Trial Of Labor Research Articles

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.

Ethnic disparities in repeat caesarean rates at Auckland Hospital

New Zealand guidelines recommend that information regarding childbirth choices be given to women with previous caesarean, so they can make informed decisions about their care. We hypothesised that rates of trial of labour (TOL) and vaginal birth after caesarean (VBAC) would vary by women's ethnicity. To estimate the association of ethnicity with TOL and VBAC rates. Clinical data were used to identify women who gave birth at Auckland Hospital in 2006-2009 with history of previous caesarean eligible for TOL. Multivariable models were used to estimate the association of women's characteristics (ethnicity, age, socio-economic status (SES), height, body mass index, lead maternity carer, diabetes, hypertension, haemorrhage, labour induction, gestational age) with rates of TOL and VBAC. In the study cohort of 2400 women, the TOL rate was 39.5%; the VBAC rate was 57.4%. Pacific women were twice as likely to have TOL, while Asian and non-New Zealand European women were half as likely to have VBAC, compared with New Zealand European women. Women in more deprived areas were more likely to have TOL, but SES was not associated with VBAC rates. Women under the care of private obstetricians were least likely to have TOL or VBAC. There are ethnic disparities in TOL and VBAC rates at our hospital. Strategies need to be developed to ensure that women of all ethnicities have access to both options for mode of delivery.

Factors associated with success of vaginal birth after one caesarean section (VBAC) at three teaching hospitals in Addis Ababa, Ethiopia: a case control study.

BackgroundVaginal delivery after previous one cesarean section for a non recurring indication has been described by several authors as safe and having a success rate of 60–80%. Hence many centers are offering VBAC for candidates leaving the century old dictum of once cesarean always cesarean. But predicting success of VBAC after trial of labor (TOL) is still a difficult task due to the lack of a validated prediction tool. Studies on predictors of success are few and most of them conducted in developed countries and difficult to generalize. Therefore assessing factors associated with successful VBAC is very important to for counseling mothers while offering VBAC. The aim of this study was to assess factors associated with successful VBAC in three teaching Hospitals in Addis Ababa Ethiopia.MethodsA case control study was conducted to compare the factors associated with successful VBAC in teaching hospitals in Addis Ababa in one year period. The cases were those successfully delivered vaginally and the controls were those with failed VBAC and delivered by caesarean section. The sample size of the cases was 101vaginal deliveries and the controls were 103 failed VBAC patients which made the case to control ratio of 1:1.ResultIn this study independent factors determining successful VBAC were, history of successful VBAC in the past, rupture of membrane at admission, and cervical dilatation of more than 3cm at admission. Presence of meconium, malposition and history of stillbirth were associated with failed VBAC. Factors like maternal age, past caesarean indications, inter delivery interval, and birth weight were not found to be significant determinants of success. The most common reason for repeat cesarean section for after trial of labor was labour dysfunction because of absence of a policy for augmentation on a scarred uterus in these hospitals.ConclusionIt is possible to prepare a decision tool on the success of VBAC by taking important past and present obstetric and reproductive performance history as predictor.

Trial of Labor Versus Repeat Cesarean

Although the use of vaginal birth after cesarean (VBAC) has been advocated, and patients have been counseled as to its benefits and risks, published literature suggests that patient education is lacking and that lack of discussion with the clinician is often associated with choosing a cesarean delivery. This prospective, observational study was undertaken to assess the hypothesis that the national low rate of VBAC is due in part to insufficient informed consent about the risks and benefits of trial of labor (TOL). Patients eligible for a TOL after cesarean (TOLAC) received prenatal care and counseling in a private physician’s office or in a hospital-based clinic. A questionnaire was administered to women after admission to the obstetric unit either just before the scheduled elective repeat cesarean section (ERCS) or after admission for TOL. The questionnaire covered demographics, prior cesarean experience, family planning goals, perceived provider preference, factors affecting patient’s choice, and risks and benefits of ERCS and TOLAC. Data were analyzed using χ2 and Fisher exact tests. Eighty-seven women presented for TOLAC, and 68 presented for ERCS; they did not differ statistically in age, level of education, ethnicity, and provider type. Patients demonstrated an overall lack of knowledge about the risks and benefits of TOLAC and ERCS. Only 13% of TOLAC patients and 4% of ERCS patients knew that the chances for a successful TOLAC are 60% to 80%, whereas 54% in the TOLAC group and 73% in the ERCS group indicated they did not know. Forty-nine percent of TOLAC patients and 26% of ERCS patients knew that the risk of uterine rupture is 0.5% to 1%, whereas 64% of ERCS patients stated that they did not know what the risk is during TOLAC. Moreover, 52% of patients in the ERCS group did not know that the recovery period after a cesarean is longer than after a vaginal delivery, and 46% did not know that the complication rates increase with each successive cesarean. Twenty percent of ERCS patients believed that the indication for the previous cesarean had no role in their chances of a subsequent successful vaginal delivery. When asked about the risks of ERCS versus TOLAC, 50% of women or greater in both groups were aware of the greater risk of damage to organs, excessive bleeding, and infection, but 30% or less knew that an ERCS carries an increased risk of maternal death, neonatal respiratory compromise, and admission to the neonatal intensive care unit. When patients thought their providers preferred ERCS, 19 (86%) of 22 chose ERCS, whereas when they thought their doctor preferred a TOLAC, 36 (78%) of 46 chose TOLAC. If patients thought their doctor had no preference or they did not know the preference, 50% chose TOLAC and 50% chose ERCS. Women in both groups were not adequately informed about the risks and benefits of TOLAC and ERCS. Opportunities for patient counseling are readily available during prenatal visits, especially at the end of the pregnancy. Respondents showed deficiencies in the area of comprehension, a major tenet of informed consent. They lacked awareness and understanding of their situation and possibilities despite the fact they were an older and more highly educated population than the average across the United States, which suggests that wider knowledge gaps could exist throughout the country. Future studies should evaluate counseling styles and decision aids and their influence on delivery preference and the patient knowledge base.

Bénéfices et risques maternels de la tentative de voie basse comparée à la césarienne programmée en cas d’antécédent de césarienne

To assess maternal outcomes during trial of labor (TOL) and elective repeat caesarean delivery (ERCD) in women with a previous caesarean delivery. French and English publications were searched using PubMed and Cochrane Library. Maternal mortality remains a very rare event regardless of the planned mode of delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of complete uterine rupture significantly increases with TOL versus ERCD but it remains low at about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood transfusion, data are heterogeneous because of the nature of the populations studied. These risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous thrombo-embolic complications and infections (endometritis and maternal fever) appears to be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the additional presence of obesity (EL2). While maternal morbidity progressively increases with the number of iterative caesarean sections, maternal morbidity in TOL after a previous caesarean delivery decreases with the number of successful TOL (EL2). In patients with a previous caesarean delivery, the risks of maternal complications are rare and similar between TOL and ERCD. There is an increased risk of complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk balance in most cases and its success reduces the risk of short and long-term maternal complications (EL3).

Bénéfices et risques néonataux de la tentative de voie basse comparée à la césarienne programmée en cas d’antécédent de césarienne

To evaluate neonatal outcome after elective repeat cesarean delivery (ERCD) versus trial of labor (TOL) after previous cesarean delivery. This systematic evidence review is based on Pubmed search, Cochrane library and experts recommendations. The risks of fetal, perinatal and neonatal mortality are low after previous cesarean delivery but significantly higher for TOL as compared with ERCD. The risk of bag-and-mask ventilation and intubation for meconium-stained amniotic fluid are higher for TOL as compared with ERCD. Infants born after ERCD are more likely presented transient tachypnea. The risk of hypoxic encephalopathy/asphyxia is low after previous cesarean delivery but significantly higher for TOL as compared with ERCD. The risk of neonatal sepsis after previous cesarean delivery is significantly higher for TOL as compared with ERCD. There is no significant difference between TOL or ERCD regarding NICU admission. The strength of evidence is low to conclude about the impact of route of delivery upon birth trauma and Apgar score. The risk of the main neonatal complications is low whatever the route of delivery after previous caesarean delivery. However, the risk of perinatal mortality, bag-and-mask ventilation, perinatal asphyxia, is higher after TOL compared with ERCD. The risk of transient tachypnea is higher after ERCD compared with TOL.

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.

A Paradigm Shift to Check the Increasing Trend of Cesarean Delivery is the Need of Hour: But How?

To check the progressive increasing trend of caesarean delivery in a tertiary facility care centre. The purpose of this study is to implement a paradigm shift in caesarean delivery by introducing a new classification system and a check list based management protocol. The study was conducted from 1st January, 2007 to 31st December, 2008 at CNMC G&O Department. All deliveries in the year 2007 were compared retrospectively and all deliveries in the year 2008 under prospective study with implementation of a new strategic protocol. Comparative audit and analysis of deliveries in retrospective and prospective year reveals significant changes in the caesarean delivery rate. In retrospective group all women in labour were allowed for spontaneous delivery and in prospective group all women were subjected to intervention protocol and caesarean delivery done in both the groups in need for risk of fetal and maternal salvage. Incidence of caesarean delivery (CD) in retrospective group was 29 % while in the prospective group it was 18.4 %. Marked decrease in CD was observed for augmentation, induction and trial of labour (TOL) for delivery in prospective group. The result was compared with Robson's studies following similar type of classification system. Marked improvement was noticed in this new paradigm and more multicentric trial is needed to check the increasing trend of CD.

Adverse Obstetric Outcomes in Women with Previous Cesarean for Dystocia in Second Stage of Labor

To evaluate obstetric outcomes in women undergoing a trial of labor (TOL) after a previous cesarean for dystocia in second stage of labor. A retrospective cohort study of women with one previous low transverse cesarean undergoing a first TOL was performed. Women with previous cesarean for dystocia in first stage and those with previous dystocia in second stage were compared with those with previous cesarean for nonrecurrent reasons (controls). Multivariable regressions analyses were performed. Of 1655 women, those with previous dystocia in second stage of labor (n = 204) had greater risks than controls (n = 880) to have an operative delivery [odds ratio (OR): 1.5; 95% confidence intervals (CI) 1.1 to 2.2], shoulder dystocia (OR: 2.9; 95% CI 1.1 to 8.0), and uterine rupture in the second stage of labor (OR: 4.9; 95% CI 1.1 to 23), and especially in case of fetal macrosomia (OR: 29.6; 95% CI 4.4 to 202). The median second stage of labor duration before uterine rupture was 2.5 hours (interquartile range: 1.5 to 3.2 hours) in these women. Previous cesarean for dystocia in the second stage of labor is associated with second-stage uterine rupture at next delivery, especially in cases of suspected fetal macrosomia and prolonged second stage of labor.

Another caesarean looks safer than a trial of labour for women with a previous section

Another caesarean looks safer than a trial of labour for women with a previous section

At what price? a cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

ObjectiveTo perform an economic evaluation on the costs and maternal health consequences associated with a trial of labour (TOL) after one previous caesarean delivery compared with elective repeat caesarean delivery...

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.

Obstetrics Outcome of Cases Referred to Tertiary Care Hospital after Trial of Labour

Introduction: Labour is the physiological process with its inherent risk of complications so it requires supervision by skilled birth attendants. Delivery con-ducted by untrained birth attendants has a 4.67 times higher mortality rate as compared to the one conducted by SBAs. This study was conducted to determine feto-maternal outcome of cases referred to Fatima Memo-rial Hospital, after a trial of labour by TBA’s. Objectives: To determine feto-maternal outcome and to identify factors associated with adverse obstetric outcome. Study Design: Case series descriptive study. Setting: Department of Obstetrics and Gynecology Fatima Memorial Hospital, Lahore. Duration with Dates: Six months from 1 st April 2011 to 30 th September 2011. Subjects and Methods: One hundred patients who were admitted through emergency after a trial of labo-ur by traditional birth attendants (TBAs), lady health visitors (LHVs) or doctors at home or private clinics were managed and followed in the department of gy-necology and obstetrics Unit II. Patients were clini-cally evaluated and relevant investigations were car-ried out in all patients. Final diagnosis was made on the basis of history, clinical examination and investi-gations. Data collection too was structured proforma specifically designed for the purpose. Results: Mean age of the patients was 27.28 ± 5.13 years. Fever was the most common complication fou-nd in 69 (69%) patients. Antepartum hemorrhage occ-urred in 22 (22%) cases. Postpartum hemorrhage com-plicated 46 (46%) pregnancies leading to shock in 51 (51%) patients. Oligohydramnios was observed in 35 (35%) patients and uterine rupture in 5 (5%) cases. There were 3 (3%) maternal deaths. Low Apgar score was observed in 36 (36%) ba-bies. Meconium staining was present in 34 (34%) cases and 34 (34%) babies needed hospitalization. (Fe-tal growth restriction was found in 23 (23%) patients. There were 23 (23%) fetal neonate deaths. Conclusion: Postpartum hemorrhage led to maternal and fetal complications in majority of the patients whi-ch was not handled appropriately and immediately. Key Words: Postpartum hemorrhage (PPH), Oligo-hydramnios, shock.

Single- Versus Double-Layer Closure of the Hysterotomy Incision During Cesarean Delivery and Risk of Uterine Rupture

Abstract Objective To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. Methods The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. Results Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66–4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58–9.52, P Conclusion Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double-layer closure in women attempting a TOL.

Optimization of clinical outcome of women with previous one lower segment cesarean section

Background and Objectives: To investigate the outcome in women with planned (VBAC) in comparison to Repeat Cesarean Section (RCS) and to those undergoing vaginal birth. Design and settings: Retrospective study, women with a history of one lower segment cesarean section (LSCS) admitted to Abha General Hospital for delivery from September, 2010 to February, 2011. Subjects and Methods: The demographic maternal and neonatal data and data concerning the course of delivery were reviewed in 418 women underwent trial of labor (TOL) and subjected to statistical analysis to study the predictive factors and outcome. All cases were divided into 3 groups, VBAC group (212 women), RCS group (206 women) and the neonates of the VBAC group were compared to those of a control group consists of 287 neonates who delivered vaginally. Results: The success rate of VBAC was 50.72%, with no uterine rupture or wound dehiscence. Failure to progress was the most common (40.2%) indication of RCS followed by fetal distress (29.9%). Young maternal age (P < 0.05), previous vaginal deliveries after CS (P < 0.05) and occiputo anterior position (P < 0.01) were significantly associated with successful VBAC. Neonatal Intensive Care Unit (NICU) admission was significantly higher in the RCS group (P < 0.001), while no significant difference was found between NICU admission in the VBAC and the control groups. Conclusion: VBAC should remain an available option. Informed consent, good reporting and thorough documentation of the VBAC decision are crucial. During TOL, continuous fetal monitoring and, ultrasound evaluation of the previous scar are recommended. Emergency CS should be considered if duration of the TOL is prolonged with non reassuring CTG.

681: The MFMU Cesarean Registry: cost-effectiveness of a trial of labor compared with an elective repeat cesarean delivery after a previous cesarean in a minimally biased cohort

of a trial of labor compared with an elective repeat cesarean delivery after a previous cesarean in a minimally biased cohort Sharon A. Gilbert For the Eunice Kennedy Shriver National Institute of Child Health and Human Development, MaternalFetal Medicine Units Network, Bethesda, MD OBJECTIVE: To determine the most cost-effective strategy for women eligible for a trial of labor (TOL) with one prior cesarean delivery and balanced baseline characteristics. STUDY DESIGN: We developed a decision analysis model comparing TOL after one prior cesarean with an elective repeat cesarean delivery (ERCD) for a hypothetical cohort of 100,000 women with no contraindication to a TOL. To derive probability estimates, a group of women who underwent either TOL or ERCD were selected from a 1999-2002 prospective study. The final probabilistic estimates were obtained from women who underwent TOL or ERCD and were selected by propensity score analysis as being matched according to their baseline characteristics. Cost data were obtained from national databases and included hospital, obstetrician, pediatrician, and anesthesiologist costs as well as opportunity costs of the mother and a caregiver. Quality adjusted life-years (QALYs) were obtained from the literature. Probability, cost and QALY data for the outcome of cerebral palsy were obtained from the literature as well. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY. RESULTS: According to baseline estimates, the TOL strategy dominated the ERCD strategy, with $142.4 million saved and 1793 QALYs gained per 100,000 women. The model was sensitive to five variables (table). Bivariable analysis on the probability of successful TOL and uterine rupture indicated when the probability of success was at the base value, 68.5%, TOL was preferred if the probability of rupture was 4.6% or less (graph). When uterine rupture was at the base value, 0.8%, TOL was preferred if the probability of successful TOL was 40.8% or more. CONCLUSION: A TOL after one prior cesarean is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics; these results are sensitive to five variables, which need to be considered in cost-effective assessment. www.AJOG.org Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health PosterSessionIV

309: Uterine rupture in women with previous cesarean for dystocia in second stage of labor

for dystocia in second stage of labor Nicole Jastrow, Suzanne Demers, Robert J. Gauthier, Nils Chaillet, Normand Brassard, Emmanuel Bujold University Hospital of Geneva, Obstetrics and Gynecology, Geneva, Switzerland, University Laval, Obstetrics and Gynecology, Quebec, QC, Canada, University of Montreal, Obstetrics and Gynecology, Montreal, QC, Canada OBJECTIVE: To evaluate the risk of uterine rupture in women undergoing a trial of labor (TOL) after a previous cesarean for dystocia in second stage of labor. STUDY DESIGN: A retrospective cohort study of women with a single previous low-transverse cesarean undergoing a first TOL was performed. Women with a previous cesarean for dystocia in second stage were compared to those with previous dystocia in first stage and those with previous cesarean for non-recurrent reasons. Chi-square and Fishers exact were used when appropriate. RESULTS: Out of 1950 women, those with previous dystocia in second stage of labor (n 220) had a similar risk of uterine rupture than women with previous dystocia in the first stage (n 639) and women with previous cesarean for non-recurrent indication (1.8%, 1.7%, and 1.5%, respectively, p 0.88). However, we found that all (100%) uterine ruptures in the former group occurred in the second stage of labor (p 0.05) compared to 18% and 25% in the two other groups (p 0.05). The median length of the second stage of labor before uterine rupture was 2.5 hours (interquartile: 1.5 3.2 hours) for those cases. CONCLUSION: Previous cesarean for dystocia in the second stage of labor is associated with uterine rupture in the second stage of the subsequent delivery. This may be related to a lower location of the uterine scar, which may be more prone to rupture at an advanced cervical dilatation during the next delivery. Prolonged second stage should be avoided in these women.

Introducing routine trial of labour after caesarean section in a second level hospital setting

Objective: We analysed the impact on caesarean section (CS) rate of introducing a routine trial of labour (TOL) for patients with a previous CS. Study design: During 2007 and 2008, we offered a TOL to all women with one previous CS planning to give birth in our hospital. The adherence to the procedure, success of vaginal delivery, overall CS rate, incidence of symptomatic uterine rupture and other complications were evaluated. Labour induction was allowed only using castor oil or Amniotomy. Results: One hundred and ninety-four women were considered eligible for TOL. A total of 87.6% of them agreed to undergo the procedure (78.7% in the first year versus 95.2% in the second year, p < 0.05). Of these, 63.5% delivered successfully (42.3% in the first year versus 78.8% in the second year, p < 0.05); 10.6% underwent a primary CS because of failed spontaneous labour or failed labour induction and 25.9% a secondary CS during labour. The CS rate decreased significantly from 19.6% (in 2003–2006) to 14.9% (iN 2007–2008) (p < 0.05). One case of symptomatic uterine rupture occurred, while no difference for other complications was observed. Conclusions: The CS rate decreased dramatically through introducing a TOL programme for patients with one previous CS. The possibility of symptomatic uterine rupture should be however considered and patients adequately informed.

Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery

PurposeTo determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery.MethodsA systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel–Haenszel method.ResultsFive studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29–0.52, P < 0.00001).ConclusionWomen with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.

The effect of obesity & ethnic origin on vbac success rates: a retrospective audit from st thomas' hospital

ObjectiveTo assess the association between obesity and successful vaginal birth after caesarean section (VBAC) in women with different ethnic backgrounds and predict the likelihood of VBAC in this group.MethodsA retrospective...