Trial Of Labor After Cesarean Research Articles

Trial of labor after cesarean in women with hypertensive disorders and no prior vaginal delivery.

Trial of labor among women who never delivered vaginally with hypertensive disorder is associated with nearly half the success rate of the general population. To study the trial of labor after cesarean (TOLAC) among women with hypertensive disorders and no prior vaginal delivery. A retrospective cohort study was conducted including women with no prior vaginal delivery undergoing TOLAC during 2010-2020. Women with hypertensive disorder were compared to those without. A total of 54/2,144 (2.5%) TOLACs had a hypertensive disorder: 32 (59%) had gestational hypertension, 16 (30%) had chronic hypertension and 6 (11%) had preeclampsia. Women with hypertensive disorders had higher BMI and higher proportion of diabetic disorders. TOLAC success rate was lower among hypertensive mothers: 32 (59%) vs. 1,605 (76.8%), p=0.003 odds ratio (OR), 95% confidence interval (CI) 0.44 (0.25-0.76). The rate of uterine rupture was 23/2,144 (1.1%). In a multivariable logistic regression analysis, hypertensive disorder was independently negatively associated with TOLAC success, adjusted OR (95% CI) 0.47 (0.26-0.85). Other factors negatively independently associated with TOLAC failure were maternal age, predelivery body mass index, dystocia at primary CD, gestational age at TOLAC, induction of labor and birth weight. Epidural was independently positively associated with TOLAC success, adjusted OR (95% CI) 1.54 (1.18-1.99). TOLAC in hypertensive women with no prior vaginal delivery is safe. Success rate is impaired in comparison to non-hypertensive women.

Oxytocin Use in Trial of Labour After Cesarean Section in a Canadian Tertiary Hospital: A Retrospective Cohort Analysis

Induction of labour and oxytocin use have been associated with an increased risk of uterine rupture (UR) in patients undergoing trial of labour after cesarean (TOLAC). We aimed to quantify the risk of UR among a Canadian cohort of patients undergoing TOLAC.

Sonographic fetal head circumference is associated with trial of labor after cesarean section success.

The purpose is to study the association of the fetal sonographic head circumference (SHC) with trial of labor after cesarean (TOLAC) success rate, among women with no prior vaginal deliveries. A retrospective case-control study including all women with no prior vaginal delivery undergoing TOLAC during 3/2011-6/2020 with a sonographic estimated fetal weight within one week from delivery. TOLAC success and failure groups were compared. Of 1232 included women, 948 (76.9%) delivered vaginally. The mean fetal SHC was smaller in the TOLAC success group (330 ± 10 vs. 333 ± 11mm, p < 0.001). In a multivariate regression analysis, predelivery BMI, hypertensive disorders, gestational age at prior CD, SHC and epidural analgesia administration were independently associated with TOLAC success. A ROC analysis of the multivariable model composed of the factors found independently associated with TOLAC success, excluding SHC, yielded an area under curve of 0.659 (95% CI 0.622-0.697) compared with 0.668 (95% CI 0.630-0.705) with SHC included. Smaller SHC is independently associated with TOLAC success among women that did not deliver vaginally before, and has additive clinical value for the prediction of TOLAC success when combined with non-sonographic factors.

Outcome of subsequent pregnancies in women with complete uterine rupture: A population-based case-control study.

In the attempt of a trial of labor after a cesarean section approximately one in 200 women experience a complete uterine rupture. As a complete uterine rupture is associated with an adverse perinatal outcome, data regarding subsequent pregnancies are needed to provide proper care and guidance to women with a complete uterine rupture when informing them of future possibilities. The objective of this study was to investigate the fetal and maternal outcomes in subsequent pregnancies after a complete uterine rupture. Retrospective population-based case-control study. Denmark 1997-2017. A total of 175 women with complete uterine rupture during an attempted trial of labor after cesarean (TOLAC) at term (cases) and a corresponding group of 272 women with no uterine rupture during an attempted TOLAC at term (controls) were labeled as index deliveries. Index deliveries were included from January 1, 1997 to December 31, 2008. From the date of the index delivery to December 31, 2017 the information on subsequent pregnancies and deliveries, and on referral to hospital with any obstetric or gynecological diagnosis were retrieved from the Danish Medical Birth Registry and National Patient Registry. Main outcome measures were miscarriage, perinatal death, neonatal morbidity, preterm birth, and recurrence of uterine rupture. Outcome measures were compared between cases and controls. After the index deliveries; there were 109 pregnancies and 70 deliveries after gestational age 22+0 weeks in the population of cases. In the population of controls, there were 183 pregnancies and 126 deliveries after 22+0 weeks. Cases had a significantly higher risk of miscarriage (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.36-13.17). The incidence of uterine rupture was 8.6% among cases and 0.8% among controls (OR 11.7; 95% CI 1.36-543.1). Among cases, 98.6% had live-born infants, and none of these had severe neonatal morbidity. No significant association was found between previous complete uterine rupture and preterm delivery, placenta previa, hysterectomy in relation to subsequent births, diagnosis such as meno/metrorrhagia, dysmenorrhea, or procedures such as hysteroscopy or hysterectomy. In pregnancies following complete uterine rupture continuing after 22+0 weeks, maternal and fetal outcomes are good when managed promptly with cesarean delivery.

Induction of labour in patients with prior caesarean births or uterine surgery.

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.

Evaluating Prediction Score For Success of Trial of Labor After Cesarean (TOLAC)

Objective: To determine the success rate for trial of labor after cesarean section in women with good prediction score.&#x0D; Study Design: Cross sectional (analytical) study.&#x0D; Place and Duration of Study: Department of Obstetrics and Gynecology, PEMH Rawalpindi, from Dec 2017 to Jun 2018.&#x0D; Methodology: A total of 141 women with previous delivery by caesarean section, planned for trial of labor with good prediction score of ≥8 were included in the study. All patients were then allowed to labor spontaneously. Data was collected for success rate after trial of labor&#x0D; Results: Age range in this study was from 18-35 years with mean age of 29.234 ± 2.13 years, mean gestational age 38.531 ± 0.99 weeks, mean weight 63.290 ± 9.97 Kg, mean height 1.532 ± 0.08 meter and mean BMI was 27.097 ± 4.59 Kg/m2. Success rate was seen in 86.5% patients.&#x0D; Conclusion: In conclusion, a prediction model was proposed that can provide useful insights to envisage VBAC success rate for the pregnant women having history of caesarean delivery at the time of admission.

Predicting Vaginal Birth After Previous Cesarean: Using Machine-learning Models and a Population-based Cohort in Sweden

(Acta Obstet Gynecol Scand. 2021;100:513–520. doi: 10.1111/aogs.14020. Epub October 31, 2020) There are risks and benefits to choosing a trial of labor after cesarean (TOLAC) or a repeat cesarean delivery (CD). When TOLAC is successful (international success rate is 40% to 80%) and the patient has a vaginal birth (VD) after cesarean (VBAC), a benefit is decreased epidemic CD rate and decreased risk for repeat CD maternal morbidity. However risks of TOLAC include unplanned repeat CD, uterine rupture, and greater likelihood of maternal and neonatal adverse outcomes. Due to these tradeoffs, it is important to make accurate predictions regarding potential TOLAC success, thus leading to improved clinical counseling, and outcomes for women. This study aims to evaluate individualized predictions using machine-learning models for TOLAC for women with no previous VD and only one previous CD. It also aims to compare machine-learning methods with established regression prediction models.

Uterine rupture risk in a trial of labor after cesarean section with and without previous vaginal births.

Previous cesarean delivery (CD) is the main risk factor for uterine rupture when attempting a trial of labor. Previous vaginal delivery (PVD) is a predictor for the trial of labor after cesarean (TOLAC) success and a protective factor against uterine rupture. We aimed to assess the magnitude of PVD as a protective factor from uterine rupture. A retrospective cohort study was conducted, including women who underwent TOLACs from 2003 to 2015. Women with and without PVD were compared. Inclusion criteria were one previous CD, trial of labor at ≥ 24weeks' gestation, and cephalic presentation. We excluded pre-labor intrauterine fetal death and fetal anomalies. The primary outcome was a uterine rupture. Secondary outcomes were maternal and fetal complications. Logistic regression modeling was applied to analyze the association between PVD and uterine rupture while controlling for confounders. A total of 11,235 women were included, 6795 of which had a PVD. Women with PVD had significantly lower rates of uterine rupture (0.18% vs. 1.1%; OR 0.19, p < 0.001), were less likely to be delivered by an emergency CD (13.2% vs. 39.4%, OR 0.17, p < 0.0001), were more likely to undergo labor induction (OR 1.56, p < 0.0001), and were less likely to undergo an instrumental delivery (OR 0.14, p < 0.001). Logistic regression modeling revealed that PVD was the only independent protective factor, with an aOR of 0.22. PVD is the most important protective factor from uterine rupture in patients undergoing TOLAC. A trial of labor following one CD should therefore be encouraged in these patients.

Trial of labor after cesarean in twin gestation with no prior vaginal delivery - evidence from largest cohort reported.

ObjectiveTo investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery.MethodsA retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011–2020. TOLAC success and failure groups were compared.ResultsOf 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56–11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (<7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07–96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07–0.69, P = 0.009).ConclusionTOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.

Strategies to increase the rate of vaginal deliveries after cesarean without negative impact on outcomes

ObjectiveTo compare the rate of vaginal birth after cesarean section (VBAC), including the maternal and perinatal outcomes, in two historical cohorts before and after the implementation of specific changes in the clinical practice. DesignA retrospective cohort study. SettingSkåne University Hospital in Malmö, Sweden. Participantsincluding all women with one previous cesarean section (CS), who delivered during two 4-year periods: 2005–2008 (Group I) and 2013–2016 (Group II). MethodsMedical records were retrieved from the hospital's computerized medical system. The surgical reports of all women delivered by repeat CS were reviewed and the appearance of the lower uterine segment at CS was assessed. The primary outcome was VBAC. Secondary maternal outcomes were uterine rupture/dehiscence, hysterectomy and blood loss. The secondary perinatal outcomes were cord blood pH < 7.05 and perinatal mortality rate. Differences for categorical data were studied using the chi-square test and Fisher's exact test. To assess differences for continuous data t-tests were used. To determine which factors predicted VBAC both univariate and multivariate logistic regression analysis with the likelihood ratio test were performed. A two-tailed P-value < 0.05 was considered statistically significant Findings2017 patients were included to the study: 792 patients in Group I and 1225 in Group II. The rate of trial of labor after cesarean (TOLAC) was 65.0% and 76.9% and the VBAC rate was 49.8% and 62.0% in Group I and II respectively (p < 0.0001). Maternal and perinatal adverse outcomes were not statistically different between the two groups. Key conclusions and implications for practiceAppropriate management of women with one previous CS might increase the VBAC rate without a negative impact on maternal or perinatal outcomes. The antenatal teamwork has the greatest contribution to VBAC rate by increasing the number of women undergoing TOLAC.

Reducing Implicit Bias in Maternity Care: A Framework for Action

Reducing Implicit Bias in Maternity Care: A Framework for Action

Total breech extraction of the second twin in trial of labor after cesarean

Maternal and neonatl outcomes in trial of labor after cesarean (TOLAC) deliveries of twins are similar to singleton TOLACs. We examined whether internal podalic version and total breech extraction of the second twin adversely impacts outcome. A retrospective multicenter study was conducted including data on deliveries occurring between 2005-2020. We included TOLACs only, at 320/7 gestational weeks and on, of twin gestations with a vertex presenting first twin upon labor admission. The exposed group was defined as deliveries with a non-vertex second twin at admission to labor, while the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of pre-labor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. Two hundred thirty-six twin TOLACs were included, of whom 128 presented with a non-vertex second twin, and 108 presented with a second vertex twin. There was no difference in the primary outcome of uterine rupture (1/128, 0.9% vs. 1/108, 0.8%, p=1.000) (Table 1). Successful TOLAC of both twins occurred in 76.6% of the exposed group vs. 81.5% in the comparison group, while cesarean delivery (CD) of both twins was performed in 21.9% of the exposed group vs. 17.6% of the comparison group (p=0.418, OR=1.32, CI 0.7-2.5). There were 2 cases of CD for the second twin in the exposed group and one case in the comparison group (1.6% vs. 0.9%, respectively, p=1.000) (Table 2). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, etc. (Table 1). Neonatal outcomes were also comparable between the groups. Non-cephalic second twin in TOLAC deliveries results in favorable maternal and neonatal outcomes, comparable with vertex-vertex TOLACs. Second twin non-cephalic presentation should not discourage parturients and caregivers from considering TOLAC if desired.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The association between gestational age and maternal adverse outcomes in patients undergoing TOLAC

Trial of labor after cesarean (TOLAC) is supported by the American College of Obstetricians and Gynecologists as a method of reducing the cesarean delivery rate. However, there is a paucity of evidence regarding the outcomes of TOLAC at preterm compared to term gestational age (GA). In other populations, preterm birth is associated with increased maternal morbidity. We hypothesized that maternal adverse outcomes would be increased in patients who undergo TOLAC prior to term. In this population-based retrospective cohort study using the U.S. vital statistics datasets on Period Linked Birth-Infant Death Data from 2014 to 2018, we compared patients who attempted TOLAC at term (37+ weeks) to preterm (23-36 weeks) GA. The primary outcome was a composite of maternal adverse outcomes (CMAO), which included maternal blood transfusion, uterine rupture, unplanned hysterectomy, or admission to the intensive care unit (ICU) as a complication of delivery. A subgroup analysis was performed and stratified by GA (23-27, 28-33, 34-36, and 37-41 weeks). Relative risks were calculated and adjusted based on differences in socio-demographic factors between the two groups. There were 455,284 patients who met inclusion criteria for the study; 39,589 were at a preterm GA and 415,695 were at a term GA. The overall CMAO was significantly higher for patients undergoing TOLAC at preterm GA (12.0 per 1,000 live births) compared to term GA (8.0 per 1,000 live births; aRR, 1.42, 95% CI, 1.29-1.56 (Table 1)). Among individual conditions within the primary composite outcome, preterm GA was associated with maternal transfusion, unplanned hysterectomy, and increased risk of admission to the ICU (Table 1). In the subgroup analysis, the rate of CMAO was highest in the 23-27 week cohort (22.8 per 1,000 live births; aRR, 2.56, 95% CI, 1.92-3.43) compared to the 28-33 week (aRR, 1.79, 95% CI, 1.50-2.15), and the 34-36 week cohort (aRR, 1.24, 95% CI, 1.10-1.39) (Table 2). In patients who underwent TOLAC, preterm GA was associated with increased maternal adverse outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Recent Trends in Term Trial of Labor After Cesarean by Number of Prior Cesarean Deliveries

Cesarean delivery (CD) is a major source of maternal morbidity and repeat CD accounts for 40% of CD, but data on trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC) are limited. The objective of this study was to report national rates of TOLAC and VBAC by number of prior cesareans.

Trial of labor after cesarean in primiparous women with fetal macrosomia

Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women in the setting of fetal macrosomia.

Trial of labor after cesarean in women with diabetes in pregnancy stratified by fetal size

Cesarean delivery rates are increasing nationally and encouraging trial of labor after cesarean (TOLAC) in appropriate candidates is one means to achieve reduction in this outcome. One potential polarizing source of candidates for trial of labor are women with diabetes, likely due to high rates of fetal overgrowth and medically indicated delivery. We aim to quantify rates and safety of TOLAC and successful vaginal birth after cesarean (VBAC) in women with diabetes in pregnancy.

Lower Uterine Segment Ultrasound Among Individuals with Prior Cesarean: A Cost-Effectiveness Analysis

Patients with a history of cesarean delivery (CD) do not always attempt trial of labor after cesarean (TOLAC) due to risk of adverse outcomes. A recent meta-analysis demonstrated the efficacy of using ultrasound to screen for lower uterine segment thickness (LUS) at a threshold of 3.65 mm to stratify risk of individuals with a prior CD. Individuals < 3.65 mm are advised to undergo CD, while those above ≥3.65 mm may attempt TOLAC. This study evaluated the cost-effectiveness of LUS screening for patients who wish to TOLAC.

MFMU TOLAC Calculator: Does knowledge of a predicted success score increase VBAC rates?

The Maternal Fetal Medicine Units (MFMU) Network developed a calculator to determine a Trial of Labor after Cesarean (TOLAC) success score based on maternal age, BMI and OB history. Despite wide-spread adoption, it is unclear whether provider knowledge of a predicted score alters the likelihood of a successful vaginal birth after cesarean (VBAC). We aimed to determine whether provider knowledge of the MFMU calculated TOLAC score effects VBAC rates.

Comparison between the old and new MFMU TOLAC Calculator – Which is more accurate?

In 2017, the Maternal Fetal Medicine Units (MFMU) Network disseminated a Trial of Labor after Cesarean (TOLAC) calculator. An updated (2021) version of the calculator does not include race and ethnicity, but instead focuses on prior medical and OB history, in addition to age and BMI. The objective of this study was to compare the actual vs predicted VBAC rates between the old and new MFMU calculators.

Updated prediction model for vaginal birth after cesarean as a tool to predict VBAC morbidity

The Maternal Fetal Medicine Units’ (MFMU) Vaginal Birth After Cesarean (VBAC) Calculator is a validated model to predict probability of successful trial of labor after cesarean (TOLAC) and has also been demonstrated to predict TOLAC-associated maternal and neonatal morbidity. This model has recently been replaced by an updated nomogram that excludes race and ethnicity. We investigate whether the updated model also predicts morbidity related to TOLAC.