Trial Of Labor After Cesarean Research Articles

743 Mode of delivery in singleton stillbirths and associated risk factors

There are limited data to inform management of delivery for women with stillbirth. This study aims to examine mode of delivery among stillbirth pregnancies and to identify factors that influence the risk of cesarean delivery. We used the California Linked Birth File to identify singleton stillbirths delivered at 20-42 weeks gestation between 2007 and 2011. Mode of delivery and maternal characteristics were determined based on linked data from fetal death records and diagnosis/procedure codes in maternal hospital discharge records. The associations between various maternal characteristics and the likelihood of cesarean delivery were analyzed using univariate as well as multivariable logistic regression. Of the total sample of 9,554 stillbirths, 3,933 (41.2%) underwent induction of labor, 4,201 (44.0%) entered spontaneous labor, and 1,420 (14.9%) had a planned cesarean delivery. Among women who were induced, 95.9% delivered vaginally. In the overall sample, 1,756 women (18.4%) were delivered via cesarean. Of these, 959 (54.6%) had a prior cesarean delivery, 467 (26.6%) had malpresentation, 310 (17.7%) had a failed trial of labor, and 82 (4.7%) had placenta previa. Among 841 women who had a trial of labor after cesarean (TOLAC), 734 (87.3%) delivered vaginally. In multivariable logistic regression, performance of cesarean delivery was associated with previous cesarean, nulliparity, term gestation, higher body mass index, placenta previa, malpresentation, and hypertensive disorder (Table 1). One in every six women with a stillbirth underwent cesarean delivery and almost half of these were primary cesarean deliveries. The most common reasons for cesarean delivery were prior cesarean and malpresentation. Induction of labor and TOLAC were associated with high success rates of vaginal delivery.

746 The effects of removing race from the VBAC calculator: implications for counseling

To explore the differences between actual vaginal birth after cesarean (VBAC) success rates and the predicted VBAC success scores when calculated both with and without race and ethnicity. A retrospective chart review of an ethnically diverse patient population with 302 women electing trial of labor after cesarean (TOLAC). The MFMU VBAC calculator was used to calculate a predicted VBAC score with and without race and ethnicity. Based on prior studies, a predicted success score of 60% or greater was defined as a favorable VBAC score. Predicted and actual rates of VBAC were then compared. Statistical analysis performed in SAS 9.4. There were no significant differences in VBAC rates when comparing non-Hispanic Black women, aOR 0.5 (95% CI 0.2, 1.28), and Hispanic women, aOR 0.9 (95% CI 0.34, 2.41), to non-Hispanic White women. However, when race and ethnicity were included in the VBAC calculator, non-Hispanic Black and Hispanic women were significantly less likely to have favorable VBAC scores compared to White women, aOR 0.26 (CI 0.1, 0.66) and aOR 0.24 (CI 0.09, 0.64), respectively. When race and ethnicity were excluded from the calculator, there was no longer a significant difference in the predicted VBAC success across racial groups, non-Hispanic Black aOR 1.29 (95% CI 0.49, 3.44); Hispanic aOR 1.71 (95% CI 0.6, 4.92). We found that with race and ethnicity included in the calculator, 33 Hispanic women (44.6%) who had a VBAC, would have been told they had an unfavorable score compared to only 7 women (9.5%) when race was excluded. Similarly, 29 non-Hispanic Black women (43.9%) who had a VBAC, would have been told they had an unfavorable score compared to only 8 women (12.1%) when race and ethnicity were excluded. The inclusion of race and ethnicity in the VBAC calculator underestimated the success rates of women of color and could lead to these women being discouraged from TOLAC when they would have been successful. Our findings support the removal of race from medical decision making.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

933 Maternal and infant outcomes in those undergoing TOLAC by hospital volume

This study assessed whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals of different volumes. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We studied outcomes stratified by low, medium, and high hospital volume based on previous literature. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance 45,763 women-infant dyads met our inclusion criteria. The odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at high volume hospitals compared to low and medium volume hospitals (aOR: 1.65 vs 0.94 and 1.00, respectively). Rates of post-partum hemorrhage were significantly different, with highest rates in high volume hospitals (3.24%) compared with medium and low volume centers (2.68% and 2.46%, respectively). Transfusion rates were also significantly different. Rates of severe maternal morbidity, endometritis, and placental abruption were not significantly different. For neonates, rates of neonatal intensive care unit (NICU) admission was highest in medium volume centers (7.8%) compared to low and high (6.56% and 6.91%, respectively). APGAR scores <7 at 5 minutes were significantly different between groups, and highest at medium volume centers (0.63%) when compared to low and high (0.60% and 0.40%, respectively). There was no significant difference in brachial plexus injuries, HIE, neonatal or infant death between groups. In women undergoing TOLAC, most outcomes were not different. However, there was a significantly higher rate of post-partum hemorrhage and maternal blood transfusion between hospital volume categorizations. Of the outcomes studied, NICU admission and low APGAR scores were the only outcomes that were significantly different. Whether or not VBAC success rate is contributing to the lack of complications seen needs to be studied further.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1164 Maternal and infant outcomes in those undergoing TOLAC by hospital setting

The objective of this study was to assess whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals in rural versus urban settings. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We compared maternal and neonatal outcomes separately between rural and urban settings. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. 45,763 women-infant dyads were included in this study. We found the odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at urban centers compared to rural hospitals (aOR: 1.00% vs 0.46%, p<0.001). In women undergoing TOLAC, rates of endometritis were significantly higher at urban hospitals than rural (0.62% vs. 0.24%, p=0.049). Rates of post-partum hemorrhage was significantly higher at urban hospitals than rural (3.07% vs 1.90%, p=0.006), although maternal transfusion rates were not significantly different. Rates of placental abruption were not significantly different between the two settings. Infants of women undergoing TOLAC were admitted to the neonatal intensive care unit (NICU) at a significantly higher rate in urban hospitals than rural hospitals (7.28% vs 3.90%, p<0.001). The remaining outcomes were not significantly different, including rates of low APGAR scores, brachial plexus injury, HIE, neonatal and infant death. In this study, we found that most outcomes in women undergoing TOLAC did not differ significantly between rural and urban settings. At hospitals in urban settings, women experienced higher rates of endometritis and post-partum hemorrhage. Neonatal outcomes were also generally not significantly different, however, infants of women in urban settings experienced higher rates of NICU admission than rural hospitals. Further research ought to be done to determine whether VBAC success rates contribute to these differences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

810 Essential factors and racial/ethnic disparities impacting the odds of vaginal birth after cesarean

We set out to evaluate the impact of several pregnancy characteristics on the odds of a vaginal birth after cesarean (VBAC). Retrospective analysis of the Centers for Disease Control & Prevention’s Natality Live Birth database (2016-2018). All term singleton births that underwent a trial of labor after cesarean (TOLAC) delivery were included and divided into two groups – failed TOLAC and VBAC. Maternal characteristics and neonatal weights were compared between the two groups using Pearson’s chi-square test with Bonferroni adjustment. Multivariate logistic regression was used to adjust outcomes for potential confounders. Results were presented as adjusted odds ratios (aOR) with 95% confidence intervals, and statistical significance was set as P value < 0.05. The study cohort included 246,594 births after TOLAC, with 178,396 (72.3%) achieving VBAC. All examined characteristics varied significantly between the two groups. Elevated maternal body mass index (BMI), and the extremes of neonatal birthweight were associated with the lowest odds of VBAC [aOR 0.46 (0.44-0.48) and 0.53 (0.49-0.57), for BMI >40 and birth weight >4500 grams, respectively] (table 1). All racial/ethnic groups evaluated were associated with lower odds of VBAC when compared to Non-Hispanic White race. Self-pay insurance status was associated with the highest odds of VBAC [aOR 1.72 (1.64-1.81) for self-pay]. Based on this large US population cohort, we found several factors which influence the likelihood of VBAC. Specifically, non-Hispanic Black and Asian race, Hispanic ethnicity, elevated maternal BMI, increasing birth weight (>3500 grams) and low birth weight (<2500 grams) were are all associated with a significantly lower odds of VBAC. Surprisingly, self-pay insurance status was associated with increased odds of VBAC. Our findings demonstrate healthcare disparities warranting further attention.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

386 Timing of previous cesarean section affects postpartum hemorrhage and maternal morbidity following sequential vaginal birth

Women following vaginal birth after cesarean (VBAC) benefit from lower morbidities and reduced risks for future pregnancies, with the expense of higher rates of post partum complications including post-partum hemorrhage (PPH). This study aimed to investigate the association between the timing of previous cesarean section (CS) and the risk of post-partum adverse maternal outcomes following a subsequent successful VBAC. Retrospective case-control study of women following term vaginal delivery in a university-affiliated medical center between 2008-2018. Post-partum complications were compared between women who had their first VBAC and a control group of women following a vaginal delivery without a prior CS. Additional analysis was performed to evaluate the association between the timing of previous CS and the severity of post-partum adverse outcomes. 2879 women met inclusion criteria , 1455 had VBAC and 1424 had a vaginal delivery without a prior CS. Overall, significant post-partum complications, primarily PPH, were observed in the VBAC group compared to controls. Women with previous CS during the 2nd stage of labor presented a higher rate of PPH with a higher drop in hemoglobin levels when compared to women who underwent either emergent CS during 1st stage of labor or an elective CS (4.3±0.9g/dL vs. 2.8±1.1g/dL vs. 2.4±0.8g/dL, respectively, p=0.033). A concomitant increase in the need for blood transfusion (8.1% vs. 3.5% vs. 2.9%, respectively, p< 0.0001) and uterine atony rates (12.6% vs. 6.2% vs. 4.4%, respectively, p=0.009) was also noted. No significant differences were shown in duration of hospitalization, rate of uterine revision, vacuum assisted deliveries, postpartum urinary retention, endometritis, and obstetric and anal sphincter injuries (OASIS) (Table 1). VBAC is associated with an increased rate of post-partum complications, primarily PPH. The risk is significantly increased in women who were previously operated during the 2nd stage of labor (Figure 1). These data should be considered when counseling women for trial of labor after cesarean (TOLAC).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Obstetricians\u2019 perspectives on trial of labor after cesarean (TOLAC) under the two-child policy in China: a cross-sectional study

BackgroundAs the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has thus become a major contributor to the increasing CS rate in China. Promoting trial of labor after CS (TOLAC) can reduce the CS rate without compromising delivery outcomes. This study aimed to investigate Chinese obstetricians’ perspectives regarding TOLAC, and the factors associated with their decision-making regarding recommending TOLAC to pregnant women with a history of CS under the two-child policy.MethodsA cross-sectional survey was carried out between May and July 2018. Binary logistic regression was used to determine the factors associated with the obstetricians’ intention to recommend TOLAC to pregnant women with a history of CS. The independent variables included sociodemographic factors and perceptions regarding TOLAC (selection criteria for TOLAC, basis underlying the selection criteria for TOLAC, and perceived challenges regarding promoting TOLAC).ResultsA total of 426 obstetricians were surveyed, with a response rate of ≥83%. The results showed that 31.0% of the obstetricians had no intention to recommend TOLAC to pregnant women with a history of CS. Their decisions were associated with the perceived lack of confidence regarding undergoing TOLAC among pregnant women with a history of CS and their families (odds ratio [OR] = 2.31; 95% CI: 1.38–1.38); obstetricians’ uncertainty about the safety of TOLAC for pregnant women with a history of CS (OR = 0.49; 95% CI: 0.27–0.96), and worries about medical lawsuits due to adverse delivery outcomes (OR = 0.14; 95% CI: 0.07–0.31). The main reported challenges regarding performing TOLAC were lack of clear guidelines for predicting or avoiding the risks associated with TOLAC (83.4%), obstetricians’ uncertainty about the safety of TOLAC for women with a history of CS (81.2%), pregnant women’s unwillingness to accept the risks associated with TOLAC (81.0%) or demand for ERCS (80.7%), and the perceived lack of confidence (77.5%) or understanding (69.7%) regarding undergoing TOLAC among pregnant women and their families.ConclusionA proportion of Chinese obstetricians did not intend to recommend TOLAC to pregnant women with a history of CS. This phenomenon was closely associated with obstetricians’ concerns about TOLAC safety and perceived attitudes of the pregnant women and their families regarding TOLAC. Effective measures are needed to help obstetricians predict and reduce the risks associated with TOLAC, clearly specify the indications for TOLAC, improve labor management, and popularize TOLAC in China. Additionally, public health education on TOLAC is necessary to improve the understanding of TOLAC among pregnant women with a history of CS and their families, and to improve their interactions with their obstetricians regarding shared decision making.

Vaginal Birth After Cesarean Section (VBAC) Model using Fuzzy Analytic Hierarch Process.

Background:There is an even more pressing need to address the issue of vaginal birth after cesarean section (VBAC), as an increase of cesarean deliveries (CDs) has been noticed. This increase however was temporarily overturned during the period 1989-1996, when some researchers tried to manifest the advantages of trial of labor after cesarean (TOLAC). Increased VBACs though raised the issue of scar ruptures, causing fear to women and guiding them once again towards the choice of cesarean deliveries. The numbers of Cesarean Sections (CS) still increase, despite the initiatives promoted by the World Health Organization (WHO) to reduce the rates of CS.Objective:This research aims to construct two fuzzy models, the Fuzzy vaginal birth after cesarean (VBAC) model and the fuzzy CS model in order to assess the medical profile of pregnant women and to suggest the most suitable type of delivery.Methods:A preliminary set of factors that affect VBAC or CS was identified after a comprehensive literature review. The final set of factors was used to develop a questionnaire and collect data regarding the identified factors, through a series of semi structured interviews with 29 highly experienced obstetricians. The Fuzzy Analytic Hierarchy Process (FAHP) method is utilized to develop the fuzzy VBAC and the fuzzy CS multicriteria decision models.Results:A set of 36 factors in total are identified as important to consider when judging the most suitable type of delivery. Results show that a subset of 27 factors support the decision to adopt CS, with top 5 most significant to be: vaginal delivery is contraindicated, prior uterine rupture, uterine incision, extensive transfundal uterine surgery and desire for sterilization at the time of delivery. A subset of 9 factors positively affects the decision towards VBAC. The top 5 of the most important factors that positively affect the decisions to adopt VBAC are: Maternal request for VBAC, Mother’s personal values/preferences, Previous bladder injury, Health care providers recommendations, Family obligations, and Prior VBAC after CS.Conclusions:The proposed approach addresses the multi-dimensional nature of judging the most appropriate type of delivery. By utilizing fuzzy logic analysis obstetricians and midwives are allowed to express their expertise and their intuition in a sound methodological approach to assess cases of pregnant women and suggest a valid route of intrapartum care.

Fetal Head Station at Second-Stage Dystocia and Subsequent Trial of Labor After Cesarean Delivery Success Rate.

To investigate whether fetal head station at the index cesarean delivery is associated with a subsequent trial of labor success rate among primiparous women. A retrospective cohort study conducted at two tertiary medical centers included all primiparous women with subsequent delivery after cesarean delivery for second-stage dystocia during 2009-2019, identified from the electronic medical record databases. Univariate and multivariate analyses were performed to assess the factors associated with successful trial of labor after cesarean (TOLAC) (primary outcome). Additionally, all women with failed TOLAC were matched one-to-one to women with successful TOLAC, according to factors identified in the univariate analysis. Of 481 primiparous women with prior cesarean delivery for second-stage dystocia, 64.4% (n=310) attempted TOLAC, and 222 (71.6%) successfully delivered vaginally. The rate of successful TOLAC was significantly higher in those with fetal head station below the ischial spines at the index cesarean delivery, as compared with those with higher head station (79.0% vs 60.5%, odds ratio [OR] 2.46, 95% CI 1.49-4.08). The proportion of neonates weighing more than 3,500 g in the subsequent delivery was lower in those with successful TOLAC compared with failed TOLAC (29.7% vs 43.2%, OR 0.56, 95% CI 0.33-0.93). In a multivariable analysis, lower fetal head station at the index cesarean delivery was the only independent factor associated with TOLAC success (adjusted OR 2.38, 95% CI 1.43-3.96). Matching all women with failed TOLAC one-to-one to women with successful TOLAC, according to birth weight and second-stage duration at the subsequent delivery, lower fetal head station at the index cesarean delivery remained the only factor associated with successful TOLAC. Lower fetal head station at the index cesarean delivery for second-stage dystocia was independently associated with a higher vaginal birth after cesarean rate, with an overall acceptable success rate. These findings should improve patient counseling and reassure those who wish to deliver vaginally after prior second-stage arrest.

A prospective study of a new prediction model of vaginal birth after cesarean section at a tertiary care centre

Objective:To create a new and simple model for predicting the likelihood of vaginal birth after cesarean (VBAC) section using variables available at the time of admission.Materials and Methods:A prospective observational study was performed at a tertiary care centre in Haryana over a period of 12 months (January 2018 - December 2018) in pregnant women attending the labour room with one previous cesarean section fulfilling the criteria for undergoing trial of labour after cesarean (TOLAC). The sample size was 150. A VBAC score was calculated for each patient using a new prediction model that included variables available at the time of admission such as maternal age, gestational age, Bishop’s score, body mass index, indication for primary cesarean section, and clinically estimated fetal weight. The results of the VBAC scores were correlated with outcomes i.e. successful VBAC or failed VBAC. The chi-square test and Student’s t-test was used for comparison among the groups. Descriptive and regression analysis was performed for the study variables.Results:Out of 150 TOLAC cases, 78% had successful VBAC and the remainder (22%) had failed VBAC. The observed probability of having a successful VBAC for a VBAC score of 0-3 was 34%, 4-6 was 68%, 7-9 was 90%, and ≥10 was 97%. The prediction model performed well with an area under the curve of 0.77 (95% CI: 0.68 to 0.85) of the receiver operating characteristics receiver operating characteristic curve.Conclusion:The present study shows that the proposed VBAC prediction model is a good tool to predict the outcome of TOLAC and can be used to counsel women regarding the mode of delivery in the current and subsequent pregnancies. Further studies of this model and other such models with different permutations and combinations of variables are required.

Number of prior vaginal deliveries and trial of labor after cesarean success

ObjectivePrior vaginal delivery (VD), including vaginal birth after cesarean (VBAC), is one of the greatest predictors of successful trial of labor after cesarean (TOLAC) and uterine rupture. We aimed to evaluate VBAC and uterine rupture rates associated with TOLAC in women with VD prior to cesarean delivery (CD) or with prior VBAC, and the cumulative effect of the number of prior VD's. Study designThis retrospective study included women having TOLAC between 2005−2019. The study compared the caesarean and uterine rupture rates of TOLAC in women with only prior VD as compared to women with only prior VBAC. Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Receiver operating characteristic (ROC) and decision tree analyses (chi-square automatic interaction detection algorithm) was conducted to evaluate the influence of the number of prior VD's on the likelihood of successful TOLAC. ResultsOverall, 9,038 women met the inclusion criteria. Women with prior VBAC and prior VD showed significantly higher rates of successful VBAC compared to those with no prior VD or prior VBAC (96 % and 86 % vs 76 %; p < 0.01). However, women with prior VBAC but not women with prior VD showed significantly lower rates of uterine rupture compare to women with no prior VD or VBAC (0.1 % vs 0.6 % and 0.6 %; p < 0.01). The prevented fraction of TOLAC success was significantly higher in women with prior VBAC than that of women with VD prior to CD (83 % vs. 42 %, p < 0.01). ROC curve showed that the number of prior VBACs was a better predictor of TOLAC success and uterine rupture than the number of prior VD's. However, each single variable was found to have low positive predictive value (PPV) and requires other variables to improve the prediction. Finally, decision tree analysis demonstrated significant association between TOLAC success rate and prior VBAC, prior VD, and CD indications, without any association with the number of prior deliveries. ConclusionPrior VBAC has some prediction value for TOLAC success and uterine rupture. However, it has low PPV as a single variable and requires other variables to improve the prediction. The number of prior VDs is not improving prediction.

Implementation of machine learning models for the prediction of vaginal birth after cesarean delivery

Objective Accurate prediction of vaginal birth after cesarean is crucial for selecting women suitable for a trial of labor after cesarean (TOLAC). We sought to develop a machine learning (ML) model for prediction of TOLAC success and to compare its accuracy with that of the MFMU model. Methods All consecutive singleton TOLAC deliveries from a tertiary academic medical center between February 2017 and December 2018 were included. We developed models using the following ML algorithms: random forest (RF), regularized regression (GLM), and eXtreme gradient-boosted decision trees (XGBoost). For developing the ML models, we disaggregated BMI into height and weight. Similarly, we disaggregated prior arrest of progression into prior arrest of dilatation and prior arrest of descent. We applied a nested cross-validation approach, using 100 random splits of the data to training (80%, 792 samples) and testing sets (20%, 197 samples). We used the area under the precision-recall curve (AUC-PR) as a measure of accuracy. Results Nine hundred and eighty-nine TOLAC deliveries were included in the analysis with an observed TOLAC success rate of 85.6%. The AUC-PR in the RF, XGBoost and GLM models were 0.3510.028, 0.3500.028 and 0.3360.024, respectively, compared to 0.3250.067 for the MFMU-C. The algorithms performed significantly better than the MFMU-C (p-values = .0002, .0004, .0393 for RF, XGBoost, GLM respectively). In the XGBoost model, eight variables were sufficient for accurate prediction. In all ML models, previous vaginal delivery and height were among the three most important predictors of TOLAC success. Prior arrest of descent contributed to prediction more than prior arrest of dilatation, maternal height contributed more than weight. Conclusion All ML models performed significantly better than the MFMU-C. In the XGBoost model, eight variables were sufficient for accurate prediction. Prior arrest of descent and maternal height contribute to prediction more than prior arrest of dilation and maternal weight.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis

Background The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD). Objectives To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term. Study design A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34–41 weeks’ gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. Results In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%). Conclusion In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Comparison of maternal-neonatal results of vaginal birth after cesarean and elective repeat cesarean delivery.

To evaluate maternal-neonatal results in women who underwent vaginal birth after cesarean (VBAC) and elec-tive repeat cesarean delivery (ERCD). In a two-year retrospective cohort analysis, 423 patients with a history of prior cesarean section, singleton pregnancy with cephalic presentation and gestational age of 37-41 weeks were investigated. The maternal and perinatal outcomes of 195 patients desiring VBAC and undergoing a trial of labor after cesarean (TOLAC) attempt and 228 patients undergoing an ERCD were compared. While the TOLAC attempt was successful in 141 patients (72.3%), it was unsuccessful in 54 patients. No statistically significant difference was determined between VBAC and ERCD patients regarding uterine rupture, dehiscence, post-partum hemorrhage, the need for a blood transfusion and wound site infection (p > 0.05). When the post-partum neonatal outcomes were compared, there was no statistically significant difference between VBAC and ERCD groups regarding the prevalence of admission to the neonatal intensive care unit (NICU), respiratory distress, sepsis and birth injury (p > 0.05). The maternal and perinatal outcomes of our study may be encouraging in favor of VBAC particularly in countries with higher cesarean rates. We think that the option of VBAC should be offered more frequently for selected appropriate patients in created safe environments.

Prediction of vaginal birth after cesarean delivery in Southeast China: a retrospective cohort study

BackgroundWe aimed to develop and validate a nomogram for effective prediction of vaginal birth after cesarean (VBAC) and guide future clinical application.MethodsWe retrospectively analyzed data from hospitalized pregnant women who underwent trial of labor after cesarean (TOLAC), at the Fujian Provincial Maternity and Children’s Hospital, between October 2015 and October 2017. Briefly, we included singleton pregnant women, at a gestational age above 37 weeks who underwent a primary cesarean section, in the study. We then extracted their sociodemographic data and clinical characteristics, and randomly divided the samples into training and validation sets. We employed the least absolute shrinkage and selection operator (LASSO) regression to select variables and construct VBAC success rate in the training set. Thereafter, we validated the nomogram using the concordance index (C-index), decision curve analysis (DCA), and calibration curves. Finally, we adopted the Grobman’s model to perform comparisons with published VBAC prediction models.ResultsAmong the 708 pregnant women included according to inclusion criteria, 586 (82.77%) patients were successfully for VBAC. Multivariate logistic regression models revealed that maternal height (OR, 1.11; 95% CI, 1.04 to 1.19), maternal BMI at delivery (OR, 0.89; 95% CI, 0.79 to 1.00), fundal height (OR, 0.71; 95% CI, 0.58 to 0.88), cervix Bishop score (OR, 3.27; 95% CI, 2.49 to 4.45), maternal age at delivery (OR, 0.90; 95% CI, 0.82 to 0.98), gestational age (OR, 0.33; 95% CI, 0.17 to 0.62) and history of vaginal delivery (OR, 2.92; 95% CI, 1.42 to 6.48) were independently associated with successful VBAC. The constructed predictive model showed better discrimination than that from the Grobman’s model in the validation series (c-index 0.906 VS 0.694, respectively). On the other hand, decision curve analysis revealed that the new model had better clinical net benefits than the Grobman’s model.ConclusionsVBAC will aid in reducing the rate of cesarean sections in China. In clinical practice, the TOLAC prediction model will help improve VBAC’s success rate, owing to its contribution to reducing secondary cesarean section.

Counselling Patients for Trial of Labour after Cesarean (TOLAC) and Invasive Placentation: Are We Missing the Mark? The Importance of Local Data and Informed Choice.

Rates of cesarean delivery are increasing, and these procedures carry potential complications, like the risk of invasive placentation, which increases with each cesarean. A trial of labour after cesarean (TOLAC) is a viable option for patients; however, it has been associated with uterine rupture, a complication with maternal and fetal risks. To better counsel patients considering TOLAC, we aimed to determine local uterine rupture rates and maternal and neonatal outcomes with TOLAC and compare these with outcomes related to invasive placentation. A 4-year retrospective chart review was conducted at our tertiary centre of all patients with a history of a previous cesarean delivery. We assessed rates of TOLAC, vaginal delivery after cesarean (VBAC), and uterine rupture, as well as maternal and neonatal outcomes associated with invasive placentation. Cases of uterine rupture from 1988 to the present were also reviewed, and their outcomes were compared with those of invasive placentation. Our uterine rupture rate was 0.44% and VBAC rate was 73.8%. We identified 8 cases of uterine rupture since 1988 and 67 invasive placentas during the 4-year chart review. Invasive placentation was associated with a significantly increased risk of neonatal respiratory morbidity, hysterectomy, maternal complications, and longer length of maternal hospital stay when compared with uterine rupture. While uterine rupture remains a potential complication of TOLAC, it is rare with overall excellent maternal and neonatal outcomes. Invasive placentation, the risk of which increases with cesarean delivery, carries potentially higher complication rates than uterine rupture. Local complication data is important for individual sites offering TOLAC. The implications of invasive placentation cannot be overlooked when counselling patients considering TOLAC.

Sonographic Lower Uterine Segment Thickness After Prior Cesarean Section to Predict Uterine Rupture: A Systematic Review and Meta-analysis

(Anaesthesia. 2019;74:850–855) The rate of trial of labor after cesarean (TOLAC) in the United States has markedly dropped over the past few decades. Uterine rupture is the most serious complication associated with TOLAC, with the risk ranging from 0.52% for women in spontaneous labor to 2.45% for women undergoing labor induction with prostaglandin. This risk may be contributing to the declining rate of TOLAC. Sonographic measurement of the lower uterine segment thickness has been evaluated by several prospective studies, but the cutoff values for recommending TOLAC in these studies have differed due to varying ultrasound methodologies. This study analyzed the ultrasound methodology used in each study and then conducted a meta-analysis of the predictive value of sonographic measurement of the lower uterine segment thickness for uterine rupture during labor.

Trial of Labor After Cesarean Section in Risk Pregnancies: A Population-based Cohort Study

(Acta Obstet Gynecol Scand. 2019;98:894–904) Increased risk of adverse outcomes is higher in cases of unsuccessful trial of labor after cesarean (TOLAC) compared with a successful vaginal delivery or a planned repeat cesarean delivery. While identifying factors that could predict TOLAC failure is of clinical interest, there has been a lack of research on the risk of TOLAC failure in the setting of specific medical conditions other than diabetes and hypertensive disorders. This study aimed to investigate medical conditions as potential risk factors for TOLAC failure in Norway, which has a high TOLAC rate of ∼70%. TOLAC failure rates were also compared between women who did and did not undergo labor induction.

Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle.

To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle-a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician-patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreasesin the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

Predicting Obstetric Anal Sphincter Injury (OASIS) in Women Undergoing Trial of Labor After Cesarean (TOLAC) [25L

INTRODUCTION: We aimed to evaluate the relationship between predicted success of trial of labor after cesarean (TOLAC) and obstetric anal sphincter injury (OASI) to develop a predictive model. METHODS: We performed a secondary analysis of the Maternal Fetal Medicine Units Network (MFMU) TOLAC prospective cohort (1999–2002) and a single-site retrospective analysis of a cohort of women with a singleton vaginal birth after cesarean (VBAC) between 2011 and 2016 (modern population [MP]) (IRB approval STU00204149). Women were stratified by the presence of OASI and characteristics were compared with bivariate analysis, including the predicted probability of achieving VBAC using the MFMU calculator. Significant risk factors were included in a backward stepwise multivariable logistic regression model to identify independent risk factors for OASI and generate a predictive model. Model performance was evaluated using concordance indices, brier scores and calibration plots. Internal validity was assessed with bootstrapping and external validation performed using MP data. RESULTS: 12,108 women met inclusion criteria and 739 (6.1%) sustained OASI. Factors independently associated with OASI included forceps (OR 5.0 CI 4.1-6.2) and vacuum (OR 2.8 CI 2.2-3.6), along with predicted likelihood of VBAC (aOR 0.5 CI 0.4-0.6), race and smoking. The concordance index of the model and MP validation cohort was 0.79 (CI 0.77-0.81) and 0.77 (CI 0.71-0.83). The model demonstrates internal validity, but slight overcalibration within the MP cohort. CONCLUSION: Predicted likelihood of VBAC is inversely proportional to the likelihood of sustaining OASI. Our model provides a robust estimate of OASI risk during VBAC that can be easily utilized in counseling.