Rate Of Vaginal Birth Research Articles

‘I'm having a baby not a labour’: Sense of coherence and women's attitudes towards labour and birth

ObjectiveIn Western countries, caesarean section rates are increasing and spontaneous vaginal birth rates are decreasing at a rapid rate. This trend has implications for childbearing women's health and calls into question the use of pathogenesis to frame maternity services. The theory and practice of salutogenesis offers a viable alternative as it emphasises health rather than illness. Sense of coherence and generalized resistant resources (GRRs) are the cornerstones of salutogenesis and sense of coherence is a predictive indicator of health. As strong sense of coherence in pregnant women is associated with half the likelihood of caesarean section compared to women with weak sense of coherence, the objective of this study is to examine the association between sense of coherence and women's attitude towards their birthing experiences. Design, setting and participantsThis paper reports on the qualitative component only of a longitudinal study where 753 women planning to have their babies in an Australian tertiary maternity service, completed questionnaires in pregnancy and postnatally. Women answered one openended question during the pregnancy and one open-ended question approximately eight weeks postnatally. Data were analysed by qualitative content analysis. FindingsWhen the open-text responses of 119 women with strong sense of coherence and 177 women with weak sense of coherence were analysed, the categories of Language, Demeanour and Focus were identified. Women with strong sense of coherence have a positive, relaxed and baby-focused attitude. In salutogenic terms this attitude towards labour and birth can be described as increased comprehensibility, increased manageability, decreased meaningfulness in the experience of giving birth, increased internal GRRs and increased external GRRs. Women with weak sense of coherence have a more negative, worried and labour-focused attitude. In salutogenic terms this attitude towards labour and birth can be described as decreased comprehensibility, decreased manageability, increased meaningfulness in the experience of giving birth, decreased internal GRRs and decreased external GRRs. Key conclusionStrong sense of coherence in childbearing women is expressed through a positive, relaxed and baby-focused attitude while weak sense of coherence is expressed through negative, worried and labour-focused attitude in childbearing women towards labour and birth. Implications for practiceAs sense of coherence is a modifiable predictor of health, application of the study findings could focus on midwifery work including antenatal education that aims to decrease caesarean section rates by strengthening women's sense of coherence in pregnancy.

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.

Outcomes of uninsured midwifery clients in Ontario, Canada: A retrospective cohort study

ObjectiveTo describe the characteristics, health service utilization, and clinical outcomes of Ontario residents who are not covered by the Ontario Health Insurance Plan and receive services from Ontario midwives. DesignRetrospective cohort study. SettingOntario, Canada. ParticipantsAll midwifery courses of care resulting in births between April 1, 2012 to March 31, 2015 and captured in the BORN perinatal registry. Within this cohort we compared midwifery clients without publicly funded health insurance to those covered by the Ontario Health Insurance Plan (OHIP). Measurements and findingsOf 55, 634 midwifery clients assessed in Ontario, 92.8% were insured by OHIP and 7.2% were not insured. Among uninsured clients, 66.3% attended a prenatal visit during the first trimester compared to 92.8% of insured women, with uninsured clients presenting with fewer pre-existing conditions. A higher proportion of uninsured clients (33.9%) planned to birth at home and 28.7% of clients’ actual place birth was in the home, compared to 19.6% and 16.6% of insured clients respectively. Rates of both spontaneous labour and spontaneous vaginal birth were higher among uninsured clients (82.1% and 81.1%, respectively), compared to insured clients (77.3% and 78.1%, respectively). Clinical outcomes were generally similar, with postpartum hemorrhage (3.4%), preterm birth (5%), and small-for-gestational age (2.1%) slightly more common among uninsured clients compared to insured clients (2.9%, 4.4%, and 1.7%, respectively). Rates of most complications were lower for uninsured clients. Key conclusionsOverall, uninsured clients used less services compared to insured clients and had good clinical outcomes under midwifery care in Ontario. Findings of this study support the policy decision in Ontario to fund midwifery care for uninsured clients and suggest that uninsured clients are well suited for midwifery care. Implications for practiceFunding midwives to serve uninsured clients is appropriate and may improve uninsured clients access to care.

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.

Giving birth after caesarean: Identifying shared preferences among pregnant women using Q methodology

BackgroundCaesarean rates are rising worldwide, the main contributor being the elective repeat caesarean. During the past decades, rates of vaginal birth after caesarean dropped considerably. This requires insight in women’s preferences regarding giving birth following a previous caesarean. AimTo gain a better understanding of women’s values and preferences regarding the upcoming birth following a previous caesarean. Using Q methodology, this study systematically explores and categorises their preferences. MethodsQ methodology is an innovative research approach to explore and compare a variety of viewpoints on a certain subject. Thirty-one statements on birth after caesarean were developed based on the health belief model. Thirty-six purposively sampled pregnant women with a history of caesarean ranked these statements from least to most important. By-person factor analysis was used to identify patterns which, supplemented with interview data, were interpreted as preferences. FindingsThree distinct preferences for giving birth after a caesarean were found; (a) “Minimise the risks for me and my child”, giving priority to professional advice and risk of adverse events, (b) “Seek the benefits of normal birth”, desiring to give birth as normal as possible for both emotional and practical reasons, (c) “Opt for repeat caesarean”, expressing the belief that a planned caesarean brings comfort. ConclusionsPreferences for birth after caesarean vary considerably among pregnant women. The findings help to understand the different types of information valued by women who need to decide on their mode of birth after a first caesarean.

Ophthalmological and obstetric management in pregnant women with retinal disorders.

To analyze the clinical significance of ophthalmological assessment in pregnant women affected with degenerative retinal lesions, and the lesions' clinical relevance in determining the obstetric management and delivery method. 69 pregnant women affected with retinal degenerative lesions were included in our study. In each patient, the risk of ophthalmological complications during vaginal delivery was evaluated. After the woman's delivery, alignment between the ophthalmological recommendations and the obstetric management were analyzed. Each case where the management plan differed from the clinical proceedings was thoroughly investigated to determine the cause. In 69 pregnant women the risk of ophthalmological complications was evaluated, and in 24 cases (35%) assessed as low, as medium in 37 cases (54%) and as high in 8 cases (11%). Among the 69 patients, 42 of women delivered vaginally and the remaining 27 underwent caesarean section. In the high-risk group, the rate of caesarean section was 87%, while in both the low- and medium-risk groups the rate of vaginal births was 75%. Two years of postnatal ophthalmological follow-up did not reveal any complications that could have been associated with the delivery. Every pregnant woman should undergo ophtalmological examination to assess peripartum risk of complications and determine the method of delivery.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BackgroundIn the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong’an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.MethodsData from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong’an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.ResultsThe EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.ConclusionsThese results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Effect of Peanut Ball and Position Changes in Women Laboring With an Epidural

ObjectiveTo examine the effect of a nurse-driven intervention using a peanut ball (PB) with position changes on length of labor and incidence of cesarean birth among women who receive epidural anesthesia. DesignQuasiexperimental comparison group design. Setting/Local ProblemA 407-bed, nonprofit, Magnet-designated, Baby-Friendly Hospital Initiative–designated hospital with 8 labor and delivery suites and an average of 100 births per month. ParticipantsA total of 343 participants were included, with 164 women in the PB group. Intervention/MeasurementsThe PB was placed after epidural administration; women were repositioned a minimum of every 1 to 2 hours, and the PB was removed at second stage of labor; duration was recorded. ResultsOverall, women in the PB group were 50% less likely to have cesarean birth. For women with cervical dilation of 4 cm or less, rates of vaginal birth were 61% with use of the peanut ball. A multivariate analysis of outcomes was used. A multiple linear regression model showed, after adjusting for other variables, that PB placement alone did not shorten labor length (p = .4684). However, a stratified analysis indicated that for women with cervical dilation of 4 cm or less, length of the first stage of labor was affected by parity (p = .0042) and frequency of position change (p < .001). For women with cervical dilation greater than 4 cm, length of the first stage of labor was influenced by frequency of position changes (p = .0130) and effacement (p = .0050). Length of the second state of labor was affected by the frequency of position change (p = .0416). ConclusionThe PB may be an effective intervention to reduce the incidence of cesarean birth. Changing position frequently was associated with reduced length of first and second stages of labor.

Effect of Service-Branch on Contraception Use and Childbirth Rates Among United States Military Recruits [6H

INTRODUCTION: Unintentional pregnancy is a common problem among US servicewomen, particularly junior enlisted, with negative effects on the mother, infant, and military readiness. METHODS: Secondary analysis of insurance records from 92,072 servicewomen, who attended basic training between 2013 and 2017, examining differences between service-branches in prescription contraception use after 6 months on active duty and childbirth in the first 24 months of active duty using Kaplan-Meier and Cox Regression Analyses. IRB approved. RESULTS: Rates of prescription contraception use after 6-months on active duty varied significantly between branches [Army (18.1%), Air Force (27.4%), Navy (37.6%), and Marines (26.5%); (P<.001)] as did the proportion of women on prescription contraception using longer-acting methods (Depot-medroxyprogesterone, Implant, or Intrauterine) [Army (15.2%), Air Force (17.5%), Navy (54.7%), and Marines (49.8%); P<.001)]. There were significant (P<.001) differences in the rate of childbirth in the first 24 months on active duty between all of the services except the Air Force and Navy (P=.057) [(Army: 11.1% (95% Confidence Interval 10.7-11.5), Air Force 6.0% (5.6-6.4), Navy 6.7% (6.3-7.1), and Marines 8.4% (7.8-9.0)). In multivariable analysis accounting for age and contraception use, there were significant (P<.001) differences between services in the risk of childbirth. For example, the Navy (Hazard Ratio 1.24 (95% Confidence Interval 1.13-1.35)), Marines (1.48 (1.33-1.65)), and Army (1.86 (1.71-2.01)) all had a higher risk than the Air Force. CONCLUSION: Despite access to an identical medical benefit, including free contraception, contraceptive use and pregnancy rates among junior enlisted vary significantly across services. Further study is needed to determine the etiology of these differences.

The continuous audit of events and outcomes of labour and birth using the Ten Group Classification System and its role in quality improvement

ObjectiveThe knowledge of a labour and birth unit’s rates of events and outcomes is essential to design any quality improvement initiative. It is in the same way important to have a system to analyse results of the ongoing changes within the unit. The Ten Group Classification System is the framework for doing this in a systematic and clinically relevant way. We aimed to use this classification system as a quality improvement tool. Study designAll labours and births during four years at a secondary level Hospital were included in a continuous analysis and of events and outcomes based on the Ten Group Classification System. From the results of the audit, policies and guidelines were designed and updated to improve outcomes. ResultsThe normal vaginal birth rate in Group 1 increased during the four-year-period and the Caesarean Section rate in Group 2 A dropped after the introduction of a new induction method. The overall Caesarean Section rate decreased. The experience of giving birth improved in Groups 1, 2 A and 3. ConclusionThe use of a continuous audit of events and outcomes based on a clinically significant classification for all women makes it possible to improve quality. Other labour and birth units are encouraged to collect and present data in a way that allows comparisons between units and over time.

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.

Hospital contribution to variation in rates of vaginal birth after cesarean.

Objective:To determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC).Study Design:This retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation.Result:Hospital-level adjusted rates varied nearly 10-fold (3.7%-35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23-6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59-8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11-7.72]). The median OR suggested significant variation by hospital after adjustment.Conclusion:The delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.

Exploring Obstetrical Interventions and Stratified Cesarean Section Rates Using the Robson Classification in Tertiary Care Hospitals in the United Arab Emirates.

The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS. The rate of vaginal birth after cesarean was 261 (6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Maternal and newborn outcomes with elective induction of labor at term

A growing body of evidence supports improved or not worsened birth outcomes with nonmedically indicated induction of labor at 39 weeks gestation compared with expectant management. This evidence includes 2 recent randomized control trials. However, concern has been raised as to whether these studies are applicable to a broader US pregnant population. Our goal was to compare outcomes for electively induced births at ≥39 weeks gestation with those that were not electively induced. We conducted a retrospective cohort study using chart-abstracted data on births from January 1, 2012, to December 31, 2017, at 21 hospitals in the Northwest United States. The study was restricted to singleton cephalic hospital births at 39+0-42+6 weeks gestation. Exclusions included previous cesarean birth, missing data for delivery type or gestational week at birth, antepartum stillbirth, cesarean birth without any attempt at vaginal birth, fetal anomaly, gestational diabetes mellitus, prepregnancy diabetes mellitus, and prepregnancy hypertension. The rate of cesarean birth for elective inductions at both 39 and 40 weeks gestation was compared with the rate in all other on-going pregnancies in the same gestational week. Maternal outcomes (operative vaginal birth, shoulder dystocia, 3rd- or 4th-degree perineal laceration, pregnancy-related hypertension, and postpartum hemorrhage) and newborn infant outcomes (macrosomia, 5-minute Apgar <7, resuscitation at delivery, intubation, respiratory complications, and neonatal intensive care unit admission) were also compared between elective inductions and on-going pregnancies at 39 and 40 weeks gestation. Logistic regression modeling was used to produce odds ratios for outcomes with adjustment for maternal age and body mass index. Results were stratified by parity and gestational week at birth. Duration of hospital stay (admission to delivery, delivery to discharge, and total stay) were compared between elective inductions and on-going pregnancies. A total of 55,694 births were included in the study cohort: 4002 elective inductions at ≥39+0 weeks gestation and 51,692 births at 39+0-42+6 weeks gestation that were not electively induced. In nulliparous women, elective induction at 39 weeks gestation was associated with a decreased likelihood of cesarean birth (14.7% vs 23.2%; adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.89) and an increased rate of operative vaginal birth (18.5% vs 10.8%; adjusted odds ratio, 1.8; 95% confidence interval, 1.28-2.54) compared with on-going pregnancies. In multiparous women, cesarean birth rates were similar in the elective inductions and on-going pregnancies. Elective induction at 39 weeks gestation was associated with a decreased likelihood of pregnancy-related hypertension in nulliparous (2.2% vs 7.3%; adjusted odds ratio, 0.28; 95% confidence interval, 0.11-0.68) and multiparous women (0.9% vs 3.5%; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.38). Term elective induction was not associated with any statistically significant increase in adverse newborn infant outcomes. Elective induction of labor at 39 weeks gestation was associated with increased time from admission to delivery for both nulliparous (1.3 hours; 95% confidence interval, 0.2-2.3) and multiparous women (3.4 hours; 95% confidence interval, 3.2-3.6). Elective induction of labor at 39 weeks gestation is associated with a decrease in cesarean birth in nulliparous women, decreased pregnancy-related hypertension in multiparous and nulliparous women, and increased time in labor and delivery. How to use this information remains the challenge.

Are prediction models for vaginal birth after cesarean accurate?

The use of trial of labor after cesarean delivery calculators in the prediction of successful vaginal birth after cesarean delivery gives physicians an evidence-based tool to assist with patient counseling and risk stratification. Before deployment of prediction models for routine care at an institutional level, it is recommended to test their performance initially in the institution's target population. This allows the institution to understand not only the overall accuracy of the model for the intended population but also to comprehend where the accuracy of the model is most limited when predicting across the range of predictions (calibration). The purpose of this study was to compare 3 models that predict successful vaginal birth after cesarean delivery with the use of a single tertiary referral cohort before continuous model deployment in the electronic medical record. All cesarean births for failed trial of labor after cesarean delivery and successful vaginal birth after cesarean delivery at an academic health system between May 2013 and March 2016 were reviewed. Women with a history of 1 previous cesarean birth who underwent a trial of labor with a term (≥37 weeks gestation), cephalic, and singleton gestation were included. Women with antepartum intrauterine fetal death or fetal anomalies were excluded. The probability of successful vaginal birth after cesarean delivery was calculated with the use of 3 prediction models: Grobman 2007, Grobman 2009, and Metz 2013 and compared with actual vaginal birth after cesarean delivery success. Each model's performance was measured with the use of concordance indices, Brier scores, and calibration plots. Decision curve analysis identified the range of threshold probabilities for which the best prediction model would be of clinical value. Four hundred four women met the eligibility criteria. The observed rate of successful vaginal birth after cesarean delivery was 75% (305/404). Concordance indices were 0.717 (95% confidence interval, 0.659-0.778), 0.703 (95% confidence interval, 0.647-0.758), and 0.727 (95% confidence interval, 0.669-0.779), respectively. Brier scores were 0.172, 0.205, and 0.179, respectively. Calibration demonstrated that Grobman 2007 and Metz vaginal birth after cesarean delivery models were most accurate when predicted probabilities were >60% and were beneficial for counseling women who did not desire to have vaginal birth after cesarean delivery but had a predicted success rates of 60-90%. The models underpredicted actual probabilities when predicting success at <60%. The Grobman 2007 and Metz vaginal birth after cesarean delivery models provided greatest net benefit between threshold probabilities of 60-90% but did not provide a net benefit with lower predicted probabilities of success compared with a strategy of recommending vaginal birth after cesarean delivery for all women . When 3 commonly used vaginal birth after cesarean delivery prediction models are compared in the same population, there are differences in performance that may affect an institution's choice of which model to use.

Impact of Audits and Multifaceted Intervention on Vaginal Birth After Caesarean: Secondary Analysis of the QUARISMA Trial.

This study estimated the effect that a multifaceted intervention aiming to improve the quality of obstetrical care and reduce Caesarean section (CS) had on the rate of vaginal birth after Caesarean (VBAC). This is a secondary analysis of the cluster randomized controlled trial Quality of Care, Obstetrics Risk Management, and Mode of Delivery involving (1) audits regarding the indications for CS, (2) provision of feedback to health professionals, and (3) implementation of best practices to reduce CS rates in Quebec. The impact of intervention on VBAC, trial of labour (TOL), and maternal and neonatal morbidity was reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Out of 105 351 women who delivered during the pre- and postintervention period, 12 493 (11.9%) had a previous CS. We observed no significant impact of the multifaceted intervention on the rates of TOL (adjusted OR 1.22; 95% CI 0.96-1.56, P = 0.11) and VBAC (adjusted OR 1.20; 95% CI 0.97-1.48, P = 0.10) in women with one previous CS. However, the rate of TOL was reduced (adjusted OR 0.38; 95% CI 0.14-0.99) in women with more than one previous CS. The intervention has no influence on maternal and neonatal morbidity. A multifaceted intervention including audits, feedback to health professionals, and implementation of best practices did not affect VBAC rates or maternal and neonatal morbidity. Our results pointed out the need for decision-making processand risk management tools specific to women with previous CS.

Outcomes of induction of labour in nulliparous women at 38 to 39weeks pregnancy by clinical indication: An observational study.

Knowledge of the outcomes of induction of labour for different indications is sparse. To describe the mode of birth and other outcomes for nulliparous women induced at 38-39weeks gestational age by indication for induction of labour. This was a retrospective observational study in a tertiary referral hospital, and a metropolitan teaching hospital in Sydney. The study population was nulliparous women with induction of labour at 38 or 39 completed weeks of pregnancy and a singleton, cephalic presenting baby planning a vaginal birth, from 2009 to 2016. The indication for induction of labour was classified into 12 groups. Mode of birth and other maternal and perinatal outcomes were described in each group, for women who spontaneously laboured at 38 or 39weeks, and for women who gave birth from 40 completed weeks onward. The main outcome measure was mode of birth. There were 3330 women with induction of labour at 38 or 39weeks gestation. Rates of vaginal birth varied widely, ranging from 54% when the indication for induction was suspected large fetus, to 82% when the indication was suspected fetal compromise, and was 74% overall. Indications for caesarean delivery also varied by indication for induction. Among women giving birth ≥40weeks gestational age, 75% had a vaginal birth. In nulliparous women, rates of vaginal birth following induction of labour at 38 or 39weeks gestation vary widely according to the indication for induction. These data are useful for antenatal counselling.

Development of a Modified Score System as Prediction Model for Successful Vaginal Birth After Cesarean Delivery.

This study was designed to establish a modified prediction score system to improve the safety and success rate of vaginal birth after cesarean delivery (VBAC). We recruited 406 patients (between January 2012 and December 2016) and generated a modified score system in predicting the success rate of VBAC. All patients were required to sign informed consent forms. There were 87.2% of patients who had successful VBAC deliveries and 12.8% patients who had repeated cesarean sections. We conducted multivariable logistic regression and found seven variables that were associated with VBAC success, including previous primary indication of cesarean delivery (odds ratio (OR), 2.1; 95% confidence interval (CI), 1.4–3.0), previous vaginal birth history (OR, 2.5; 95% CI, 1.8–3.8), < 40 years of age (OR, 2.1; 95% CI, 1.2–3.3), < 20 kg weight gain (OR, 1.5; 95% CI, 1.2–2.3), no labor induction (OR, 1.9; 95% CI, 1.5–2.9), high score of pelvic/birth weight (OR, 1.4; 95% CI, 1.1–2.1), and Bishop score (OR, 1.3; 95% CI, 1.2–1.4). After adjustment for optimism, the area under the receiver operating characteristic curve (AUC‐ROC) was 0.849 (95% CI, 0.78–0.89), and the modified VBAC score was positively correlated with the success rate of trial of labor after cesarean delivery (TOLAC). A valid and useful score system was established to predict VBAC success rate.

Factors Associated with Success Rate of Vaginal Birth after One Caesarean Section (VBAC) in Ibrahim Malik Teaching Hospital, Khartoum-Sudan

Factors Associated with Success Rate of Vaginal Birth after One Caesarean Section (VBAC) in Ibrahim Malik Teaching Hospital, Khartoum-Sudan