VBAC Group Research Articles

Delivery Progress, Labor Interventions and Perinatal Outcome in Spontaneous Vaginal Delivery of Singleton Pregnancies between Nulliparous and Primiparous Women with One Previous Elective Cesarean Section: A Retrospective Comparative Study.

This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally. The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used. Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.

Retrospective evaluation of outcomes of vaginal birth after caesarean section in a tertiary center: a single-center study from Türkiye.

The aim of this study was to evaluate the trial of labor after caesarean (TOLAC) outcomes and determine its reliability by comparing it with elective repeat caesarean delivery (ERCD) and vaginal delivery. For this purpose, the outcomes of patients aged 18-40 years who had 57 TOLACs, 72 vaginal deliveries, and 60 elective caesarean sections in Ankara Koru Hospital between January 1, 2019, and January 1, 2022 were compared. Gestational age was lower in the normal vaginal delivery (NVD) group than in the elective caesarean section and vaginal birth after caesarean delivery (VBAC) groups (p < 0.0005). The birth weight was statistically significantly lower in the NVD group than in the elective caesarean section and VBAC groups (p < 0.0002). No statistically significant correlation was found between the BMI values in all three groups (p < 0.586). There was no statistically significant difference between the groups in terms of pre- and post-natal haemoglobin and APGAR scores (p < 0.575) (p < 0.690) (p < 0.747). The rate of epidural and oxytocin use was higher in the NVD group than in the VBAC group (p < 0.001) (p < 0.037). There was no statistically significant correlation between the birth weights of the infants in the TOLAC group and failed VBAC (p < 0.078). No statistically significant correlation was observed between the use of oxytocin for induction and failed VBAC (p < 0.842). There was no statistically significant correlation between epidural anaesthesia and failed VBAC (p < 0.586). A statistically significant correlation was found between gestational age and caesarean section as a result of a failed VBAC (p < 0.020). The main reason for not preferring TOLAC continues to be uterine rupture. It can be recommended to eligible patients in tertiary centers. Because even when the factors increasing the success of VBAC were excluded, the rate of successful VBAC remained high.

Prediction of Success Rates of Vaginal Birth after Cesarean Delivery According to the Previous Indication for Cesarean Delivery

Background: Trial of labor after cesarean delivery (TOLAC) has long been accepted as a safe option for women with previous cesarean delivery. Previous efforts have been exerted in trials to predict the success rates of TOLAC according to specific parameters related to previous cesarean section and before TOLAC. We aimed to investigate the different indications of previous cesarean delivery as independent predictors for successful vaginal birth. Methods: A retrospective study was conducted in Armed Forces Hospitals of the Southern Region between December 15, 2019, and July 1, 2020. The included 566 patients with previous cesarean section who were willing to undergo a trial of labor were divided into two groups according to the success of vaginal birth (VBAC). Results: The nonrecurring indications for previous cesarean delivery were higher in the successful group (fetal distress 54.7% vs 41.1%, malpresentation 26% vs 21.4%, multifetal pregnancy 3.8% vs 2.7%). Additionally, the successful VBAC group had a significantly higher percentage of previous successful VBAC (47.7% vs 21.9%) and prior vaginal deliveries (58.5% vs 44.2%) and less coincidence of medical disorders and meconium-stained liquor (18.1% vs 26.3% and 3.2% vs 8.2%, respectively) than the unsuccessful group. Conclusion: During counseling regarding trial of labor after cesarean section, indications for previous cesarean section not related to arrest of labor can predict higher success of VBAC. Moreover, previous successful vaginal delivery or VBAC improves the success rates.

Increased risk of obstetric anal sphincter injury in women undergoing vaginal delivery after caesarean section: A systematic review and meta‐analysis

There is increased focus on obstetric anal sphincter injury (OASI) and there are several well-established risk factors such as birthweight, instrumental delivery and median episiotomy. Some studies have found increased risk of OASI in women delivering vaginally after a previous caesarean section (VBAC). To evaluate whether there is increased prevalence of OASI in VBAC compared with primiparous women. Literature search using PubMed, Embase and Cochrane databases. All studies with data on both primiparous women and women undergoing VBAC were included. All included studies were evaluated using the "SIGN-methodology checklist" to verify if the quality was acceptable. This systematic review included 23 articles conducted in 11 countries over 19 years. Included studies were analysed using RevMan version 5.4. We found increased prevalence of OASI in the VBAC group; 8.18% (95% confidence interval [CI] 8.07-8.29) compared with 6.59% (95% CI 6.56-6.62) in primiparous women. Correspondingly, the meta-analysis revealed increased prevalence for OASI in the VBAC group (odds ratio 1.27, 95% CI 1.10-1.47). We found a high level of heterogeneity (I2 = 98%). Women undergoing VBAC had a higher prevalence of OASI compared with primiparous women.

Vaginal birth after cesarean section: Experience from a regional hospital

ObjectiveTrial of labor after cesarean section (TOLAC) is an option for women with previous cesarean section. However, few women choose this option because of safety concerns. We evaluate the safety and risks associated with TOLAC and the success rate of vaginal birth after cesarean delivery (VBAC). Material and methodsWe reviewed all patients with a history of previous cesarean section that underwent elective repeat cesarean section (ERCS) or TOLAC in a regional teaching hospital from Nov, 2013 to May, 2018. Maternal basic clinical information, intrapartum management, postpartum complications, and neonatal outcomes were analyzed. Results199 pregnant women with a history of at least one previous cesarean section were enrolled. 156 women received ERCS and 43 women (21.6%) underwent TOLAC, with 37 (86.0%) who underwent successful VBAC. The VBAC rate was 18.6%. Higher success rate was found in women with previous vaginal birth than in women without vaginal birth (100% vs. 81.8%). One case (2.3%) in the VBAC group was complicated with uterine rupture and inevitable neonatal death during second stage of labor. The uterus was repaired without maternal complications. In another case, the newborn's condition was complicated with low APGAR score (<7) at birth due to maternal chorioamnionitis. Among indications for previous cesarean section, cephalo-pelvic disproportion (CPD) was associated with TOLAC failure and uterine rupture after VBAC. ConclusionVBAC is a feasible and safe option. Modes of delivery should be thoroughly discussed when considering TOLAC for women with history of previous cesarean section due to CPD, considering its association with TOLAC failure in second stage of labor.

Vaginal Birth after Cesarean Section in Iran: A Narrative Review

Background & aim: birth after cesarean (VBAC) is a global solution to reduce the number and complications of repeat cesarean section (C-section); however, fear of consequences is an obstacle preventing its performance. Knowledge of research available in each country provides the support needed for making decisions regarding evidence-based actions for healthcare service providers in the country. This study aimed to review the studies performed to investigate VBAC in Iran. Methods: Search was carried out on Engliah and Persian databases including PubMed, Scopus, Google Scholar, Magiran, and SID. Retrieved articles up to October 2020 were included in the review and the search process was performed using the keywords of Vaginal birth after cesarean, Repeat C-section, Trial of labor after C-section, VBAC, and TOLAC. All related studies without time restriction were entered into the study, resulting in a total of 12 studies. Results: The success rate of VBAC varied from 27%-91.2% in different parts of Iran between 1981 and 2020. Moreover, maternal and neonatal adverse outcomes and cost and length of hospitalization were lower in the VBAC group. No related maternal death was reported in all reviewed studies. Conclusion: The findings of the present review indicated the lack of access to sufficient study resources on this field of research in Iran. Nevertheless, it is required to employ strategies as building an organizational culture, clinical contextualization at the level of healthcare services, and improving service environments, including VBAC supportive centers to promote this practice in the country.

Comparative study of maternal and fetal outcome in patients with Vaginal Birth after caesarean section and elective repeat caesarean section

Women after delivering her first baby by section have a choice about mode of delivery for her second baby. The study was planned to compare maternal and perinatal outcome between VBAC and repeat elective LSCS in patients with prior one LSCS and their complications. A prospective observational study was carried out in department of obstetrics and . Total 180 cases of previous LSCS who were eligible for vaginal delivery were recruited 90 in each group as per consent given by them. Group 1: Vaginal Birth after section Group 2: elective repeat section. It was observed that majority of the patients group 1(51.1%) and group 2 (47.8%) were in age group of 25 to 30 years. More than 25kg/m2 BMI was found in 18(20%) cases of VBAC group and 30(33.3%) cases of LSCS group pregnancy interval was significantly lower in LSCS group compared to VBAC group. Mean birth weight was 2.832 kg to 2.917kg in both group. with improved maternal care, close fetal monitoring and institutional delivery for a previous one section, VBAC is considered safer than repeat elective section in carefully selected patient.

Clinical analysis of delivery mode of 576 cases of re-pregnancy after cesarean section

Objective To explore the choice of re-pregnancy delivery mode after cesarean section. Methods From January 2015 to December 2017, a retrospective study was performed on 576 pregnant women who received re-pregnancy after cesarean section in National Nuclear Corporation 416 Hospital and randomly selected 40 cases of vaginal birth after cesarean delivery(VBAC), 40 cases of cesarean section after trial of labor after cesarean delivery(TOLAC) and 40 cases of elective repeat cesarean delivery(ERCD) for comparative analysis.The postpartum hemorrhage, neonatal Apgar score, hospitalization time, hospitalization expenses and complication were compared. Results All the 159 pregnant women chose transvaginal trials and 112 had successful vaginal delivery.The success rate of delivery was 70.4%.Compared with the other two groups, the VBAC group had less postpartum hemorrhage [(172.50±59.86)mL, (281.25±192.05)mL, (260.00±125.68)mL], less average hospital stay [(3.9±0.9)d, (5.7±1.5)d, (4.6±0.7)d] and lower medical expenses [(6 491.79±1 104.78), (11 871.96±1 784.30), (10 724.69±1 843.63)], and the differences were statistically significant (F=7.086, 26.243, 123.488; P=0.001, 0.000, 0.000). The neonatal Apgar score, incidence rates of complications (incomplete uterine rupture, postpartum hemorrhage, urinary retention, thrombotic disease and neonatal conversion) had no statistically significant differences between the two groups (all P>0.05). The TOLAC failed to change to the cesarean section group compared with the ERCD group, the average hospitalization cost was more [(11 871.96±1 784.30)CNY, (10 724.69±1 843.63)CNY], the average hospitalization days was longer [(5.7±1.5)d, (4.6±0.7)d], the difference was statistically significant (P=0.000, 0.005). The postpartum hemorrhage volume, neonatal Apgar score, complications had no statistically significant differences between the two groups(all P>0.05). Conclusion It is safe and feasible to perform vaginal trials under close monitoring without vaginal trials.It is safe and feasible to perform vaginal trials under strict monitoring.Even if the vaginal trial fails to change to cesarean section, it will not increase the occurrence of serious complications.Infant outcomes are good. Key words: Cesarean section; Pregnancy; Mode of delivery

Clinical analysis and countermeasures of the perinatal outcome of vaginal birth after cesarean delivery

Objective To provide midwives evidence for the evaluation of pregnant women during the process of vaginal birth after cesarean delivery (VBAC) by analyzing the clinical data of perinatal outcome of VBAC, so as to develop supporting interventions, ensure maternal safety and improve the success rate of vaginal delivery. Methods Totals of 284 pregnancy women who were pregnant after cesarean section and admitted from April 2015 to July 2016 were selected. According to the perinatal outcome of delivery, they were divided into VBAC group (n=119) , elected repeat cesarean delivery (ERCS) group (n=106) , and the unsuccessful trial of labor after cesarean (TOLAC) group (n=59) . Maternity outcomes were compared among these three groups. Results In 284 cases, 62.7% (178 cases) selected vaginal delivery, of which 119 were successful, with a success rate of 66.85%, and the remaining 59 cases transferred to cesarean section. Compared with the ERCS group, the VBAC group had lighter prenatal weight, higher cervical score, and shorter postpartum hospitalization time, with a statistical difference (P<0.05) . Compared with the unsuccessful TOLAC group, the cervical score and the natural fertility rate of the fetus of the VBAC group were higher (P<0.05) . Conclusions Midwives can conduct a comprehensive assessment of pregnant women who are pregnant after cesarean according to their individual problems, and provide targeted nursing management and support during delivery. It is recommended prenatal knowledge education should be given in outpatient clinic to promote the success of the VBAC. Key words: Cesarean section; Vaginal birth after cesarean; Perinatal outcome; Countermeasures

EP01.10: Cervical measurement are useful predictor of success of TOLAC

To evaluate whether measurement of cervix is helpful in predicting vaginal delivery in patients whose indication of previous Caesarean section was protraction disorder. We studied retrospectively about pregnant women who were admitted for trial of labour after Caesarean delivery (TOLAC) from January 2014 to December 2014 in St Mary's Hospital, Seoul, Republic of Korea. Among them, women whose indication of previous Caesarean section was protraction disorder were enrolled. Exclusion criteria were premature rupture of membrane (PPROM), suspicious macrosomia, pregnancy with diseases affecting labour course (ex.gestational diabetes, pre-eclampsia etc). Total 94 patients were studied. At 39 weeks of gestation, we checked cervical volume, cervical length and Bishop score. Success of TOLAC defined vaginal delivery (VBAC). After delivery we compared the outcome between VBAC (n = 62) and failed group (n = 32). VBAC rate was 66%. It was significantly lower rate compared with group of another previous Caesarean indications. In VBAC group, Cervical length was significantly shorter than failed group (3.0 ± 0.3 cm vs. 4.1 ± 0.5 cm, P < 0.001). Cervical volume and Bishop score were not significant in both group. Measuring cervical length is useful marker in predicting VBAC among TOLAC with previous protraction disorder history.

English

OBJECTIVE: The aim of the study was to see the fetomaternal outcome of pregnancy with previous cesarean section. METHODS: This study was conducted in the department of OBGYN, BARC Hospital, Mumbai from October 2011 to September 2012, a period of one year. All the pregnant women with previous one cesarean section attending ANC clinic for confinement were included in the study group after giving consent. RESULTS: Out of total75 cases, a total of 23 patients (30.67%) were given trial of labor. Out of 23 patients given trial of labor, 12 patients (52.17%) had successful VBAC. Commonest indication for unsuccessful trial of labor undergoing repeat cesarean section was nonprogress of labor (54.55%) and failed IOL (36.67%). Out of 12 patients who had successful VBAC, 3 patients (25%) had complication like episiotomy hematoma, perineal tear and cervical tear. No patients had major complications. In present study no baby had apgar score <7 at 1min and 5 min in VBAC group and elective LSCS group. CONCLUSION: The current study concludes that women with a prior cesarean are at increased risk for repeat cesarean section. Vigilance with respect to indication at primary cesarean delivery, proper counseling for trial of labor and proper antepartum and intrapartum monitoring of patients, are key to reducing the cesarean section rates. The antepartum, intrapartum and postpartum complications are more in repeat cesarean section cases. There is no doubt that a trial of labor is a relatively safe procedure, but it is not risk free. Therefore, patient evaluation prior to TOLAC, careful observation throughout labor in a well-equipped unit with around the clock services for emergency surgery and availability of expertise is the backbone for successful VBAC.

Are women having a vaginal birth after a previous caesarean delivery at increased risk of anal sphincter injury?

To examine the incidence of obstetric anal sphincter injury in women who had a successful vaginal birth after a previous caesarean delivery (VBAC). Retrospective analysis of prospectively gathered data. A tertiary referral university institution. All secundiparous women with a previous caesarean delivery who had a VBAC from 2001 to 2011. Details of maternal demographics, intrapartum characteristics and outcomes were examined in cases of VBAC with accompanying anal sphincter injury. Rates of obstetric anal sphincter injury and associated risk factors. During the study period there were 3071 trials of labour in secundiparous women with a previous caesarean delivery; 65% (1981/3071) of these had a successful VBAC. Women having a VBAC were at greater risk of anal sphincter injury than nulliparous women having a vaginal delivery over the same period (5% [98/1981] versus 3.5% [1216/34,496], P = 0.001, odds ratio 1.4, 95% CI 1.15-1.75). The rate of instrumental delivery in woman having a VBAC was 39% (771/1981). On multiple logistic regression analysis an increased rate of instrumental delivery was a strong predictor of sphincter injury (P = 0.03, odds ratio 1.15, 95% CI 1.01-1.3). When the first labours of women with sphincter injury in the VBAC group were examined, 70% (60/86) had been in labour before undergoing their caesarean delivery. The incidence of anal sphincter injury in women undergoing VBAC is 5% and birthweight is the strongest predictor of this. The rate of instrumental delivery in this group was also increased.

Impacto do parto vaginal após uma cesárea prévia sobre os resultados perinatais

To analyze the impact of vaginal delivery after a previous cesarean section on perinatal outcomes. Case-control study with selection of incident cases and consecutive controls. Maternal and perinatal variables were analyzed. We compared secundiparas who had a vaginal delivery after a previous cesarean delivery (VBAC) (n=375) with secundiparas who had a second cesarean section (CS) (n=375). Inclusion criteria were: secundiparas who underwent a cesarean section in the previous pregnancy; singleton and term pregnancy; fetus in vertex presentation, with no congenital malformation; absence of placenta previa or any kind of bleeding in the third quarter of pregnancy. The rate of vaginal delivery was 45.6%, and 20 (5.3%) women had forceps deliveries. We found a significant association between VBAC and mothers younger than 19 years (p<0.01), Caucasian ethnicity (p<0.05), mean number of prenatal care visits (p<0.001), time of premature rupture of membranes (p<0.01), labor duration shorter than 12 hours (p<0.04), Apgar score lower than seven at 5th minute (p<0.05), fetal birth trauma (p<0.01), and anoxia (p<0.006). In the group of newborns delivered by cesarean section, we found a higher frequency of transient tachypnea (p<0.014), respiratory disorders (p<0.048), and longer time of stay in the neonatal intensive care unit (p<0.016). There was only one case of uterine rupture in the VBAC group. The rate of neonatal mortality was similar in both groups. Vaginal delivery in secundiparas who had previous cesarean sections was associated with a significant increase in neonatal morbidity. Further studies are needed to develop strategies aimed at improving perinatal results and professional guidelines, so that health care professionals will be able to provide their patients with better counseling regarding the choice of the most appropriate route of delivery.

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.

222: Validation of the vaginal birth after cesarean (VBAC) nomogram

To validate the VBAC prediction nomogram published by Grobman et al. (Obstet Gynecol 2007) using a different patient cohort than the MFMU cesarean delivery (CD) registry from which it was derived. Historical cohort study of term pregnant women with a single prior low transverse CD attempting a trial of labor (TOL). Maternal age, pre-pregnancy body mass index (BMI), ethnicity, prior vaginal delivery (VD), prior VBAC, and indication of prior CD were used in the nomogram to calculate the predicted VBAC success rates, which were then partitioned into deciles, and compared to actual VBAC rates. Data were analyzed using Student t-test, chi-square test and receiver operating characteristics (ROC) curve. 4853 patients with prior CD delivered between 1/2002-8/2007. 497 fit the inclusion criteria and had all data available. 259 (52.2%) had a VBAC. Prior VD, prior VBAC and non-recurrent indications were significantly more prevalent in the VBAC group comparted with the failed group. However, age, BMI and ethnicity were not different between the 2 groups. The nomogram was predictive of success (ROC: AUC 0.69, 95% CI 0.64-0.74, p<0.01). Our actual VBAC rates did not differ from the predicted ones when < 50%. Above a 50% predicted success, the achieved success rates were significantly and consistently less by 10-20% (table).TablePredicted vs. actual VBAC success ratePredicted VBAC (%)# of patientsActual VBAC (%)95% CI0-200n/an/a20-30633.334-7730-403026.6712-4640-505343.430-5850-609131.8722-4260-707441.8931-5470-806860.2948-7280-9012167.7759-7690-1005479.6366-89 Open table in a new tab We confirmed that the published nomogram is predictive of VBAC success. Its accuracy will depend on the specific population.

Safety and Success of Vaginal Birth after Cesarean Delivery in Patients with Preeclampsia

The objective of this study was to determine if preeclampsia (PRE) or gestational hypertension (GH) affects the rate of success of vaginal birth after cesarean delivery (VBAC), VBAC-related complications, or patient election to attempt VBAC. We performed a retrospective cohort study of all women who were offered VBAC from 1996 to 2000 in 17 community and university hospitals. Demographic, medical, and obstetric history, complications, treatment, and index pregnancy outcome information was collected on all patients in the database. Bivariate analysis and multivariable logistic regression were used to assess the independent association between GH and PRE and the rate of success of VBAC, VBAC-related complications, or patient election to attempt VBAC. A total of 25,005 patients were registered in the database. 13,706 (54.81%) attempted VBAC and 11,299 (45.19%) elected repeat cesarean delivery. After adjusting for confounding variables using multivariable logistic regression, patients with PRE were more likely to fail VBAC (relative risk [RR], 1.56; 95% CI, 1.22 to 2.00). Patients with GH were less likely to attempt VBAC (RR, 0.39; 95% CI, 0.34 to 0.46). A total of 304 (1.46%) patients had a uterine rupture. The VBAC group had a rupture rate of 0.93% and the elective cesarean group had a rupture rate of 0.04%. There was no difference in uterine rupture rates between the cohorts. Patients with gestational hypertension were less likely to attempt a VBAC. Patients with PRE, if they attempted a VBAC trial, had a higher VBAC failure rate. Patients with PRE or GH do not have increased uterine rupture rates. These findings can be used to improve mode of delivery counseling for VBAC candidate patients with preeclampsia.

Comparison of maternal satisfaction following vaginal delivery after caesarean section and caesarean section after previous vaginal delivery

Objectives: To compare (i) satisfaction levels among women who delivered vaginally after one previous caesarean (VBAC) with women delivered by caesarean after previous vaginal delivery (CSAVD) and (ii) to assess reasons why women may request caesarean delivery on subsequent pregnancies. Study design: We conducted a prospective questionnaire-based study of maternal satisfaction following both modes of delivery during an 8-month period. Results: One hundred and forty women completed an early postnatal questionnaire, 70 each in VBAC and CSAVD cohorts. The vast majority in both groups were satisfied with their respective mode of delivery, but would opt for vaginal delivery in their next pregnancy (89% in VBAC versus 94% in CSAVD). The VBAC group experienced minimal pain after delivery and had felt better prepared for delivery (74% versus 41% in the CSAVD group). Reasons for dissatisfaction in the VBAC group included the physical stress of labour and inadequacy of analgesia. Conclusion: Maternal satisfaction with vaginal delivery is high. Those who have experienced both modes of delivery would prefer vaginal birth on future pregnancies. These findings are reassuring to women contemplating vaginal delivery.

Vaginal birth after Cesarean delivery: predicting success, risks of failure

Objectives: To identify predictors of successful trial of labor in women after one low transverse Cesarean delivery and no prior deliveries, and to assess perinatal morbidity associated with a failed vaginal birth after Cesarean delivery (VBAC).Methods: Retrospective chart review of women with one low transverse Cesarean delivery in their first pregnancy who delivered their next pregnancy at our institution. Clinical characteristics and intrapartum data were reviewed to identify predictors of successful VBAC. Perinatal outcomes were reviewed to assess morbidity associated with VBAC attempt and failed VBAC.Results: Of 768 women studied, 522 (68%) attempted VBAC and 344 (66%) of these were successful. Uterine rupture occurred in 0.8% of the VBAC group. On initial examination, women with cervical dilation > 1 cm, effacement > 50% and station lower than – 1 were more likely to deliver vaginally. Women with successful VBAC had more spontaneous labor (85.2 vs. 76.4%, p = 0.02) and less oxytocin use (49.7 vs. 70.8%, p < 0.0001). There were no differences in outcomes between failed and successful VBAC, except more frequent 1-min Apgar scores < 5 (10.1 vs. 4.1%, p = 0.01) and increased endometritis (9.6 vs. 2%, p = 0.0002) with failed VBAC. Compared with elective repeat Cesarean delivery, VBAC attempt was associated with amnionitis (5.9 vs. 0%, p < 0.0001) and low 1- and 5-min Apgar scores (6.1 vs. 2.4%, p = 0.03 and 2.3 vs. 0%, p = 0.01, respectively), but not endometritis, admission to a neonatal intensive care unit (NICU), ventilation, intraventricular hemorrhage (IVH) or seizures. Failed VBAC had more amnionitis (7.3 vs. 0%, p < 0.0001), postpartum fever (11.2 vs. 2.4%, p = 0.0003) and endometritis (9.6 vs. 2.0, p = 0.0007) than elective repeat Cesarean delivery and was associated with low 1- and 5-min Apgar scores (10.1 vs. 2.4%, p < 0.001 and 2.8 vs. 0%, p = 0.01, respectively), but not NICU admission, ventilation, IVH or seizures.Conclusions: Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.

Elective repeat cesarean delivery vs trial of labor: a comparison of morbidities in a community hospital setting

Objective: In an attempt to reduce the cesarean delivery rate nationally, many obstetricians are offering a trial of labor to their patients who have had a prior low transverse cesarean delivery. Many studies have demonstrated the success and safety of a vaginal birth after cesarean. However, few studies have actually compared elective repeat cesareans with a trial of labor. Recent articles suggest that the morbidities associated with a failed trial of labor (TOL) may be more serious than that associated with an elective repeat cesarean delivery (RC/D). Our objective was to review and compare the morbidities and complications of repeat elective cesarean delivery versus patients attempting a trial of labor in our institution. Methods and Materials: A retrospective or nonconcurrent cohort study was conducted. Inclusion criteria included all women at our institution who had delivered from July 1993 through March 1997 and had a prior cesarean delivery. Patients were eligible for a trial of labor according to the recommendations of ACOG Practice Patterns. Exclusion criteria were nonvertex presentation, prior classical or T-incision, placenta previa, previous myomectomy, or multiple gestation. The patients were divided into those who underwent an elective repeat delivery and those who consented to a trial of labor. Outcomes studied included major complications (uterine rupture or operative injury) and minor complications (puerperal fever, postpartum hemorrhage requiring transfusion or operative intervention, or abdominal wound infection). Data were ascertained from medical records, the delivery log book, and the Quality Improvement data base. Prior to performing this study, a power analysis was conducted using an alpha of 0.05 and beta of 0.20. The required number in each arm was 2,280 to determine a 50% difference in outcome. Results: There were 1,148 women who had a repeat cesarean delivery during the study time period. Of that, 174 were excluded by the criteria, leaving 973 eligible. There were 1,030 women who underwent a trial of labor. Seven hundred seventy-three women successfully delivered vaginally (75%). The overall maternal morbidity was 2.4%; 0.8% had a major complication and 1.5% had a minor complication. The total complication rate was similar for both the trial of labor group (TOL) and the elective repeat cesarean delivery group (RC/D): 2.33% and 2.57%, respectively. However, major complications were more frequent among those that attempted a trial of labor than those who underwent an elective repeat cesarean delivery; 1.65% versus 0.1% (relative risk 16.08 with a 95% CI of 2.14–120.57; P = .00024). The relative risk for minor complications in the TOL group compared to the RC/D group was 0.28 with a 95% CI 0.12–0.64 ( P = .001). Stratified analysis of the TOL group was performed. Compared to the RC/D group, those who failed VBAC had a relative risk for major complications of 56.85 using a 95% CI of 7.45–428.37. The successful VBAC group did not have statistically higher major complication rate (RR = 2.52, CI 0.23–27.74, P = .4). Conclusions: At our institution, there is a trend that major maternal complications are more frequent among those who have a trial of labor compared to those who have an elective repeat cesarean delivery. This trend was even more evident in those who failed a VBAC trial. When VBAC was successful, complications did not seem to be higher than repeat cesarean delivery. Our study did not have the power because of insufficient numbers in each arm. However, data collection is continuing to achieve the power to this study. This prompted us to reconsider the safety for a trial of labor. Perhaps more stringent criteria for selection of VBAC candidates and determination of when a trial of labor should be abandoned need to be defined. Ongoing study is warranted in this area.