Search

Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture. A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 – women who had a parity of 1; group 2 – parity of 2–4; group 3 – parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher's exact test, Chi-square test, ANOVA, and paired t-test. Five thousand four hundred and forty-seven women comprised the study group: group 1 – 879 patients, group 2 – 2374 patients, and group 3 − 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9–6.5, p<.001) and group 3 (OR 5.17, 95% CI 4.0–6.7, p<.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8–1.4, p=.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively (p<.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% p=.02) and group 3 (1.02% vs. 0.2%, p=.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% p=.78). Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC. [ABSTRACT FROM AUTHOR]

The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units Network (MFMU) helps to identify the likelihood of VBAC. We sought to compare adverse maternal and neonatal outcomes of trial of labor after cesarean (TOLAC) to those of elective cesarean delivery after stratifying by VBAC likelihood. This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton term delivery with vertex presentation occurred at an academic center from January 2009 to June 2018. Only data from the second pregnancy were analyzed. The final analysis included 835 women. The MFMU VBAC calculator was used to assess the likelihood of VBAC. The two primary outcomes were composite adverse maternal (death or severe maternal complications) and neonatal outcomes (perinatal death or severe neonatal complications). The analyses were stratified based on the VBAC likelihood (less than 60% and 60–100%). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates. Among women with VBAC likelihood less than 60%, TOLAC compared with elective cesarean was associated with increased odds of the primary adverse maternal outcome (16.4% vs. 4.2%; adjusted OR 4.60 [95%CI 1.48–14.35]) and the primary adverse neonatal outcome (17.8% vs. 6.3%; adjusted OR 3.93 [95%CI 1.31–11.75]). Among women with VBAC likelihood of 60–100%, TOLAC compared with elective cesarean was associated with decreased odds of the primary adverse maternal outcome (6.4% vs. 11%; adjusted OR 0.47 [95%CI 0.25–0.89]) and similar odds of the primary adverse neonatal outcome (6.7% vs. 8.3%; adjusted OR 0.98 [95%CI 0.52–1.84]). Among women with a history of a primary low transverse cesarean delivery, those who underwent TOLAC compared to those who had elective cesarean had increased odds of adverse maternal and neonatal outcomes when VBAC likelihood was less than 60%. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association of the timing of primary cesarean delivery with the progress of labor and the operative delivery rate at the subsequent successful trial of labor. Methods: A retrospective study of women with a primary cesarean and subsequent term cephalic vaginal delivery in two medical centers. Cesarean deliveries were classified as planned, intrapartum first stage or intrapartum second stage. The second stage duration and the operative delivery rate, adjusted to epidural analgesia and oxytocin use, were compared between the groups. χ² and Kruskal–Wallis tests were used for analysis of categorical and continuous variables, respectively. Results: The study population included 1166 women. The second stage of labor was longer when the previous cesarean delivery occurred during the second stage compared to planned or first stage (1.7 h vs 1.3 h vs 1.3 h, p = 0.005). The proportion of operative deliveries was greater among women with previous cesarean in the second stage of labor (39.6%), compared to planned (26.9%) or first stage (28.8%), p = 0.006. Conclusion: Cesarean delivery at the second stage of labor is associated with a longer second stage and an increased operative delivery rate at the subsequent vaginal birth. Our findings attest to the delicate passenger-passage relations that can exist in some parent-couples. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated spontaneous labor patterns among women achieving a vaginal birth after cesarean (VBAC), without a previous vaginal delivery in relation to nulliparous women. Methods: This historical cohort study included 422 women attempting VBAC and 150 nulliparas. We examined time intervals for each centimeter of cervical dilation and compared labor progression in 321 women who achieved spontaneous VBAC and 147 nulliparous women achieving a spontaneous vaginal delivery. Epidural anesthesia use, delivery mode, cord arterial pH and 5-minute Apgar score were also compared. Findings: Women in the VBAC group compared to nulliparous women had similar durations of first (4–10 cm: 4:22 (00:54–13:10) h vs. 4:47 (1:10–15:10) h, p = .61), second (1:07 (8:00–3:21), vs. 1:34 (10:00–3:40), p = .124) and third stages of labor (10:00 (2:00–22:00) vs. 08:00 (3:24–22:12), p = .788). When comparing women who had epidural analgesia to those who did not, no differences were found between the groups regarding durations of first and second stages of labor. Interestingly, among parturients without epidural anesthesia only, the VBAC group had shorter second stage compared to the nulliparous (00:19 (0:04–1:59) vs. 00:47 (0:08–2:09), p = .023). Conclusion: Labor patterns among women achieving spontaneous VBAC are similar to those of nulliparous women with spontaneous vaginal deliveries. [ABSTRACT FROM AUTHOR]

Introduction: Women with a successful vaginal birth after cesarean delivery (VBAC) have less morbidity than women undergoing repeat cesarean delivery. Although several scores and models predict VBAC success, none focus on pregnant women with pre-labor rupture of membranes (PROM). We evaluated different clinical variables that might predict the likelihood of VBAC success in women with PROM.Study Design: A retrospective, 5-year study in a large referral center from December 2013 to December 2018. Inclusion criteria were women with singleton pregnancy, at or beyond 37 weeks' gestation, admitted with spontaneous PROM, with one previous cesarean delivery that consented trial of labor. Exclusion criteria were history of two cesarean deliveries, multiple gestations or obstetrical contraindications for TOLAC, including maternal request for repeat cesarean delivery. Variables associated with successful VBA C were identified using multivariate logistic regression.Results: Of 302 women in the cohort, 74.8% (226/302) delivered vaginally (successful VBAC) and 25.2% (76/302) by repeat CD (failed TOLAC). Multiple logistic regression showed that duration of PROM-to-delivery time was the only significant factor associated with successful TOLAC (78% delivered vaginally within 24 h and 93.3% within 36 h), while none of the other variables (maternal age, gravidity, BMI, gestational and birthweight at delivery, effacement or station at admission, previous indication for cesarean delivery, time interval between previous and current delivery, presence of meconium-stained liquor, and documented temperature >38 °C) were associated with the prediction of successful VBAC.Conclusion: Women with spontaneous pre-labor PROM and previous cesarean delivery have high success rates of VBAC. The only significant variable associated with successful TOLAC in women with spontaneous PROM at term was the duration of PROM-to-delivery time. Our findings suggest that the success rate of VBAC is likely multifactorial, not-necessarily related to a specific underlying factor, and in the absence of contraindications, a fair trial of labor after cesarean delivery is justified. [ABSTRACT FROM AUTHOR]

To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women. A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3–5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p <.01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p =.03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p <.01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p =.33) and adverse neonatal outcomes were comparable between the groups. Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture. [ABSTRACT FROM AUTHOR]

To assess whether pre-labor measurement of the angle of progression (AOP) can assist in predicting a successful vaginal birth after cesarean in women without a previous vaginal birth. A prospective observational cohort study performed in a single tertiary center including women at term with a single previous cesarean delivery (CD), without prior vaginal births, who desire a trial of labor. Transperineal ultrasound was used to measure the AOP before the onset of labor. The managing staff in the delivery suite was blinded to the ultrasound measurements. Clinical data and delivery outcome were retrieved from medical records. The study was approved by the institutional ethics committee (KMC 0117-10). Of the 111 women included in the study, 67 (60.4%) had a successful vaginal birth after CD. Women were sonographically assessed at a median of 3 days [interquartile range (IQR) 1–3 days] prior to delivery. The median AOP was significantly narrower in women who eventually underwent a CD than in those who delivered vaginally (88°, IQR 78–96° vs. 99°, IQR 89–107°, respectively; p <.001). An AOP >98° (derived from a receiver operating characteristic curve) was associated with a successful vaginal birth after CD in 87.5% of women. Multivariable regression analysis demonstrated that each additional 1° in the AOP increases the chance for a successful vaginal birth after CD by 6%. Pre-labor AOP may be a useful sonographic tool for predicting vaginal birth after CD and can assist in consulting primiparous women with a prior CD opting for a trial of labor. [ABSTRACT FROM AUTHOR]

Objective: To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women.Study Design: A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3-5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models.Results: During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p < .01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p = .03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p < .01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p = .33) and adverse neonatal outcomes were comparable between the groups.Conclusion: Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture. [ABSTRACT FROM AUTHOR]

Objective: In 2010, the American College of Obstetricians & Gynecologists (ACOG) published a new clinical practice guideline on trial of labor after cesarean (TOLAC) that was considered less restrictive. It allowed for offering TOLAC to women with two prior cesarean deliveries, even without a prior vaginal delivery, and for labor induction. As a result, our hospital, a public tertiary care academic center, updated our TOLAC practice guideline to reflect ACOG's new recommendations. We thus aim to evaluate maternal and neonatal outcomes for women undergoing TOLAC with 1 versus 2 prior cesareans, with and without a prior vaginal delivery, following these clinical practice changes at our hospital.Study design: This was a secondary analysis of a 2-year retrospective cohort following implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 0/7 weeks and 1 or 2 prior cesarean deliveries. Maternal and neonatal outcomes in women with one prior cesarean were compared to women with two prior cesareans. The primary outcome was composite maternal morbidity (uterine rupture, uterine dehiscence, hysterectomy, transfusion, postpartum venous thromboembolism, delivery/surgical injury, chorioamnionitis or endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity. The analysis was performed in SAS; p < .05 was considered significant.Results: Seven hundred women with one prior cesarean and 73 women with two prior cesareans underwent TOLAC after the 2011 guideline implementation. Post guideline maternal demographics, labor length, comorbid conditions, simplified Bishop score, and induced labor were similar between groups. Composite maternal morbidity was similar between groups (18.3 versus 23.3%, p = .30 for women with 1 versus 2 prior cesarean deliveries, respectively). The same was true when comparing women with 1 versus 2 prior cesareans who had never had a prior vaginal delivery (25.5 versus 33.3%, p = .28 for 1 versus 2 prior cesarean deliveries, respectively). There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were similar between groups (78.9% in women with 1 prior cesarean versus 74.0% in women with 2 prior cesareans, p=.33), even when only analyzing women without a prior vaginal delivery (69.4% in women with 1 prior cesarean versus 71.4% in women with 2 prior cesareans, p = .78).Conclusion: Adoption of ACOG's TOLAC practice changes, specifically offering TOLAC to women with two prior cesareans even without a prior vaginal delivery, and offering induction of labor regardless of cervical favorability, may increase VBAC rates without increasing maternal or neonatal morbidity from TOLAC. [ABSTRACT FROM AUTHOR]

Introduction: Obesity is associated with higher risks for intrapartum complications. Therefore, we sought to determine if trial of labor after cesarean section (TOLAC) will lead to higher maternal and neonatal complications compared to repeat cesarean section (RCD).Methods: This was a retrospective cohort analysis of singleton nonanomalous births between 37 and 42 weeks GA complicated by maternal obesity (body mass index (BMI) ≥ 30 kg/m2) and history of one or two previous cesarean deliveries. Outcomes were compared between TOLAC and RCD. The maternal outcomes of interest included blood transfusion, uterine rupture, hysterectomy, and intensive care unit admission. Neonatal outcomes of interest included 5-minute Apgar score <7, prolonged assisted ventilation, neonatal intensive care unit admission, neonatal seizures, and neonatal death.Results: There were 538,264 pregnancies included. Compared with RCD, TOLAC was associated with an absolute increase in the following neonatal outcomes: low 5-min Apgar score (0.6%, p < .001), neonatal intensive care unit (NICU) admission (0.8%, p < .001), neonatal seizure (0.1 per 1000 births, p = .037), and neonatal death (0.2 per 1000 births, p = .028). Additionally, TOLAC was associated with an absolute increase in following maternal outcomes: blood transfusion (0.1%, p < .001), uterine rupture (0.18%, p < .001) and ICU admission (0.1%, p = .011).Conclusions: TOLAC among obesity pregnancies at term increases the risk of maternal and neonatal complications compared with RCD. [ABSTRACT FROM AUTHOR]

Objective: To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean.Methods: A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007-2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes.Results: Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p = .036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p < .001). In multivariate analysis, previous VBAC was associated with decreased risk of uterine rupture (OR = 0.46, 95% CI 0.21-0.97, p = .04).Conclusions: In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth. [ABSTRACT FROM AUTHOR]

Objective: To evaluate maternal-neonatal morbidity for women undergoing trial of labor after cesarean (TOLAC) following clinical practice changes based upon ACOG's 2010 VBAC guideline.Study Design: Four-year retrospective cohort analysis around implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 weeks and ≥1 prior cesarean. Maternal-neonatal outcomes pre- and post-guideline implementation were compared. Primary outcome was composite maternal morbidity (uterine rupture or dehiscence, hysterectomy, transfusion, thromboembolism, operative/delivery injury, chorioamnionitis/endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity.Results: Four hundred and fifty women underwent TOLAC before and 781 after guideline implementation. Post-guideline, there was a significant increase in age, body mass index, labor length, women with >1 cesarean, comorbid condition and induced labor. Composite maternal morbidity was significantly higher after the guideline (13.78% versus 18.82%, p = 0.02), possibly due to an increased rate of chorioamnionitis/endometritis, which was no longer significant after control for potential confounders in multivariable analysis. There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were unchanged (78.9% before versus 78.1% after, p = 0.75), however hospital VBAC rates increased after the guideline (26% versus 33%, p < 0.0001).Conclusions: Adoption of ACOG's TOLAC practice changes can increase VBAC rates without increasing maternal-neonatal morbidity from TOLAC. [ABSTRACT FROM AUTHOR]

Objective: To examine the outcomes of vaginal birth after cesarean (VBAC) in women, in spontaneous labor, delivering after 37 weeks' gestation at an institution where trial of labor after a previous cesarean delivery (TOLAC) is encouraged and management of labor is standardized.Methods: This retrospective cohort study included 3071 women with one previous cesarean only and no vaginal delivery who underwent a trial of labor from 2001 to 2011. Women were managed using the standardized "active management of labor" intrapartum protocol. Outcomes and characteristics of women who delivered vaginally were compared with those who required cesarean delivery.Results: In spontaneous labor in their second pregnancy, those who attempted TOLAC had a 72.5% (1611/2222) rate of successful VBAC. Women who had a successful VBAC had smaller babies (3584 ± 452 g versus 3799 ± 489 g; p < 0.0001) at earlier gestations than those who had a repeat intrapartum cesarean delivery. They also required less intrapartum intervention, such as oxytocin augmentation (14.5% [234/1611] versus 41% [251/611]; p < 0.0001) and epidural anesthesia (64.8% [1044/1611] versus 82.8% [506/611]; p < 0.0001). The rate of uterine rupture was 0.54% (12/2222), while the rate of peri-partum hysterectomy was 0.18% (4/2222).Conclusion: This study shows that serious complications associated with TOLAC are rare providing intrapartum care and decision-making is made simple for the benefit of staff and patients alike. This is achieved through a standardized labor management protocol. [ABSTRACT FROM AUTHOR]

Objective: To compare induction of labor methods in patients attempting a trial of labor after cesarean (TOLAC) with an unfavorable cervix.Methods: This is a retrospective cohort study from patients attempting TOLAC from 2009 to 2013. Patients with a simplified Bishop score of three or less where labor was initiated with either a Cook balloon or oxytocin were included. Our primary outcome was mode of delivery. Our secondary outcomes included duration of labor and multiple maternal and neonatal morbidities.Results: Two-hundred and fourteen women met inclusion criteria: 150 received oxytocin and 64 had the Cook balloon placed. The vaginal birth after cesarean delivery rate was significantly higher in the oxytocin group at 70.7% versus 50.0% in the Cook balloon group (p = 0.004). In the multivariable analysis, odds for cesarean delivery were two times higher with the Cook balloon than with oxytocin (Adjusted OR = 2.09, 95% CI = 1.05-4.18, p = 0.036). The duration of labor was longer with the Cook balloon versus oxytocin (21.9 versus 16.3 hours, p = 0.0002). There were no significant differences in maternal and neonatal health outcomes.Conclusion: Oxytocin induction of labor was associated with a higher rate of vaginal delivery and a shorter duration of labor compared to the Cook balloon in women undergoing TOLAC with an unfavorable cervix. [ABSTRACT FROM AUTHOR]

Objective: We sought to evaluate neonatal morbidity and mortality among women who experienced successful vaginal births after previous cesarean delivery (VBAC) by obesity subtypes. Methods: Missouri maternally linked cohort data files were utilized. Analyses were restricted to successful singleton VBACs. Main study outcomes were neonatal death and neonatal morbidity. Risk estimates were obtained using logistic and hazards regression modeling. Results: A total of 30,017 singleton births met inclusion criteria. The prevalence of VBAC was 2.3%. The neonatal death rate (per 1000) by maternal obesity subtype was 4.1 for moderate, 3.2 for severe, 4.5 for extreme and 14.3 for super-obese. The overall risk for neonatal morbidity was 56% greater among obese women when compared with normal weight women, with risk estimates increased incrementally with ascending body mass index (BMI) ( p for trend < 0.01). Conclusion: Infants of obese women undergoing successful VBAC are at elevated risk for neonatal morbidity, and the risk increases progressively with ascending BMI. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate obstetricians' practice patterns, opinions and factors influencing decision-making about mode of delivery in women with two previous c-sections. Methods. A questionnaire was mailed to the 160 obstetricians from the Rhone-Alpes perinatal network. Questionnaires included demographic, organisational information and questions about physicians' opinion, practice patterns and patient counseling concerning vaginal birth after c-section (VBAC) after one and two caesarean sections. Results. Response rate was 65.6%, 100% and 23.8% would offer VBAC to women with respectively one and two previous c-sections. Uterine rupture rate was largely overestimated in both women with one (2.8%) and two prior c-sections (14.2%). Factors positively influencing obstetricians were cerebral palsy estimated rate less than 20%, a minimal decision to birth delay less than 20 min when emergency c-section would be required. Neonatal severe outcomes consecutive to trial of labour as well as placenta praevia or accreta risk and morbidity associated with multiple c-sections would be insufficiently discussed. Conclusion. Obstetricians largely prefer a third planned c-section in women with two previous c-sections. This decision is partly based on a large overestimation of immediate maternal and neonatal serious outcomes consecutive to trial of labour as well documented serious long term outcomes of multiple c-sections are insufficiently considered. [ABSTRACT FROM AUTHOR]

Objective. To show the results of vaginal birth after primary caesarean (VBAC) without using prostaglandin for induction and/or syntocinon augmentation are comparable when induction is done with these agents but without the added risks of uterine rupture. Method. A review of the obstetric records of 16,498 parturient from 1 January 2001 to 31 December 2006 was carried out. The 229 cases of women who wanted VBAC were subjected to further analysis to determine the number of successful vaginal delivery after spontaneous onset of labour or membrane sweep. The instrumental vaginal delivery rate, analgesia commonly used and the complication rate were analysed. Results. The result showed that 34.49% had spontaneous onset of labour, 27.07% laboured after membrane sweep and 38.42% had repeat urgent caesarean section as they failed to go into spontaneous labour. Of those who went into labour spontaneously or after membrane sweep, 67% had vaginal delivery, a further 13.97% had instrumental vaginal delivery and 16% had emergency caesarean section. There was no case of uterine rupture. Conclusion. VBAC can end successfully in a high proportion of cases without the use of prostaglandin or syntocinon for induction of labour and or syntocinon for augmentation in these women because of their associated increased relative risk of uterine rupture. [ABSTRACT FROM AUTHOR]

Objective. To determine the vaginal birth after cesarean section (VBAC) rate and risk of uterine rupture in women with a previous early preterm cesarean section. Methods. Women who delivered their first child by cesarean section between 26 and 34 weeks of gestation were included in a retrospective cohort study. Medical charts were reviewed for characteristics of the index pregnancy and delivery. Information of the subsequent delivery was obtained from the medical charts or from information of the attending gynecologist if the delivery was elsewhere. Results. Two hundred and forty-six women were included: 131 (53.3%) women had a subsequent pregnancy, 64 (26.0%) had no subsequent pregnancy, and from 51 (20.7%) women no information could be obtained. Of the 131 women with a subsequent pregnancy, 93 (71.0%) underwent a trial of labor (TOL) and 80 (86.0%) achieved a vaginal delivery, resulting in a VBAC rate of 61.1%. One uterine rupture occurred with favorable neonatal outcome. The uterine rupture rate for the whole cohort was 0.8% (95% CI 0.02–4.0) and for the group of women undergoing a TOL 1.1% (95% CI 0.03–5.8). Conclusion. In this small series of women with a previous early preterm cesarean section the VBAC rate was high (61.1%) and the uterine rupture rate was 1.1%. [ABSTRACT FROM AUTHOR]

Objective. To evaluate whether closure of the uterine incision with one or two layers changes uterine rupture or vaginal birth after cesarean section (VBAC) success rates.Methods. Subjects with one previous cesarean section by documented transverse uterine incision that attempted VBAC were identified. Exclusion criteria included lack of documentation of the type of closure of the previous uterine incision, multiple gestation, more than one previous cesarean section, and previous scar other than low transverse.Uterine rupture and VBAC success rates were compared between those with single-layer and double-layer uterine closure. Time interval between deliveries, birth weight, body mass index (BMI), and history of previous VBAC were evaluated as possible confounders.Results. Of 948 subjects identified, 913 had double-layer closure and 35 had single-layer closure. The uterine rupture rate was significantly higher in the single-layer closure group (8.6% vs. 1.3%, p = 0.015). This finding persisted when controlling for previous VBAC, induction, birth weight >4000 g, delivery interval >19 months, and BMI >29 (OR 8.01, 95% CI 1.96–32.79). There was no difference in VBAC success rate (74.3% vs. 77%, p = 0.685).Conclusion. Single-layer uterine closure may be more likely to result in uterine rupture. [ABSTRACT FROM AUTHOR]

Objective . To estimate whether maternal race/ethnicity is independently associated with successful vaginal birth after cesarean delivery (VBAC). Study design . A retrospective cohort study from January 1, 1997 to July 30, 2002 of women with singleton pregnancies and a previous cesarean delivery. The odds ratio (OR) for successful VBAC as a function of ethnicity was corrected for age >35 years, parity, weight gain, diabetes mellitus, hospital site, prenatal care provider, gestational age, induction, labor augmentation, epidural analgesia, and birth weight >4000 g. Results . Among 54 146 births, 8030 (14.8%) occurred in women with previous cesarean deliveries. The trials of labor rates were similar among Caucasian (46.6%), Hispanic (45.4%), and African American (46.0%) women. However, there was a significant difference among ethnic groups for VBAC success rates (79.3% vs. 79.3% vs. 70.0%, respectively). When compared to Caucasian women, the adjusted OR for VBAC success was 0.37 (95% confidence interval (CI) 0.27–0.50) for African American women and 0.63 (95% CI 0.51–0.79) for Hispanic women. Conclusion . African American and Hispanic women are significantly less likely than Caucasian women to achieve successful VBAC. [ABSTRACT FROM AUTHOR]

Objective . A major risk of trials of labor in patients with prior cesarean delivery is uterine rupture. We evaluated the question of whether a previous cesarean delivery at an early gestational age predisposes the patient to subsequent uterine rupture. Methods . This was a retrospective chart review of patients delivering at North Shore University Hospital with a trial of labor after previous cesarean delivery to ascertain all cases of uterine rupture. Patients who had had a previous cesarean delivery at our institution who did not suffer uterine rupture during a trial of labor served as controls. Results . Twenty-five patients suffered a uterine rupture. The incidence of prior preterm cesarean delivery (PPCD) in this group was 40%, compared to 10.9% of 691 laboring vaginal birth after cesarean (VBAC) patients without rupture ( p < 0.001). Patients in the rupture group with a PPCD were less likely to have experienced labor in the index pregnancy and more likely to have had an interdelivery interval of less than two years. Conclusions . An undeveloped lower segment in the preterm uterus represents a risk for later rupture, even if the incision is transverse. [ABSTRACT FROM AUTHOR]

Risk of uterine rupture with trial of labor after cesarean (TOLAC) is less than one percent. Discovery of uterine rupture often occurs during labor. In our case, the uterine scar is discovered to be ruptured during the postpartum period. The exact cause and time of uterine rupture is difficult to ascertain in this case, yet manual palpation of the uterine scar did not aid in the eventual diagnosis. [ABSTRACT FROM AUTHOR]

Uterine scar rupture in vaginal birth after cesarean section (VBAC) usually occurs during labor or after placental extraction. We report herein the case of a patient who had a cesarean section in her first pregnancy and a VBAC in her second. The present one also ended with a normal VBAC and a documented intact scar, which then ruptured three weeks later. [ABSTRACT FROM AUTHOR]