Vaginal Birth After Caesarean Section Rates Research Articles

A jump into the deep end - Women's strategies on the way to VBAC in Poland

ProblemIn Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BackgroundResearch shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AimThis study aims to explore the elements of Polish maternity services that contribute to or hinder women’s chances of having a VBAC. MethodsThe study used qualitative methods of research based on semi-structured interviews.We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FindingWomen who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. ConclusionsPolish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women’s social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Trend, prevalence and predictors of successful vaginal birth after caesarean section in Ethiopia: a systematic review and meta-analysis.

Vaginal birth after caesarean section (VBAC) is an alternative to a caesarean section (CS) in the absence of repeat or new indications for primary CS. There is a knowledge gap regarding the trend and successful VBAC in Ethiopia. Therefore this systematic review and meta-analysis aimed to assess the trend, pooled prevalence of successful VBAC and its predictors in Ethiopia. Electronic databases (SCOPUS, CINAHL, Embase, PubMed and Web of Science), Google Scholar and lists of references were used to search works of literature in Ethiopia. Stata version 14 was used for analysis and the odds ratios of the outcome variable were determined using the random effects model. Heterogeneity among the studies was assessed by computing values for I2 and p-values. Also, sensitivity analyses and funnel plots were done to assess the stability of pooled values to outliers and publication bias, respectively. A total of 12 studies with a sample size of 2080 were included in this study. The overall success rate of VBAC was 52% (95% confidence interval 42 to 65). Cervical dilatation ≥4cm at admission, having a prior successful vaginal delivery and VBAC were the predictors of successful VBAC. Meta-analyses and sensitivity analyses showed the stability of the pooled odds ratios and the funnel plots did not show publication bias. The pooled prevalence of successful VBAC was relatively low compared with existing evidence. However, the rate was increasing over the last 3decades, which implies it needs more strengthening and focus to decrease maternal morbidity and mortality by CS complications. Promoting VBAC by emphasizing factors favourable for its success during counselling mothers who previously delivered by CS to enhance the prevalence of VBAC.

Predictors of vaginal delivery following balloon catheter for labor induction in women with one previous cesarean

BackgroundThe aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix.MethodsThis 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL.ResultsA total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight (< 4000 g) (odds ratio [OR]5.26; 95% confidence interval [CI] 2.09,13.27), lower body mass index (BMI,<30 kg/m2) (OR 2.27; CI 1.21, 4.26), Bishop score after cervical ripening > 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC.ConclusionsThe influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.

Validation of updated antenatal vaginal birth after caesarean section prediction model without race and ethnicity in Australia.

The Grobman antenatal nomogram to predict likelihood of successful vaginal birth after caesarean section (VBAC) has been validated in multiple institutions. However, due to concerns regarding inclusion of ethnicity, a new nomogram has been developed. The aim was to evaluate the efficacy of the updated Grobman nomogram without ethnicity in a regional hospital in Australia. This was a retrospective cohort study of women electing to have a VBAC at a regional hospital over a nine-year period. Maternal demographics and obstetric outcomes were collected. Women were assigned a predicted likelihood of successful VBAC using the updated Grobman nomogram, with variables such as age, pre-pregnancy weight, height and arrest disorder as indications for previous caesarean birth, previous vaginal birth, previous VBAC and treated chronic hypertension. The predicted likelihood of successful VBAC was compared with actual successful VBAC rates. A total of 541 women attempted VBAC with a VBAC success rate of 74.3% (402/541). The nomogram demonstrated good fit, with a receiver operating curve area under the curve of 0.707 (95% confidence interval 0.659-0.755). Using a cut-off value of 0.5, the success rate of classification with this model was 74.3%. On comparing each predicted decile, the nomogram performed poorly in those predicted to have a <40% chance of successful VBAC. This study confirms the use of the updated Grobman nomogram without ethnicity, alongside usual counselling, to provide individualised advice for informed decision-making. However, clinicians should be mindful of the limitation of poor accuracy in women with a low predicted probability of VBAC.

Implementation of guidelines about women with previous cesarean section through educational/motivational interventions.

To investigate the effect of a quality improvement project with an educational/motivational intervention in northern Italy on the implementation of the trial of labor after cesarean section (CS). A pre-post study design was used. Every birth center (n= 23) of the Emilia-Romagna region was included. Gynecologist opinion leaders were first trained about Italian CS recommendations. Barriers to implementation were discussed and shared. Educational/motivational interventions were implemented. Data of multipara with previous CS, with a single, cephalic pregnancy at term, were collected during two periods, before (2012-2014) and after (2017-2019) the intervention (2015-2016). The primary outcome was the rate of vaginal birth after CS (VBAC) and perinatal outcomes. A total of 20 496 women were included. The VBAC rate increased from 18.1% to 23.1% after intervention (P< 0.001). The likelihood of VBAC-adjusted for age 40 years or older, Caucasian, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) at least 30, previous vaginal delivery, and labor induction-was increased by the intervention by 42% (odds ratio 1.42, 95% confidence interval 1.31-1.54). Neonatal well-being was improved by intervention; neonates requiring resuscitation decreased from 2.1% to 1.6% (P= 0.001). Educating and motivating gynecologists toward the trial of labor after CS is worth pursuing. Health quality improvement is demonstrated by increased VBAC even improving neonatal well-being.

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

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

Factors associated with the outcome of TOLAC after one previous caesarean section: a retrospective cohort study

The factors associated with the outcome of trial of labour after one previous Caesarean Section; a retrospective cohort study. A retrospective observational study was performed on all eligible consecutive singleton pregnancies planned for trial of labour after one previous Caesarean Section (TOLAC) over a period of 18 months to study the success rate of vaginal birth after Caesarean Section (VBAC) and to find out the factors associated with successful and failed TOLAC. All of the data were entered in electronic format and the data was analysed in detail. Of the 1324 women studied, the VBAC rate was 65.3% and the incidence of scar rupture was 0.5%. The composite adverse maternal (postpartum haemorrhage and intensive care admission) and foetal outcome (still birth, 5–minute APGAR <7 and NICU admission) was more in the failed TOLAC group. Various demographic, clinical and obstetric factors were studied in detail between the successful and failed TOLAC groups. The favourable Bishop Score (>4) was independently associated with successful TOLAC (OR 4.3; 95% CI 3.3–5.6 p < .001). Maternal age of >30 years, (OR 0.57; 95% CI 0.41–0.79; p = .001), labour induction (OR 0.43; 95% CI 0.33–0.56; p < .001) and estimated foetal weight of >3500 g (0.31; 95% CI 0.14–0.6; p = .002) were the factors independently associated with failed TOLAC. Previous indication for a Caesarean Section and previous vaginal delivery were not found to be independently associated with the outcome of TOLAC. The predictive models for TOLAC need to be used cautiously and the risk assessment should be done on an individual basis. IMPACT STATEMENT What is already known on this subject? TOLAC is a reasonable strategy in Obstetrics especially after one Caesarean Section to minimise the morbidity associated with rising Caesarean Section. However, the maternal and foetal morbidity are more following unsuccessful TOLAC. The factors which predict the outcome of TOLAC are multifactorial which include maternal demographic factors, previous obstetric factors like indication for Caesarean Section, intraoperative complications, inter-pregnancy interval, current obstetric factors such as gestational age, Bishop Score before delivery, labour factors and foetal factors, e.g. sex and foetal size. What do the results of this study add? We tried to include all the possible factors which probably influence TOLAC and found only Bishop Score, maternal age, foetal size and labour induction were the factors independently associated with the outcome of TOLAC. A Bishop Score of >4 admission was the greatest predictor of successful TOLAC (OR 4.3). Similarly, labour induction and foetal size of >3.5 kg were associated with 60% and 70% less chance of VBAC, respectively. What are the implications of these findings for clinical practice and/or further research? The factors found to be associated with successful and failed TOLAC may be utilised to develop a predictive model. More so, prospective studies are needed to test such predictive models.

Economic implications of reducing caesarean section rates - Analysis of two health systems.

Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.

OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section

BackgroundDespite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries.MethodsOptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women.ResultsThe OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000.ConclusionsChanging clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances.Trial registrationThe OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Vaginal Birth after Cesarean Section in Taiwan: A Population-Based Study.

The rate of vaginal birth after cesarean section (VBAC) is extremely low in Taiwan probably due to the high perceived risk of trial of labor after a cesarean (TOLAC). To promote the benefits associated with vaginal birth, this study provides evidence to potentially assist relevant public authorities adopt appropriate guidelines or optimize health insurance reimbursement policies to achieve a higher VBAC rate. Employing the National Health Insurance (NHI) Claim Data, this study analyzes women’s adoptions of birth-giving methods for those who had previous cesarean section (CS) experiences. Empirical methods include logit, probit, and hierarchical regression models controlling women’s demographics, incentive indicators, as well as hospital and obstetrician characteristics. Taiwan continues to have a decreasing trend in VBAC rate even with an increase in NHI payment for vaginal birth delivery in 2005, which stimulated a surge in VBAC rate only temporarily. Factors that significantly influence women’s adoption of VBAC include institution-specific random effects, weekend admission, comorbidities during pregnancy, and income and fertility of women. Change in service payment from National Health Insurance (NHI) to healthcare providers constitutes an effective policy in directing clinical practices in the short term. Constant and systematic policy review should be undertaken to promote safe and beneficial medical practices. The results of the study suggest that women’s adoption of birth-giving method is dominated by non-medical considerations. Significant institution-specific effects imply that women might not be well-informed regarding their optimal birth-giving choice. Health education and training programs for hospital personnel should be kept up to date to better serve society.

The determinants of obstetricians' willingness to undertake delivery by vaginal birth after cesarean section in Taiwan.

BackgroundBabies are sometimes delivered by cesarean section (CS) to women eligible for trial of labor after a cesarean (TOLAC) due to a fear of complications during the delivery process. This view is especially widespread in Taiwan, as evidenced by the extremely low rate (<5%) of vaginal birth after cesarean section (VBAC). To improve the safety and quality of childbirth and the obstetrical practice environment, this study aimed to identify ways to contain the ever-increasing rate of CS by investigating the determinants for TOLAC from the viewpoint of obstetricians.MethodsA specially designed questionnaire was employed that incorporated the perceived risk of VBAC, institutional managerial attitude, and obstetricians’ personal characteristics. Face-to-face surveys were conducted with obstetricians from across Taiwan. Regression analysis was used as appropriate.ResultsAmong the 231 recruited obstetricians, 86.7% were willing to undertake VBAC, but only 71.4% had actually done so. Obstetricians with a more risk-tolerant personality were more likely to undertake VBAC. Institutional characteristics, such as the time it takes to transfer a woman from the delivery table to the operating table (table to table) and the general facilities of the hospital to handle delivery complications resulting from VBAC were also key determinants for attempting VBAC.ConclusionIn Taiwan, a country with a low birthrate, obstetricians need to be risk-tolerant to undertake VBAC. This phenomenon is probably due to underinvestment in facilities for vaginal delivery and thus a general perception that VBAC is risky. The study’s results will potentially help medical institutions to adopt appropriate guidelines and build incentive structures to achieve a higher VBAC rate.

Rates of vaginal birth after caesarean section: What chance do obese women have?

For women considering vaginal birth after caesarean section (VBAC), obesity has been associated with a lower rate of vaginal birth and a higher rate of uterine rupture. To enhance antenatal counselling, this study aimed to evaluate the success rates of morbidly obese women undergoing a trial of labour (TOL). A retrospective analysis was performed of women who birthed at our hospital who had previously had one caesarean section. Routinely collected data were reviewed for mode of birth for women who underwent a TOL. A number of maternal and neonatal outcomes were also gathered. The data were analysed according to those women with a body mass index (BMI) equal to or above 40, compared to those women with a BMI below 40. From 2011 to 2018, 2097 women gave birth at our hospital and had a caesarean section for a prior pregnancy. Of these women, 1234 (58.9%) had an elective caesarean section and 863 (41.1%) underwent a TOL. Of the women undertaking a TOL, 73.1% gave birth vaginally. Women with a BMI equal to or greater than 40 were less likely to have a successful VBAC compared to women with a BMI less than 40 (58.9% vs 74.1%, P=0.013). Only 50% of women with a BMI equal to or greater than 40 had a successful VBAC if they had not previously had a vaginal birth. Women with a BMI over 40 had lower rates of successful VBAC. Rates were even lower for those who had not had a prior vaginal birth.

Health economic analysis of a cluster-randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section.

To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care. Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care). Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates. Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control. A cost-utility analysis from both societal and health-services perspectives, using a decision tree. Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country. The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95%CI €258-268) and 0.008QALYs (95%CI 0.008-0.009QALYs) for Germany, €456 (95%CI €448-464) and 0.052QALYs (95%CI 0.051-0.053QALYs) for Ireland, and €1174 (95%CI €1170-1178) and 0.006QALYs (95%CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy. The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany. The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.

VBAC: antenatal predictors of success.

To determine antenatal factors that may predict successful vaginal birth after Caesarean section (VBAC), to develop a relevant antenatal scoring system and a nomogram for prediction of vaginal birth after caesarean delivery. A non recurring indication for previous Caesarean section (CS), such as breech presentation or foetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Foetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. An inter-pregnancy interval of <24 months is not associated with a decreased success of VBAC. Success rates decrease when interval increases. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases. There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases. (www.actabiomedica.it)

Single prior caesarean section and risk of anal sphincter injury.

Injury to the anal sphincter at vaginal delivery remains the leading cause of faecal incontinence in women. Previous studies reported an increased incidence of obstetric anal sphincter injury (OASI) in women attempting vaginal birth after caesarean section (VBAC). The aim of the paper was to establish whether women in their second pregnancy, with one previous uterine scar, are at a higher risk of OASI compared with nulliparous women. All primiparous and secundiparous women with a previous caesarean section who delivered from 2008 to 2017 were analysed in a single-centre retrospective study. The primary endpoint was OASI. Labour characteristics in both groups were compared, and a multiple regression model was created. There were 8573 vaginal deliveries of nulliparous women and 3453 deliveries of women in their second pregnancy with a previous caesarean section, of whom 550 had a successful VBAC. There was no significant difference in the rate of OASI between primiparous women and those who had a successful VBAC: 3.5% (297/8573) versus 3.1% (17/550), P = 0.730). Foetal macrosomia (>4kg) and forceps delivery were risk factors for sphincter injury, while episiotomy and epidural anaesthesia were protective. VBAC does not confer an increased risk of OASI after a first delivery by caesarean section when compared with nulliparous women. The rate of successful VBAC may be contributory and suggests that the risk conferred by VBAC may be unit-specific. Unit and national-level audit is necessary to investigate this risk further.

Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates.

BackgroundCaesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians’ views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of “OptiBIRTH”, an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates.MethodsFocus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.ResultsThe findings are presented in four main categories with several sub-categories: 1) “prameters for VBAC”, including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) “organisational support and resources for women undergoing a VBAC”, meaning a successful VBAC requires clinical expertise and resources during labour; 3) “fear as a key inhibitor of successful VBAC”, including understanding women’s fear of childbirth, clinicians’ fear of VBAC and the ways that clinicians’ fear can be transferred to women; and 4) “shared decision making – rapport, knowledge and confidence”, meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician–woman relationship.ConclusionsThe findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.

An audit on the outcome of vaginal Birth after Caesarean Section (VBAC) in a Sri Lankan tertiary care setting and factors associated with failure

Introduction: Caesarean section is a major surgical operation and its rate is on the rise in Sri Lanka as well as in the world. It is recommended to lower the Caesarean section rate due to the risk of potential complications and burden on the health care system. Previous Caesarean is a common indication for planned Caesarean section and vaginal birth after Caesarean section (VBAC) is considered a safe alternative for many women. This audit study was aimed at determining the success rate of VBAC in a local setting and to identify the factors that are associated with failure in this study population. Method: An audit study was carried out in two obstetric units if South Colombo Teaching hospital, Kalubowila and De Soysa hospital for women, Colombo 8 to assess the success rate among women who underwent VBAC. The unit policies included patient choice for decision to undergo VBAC and non-usage of medication either for induction or augmentation of labour. The audit standards were set as a VBAC success rate of 72% (RCOG Green-top guidelines) and a low APGAR (<7) in less than 2% of neonates (set by clinical experience). The demographic and past obstetric factors were compared between groups to determine significant associations. Results: A total of 161 women (37.8% of those with a previous one Caesarean) had opted to undergo VBAC during the study period. It was successful in 69.6% of the total study sample and 84.6% who has had a previous vaginal delivery. Low APGAR scores at 5 minutes was observed in two neonates (1.2%) and both these were in the group with a successful VBAC. The factors associated with failed VBAC in this study population included not having had a previous vaginal delivery (Odds ratio 2.99), poor progress of labour being the indication for previous section (OR 2.32), a cervical dilatation of <2cm at onset of labour (OR 4.43), malpositions in early labour (OR 12.24), and a birth weight of more than 3000g (OR 2.11). Other preciously described factors such as a high BMI and inter-delivery interval failed to show a significant association in this study group. Discussion and recommendations: The take up rate of VBAC in our study population seems to be low. However, the study did not study the reasons contributing to this low rate hence no recommendations can be made. The success rate of VBAC on our group (69%) was very close to the set standards (72%) and the rate of low APGAR at 5 minutes was 1.2% and was achieving the set standard. These figures along with the factors identified to be associated with the failure at VBAC should be used for patient counseling in our local setting. Other units also should carry out such audit projects to find out the success rate of VBAC in their respective units. More in-depth studies should be carried out to find causes for low rate of undergoing VBAC and to determine effective ways to improve it.

Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.

BackgroundThe number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC.MethodsThe bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates.Results238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates.ConclusionsThis systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0441-3) contains supplementary material, which is available to authorized users.

Vaginal birth after caesarean section in out-of-hospital settings: a literature review

Even though vaginal birth after Caesarean section (VBAC) is recommended, an out-of-hospital setting is discussed controversially. First of all, uterine rupture and placental complications are named. Nevertheless, an increasing number of women with a prior Caesarean section decide to give birth in an out-of-hospital setting. What is the maternal and neonatal outcome in international studies in these cases? The databases of Medline, Cinahl, Embase and Cochrane Library on vaginal birth after Caesarean section in out-of-hospital settings were searched. Included are studies in German and English language without a limit on year of publication, which describe maternal and neonatal outcomes. 5 studies were found. All of them describe a high VBAC rate (73.5-98%). Only one study found uterine ruptures. Haemorrhage/placental complications were described in 2 studies (0.5 and 1.7%). None of the studies found maternal deaths. Neonatal death was described in 3 studies in a range from 0 -1.7%. There is a wide difference in the population of the studies. An important difference is the parity of the women and the prior mode of birth. 4 of the 5 studies do not see a reason not to try VBAC in an out-of-hospital setting. Further studies are necessary to inform the increasing number of women who decide to try VBAC in an out-of-hospital setting.

Improving VBAC rates: the combined impact of two management strategies.

Caesarean section rates in Australia have risen to >30%, with repeat caesarean delivery the most common indication. One method of reducing caesarean delivery rates is to increase rates of vaginal birth after caesarean section (VBAC). To determine the combined effect of two management strategies on the rates of successful VBAC in women experiencing their first pregnancy following primary caesarean section. Prospective cohort study from May 2009 to October 2010 at a metropolitan Australian teaching hospital. The strategies studied were (i) allocating responsibility for VBAC candidates attempting labour to the hospital's three high-risk obstetric consultants and (ii) implementing a next birth after caesarean (NBAC) antenatal clinic designed to counsel and support women deciding on mode of birth for their next pregnancy after a primary caesarean section. Data were collected from Obstetrix, a NBAC logbook and medical records of 396 eligible women who gave birth during the study period. Overall VBAC rates improved from 17.2% in 2006 prior to implementation of the combined strategies, to 27.0% over the studied period (P<0.001). Of those women who desired and attempted a VBAC, the success rate was 64.4%. Regression analysis identified an increased likelihood of attempted vaginal birth where malpresentation was the indication for previous caesarean, while Eastern Asian ethnicity was associated with increased likelihood of choosing repeat caesarean. A dedicated NBAC clinic and more consistent approach to labour management can help improve VBAC rates. Further targeted counselling towards women with previous malpresentation and/or East Asian descent may further improve VBAC attempt rates.