Trial Of Labor Group Research Articles

Maternal and neonatal outcomes in adolescent pregnant women with one prior Cesarean section in Baghdad

Repeat adolescent pregnancy is a hot topic worldwide and imposes a challenge on the health system, especially when faced with limited resources. We aimed to assess maternal and neonatal outcomes in adolescent pregnant women with one prior cesarean section (CS). Singleton adolescent pregnant women with one prior CS scar were recruited and divided into two groups based on the obstetric decision for delivery and/or mother’s wish, either trial of labor (TL) or elective cesarean section (ECS). If TL failed, an emergency CS was performed. Out of the total 109 involved women, TL and ECS groups included 78 (71.6%) and 31 (28.4%) women, respectively. Emergency CS was done for 57 (52.3%) women from the TL group, leaving only 21 (19.3%) women with successful TL who had statistically significant (non-recurrent) indications of the prior CS [12 (57.1%)]. Malpresentation (n=24; 77.4%) was the major indication in the ECS group, while fetal distress (n=29; 50.9%) was the main cause of failed TL. Total maternal morbidities in the TL group were significantly higher for adjusted [1.5 (1.1-4.2)] and non-adjusted odds ratios (OR) [2.4 (1.6-5.6)]. Neonatal complications, such as admission to neonatal intensive care unit, were higher in the TL group without reaching significance. However, the adjusted OR [1.9 (1.1-3.3)] for perinatal asphyxia was significantly increased in TL group. Maternal morbidities and perinatal asphyxia were significantly higher in the TL group of adolescent women compared with the ECS group in this study.

Trial of labor versus elective cesarean delivery for patients with two prior cesarean-sections: A retrospective propensity score analysis

IntroductionDespite awareness of obstetricians to the constant increase in the number of cesarean sections in recent years, the fear of a uterine scar rupture is still present and influences the choice of the mode of delivery in patients with two previous cesarean sections. However, several clinical studies have suggested that, under certain conditions, vaginal birth after two cesarean sections is usually successful and safe. ObjectiveThe objective of this study was to compare maternal and neonatal issues according to the planned mode of delivery in patients with two previous cesarean sections. MethodsIt was a retrospective observational comparative study at Rennes University Hospital between January 1, 2013, and December 31, 2020. We performed a propensity score for the comparison of neonatal outcomes: cord pH, cord lactates, Apgar scores, transfer to neonatal unit and deaths, according to the planned delivery mode. Secondary outcomes were maternal issues: uterine rupture, post-partum hemorrhage, deaths. ResultsA total of 410 patients with two previous cesarean section were eligible for our study. Prophylactic cesarean was performed in 358 cases (87.3%). Trial of labor was attempted in the 52 remaining patients (12.7%), 67.3 % of whom were successful. Neonatal weight, APGAR score at 1–5–10 min, and pH on cord blood were comparable in both groups. One case of uterine rupture occurred in the trial of labor group. ConclusionTrial of labor seems to be a reasonable option for women with two previous cesarean sections in a selected population.

Neonatal outcomes in trial of vaginal birth versus repeat caesarean delivery in preterm pregnancies: A prospective cohort study.

To characterise neonatal morbidity following preterm trial of labour (TOL) in comparison with elective repeat caesarean section (eRCS) specifically among patients without a previous vaginal delivery who may have a lower success rate of vaginal birth after caesarean. This is a secondary analysis of a multicentre prospective database. Maternal and Fetal Medicine Unit Cesarean Section Registry. Singleton pregnancies in women without a previous vaginal delivery who delivered at 24+0 weeks to 36+6 weeks gestation. Neonatal outcomes were compared between those with a TOL and those undergoing eRCS. Logistic regression was used to control for confounders, including gestational age at delivery. Composite neonatal morbidity. A total of 1906 patients were included, 985 with TOL and 921 with no TOL. The TOL success rate was 63.1%. The rate of uterine rupture was low, at 0.10% in the TOL group and 0.11% in the eRCS group (p=0.32). After adjustment, neonates born to women undergoing a TOL had no statistically significant difference in outcomes including composite neonatal outcome (adjusted odds ratio 0.86, 95% CI 0.68-1.09), neonatal intensive care unit admission, respiratory distress syndrome, necrotising enterocolitis, hypoxic ischaemic encephalopathy, seizures, transient tachypnoea of the newborn, compared with patients who underwent eRCS, with the exception of decreased risk of proven/suspected sepsis (adjusted odds ratio 0.68, 95% CI 0.52-0.87) CONCLUSION: A TOL in preterm patients without a previous vaginal delivery was not found to have a statistically significant association with increased neonatal morbidity.

Do women in Slovenia prefer vaginal birth after prior caesarean and what hinders its successful outcome? A single institution retrospective analysis

Background: To analyze the mode of delivery and the outcome of a trial of labor in women with one prior caesarean birth. Methods: We extracted from the national database our hospital’s information on women with a prior caesarean section from January 2014 to July 2019. They were then divided into groups that either opted for a trial of labor or repeat caesarean section. We further focused on the trial of labor group and divided them in two subgroups of either a vaginal delivery or repeat caesarean section. Results: 796 women with one prior caesarean section were identified and 201 (25.3%) opted for a trial of labor. Successful vaginal delivery was achieved in 84.1% of women that opted for a trial of labor. Women pregnant for the third time or greater delivered vaginally at a higher rate (24.3% vs 10.7%). More women who had labor induced with a Foley catheter ended in caesarean section (8.1% vs 17.9%). There was one uterine rupture without further complications. Failed trial of labor was caused by the lack of persistence (14.3%) and arrest of labor (50.0%). Conclusion: Improved counselling is needed for those women who choose a trial of labor. The rate of successful vaginal delivery following a trail of labor is high, but could be improved with more conservative management during the first stage of labor.

Impact of mode of delivery on perinatal outcome in moderately and late preterm twin birth.

To examine the impact of the mode of delivery on neonatal and maternal outcomes in moderately and late preterm twin birth. This single-center cohort study included 275 live diamniotic moderately and late preterm twin deliveries at 32+0 -36+6 weeks of gestation. These twin deliveries were divided into two groups according to the planned mode of delivery: trial of labor (TOL) (N=199, 72.4%) and planned cesarean section (CS) (N=76, 27.6%). The primary outcome was neonatal morbidity. Maternal outcome and the effects of gestational age and chorionicity on neonatal outcome were also studied. Of the women in the TOL group, 170 (85.4%) delivered vaginally. Both for the first and second twin, and for dichorionic or monochorionic deliveries, there were no differences between the TOL and CS groups in composite neonatal morbidity or in other neonatal outcomes. No significant differences were found between the TOL and CS groups when the moderately and late preterm gestational age cohorts were studied separately. Mothers in the planned CS group more often had puerperal infection and surgical complications in comparison with mothers in the TOL group. Among 275 moderately and late preterm twin deliveries, planned mode of delivery did not affect neonatal outcome.

Labor patterns in Chinese women in Fuzhou attempting vaginal birth after previous cesarean delivery: a retrospective cohort study.

ObjectiveTo investigate the characteristics of labor in Chinese women who successfully have vaginal birth after cesarean section (VBAC).MethodsA retrospective cohort study was conducted in a hospital with 1000 beds between January 1 2015 and December 31 2017. A total 657 parturients with VBAC were selected. Women were divided into two groups according to previous cesarean section with or without trial of labor. Labor curves were analyzed and interval-censored regression was used to estimate the duration of labor.ResultsThe 95th percentile for the first stage of labor in VBAC was 13.03 hours, and labor accelerated after 4 cm of cervical dilation in both groups. The dilation rate in the trial of labor group was superior to that in the non-trial of labor group at 6–10 cm of dilation. After 6 cm, labor accelerated much faster in the trial of labor group than in the non-trial of labor group.ConclusionsManagement of labor in parturients with VBAC whose cervical dilation is >6 cm should be treated differently according to previous cesarean section with or without trial of labor. If there is trial of labor in a previous delivery, the duration of labor should be shortened.

Choice of scheduled cesarean delivery versus trial of labor for advanced maternal age primiparous women

Objective: We aimed to evaluate perinatal outcomes of advanced maternal age (AMA) primiparous women seeking scheduled cesarean delivery (CD) versus a trial of labor (TOL).Materials and methods: This was a retrospective cohort study of primiparous women ≥40 years of age carrying a single fetus, who delivered at a tertiary, university-affiliated medical center (2007–2014). We compared perinatal outcomes of women who chose a scheduled CD with those who chose TOL. Subsequently, we compared women who had successful TOL (sTOL) with those who had a failed TOL (fTOL).Results: Out of 62 102 deliveries during the study period, inclusion criteria were met by 374 women. Of them, 83 (22.2%) women had a scheduled CD, and 291 (77.8%) had TOL. Of the TOL group, 118 women (40.5%) had fTOL and 173 (59.5%) had sTOL. Women in the fTOL had higher rates of 1-min Apgar score <7, neonatal asphyxia and adverse neonatal composite outcome compared with women in the sTOL group (p < .05). After adjusting for potential confounders, compared with sTOL, fTOL was not associated with adverse neonatal composite outcome. Compared with scheduled CD, fTOL was associated with an increased risk for adverse neonatal composite outcome (aOR 2.65, 95% CI 1.13–6.19, p = .03).Conclusion: AMA primiparous women attempting TOL have comparable outcome to those seeking scheduled CD, however, women with fTOL have higher rates of adverse neonatal outcome.

Maternal and perinatal outcome after previous caesarean section in rural Rwanda

BackgroundOffering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda.MethodsAudit of women’s records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014.ResultsOut of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n = 23, 7.7%) compared with women who had an ERCS (n = 5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2–5.4). There was no difference in neonatal admissions between women who underwent ToL (n = 64/297; 21.5%) and those who delivered by ERCS (n = 35/138; 25.4%: aOR 0.8; CI 0.5–1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n = 40, 13.4%) compared to those who delivered by ERCS (n = 15, 10.9%: aOR 1.9; CI 1.6–3.6). Perinatal mortality was similar among infants whose mothers had ToL (n = 8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n = 4; 29/1000 ERCSs).ConclusionsA considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL.

Trial of vaginal delivery for twins – is it safe? a single center experience

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL.Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL.Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p < .05), although transfusion rates in each group were similar. Neonatal outcomes between groups did not differ. Induction and gestational age at delivery were risk factors for failed TOL.Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.

Term twin birth - impact of mode of delivery on outcome.

The main aims of this study were to compare maternal and neonatal outcomes in term twin birth according to the planned mode of delivery and to study the effects of chorionicity and inter-twin delivery time on neonatal outcome. A single-center cohort study of 495 women with twin deliveries at ≥37+0 weeks of gestation. Term twin deliveries were divided into a trial of labor group (TOL, 69.3%) and a planned cesarean section (CS) group (30.7%). The primary outcomes were maternal and neonatal morbidity. 80.8% of women attempting TOL achieved vaginal birth. In the TOL group, mothers had less bleeding [median 500 mL (range 150-2700 mL) vs. 950 mL (range 150-3500 mL), p < 0.001) and fewer surgical complications (3.2% vs. 8.6%, p = 0.011), whereas second twins more often had five-minute Apgar scores of <7 (5.0% vs. 0%, p = 0.002) or umbilical artery pH < 7.05 (5.7% vs. 0%, p = 0.003), compared with the planned CS group. There was a slight, non-significant tendency for more NICU admissions in the TOL group, yet the need for NICU treatment was infrequent in the whole study material. Outcomes among dichorionic (DC) second twins were similar to those in the whole material, but among monochorionic (MC) second twins there were no differences between the TOL and planned CS groups. In secondary analysis, a five-minute Apgar score <7 occurred significantly more often in the DC group among second twins if the inter-twin delivery time exceeded 30 min. TOL is a good option for women with twin pregnancy at term, regardless of chorionicity. Active management of labor for the second twin is important, also in DC births. Maternal outcomes were more favorable with TOL and although low Apgar scores and low umbilical blood pH may be more frequent after TOL - especially with the second twin - serious neonatal morbidity is rare and does not differ from that after planned CS.

Trial of labor after cesarean in the low-risk obstetric population: a retrospective nationwide cohort study.

The purpose of this study was to evaluate the risk of adverse maternal outcomes associated with trial of labor (TOL) after cesarean during subsequent pregnancies in the low-risk population. We conducted a retrospective cohort study using the Nationwide Inpatient Sample and ICD-9 diagnostic and procedure codes from the years 2003 to 2011. A cohort of low-risk pregnant women with a history of previous cesarean delivery were identified and separated into two groups: TOL and no TOL. Logistic regression analysis was used to calculate odds ratios (ORs) comparing adverse maternal outcomes between these two groups. Out of 7 290 474 registered deliveries, there were 685 137 low-risk women who met inclusion criteria. Of these women, 144 066 (21.0%) underwent a TOL, with rates remaining steady over the course of our study. The TOL group was at increased risk of overall morbidity (OR 1.74, 95% confidence interval (CI), 1.66-1.79), most notably uterine rupture (OR 22.52, 95% CI, 19.35-26.20, P<0.01). A secondary analysis showed no apparent correlation between TOL and concomitant adverse maternal outcomes in cases of uterine rupture. Although these outcomes remain rare, low-risk women undergoing a TOL remain at increased risk of adverse maternal events as compared with those who chose elective repeat cesarean delivery.

A prospective comparative study of a trial of labor after cesarean vs. elective repeat cesarean section (ERCS) in view of maternal outcomes

Background: There has been a wide range of success rates reported for those achieving vaginal birth following a planned vaginal birth after cesarean (VBAC). Objective: (1) To find out the incidence of rupture uterus and dehiscence in patients with trial of labor after cesarean section, (2) to evaluate the incidence of vaginal delivery in women who had previously undergone a cesarean section, and (3) comparison of a trial of labor after cesarean with an elective repeat cesarean section (ERCS) in view of maternal outcomes. Materials and Methods: This prospective observational study was carried out in the Department of Obstetrics and Gynecology, PDU Medical College, Rajkot, Gujarat, India, from January 1, 2014 to June 30, 2015. Result: During the study period, 10,315 deliveries were noted, of which patients who underwent a previous cesarean section were 1,082. Among the previous cesarean cases, trial of labor was given for 222 of them, of which, successful VBAC was found in 136 (61.26%) cases, while in 86 (38.74%) cases, an emergency cesarean was performed. In 860 cases, ERCS was done. Incidence of rupture and dehiscence in trial of labor group was 4.5% (10 cases) and 2.7% (6 cases), respectively, while no rupture was noted in the ERCS group. Scar dehiscence was found in 8 cases (0.93%) in the ERCS group. In 2 cases among the trial of labor group, obstetric hysterectomy was performed for rupture, while in 2 cases, bladder injury was noted. No maternal morbidities were noted in the ERCS group. No mortality was recorded in the study period. Conclusion: Hence, decision for trial of labor or ERCS should be taken as per the patient’s choice, through detailed history and examination. Even though many studies showing success rate of VBAC higher, maternal morbidities associated complications of trial of labor are life threatening, and we conclude ERCS is safer when compared with VBAC in view of maternal outcome.

Trial of labour after previous caesarean section in sub-Saharan Africa.

In this issue, Kaboré et al. report that trial of labour can be offered to women with one previous caesarean section in resource-poor sub-Saharan African settings. This is an emerging issue in Africa where caesarean section rates are rising (Litorp et al. BMC Pregnancy and Childbirth 2013;13:107). Experience of working in these settings raises the question of why elective repeat caesarean section should not be the delivery method of choice for all women with one previous caesarean section. The argument is that trial of labour is unsafe because of suboptimal emergency transport and intrapartum monitoring, and that surgical skills are not available at all hours to deal with uterine rupture, the dreaded complication of labour in these women. From high-income countries, research suggests that the increased risk of uterine rupture is offset by reduced risks of surgical complications when trial of labour is successful (Rossi et al. Am J Obstet Gynecol 2008;199:224–31). But this balance of risks may not be the same in resource-poor settings. Kabore et al.'s work fills a significant research gap for sub-Saharan Africa. The setting was typically resource-poor (Senegal and Mali), and included a range of hospitals with differing levels of care and expertise. The sample size was large enough, at 9712 women, to make conclusions on maternal and perinatal safety, and allowed adjustment for potential confounders. The data can be regarded as reliable, collected for the landmark QUARITE trial (Dumont et al. Lancet 2013;382:146–57). In their analysis, Kabore et al. separated the women into low-risk (age <35 years, attended antenatal care, no obstetric comorbidity, and not referred from another facility) and high-risk (at least one of those four factors) groups. For high-risk women, trial of labour was associated with significantly increased maternal and perinatal mortality compared with elective repeat caesarean section. But for low-risk women, overall maternal morbidity and mortality were not increased. While uterine rupture itself was more frequent in the trial of labour group (0.64 versus 0.22%), this difference was small in absolute terms and not significant after adjustment. Intrapartum stillbirths were significantly more frequent (1.3 versus 0.3%) with trial of labour, with one-quarter related to uterine rupture. But total perinatal mortality, including intrapartum stillbirths, was not significantly increased after adjustment. While the ideal study design for this research question would be a randomised trial, it should be remembered that it has not been possible to conduct an adequately powered trial even in a high-income setting (Dodd et al. Cochrane Database Syst Rev 2013;12:CD004224). Kabore et al.'s contribution provides the next-best level of evidence, a prospective observational study. There are limitations, related to residual confounding, and also the study's power (large as it was) to detect differences in rare catastrophic outcomes. There should be concern about the relatively high level of intrapartum stillbirths. But overall, unless better evidence emerges to the contrary, there is no reason why a low-risk woman in sub-Saharan Africa with one previous caesarean section should not be offered an appropriately monitored trial of labour in hospital. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Elective repeat cesarean delivery compared with trial of labor after a prior cesarean delivery: a propensity score analysis

ObjectiveTo determine neonatal and short term maternal outcomes according to intentional mode of delivery following a cesarean delivery (CD). Study designWomen pregnant after CD between January 2000 and December 2007 were categorized according to whether they had an elective repeat CD (ERCD) or a Trial of Labor (TOL). Prognostically equal ERCD and TOL groups were created using the propensity score matching technique. Conditional logistic regression was performed to assess differences in neonatal and maternal outcomes. PopulationWomen in their second ongoing pregnancy with a history of CD. ResultsAfter ERCD the rates of low 5min Apgar score (OR 0.3, 95%CI 0.2–0.5, p<0.001), meconium aspiration (OR 0.0, 95%CI 0–0.7, p=0.02) and birth trauma (OR 0.08, 95%CI 0.002–0.5, p<0.001) were lower compared to TOL. The rate of transient tachypnoea of the newborn (TTN) appears higher in the ERCD group (OR 1.7, 95%CI 1.0–2.8, p=0.04). Uterine rupture (OR 0.1, 95%CI 0.003–0.8, p=0.02) and hemorrhage (OR 0.6, 95%CI 0.5–0.8, p<0.001) occurred less in the ERCD group. ConclusionNeonatal and short term maternal morbidity appears to be lower after ERCD than after TOL. Only TTN was seen more often after ERCD.

The effects of labor and delivery on maternal and neonatal outcomes in term twins: a retrospective cohort study.

To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean. Retrospective cohort study. 19 US hospitals from the Consortium on Safe Labor. Of 2225 twin sets ≥36weeks' gestation. Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar <7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes. Maternal and neonatal outcomes. Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [OR 2.5, 95% confidence interval (CI) 1.4-4.5] and blood transfusion (OR 1.9, 95%CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar <7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95%CI 1.05-14.5; B: OR 3.9, 95%CI 1.3-12.3). Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases.

Neonatal outcome after trial of labor or elective cesarean section in relation to the indication for the previous cesarean delivery

To compare the neonatal outcome after a trial of labor (TOL) with that after an elective cesarean section (CS) following one previous cesarean delivery, considering the indication for the first CS. Population-based cohort study. Sweden. Women with their first two deliveries between 1992 and 2007 registered in the Swedish Medical Birth Registry. The risk of low Apgar score (<7 at 5min) after a TOL was compared with that after an elective CS among 407159 singletons of women with one previous vaginal delivery and 59643 singletons of women with one previous CS. The indication for the first-delivery CS was estimated using a hierarchical system. For each indication group, the odds ratio and 95% CI for low Apgar score, TOL vs. elective CS, was computed. Low Apgar score. The overall risk of low Apgar score was increased in the TOL group (adjusted odds ratio 1.8, 95% CI 1.5-2.1), but the estimate differed substantially by the indication for the first CS (p-value for homogeneity=0.0001). There was a high risk for low Apgar score after TOL and first CS indication "complications during labor/delivery" (adjusted odds ratio 2.4, 95% CI 1.7-3.4), but low risk with TOL and first CS "without medical indication" (adjusted odds ratio 0.7, 95% CI 0.2-2.1). Neonatal outcome might be improved by considering the indication for the first CS when choosing between an elective CS or a TOL for the second delivery.

The recovery of pelvic organ support during the first year postpartum

Compare changes in pelvic organ prolapse (POP) from 36-38 weeks of gestation to 1 year postpartum after unlaboured cesarean delivery(UCD)and trial of labour (TOL). Prospective observational cohort study. Wenzhou Third People's Hospital, Wenzhou, Zhejiang, China. Nulliparous women undergoing UCD or TOL. Pelvic organ prolapse was assessed at 36-38 weeks of gestation, then at 6 weeks, 6 months and 1 year postpartum, using the Pelvic Organ Prolapse Quantification (POPQ) system. Postpartum POP status in UCD and TOL determined by POPQ measurements over time. Points Aa (Ba) determined the final stage assignment in most cases. Stage II POP was present in 35% and 37% of women in UCD and TOL at 36-38 weeks of gestation. After delivery, the likelihood of stage II POP declined during the first year postpartum in the whole cohort. The TOL group was much less likely to recover from stage II POP compared with the UCD group (odds ratio 0.04, 95% confidence interval 0.01-0.18) after adjustment for POP status at 36-38 weeks of gestation, age, first-trimester body mass index, newborn birthweight, educational level, gravidity and smoking status. With the exception of age, education and gravidity, these covariates were also independent predictors of postpartum POP. Factors unique to labour and delivery lead to sustained pelvic floor relaxation postpartum. Pelvic organ prolapse at 36-38 weeks of gestation, and higher first-trimester body mass index also appear to predict long-term POP. Further investigation into mechanisms leading to persistent or progressive POP after TOL are warranted. In addition, caution is needed in generalising the findings due to the single-centre design.

Induction of labor after a prior cesarean delivery: lessons from a population-based study

The aims of this study were (1) to determine the success rate of induction of labor (IOL) in women with a prior cesarean section (CS) and (2) to compare the perinatal outcome of a trial of labor (TOL) in women with one prior CS who had an IOL, spontaneous onset of labor, or an elective repeated CS (ERCS). This study population was divided into three groups: women who had (1) ERCS (n = 1916), (2) spontaneous TOL (n = 4263), and (3) IOL (n = 1576). (1) The rate of IOL in the study cohort was 20.3%; of these, 67.4% had a successful vaginal birth after cesarean (VBAC). (2) Patients in the spontaneous TOL group had a higher VBAC rate than did those who had IOL (P < 0.001). (3) The rate of uterine rupture was comparable among all study groups. And (4) a prior vaginal birth increased the likelihood of having a successful induction and a VBAC by 50%. IOL in patients with a previous CS is successful in about two-thirds of the cases. Induction is a safe and useful tool that can serve as an alternative for ERCS and assist to reduce the rate of ERCS.

Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis

The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or trial of labor (TOL). Women who were eligible for a TOL with 1 previous low transverse incision were categorized according to whether they underwent an ERCD or TOL. A propensity score technique was used to develop ERCD and TOL groups with comparable baseline characteristics. Outcomes were assessed with conditional logistic regression. The rates of endometritis, operative injury, respiratory distress syndrome, and newborn infant infection were lower and the rates of hysterectomy and wound complication were higher in the ERCD group. Propensity score techniques can be used to generate comparable ERCD and TOL groups. Some types of maternal morbidity (such as hysterectomy) are higher; other types (such as operative injury) are lower in the ERCD group. Although the absolute risk is low, neonatal morbidity appears to be lower in the ERCD group.

The Outcome and Cumulative Morbidity Associated with the Second and Third Postcesarean Delivery

The purpose of this study was to compare the outcome and cumulative morbidity among women who delivered twice after a cesarean delivery (CD), and who underwent in the second delivery either a trial of labor (TOL) or planned cesarean delivery (PCD). Eligible women (N = 399) were divided into two groups based on first post-CD: a TOL (n = 304) or PCD (n = 95). Women attempting a TOL were successful in 70 and 75% in the first and second post-CD, respectively. All participants undergoing a PCD subsequently had a third PCD. The overall morbidity was 8.4 and 5.3% among PCD and TOL groups, respectively ( P = 0.258). Women attempting a TOL after a previous CD had a 70 and 53% likelihood for at least one successful or two successful vaginal births in the two subsequent deliveries, respectively. No significant difference was documented between the groups regarding the cumulative morbidity.