babies in 16.28%, APGAR score <7 at 1 minute was 23.26% and NICU admission as 9.30% in women undergoing vaginal birth after caesarean section. Appropriate selection of patients for the trial of VBAC can help reduce the higher rate of repeat caesarean section after a previous caesarean section and increase the chances of successful vaginal birth.

Caesarean section following antepartum stillbirth in Western Australia 2010-2015: A population-based study.

There is scant literature about antepartum stillbirth management but guidelines usually recommend reserving caesarean sections for exceptional circumstances. However, little is known about caesarean section rates following antepartum stillbirth in Australia. We aimed to describe the onset of labour, mode of birth, and use of analgesia and anaesthesia following antepartum stillbirth and to identify factors associated with caesarean section. In this retrospective cohort study, we used a population-based dataset of all singleton antepartum stillbirths ≥20weeks gestation in Western Australia between 2010-2015. The overall, primary and repeat caesarean section rates for antepartum stillbirths were calculated and multivariable Poisson regression analyses were performed to identify associated factors, and to calculate relative risks (RRs) and 95% confidence intervals (CIs). This study included 634 antepartum stillbirths. Labour was spontaneous for 134 (21.1%), induced for 457 (72.1%), and 43 (6.8%) had a prelabour caesarean section. The overall, primary and repeat caesarean section rates were 8.5%, 4.6% and 23.0% respectively and increased with gestation (P trends all <0.01). Other factors associated with an increased caesarean section risk included: any placenta praevia or placental abruption, birth at a metropolitan private hospital, large-for-gestational-age birthweight, and any maternal chronic condition. During labour, the most frequently used types of analgesia were systemic narcotics (46.0%) and regional blocks (34.7%) while among those who had a caesarean section, 40.7% had a general anaesthetic. In Western Australia between 2010-2015, the caesarean section rates among women with antepartum stillbirths were low, in line with current guidelines.

A Losing Game? – Recent trends in success rates of vaginal birth after Caesarean Section

Increasing rates of elective repeat cesarean section and reducing rates of vaginal births after previous cesarean (VBAC) are contributing to the increasing trend in cesarean delivery worldwide. Success rates of VBAC vary between continents, countries and institutions. While attempting VBAC is not without risk, it can be safely achieved with tremendous patient benefit. We examined how the rate of successful trials of labor after cesarean delivery has changed in recent years, in order to give patients and medical professionals an up to date perspective on VBAC.

The effect of mode of delivery and duration of labour on subsequent pregnancy outcomes: a retrospective cohort study.

To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy. Retrospective analysis of prospectively collected data. 15 Maternity units in North West London (1988-2000). 30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. Compared with vaginal birth, an emergency CS in the first-term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy. An emergency caesarean section in the first-term pregnancy affects the duration and outcome of the next pregnancy.

THE RATE AND INDICATION OF CAESAREAN SECTION IN A TERTIARY CARE CENTRE

Method: The rate of caesarean section was only slightly higher than recommended by the WHO. Most of caesarean sections were emergency caesarean sections. Data on all live births were collected, including type of delivery, and indication was recorded if cesarean section was done. Total, primary, &amp; repeat cesarean section rates were calculated for each year. The cesarean rate was calculated as the number of cesarean births divided by total live births. The rate for each indication was calculated annually as the number of cesarean births performed for each indication per 1,000 live births. &#x0D; Result: These two groups constituted nearly 87.7% of total C-Sections. Only 3.4% of the cases belonged to the elderly age group of above 35 years. Maximum no. of caesarean sections was in multiparous females (54.3%). Out of 550 caesarean deliveries 76.7% were from urban area. Also, result showed that only 68.7% were booked for antenatal care.&#x0D; Conclusion: The rate of cesarean section has increased with time with primary and repeat cesareans both showing an increase. In the primary CS rate, indications like labor arrest disorders &amp; fetal distress show an increase more than the objective indications like malpresentation. In repeat CS, history of 02 or more previous sections &amp; scar tenderness contributed more than the fetal distress.&#x0D; Keywords: Indication, Caesarean

Health Care System Barriers to Vaginal Birth after Cesarean Section: A Qualitative Study.

Background:Approximately half of mothers give birth by cesarean section in Iran and two-thirds of them are repeated cesareans. Repeated cesarean is threatening for the mothers and newborns and not compatible with fertility policies in Iran. Vaginal Birth After Cesarean (VBAC) is a reasonable strategy but its prevalence is very low due to some barriers. The aim of this study was to explore barriers to VBAC in health care system.Materials and Methods:In this qualitative study, 26 semi-structured individual interviews with maternity care providers and mothers with prior cesarean section as well as one focus group discussion with maternity care providers were conducted. Interviews and focus group discussions were tape-recorded, transcribed verbatim and analyzed with conventional content analysis developed by Graneheim and Lundman using MXQDA10 software.Results:Barriers to VBAC in health care system identified in the main category of “the climate of restriction, fear and discourage” and eight subcategories including: “defective access to specialized services,” “insufficient encouragement system,” “modeling in cesarean section,” “physician-centeredness in VBAC,” “fear of legal responsibilities,” “imposed policies,” “marginalization of midwives,” and “unsupportive birth team.”Conclusions:To remove barriers of VBAC in health care system, appropriate strategies including establishment of specialized VBAC counseling centers, performance-based incentive policies, cultural development and promotion of natural childbirth, promoting of teamwork culture, shared decision making, improvement of knowledge and skills of maternal care providers and implementation of clinical guidelines, should be considered. Future research could be focused on the effect of implementing these strategies to decrease repeat cesarean section rate.

Repeat Caesarean Sections: Complications and Outcomes

Background: The rising incidence of caesarean section all over the world has been of great concern both to the patients and obstetrician.1 Repeat caesarean section is one of the major reasons which have contributed greatly to high caesarean section (CS) rate.1,2 Although maternal death as a result of CS is now rare, reports of the short-and long-term consequences of the rising CS rate on the childbearing population are conflicting.3 Available data show that repeat caesarean section is associated with many maternal complications, specially intra-abdominal adhesions, central placenta praevia, uterine rupture, caesarean scar pregnancy, caesarean hysterectomy etc.4&#x0D; Objective: To evaluate outcome and complications of multiple repeat caesarean section.&#x0D; Methodology: This was a cross sectional prospective study conducted in Shaheed Suhrawardy Medical College Hospital (ShSMCH) from 1st June’2016 to 30th November’2016 for a period of six months. The study population were 102 patients, selected randomly who were admitted in ShSMCH for repeat caesarean section.&#x0D; Results: Out of 102 patients admitted with history of previous caesarean section, maternal morbidity was 26 (25.49%), which includes intra-abdominal adhesions 19 (18.62%), excessive blood loss 6(5.88%), placenta praevia 4 (3.94%), placenta accreta 1 (.98%), postpartum haemorrhage 11 (10.78%), wound infection 12 (11.76%) etc.&#x0D; Conclusion: As the rate of repeat caesarean section continue to rise, surgeons should be more judgemental in doing caesarean section.&#x0D; J Shaheed Suhrawardy Med Coll, December 2018, Vol.10(2); 74-79

Trial of Vaginal Birth After Caesarean (VBAC): Sharing Experience From a Tertiary Care Center of Eastern Nepal

Background: Rising rates of cesarean section is a matter of great concern and trial of labor in previous cesarean section women is an attractive alternative. Vaginal Birth After Caesarean (VBAC) may be one of the strategy developed to control the rising rate of cesarean deliveries in our country. Analyzing outcome of previous caesarean pregnancies will provide an insight for reducing the caesarean rates and formulating protocols and policies for trial of labor. The purpose of this study is to evaluate the pregnancy outcome in previous caesarean section women with VBAC trial with the hope of avoiding unnecessary repeat caesarean section rates. Methodology: It is a cross-sectional observational institute based study carried out in Nobel Medical College Teaching Hospital from 15th March 2017 to 14th March 2018 after the approval from Institutional Review Committee (IRC). This consists of patient with past history of cesarean section, who delivered in NMCTH during the study period and meeting the Royal College of Obstetrics and Gynecology (RCOG) inclusion criteria for VBAC. Feto-maternal outcomes were analysed. Results: There were 1225 previous cesarean cases, among them, we did VBAC trial in 135(11%) patients, 99 (73.33%) had successful vaginal delivery whereas 36(26.66%) could not do the same after labor trial. Feto-maternal outcome was better in VBAC patients than cesarean group.No maternal and neonatal mortality occurred. Conclusion: In the country like ours where rate of caesarean section is increasing alarmingly we have to try VBAC in appropriate group of patients. National policy and guidelines are necessary after large multicenter prospective studies. Journal of Nobel Medical College Volume 7, Number 1, Issue 12, January-June 2018, Page: 18-25

Outcome of the vaginal birth after cesarean section during the second birth order in West Kazakhstan.

Background:Vaginal birth after cesarean section (VBAC) increases the chance of subsequent vaginal deliveries and reduces the repeat cesarean section (CS) rate with subsequent postoperative morbidity.Objectives:To detect the outcome of VBAC during the second birth order in Aktobe region of West Kazakhstan.Patients and Methods:A total of 832 women eligible for trial of VBAC were included in this study. Women who signed the consent of VBAC were evaluated thoroughly and data such as maternal age, body mass index, height, gestational age at admission, indication of the previous CS, estimated fetal weight, engagement of the fetal head, condition of the membranes, and cervical dilatation were collected. Data collected after delivery include duration from active phase of labor, mode of delivery, fetal, and neonatal outcomes. The collected data analyzed to detect the outcome of trial of VBAC during the second birth order in Aktobe region of West Kazakhstan.Results:Logistic analysis and odds ratio (OR) showed that body mass index (BMI) ≤25 kg/m2 (OR 1.7; P = 0.0004), height ≥150 cm (OR 1.7; P = 0.002), gestational age ≤40 weeks (OR 2.3; P = 0.0001), and inter-delivery interval ≥2 years (OR 1.6; P = 0.008) were significantly associated with successful VBAC. In addition, <2/5 of the fetal head palpable abdominally, station <−2 (OR 1.7; P = 0.0009), cervical dilatation ≥4 cm (OR 1.7; P = 0.003), and duration of active phase of labor ≤7 h (OR 1.6; P = 0.01) were significantly associated with successful VBAC.Conclusion:VBAC is safe in properly selected cases. BMI ≤25 kg/m2, gestational age ≤40 weeks, inter-delivery interval ≥2 years, and fetal head <−2 station increase the success of VBAC. Prolonged active phase of labor >7 h and the need for labor augmentation decrease the chance of VBAC success.

Practice variation of vaginal birth after cesarean and the influence of risk factors at patient level: a retrospective cohort study.

Large practice variation exists in mode of delivery after cesarean section, suggesting variation in implementation of contemporary guidelines. We aim to evaluate this practice variation and to what extent this can be explained by risk factors at patient level. This retrospective cohort study was performed among 17 Dutch hospitals in 2010. Women with one prior cesarean section without a contraindication for a trial of labor were included. We used multivariate logistic regression analysis to develop models for risk factor adjustments. One model was derived to adjust the elective repeat cesarean section rates; a second model to adjust vaginal birth after cesarean rates. Standardized rates of elective repeat cesarean section and vaginal birth after cesarean per hospital were compared. Pseudo-R2 measures were calculated to estimate the percentage of practice variation explained by the models. Secondary outcomes were differences in practice variation between hospital types and the correlation between standardized elective repeat cesarean section and vaginal birth after cesarean rates. In all, 1068 women had a history of cesarean section, of whom 71% were eligible for inclusion. A total of 515 women (67%) had a trial of labor, of whom 72% delivered vaginally. The elective repeat cesarean section rate at hospital level ranged from 6 to 54% (mean 29.8, standard deviation 11.8%). Vaginal birth after cesarean rates ranged from 50 to 90% (mean 71.8%, standard deviation 11.1%). More than 85% of this practice variation could not be explained by risk factors at patient level. A large practice variation exists in elective repeat cesarean section and vaginal birth after cesarean rates that can only partially be explained by risk factors at patient level.

Variation in hospital caesarean section rates for women with at least one previous caesarean section: a population based cohort study.

BackgroundInternationally, repeat caesarean sections make the largest contribution to overall caesarean section rates and inter-hospital variation has been reported. The aim of this study was to determine if casemix and hospital factors explain variation in hospital rates of repeat caesarean sections and whether these rates are associated with maternal and neonatal morbidity.MethodsThis population-based record linkage study utilised data from New South Wales, Australia between 2007 and 2011. The study population included maternities with any previous caesarean section(s) and were singleton, cephalic and ≥37 weeks’ gestation (Robson Group 5). Multilevel regression models were used to examine variation in hospital rates of ‘planned repeat caesarean section’ and, among women who planned a vaginal birth, ‘intrapartum caesarean section’. We assessed associations between risk-adjusted hospital rates of planned and intrapartum caesarean sections and rates of casemix adjusted maternal and neonatal morbidity, postpartum haemorrhage and Apgar score <7 at five minutes.ResultsOf 61894 maternities with a previous caesarean section in 81 hospitals, 82.1 % resulted in a caesarean section (72.7 % planned and 9.4 % unplanned intrapartum caesareans) and 17.9 % in vaginal birth. Observed hospital rates of planned caesarean sections ranged from 50.7 % to 98.4 %. Overall 49.0 % of between-hospital variation in planned repeat caesarean section rates was explained by patient (17.3 %) and hospital factors (31.7 %). Increased odds of planned caesarean section were associated with private hospital status and lower hospital propensity for vaginal birth after caesarean. There were no associations between hospital rates of planned repeat caesarean section and adjusted morbidity rates. Among women who intended a vaginal birth, the observed rates of intrapartum caesarean section ranged from 12.9 % to 71.9 %. In total, 27.5 % of between-hospital variation in rates of intrapartum caesarean section was explained by patient (19.5 %) and hospital factors (8.0 %). The adjusted morbidity rates differed among hospital intrapartum caesarean section rates, but were influenced by a few hospitals with outlying morbidity rates.ConclusionsAmong women with at least one previous caesarean section, less than half of the variation in hospital caesarean section rates was explained by differences in hospital’s patient characteristics and practices. Strategies aimed at modifying caesarean section rates for these women should not affect morbidity rates.

Factors Affecting the Pregnancy Outcome in Patients with Previous One Caesarean Section

This case series study was designed to determine the factors affecting the pregnancy out come in patients with previous one caesarean section. The study was conducted at Marie Stopes Clinic Primium-1 Dhanmondi from July 01, 2012 to January 31, 2013. A total of 150 patients with previous one caesarean section who presented at term were included in the study. The data were collected through proforma and subjected to statistical analysis. Out of 150 patients, 81 (54%) patients had trial of scar and the remaining 69 (46%) patients underwent repeat elective caesarean section. Among those who had trial of scar only 35 (43.2%) patients achieved successful vaginal delivery and remaining 46 (56.8%) had emergency caesarean section. Common indication for repeat emergency caesarean section was non progress of labour (47.8%). It was frequent in women who reported late to hospital after the onset of labour and in women who did not seek antenatal booking in pregnancy. Maternal complications like post partum hemorrhage, scar dehiscence, wound infection and febrile illness were more in those who had emergency caesarean section. There was no maternal mortality in the study. Perinatal outcome was not affected by the mode of delivery. There were two perinatal deaths which occurred in non-booked patients who underwent emergency caesarean section. Most of the women in our study had repeat caesarean section for failed progress. Regular antenatal check up and early report to hospital after the onset of labour can reduce the rate of repeat caesarean section. DOI: http://dx.doi.org/10.3329/medtoday.v26i1.21300 Medicine Today 2014 Vol.26(1): 01-03

Cesarean section in a high-parity community in Saudi Arabia: clinical indications and obstetric outcomes.

BackgroundThe study of the indications for cesarean section (CS) and its outcomes are useful for hospitals, clinicians, and researchers in determining strategies to lower the primary and repeat CS rate. The aim of this study was to identify the indications for CS and the incidence of adverse maternal/fetal outcomes in a tertiary care setting.MethodsA retrospective cohort study of women (n = 4305) who gave birth by CS at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia (June 2008 to February 2011), was performed. All of the women’s medical records were reviewed by two consulting physicians to obtain the primary indications for CS and determine the maternal characteristics, type of CS (emergency or elective), and birth weight. All adverse maternal and fetal outcomes were recorded. The point and interval estimates of the odds ratios were calculated using a logistic regression model to identify the significant predictors of adverse maternal and/or fetal outcomes.ResultsOf a total of 22,595 deliveries from 2008 to 2011, 4,305 deliveries were CS deliveries (19.05%). Two-thirds (67%) of all CS deliveries were emergency CSs, and the remaining deliveries were elective CSs (33%). Difficult labor (35.9%), fetal distress (21.9%) and breech presentation (11.6%) were the most frequent indications of emergency CS, while previous CS (54.3%), breech presentation (20.4%) and maternal request (10.1%) ranked first for elective CS. Adverse maternal and fetal outcomes were diagnosed in 5.09% and 5.06% of deliveries, respectively, with a significantly higher incidence in the emergency (6.06% & 5.51% respectively) than in elective CS (3.10 & 4.16% respectively). Blood transfusion was the most frequent adverse maternal outcome (3.72%), followed by ICU admission (0.63%), HELLP (0.51%), and hysterectomy (0.30%), while IUGR (3.25%) was the most frequent adverse fetal outcome, followed by IUFD and the need for ICU admission (0.58% each). Adverse maternal outcomes were significantly predicted by high gravidity (OR = 2.84, 95% CI:1.26-6.39, p = 0.011) and preeclampsia (OR = 2.84, 95%CI:1.83-4.39, p < 0.001), while adverse fetal outcomes were predicted by: twinning (OR = 1.81, p = 0.002), hydramnios (OR = 6.70, p < 0.001), and preeclampsia (OR = 2.74, p < 0.001). Preterm delivery was a significant predictor for both adverse maternal and fetal outcomes (OR = 2.39, p < 0.001 & OR = 4.57, p < 0.001, respectively).ConclusionsDifficult labor and previous CS were the main indications for CS in Saudi Arabia. High gravidity was a significant predictor of adverse maternal outcomes. Encouraging Saudi women to consider embarking on fewer pregnancies could act as a safeguard against mandatory CSs for subsequent births in multigravida and grand-multigravida Saudi females. Future prospective study that addresses women with repeat CSs and their association with adverse maternal and fetal outcomes is recommended.

Important factors working to mediate Swedish fathers' experiences of a caesarean section

Objectiveto describe and explore fathers' experiences of their partner's caesarean section birth. Designa qualitative descriptive design was employed. A self-selected sample of 22 Swedish fathers who had experienced an elective or emergency caesarean section agreed to participate. Men were interviewed by telephone seven to 16 months after the birth of their baby. Thematic analysis and the techniques of constant comparison were used to analyse the data. Findingsmen were generally worried about the health and well-being of their baby and partner regardless of birth mode. As the reality of the caesarean section approached men's anxiety escalated and remained high during the procedure. The rapid nature of surgical birth was therefore considered as an advantage; once the baby was born and cried men's fear dissipated. Four factors were identified that mediated the men's experience. Men's perceptions of control, preparedness and how the health-care team behaved and interacted with them were integral to their experience. Knowing the date and time of birth also mediated the experience by providing a sense of certainty to men's experiences of the caesarean birth. Key conclusionscaesarean section was considered as a routine and safe procedure that offered most fathers a sense of certainty, control and safety lessening their sense of responsibility over ensuring a healthy baby. The communication patterns of staff played a key role in ensuring a positive caesarean birth experience. Implications for practiceensuring that men have a positive birth experience, regardless of birth mode, is important for family functioning. However the findings also lend insight into how men may reframe caesarean birth as normal and safe. This may have implications for decision making around birth mode in a subsequent pregnancy further impacting on rising repeat caesarean section rates. Health-care professionals need to provide balanced information about the risks associated with caesarean birth. Any potential benefits need to be contextualised to the pregnant woman's own individual situation. Where possible, and appropriate, professional discourses should support vaginal birth as the safest option for a woman and her baby.

Non-clinical interventions for reducing unnecessary caesarean section

Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. We included 16 studies in this review.Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective.Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.

Does Education Level Influence the Decision to Undergo Elective Repeat Caesarean Section Among Women With a Previous Caesarean Section?

ObjectivePatient education level has been shown to affect health care outcomes in a variety of clinical contexts. The aim of this study was to evaluate whether maternal education level influences women to plan elective repeat Caesarean section rather than attempt a vaginal birth after Caesarean. MethodsWe conducted a retrospective cohort study of women with a previous Caesarean section who delivered at the Royal Victoria Hospital between 2001 and 2006. Education level was stratified as follows: ≤ 11 years (up to and including a high school diploma), 12 to 15 years (some college or university education), and ≥ 16 years (university degree). We used unconditional logistic regression to calculate age-adjusted estimates of the risk of having a planned Caesarean section. ResultsAmong 18 673 deliveries in our cohort, 1915 were in women with a previous Caesarean section. Of these, 12.6% had a high school degree or less, 38.3% had some college or university education, and 49.1% had a university degree. Compared with women whose maximum education was a high school diploma, there was a higher rate of planned Caesarean section in women with some college or university education (OR 1.38; 95% CI 1.00 to 1.89, P = 0.047) and in women with a university degree (OR 1.42; 95% CI 1.04 to 1.94, P = 0.03). ConclusionHigher education appears to be associated with an increased rate of elective repeat Caesarean section. Whether this is due to patient differences or physician bias, physicians should be aware of this disparity and should attempt to provide unbiased informed consent for all women regardless of their level of education.

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Is gestational age an independent variable affecting uterine scar rupture rates?

Objective : To evaluate the influence of gestational age on uterine scar rupture. Methods : This was a population-based study of data from Cardiff Births Survey over a 10-year (1990–1999) period. Women with only one previous lower segment caesarean section with singleton uncomplicated pregnancy of 37 or more week's gestation, undergoing trial of vaginal delivery were included. SPSS version 10 was used for statistical analysis. Mann–Whitney, Fisher's exact test and Chi-square tests were used wherever appropriate. Odds ratio (OR) with confidence intervals (CI) was used to quantify the risk. Potential confounding by other factors was controlled using logistic regression and corrected odds ratios with 95% confidence intervals were calculated. The data was analysed separately for induced and spontaneous labours. Primary outcome measure assessed was uterine scar rupture rate. Secondary outcome measures were repeat caesarean section rates, maternal and perinatal mortality and morbidity. Results : Total sample number was 1620. Eighty percent ( n = 1301) of the population went into spontaneous labour and 20% ( n = 319) were induced. Successful trial of vaginal birth was accomplished in 60% and trial of scar after estimated date of delivery did not alter this outcome significantly (39.1% versus 43.6%, p>0.05). We noted an overall scar rupture rate of 0.9% ( n = 14) and caesarean section rate of 40.4% ( n = 654). Scar rupture rates significantly increased in women who underwent trial of labour after estimated date of delivery ( p < 0.001, OR 6.3, CI 1.9–20.2) without a corresponding increase in caesarean section, maternal and perinatal morbidity figures. The influence of gestational age on scar rupture persisted even after controlling for other confounding factors such as birth weight, induction of labour and BMI (corrected OR 1.9, CI 1.1–3.5). Conclusions : The overall incidence of scar rupture and success of trial of scar after previous caesarean section in our population was similar to that quoted in the literature. Previous evidence has suggested that it is safe for these women to exceed 40 weeks gestation but our data do not support this.

Lowering the cesarean section rate in a private hospital: Comparison of individual physicians' rates, risk factors, and outcomes

Objective: Our purpose was to compare the practice patterns and outcomes of physicians delivering in our institution to identify risk factors and management techniques that could explain the differences in individual cesarean section rates. Study Design: We retrospectively reviewed detailed computerized delivery records ( n = 16,230) collected from May 16, 1988, to July 30, 1995. We excluded physicians who had <100 deliveries at our institution during the study period. The physicians were divided into two groups depending on whether their individual cesarean section rates were greater than (control group) or less than 15% (target group). Various cesarean section rates, risk factors for abdominal delivery, labor management techniques, and neonatal outcome parameters were calculated for each group. The cesarean section rates of the two groups were analyzed by year to assess changes. Results: As expected by study design, the overall cesarean section rate was markedly different between the two groups (13.8% vs 23.8%). In addition, the primary, repeat, primigravid, and multiparous cesarean section rates were all lower for the target group. The rates of cesarean section for fetal distress (1.5% vs 3.3%) and cephalopelvic disproportion (5.3% vs 8.5%) were also significantly less in the target group. The rates of breech presentation, third-trimester bleeding, and active herpes cesarean sections were not lower. The control group had more postterm (8.6% vs 14.7%) and >4000 gm infants (12.0% vs 13.7%) but similar numbers of low birth weight, multiple gestation, and preterm infants. The target group used more epidural anesthesia, oxytocin induction, and trial vaginal births after cesarean delivery and more successful trial vaginal births after cesarean sections. Over the study period the cesarean section rate in the target group remained unchanged, whereas it steadily declined in the control group. Conclusions: Individual physician's lower cesarean sections are primarily obtained by labor management and attempting vaginal birth after cesarean delivery. These practice patterns did not appear to lead to any increase in perinatal morbidity or mortality. Efforts to lower cesarean section rates of individual practitioners should focus on the areas of fetal distress, cephalopelvic disproportion, and repeat cesarean section. (Am J Obstet Gynecol 1998;178:1207-14.)

Decreasing the cesarean section rate in a private hospital: Success without mandated clinical changes

OBJECTIVE: We analyzed the delivery statistics from our institution to describe a successful program of cesarean section delivery reduction and to help us understand what factors explained the reduction. STUDY DESIGN: A retrospective analysis of various cesarean section rates and risk factors from a prospectively collected delivery database of all patients delivered between May 15, 1988, and June 30, 1994. During the study period we instituted a program of increasing awareness, confidential provider feedback, more aggressive laboring techniques, and other clinical guidelines. The delivery data were divided into 6-month intervals and analyzed by χ 2 tables. RESULTS: The overall cesarean section rate fell from 31.1% to 15.4%. Similar reductions were noted in the primary (17.9% to 9.8%) and repeat cesarean section rates (13.2% to 5.7%). The primary cesarean section rate fall was accompanied by a drop in abdominal delivery for cephalopelvic disproportion and fetal distress. The repeat cesarean section rate is explained by a significant increase in trial and successful vaginal birth after cesarean delivery. No increase in maternal, fetal, or neonatal morbidity or mortality was observed. CONCLUSIONS: We have demonstrated that the cesarean delivery rate can be safely lowered in a private hospital without mandated clinical changes. Our data suggest that careful and detailed feedback can lead to improved clinical practice. (A M J O BSTET G YNECOL 1996;174:184-91.)