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Objectives: To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource‐limited setting. Design: Prospective study. Setting: Obstetrics and Gynaecology department in a tertiary hospital in Ghana. Population: Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD. Methods: Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements. Main outcome measures: Lower uterine segment findings at laparotomy, successful vaginal birth. Results: A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI −0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80–1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03–1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5–99.8%) and specificity of 81.8% (95% CI 75.8–86.8%). Conclusion: Accurate TVUS measurement of the LUS is technically feasible in a resource‐limited setting. This approach could help in making safer decisions on mode of birth in limited‐resource settings. Linked article: This article is commented on by Oyelese pp. 1780–1781 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17909. [ABSTRACT FROM AUTHOR]

• Women undergoing trial of labour following two previous caesareans (TOLA2C) are more likely to develop endometritis or sepsis postnatally. • Women undergoing TOLA2C are more likely to have a longer postnatal stay. • Neonates of women undergoing TOLA2C are more likely to have Apgar scores less than seven and require neonatal unit admission. • The best predictor of successful vaginal delivery following TOLA2C is a prior successful vaginal birth after caesarean. To assess the (i) predictors of and associated rates of success and; (ii) maternal and perinatal outcomes of women undergoing trial of labour after two previous caesarean sections (TOLA2C). This retrospective cohort study collected data from two regional obstetric centres with 12,000 deliveries per annum collectively. The population included singleton pregnancies undergoing (i) TOLA2C, (ii) elective repeat caesarean section following two caesarean sections (ERCS) and (iii) trial of labour after one caesarean section (TOLA1C). Data was collected electronically from 2013 to 2021. Statistical analysis included Fisher exact and Kruskal-Wallis test to compare unpaired samples alongside univariate and multivariable logistic regression. The primary outcome measure was maternal and perinatal outcome. The three groups included; n = 146 TOLA2C, n = 206 ERCS and n = 99 TOLA1C. TOLA2C had a success rate of 65 % compared to 74 % for TOLA1C (p = 0.16). The optimal predictor of successful TOLA2C was previous successful TOLA1C OR 8.65 (95 % CI 2.75–38.41). TOLA2C was associated with greater risk of endometritis and/or sepsis postnatally compared to the other two groups [10.3 % (n = 15) versus 0.5 % (n = 1) and 3 % (n = 3) for ERCS and TOLA1C respectively p < 0.01]. It was also associated with longer maternal hospital stay [2.4 days (+/-1.8) versus 1.8 (+/-0.8) and 1.8 (+/-1.7) p < 0.01], a greater proportion of neonates with Apgar scores less than 7 (p =<0.01) and higher rates of neonatal unit admission [14 % (n = 20) versus 5 % (n = 11) versus 4 % (n = 4) (p =<0.01)]. Women considering trial of labour following two caesarean sections should be counselled regarding the potential increased risk of endometritis, sepsis and adverse neonatal outcome. [ABSTRACT FROM AUTHOR]

Objective: To compare the maternal morbidity associated with a successful trial of labour after the previous scar versus a failed trial of labour after the previous scar and ending in repeat Caesarean section. Study Design: Cross-sectional study. Place and Duration of Study: Department of Gynaecology and Obstetrics, Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Jun to Dec 2022. Methodology: A total of six hundred and ten (n=610) patients were in the study. The variables studied while observing the outcome included indication of Caesarean section in the previous delivery, birth weight of the baby, overall outcome and post-operative maternal complications. Results: The mean age of the participating patients was 24.44±3.89 years. Of the 610 patients, 278(45.6%) delivered successfully via vaginal delivery after a previous Caesarean section, while 332(54.4%) had to be delivered again via repeated Caesarean section. Overall outcome in both groups revealed 331(99.7%) patients were delivered by Caesarean section, with 01(0.3%) patients landing in a ruptured uterus in the Caesarean Section Group. Conclusion: Previous history of normal vaginal delivery, increased parity and birth weight less than 3 kg have a better chance of a successful Vaginal Birth after a Caesarean section in selected patients resulting in fewer complications and decreasing the overall Caesarean section rate.

Background: Vaginal breech delivery (VBD) has been widely discouraged over the last two decades due to associated neonatal risks. However, many gynaecologists are still challenging this approach, at least in selected settings.Objective: To study short-term neonatal outcomes in singleton pregnancies undergoing VBD.Materials and Methods: Retrospective cohort study conducted on singleton pregnancies who delivered in breech presentation between 2012 and 2019. Neonatal complications in terms of mortality, umbilical artery (UA) pH, 5-min Apgar score, and postnatal admission to neonatal intensive care unit (NICU) were evaluated.Results: Overall, 804 breech deliveries were considered. Of these, 53.86 % had VBD, 26.62 % had emergency caesarean sections (CS) and 19.53 % had elective CS. No perinatal deaths were reported. After multivariate adjustment, VBD was associated with higher incidence of UA pH < 7.10 compared with both elective and emergency CS. No significant associations were found between VBD and UA pH < 7.00 or 5-min Apgar score < 3 or < 7. No significant differences in NICU hospitalization were observed for different modes of delivery. Gestational age was inversely correlated with UA pH < 7.00, 5-min Apgar score < 3 and < 7, and NICU hospitalization.Conclusions: VBD in an experienced setting does not increase the risk of negative short-term perinatal outcomes significantly. Gestational age was the most important risk factor for low UA pH or 5-min Apgar score and NICU hospitalization, independent of mode of delivery. [ABSTRACT FROM AUTHOR]

Abstract Background The worldwide incidence of birth by Caesarean Section (CS) is rising. Many births after a previous CS are by repeat surgery, either by an elective CS or after a failed trial of labour. Adhesion formation is associated with increased maternal morbidity in patients with repeat CSs. In spite of large-scale studies the relation between the incidence of adhesion formation and CS surgical technique is unclear. This study aims to assess maternal and neonatal morbidity and mortality after repeat CSs in a rural hospital in a low-income country (LIC) and to analyse the effect of surgical technique on the formation of adhesions. Methods A cross-sectional, retrospective medical records study of all women undergoing CS in Ndala Hospital in 2011 and 2012. Results Of the 3966 births, 450 were by CS (11.3%), of which 321 were 1st CS, 80 2nd CS, 36 3rd CS, 12 4th and one 5th CS (71, 18, 8, 3 and 0.2% respectively). Adhesions were considered to be severe in 56% of second CSs and 64% of third CSs. In 2nd CSs, adhesions were not associated with closure of the peritoneum at 1st CS, but were associated with the prior use of a midline skin incision. There was no increase in maternal morbidity when severe adhesions were present. Adverse neonatal outcome was more prevalent when severe adhesions were present, but this was statistically non-significant (16% vs 6%). Conclusions Our results give insight into the practice of repeat CS in our rural hospital. Adhesions after CSs are common and occur more frequently after midline skin incision at 1st CS compared to a transverse incision. Reviewing local data is important to evaluate quality of care and to compare local outcomes to the literature.

Objectives: To determine the factors responsible for repeat caesarean section. Material and Methods: It was a retrospective descriptive study, conducted at department of Obstetric and Gynecology of Al-Aleem Medical College att ached with Gulab Devi Educational Complex Lahore, over a period of two years from October 2018 to September 2020 after approval from Institutional Ethical Committ ee. A total of 70 pregnant women fulfilling the inclusion criteria were included in the study. Results: In this study a total of 70 women were included, only 40% had successful VBAC and 60% ended into caesarean delivery. Majority of the women (78.56%) were between 20-30 years and mean age was 24.05±2.15 years. 60% women were multiparous. Inter-pregnancy interval less than two years was observed in 67.14%. In 52.85% women BMI was less than 24 kg/m2. Factors responsible for repeat caesarean sections were observed in women, 35.71% > 30 years of age, previous unsuccessful vaginal birth after cesarean in 64.28%, inter-pregnancy interval <2 years in 73.80%, BMI > 24 kg/m2, Bishop score <5 cm 71.42% and fetal weight > 3 k.g in 59.52%. Conclusions: Several factors responsible for repeat caesarean section in this study were considered as negative predictors for successful vaginal birth after cesarean. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to determine the risk factors for caesarean sections in the second stage of labour after a previous caesarean section among women who underwent trial of labour (TOL). Material and methods: From a total of 639 women who experienced one caesarean section, 456 women were qualified for TOL. From this group, 105 women were subjected to a caesarean section in the first stage of labour and another 351 women reached the second stage of labour. From the latter group, 309 women delivered naturally and 42 were subjected to a caesarean section. Results: Risk factors for the necessity of performing a caesarean section in the second stage of labour after a previous caesarean section was the weight gain during pregnancy (OR = 1.07), the height of fundus uteri (OR = 1.25) before delivery, and the estimated foetal weight (OR = 1.01), a past delivery of a child with a birth weight exceeding 4.000 g (OR = 2.14), the presence of pre-gestational diabetes (OR = 15.4) and gestational diabetes (OR = 2.22), necessity of applying a delivery induction (OR = 2.52), stimulation of uterine activity during delivery (OR = 2.43) and application of epidural analgesia (OR = 4.04). A factor reducing the risk of a caesarean section in the second stage was a vaginal delivery in a woman's history (OR = 0.21). Conclusions: Women should be encouraged to deliver naturally after a previous caesarean section, especially when their history includes a vaginal delivery and if there is no need for labour induction. [ABSTRACT FROM AUTHOR]

Caesarean 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. To 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. Q 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. Three 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. Preferences 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. [ABSTRACT FROM AUTHOR]

Background: Systematic approaches to information giving and decision support for women with previous caesarean sections are needed. Aim: To evaluate decision support within a 'real‐world' shared decision‐making model. Methods: A pragmatic comparative effectiveness randomised trial in the Positive Birth After Caesarean Clinic. Women with one previous caesarean and singleton pregnancy <25 weeks were randomly allocated to standard Positive Birth After Caesarean care, or standard Positive Birth After Caesarean care plus a decision aid booklet. Main outcome measure was mode of birth, with secondary measures of knowledge, decisional conflict, birth choice, adherence to birth choice, perception of decision support, and satisfaction. Results: Of 297 participants, rate of attempted vaginal birth after caesarean increased and was similar for both groups (61% vs 57%, P = 0.5). Knowledge scores increased more for women in the additional decision aid group (2.0 vs 1.6 points, P = 0.2). Decisional conflict score reduction was similar between groups (P = 0.5). Women initially unsure of their birth preference who received the additional decision aid had greater reduction in decisional conflict score (P = 0.04) and were more likely to plan vaginal birth after caesarean (49% vs 33%, P = 0.2). Adherence to birth choice and birth satisfaction was similar between groups. Women in the additional decision aid group rated their decision support tool higher (P < 0.01). Conclusions: In a 'real world' shared decision‐making model, an additional decision aid conferred some benefits in factors associated with preparation for shared decision‐making. Decision aids may provide particular benefit for women who are initially unsure and need assistance in the deliberation phase. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence and risk factors for recurrent shoulder dystocia in women. Methods: We searched Medline, Pubmed, Embase, and CINAHL for relevant articles in English and French from 1980 to February 2018 that described risks of recurrent shoulder dystocia undergoing a trial of labour in subsequent pregnancies. A total of 684 articles were found, of which 13 were included as they met criteria. We extracted data on study characteristics, incidence of recurrent shoulder dystocia, degree of neonatal injury, and presence of known risk factors. Results: There was a wide variation in the incidence of shoulder dystocia in subsequent pregnancies from 1-25%. The largest cohort reported a risk of 13.5%. The most important risk factor for recurrent shoulder dystocia is an increase in birthweight in the subsequent pregnancy compared to the index pregnancy (OR 7-12). Prolonged second stage, instrumental delivery, maternal diabetes, increased maternal BMI, and severe neonatal morbidity in the index pregnancy were also associated with an increased risk of recurrent shoulder dystocia. However, many of these risk factors were present in women who did not have a recurrent shoulder dystocia. In addition, women with recurrent shoulder dystocia rarely had identifiable risk factors, other than the history of previous shoulder dystocia. Sample sizes were low as most studies are single centre, retrospective cohorts with low rates of subsequent pregnancy and vaginal birth as many women may have elected to have a caesarean section in subsequent pregnancies or were lost to follow up. There was a high rate of reporting bias and heterogeneity, prohibiting formal meta-analyses. Conclusion: Recurrent shoulder dystocia is an unpredictable obstetric complication with potentially devastating consequences. Individual assessment and thorough counselling should be offered to women contemplating a subsequent planned vaginal birth with specific attention paid to those women where the estimated birthweight is >4000 g or greater than in the index pregnancy. [ABSTRACT FROM AUTHOR]

Background: Currently, little evidence exists to guide mode of delivery in pregnant women with super obesity. There is a trend toward elective caesarean delivery in this population with little evidence of improved maternal or neonatal outcomes. Aim: Our study compares maternal and neonatal outcomes based on planned mode of delivery and aimed to identify predictors for a successful vaginal delivery. Materials and Methods: This retrospective observational study explored maternal and neonatal outcomes of women with a body mass index ≥50 who birthed following a singleton pregnancy at ≥36 weeks gestation over a 10 year period at a single centre in Melbourne, Australia. Outcomes between women having a planned vaginal or planned caesarean birth were compared on an intention‐to‐treat basis, with logistic regression used to determine factors predictive of a vaginal birth. Results: A total of 275 women with super obesity were identified. One hundred and ninety‐nine (72%) planned a vaginal birth, which was successful for 70%. Planned vaginal birth was associated with lower rates of postpartum complications requiring readmission (5% vs 16%; P = 0.003). Neonatal resuscitation requirements and Apgar scores at five minutes were similar between groups. Multiparity was the strongest predictor of a successful vaginal birth while medical intervention in labour was associated with a reduced rate of success in primiparous women. Conclusions: Contrary to current trends in practice, a trial of labour for women with super obesity, when facilities and skills permit, appears a safe option for mother and baby. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the outcome of pregnancy in women with previous one cesarean section in relation to vaginal delivery and maternal and perinatal complications. It also aimed at identifying the factors, which can influence the outcome of trial of scar (TOS). Materials and Methods: A retrospective analysis of medical records of 151 women with previous one cesarean section who delivered at the Mafraq Hospital, Abu Dhabi between January– August 2011was carried out. Those women with previous classical cesarean section and those with extreme prematurity were excluded. The collected data were analyzed using SPSS software version 20. Continuous and categorical data were presented in the form of mean, standard deviation and percentage, while proportions were analyzed using the chi-square test. A p-value ≤0.05 was considered statistically significant. Results: Of the 151 women, 115 were candidates for TOS. Of them, 96 (83.47%) had vaginal birth after cesarean (VBAC) and 19 (16.5%) had a repeat cesarean section. There were four cases of primary postpartum hemorrhage (PPH) and two cases of scar dehiscence in the study group. No significant perinatal morbidity was observed. VBAC rate was significantly more in women who had prior vaginal deliveries, especially in those with previous VBAC. Conclusion: In carefully selected cases, trial of labour (TOL) after a prior cesarean is safe and often successful. A prior vaginal delivery, particularly, a prior VBAC are associated with a higher rate of successful TOL.

We conducted a retrospective study aimed at determining variables associated with a higher success rate for vaginal delivery after caesarean section, and assessing the impact of induction of labour. Secondarily, we aimed to describe our vaginal delivery and uterine rupture rates with the use of a controlled-release dinoprostone vaginal insert for cervical ripening. Of 292 women who met the inclusion criteria, induction of labour occurred in 48% (94% with dinoprostone). There was a non-significant difference between the vaginal delivery rate of spontaneous labour (57%) and induction of labour (33%), after adjusting for confounding variables. The success rate was influenced by a Bishop score ≥6, previous vaginal delivery and previous caesarean for dystocia or failed induction. There was only one case of uterine rupture, which was associated with dinoprostone use (overall rate 0.34%, 0.77% for dinoprostone). Impact statement Trial of labour after caesarean section is considered an alternative to elective repeat caesarean. Both present associated benefits and risks, the most fearsome of which is uterine rupture during labour (0.78% in term pregnancies). Induction is also possible but carries a higher risk of uterine rupture and lower success rate for vaginal birth. Prostaglandins have been of particular concern due to a higher risk of uterine scar rupture, estimated at 2% for dinoprostone; however, its use as a controlled-release vaginal insert has been under-reported. Our study confirms the reported impact of previous vaginal delivery, previous caesarean indication and Bishop score at admission on success rate for vaginal birth after caesarean. We were unable to prove a lower success rate for induction of labour after adjusting for other variables. Despite our study limitations, we report on the use of a controlled-release vaginal insert with 10mg of dinoprostone in 130 women with a uterine rupture rate of 0.77%, lower than previously reported and similar to the overall rate estimated for term pregnancies. This dinoprostone formulation may be safer than previously reported but larger studies, and preferably randomised controlled trials, are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Introduction: We analysed the efficacy and safety of double-balloon catheter for cervical ripening in women with a previous cesarean section and which were the most important variables associated with an increased risk of repeated cesarean delivery.Materials and Methods: We designed an observational retrospective study of 418 women with unfavourable cervices (Bishop Score <5), a prior cesarean delivery, and induction of labour with a double-balloon catheter. Baseline maternal data and perinatal outcomes were recorded for a descriptive, bivariate, and multivariate analysis. A p value <0.05 was considered statistically significant.Results: Most women improved their initial Bishop Score (89.5%) although only a 20.8% of them went into spontaneous active labour. Finally, 51.4% of the women achieved a vaginal delivery. Five cases of intrapartum uterine rupture (1.2%) occurred. After multivariate analysis, main risk factors for repeated cesarean section were dystocia in the previous pregnancy (OR 1.744; CI 95% 1.066-2.846), the absence of previous vaginal delivery (OR 2.590; CI 95% 1.066-6.290), suspected fetal macrosomia (OR 2.410; CI 95% 0.959-6.054), and duration of oxytocin induction period (OR 1.005; CI 95% 1.004-1.006). The area under the curve was 0.789 (p < 0.001).Conclusions: Double-balloon catheter seems to be safe and effective for cervical ripening in women with a previous cesarean delivery and unfavourable cervix. In our study, most women could have a vaginal delivery in spite of their risk factors for cesarean delivery. A multivariate model based on some clinical variables has moderate predictive value for intrapartum cesarean section. [ABSTRACT FROM AUTHOR]

Recent studies show a steep rise in caesarean sections in China. Most couples are now eligible to apply for a second child. This retrospective cohort study compares the prevalence of trial of labour and vaginal birth after caesarean section among Chinese and foreign women in Shanghai. In total, 135 of 368 women underwent trial of labour (36.68%), and of those, 77 (57.04%) had a vaginal birth. After inclusion in a multivariate model, factors associated with trial of labour were maternal age <35 years with an adjusted odds ratio of 2.58 (1.49–4.46), absence of a history of ≥3 abortions (2.22 (1.08–4.57)), and European citizenship (1.94 (1.05–3.59)). The prevalence of trial of labour and vaginal birth seems to mirror rates found in countries of origin, but despite a high rate of caesarean section, Chinese women had a higher rate of vaginal birth after caesarean section than North American and Australian women, in particular.Impact statementWhat is already known on this subject:Caesarean section (CS) rates are rising worldwide. Repeat CS contributes largely to these rates, although vaginal birth after CS (VBAC) rates varies widely between countries.What the results of this study add:North American and Australian women who deliver in Shanghai have low rates of attempted trial of labour after CS (TOLAC) and VBAC, with European women having the highest rate of TOLAC, followed by Chinese women.Implications for clinical practice and/or further research:These findings might reflect different levels of acceptance in line with respective national trends. Studies evaluating the influence of cultural norms on birth preferences after CS are needed. Further research is also needed to assess the overall acceptance of TOLAC in the context of the softening of the one-child policy in China. [ABSTRACT FROM PUBLISHER]

Objectives Variations in caesarean section (CS) between some immigrant groups and receiving country populations have been widely reported. Often, African immigrant women are at higher risk of CS than the receiving population in developed countries. However, evidence about subsequent mode of birth following CS for African women post-migration is lacking. The objective of this study was to examine differences in attempted and successful vaginal birth after previous caesarean (VBAC) for Eastern African immigrants (Eritrea, Ethiopia, Somalia and Sudan) compared with Australian-born women. Design A population-based observational study was conducted using the Victorian Perinatal Data Collection. Pearson's chi-square test and logistic regression analysis were performed to generate adjusted odds ratios for attempted and successful VBAC. Setting Victoria, Australia. Participants 554 Eastern African immigrants and 24,587 Australian-born eligible women with previous CS having singleton births in public care. Findings 41.5% of Eastern African immigrant women and 26.1% Australian-born women attempted a VBAC with 50.9% of Eastern African immigrants and 60.5% of Australian-born women being successful. After adjusting for maternal demographic characteristics and available clinical confounding factors, Eastern African immigrants were more likely to attempt (OR adj 1.94, 95% CI 1.57–2.47) but less likely to succeed (OR adj 0.54 95% CI 0.41–0.71) in having a VBAC. Conclusion/Implications for practice There are disparities in attempted and successful VBAC between Eastern African origin and Australian-born women. Unsuccessful VBAC attempt is more common among Eastern African immigrants, suggesting the need for improved strategies to select and support potential candidates for vaginal birth among these immigrants to enhance success and reduce potential complications associated with failed VBAC attempt. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) rates are increasing worldwide and as a result repeat CS is common. The optimal mode of delivery in women with one previous CS is widely debated and the risks to the infant are understudied. The aim of the current study was to evaluate if women with a trial of labour after caesarean (TOLAC) had an increased odds of neonatal and infant death compared to women with an elective repeat CS (ERCS).Methods: A population register-based cohort study was conducted in Denmark between 1982 and 2010. All women with two deliveries [in which the first was a CS, and the second was an uncomplicated, term delivery (n = 61,626)] were included in the study. Logistic regression models were used to report adjusted odds ratios (AOR) and 95% confidence intervals (CI) of the odds of death according to mode of delivery. The main outcome measures were neonatal death (early and late) and infant death.Results: Women with a TOLAC had an increased odds of neonatal death (AOR 1 · 87, 95% CI 1 · 12 to 3 · 12) due to an increased risk of early neonatal death (AOR 2 · 06, 95% CI 1 · 19 to 3 · 56) and no effect on late neonatal death (AOR 0 · 97, 95% CI 0 · 22 to 4 · 32), or infant death (AOR 1 · 12, 95% CI 0 · 79 to 1 · 59) when compared to the reference group of women with an ERCS. There was evidence of a cohort effect as the increased odds of neonatal death (AOR 3 · 89, 95% CI 1 · 33 to 11 · 39) was most significant in the earlier years (1982-1991) and gradually disappeared (AOR 1 · 01, 95% CI 0 · 44 to 2 · 31) in the later years (2002-2010).Conclusions: Although an increased risk of neonatal death was found in women with a TOLAC, there was evidence of a cohort effect, which showed this increased odds disappearing over time. Advances in modern healthcare including improved monitoring and earlier detection of underlying pregnancy complications may explain the findings. [ABSTRACT FROM AUTHOR]

Objective: To assess the risks of uterine rupture, maternal and perinatal outcomes associated with a trial of labour (TOL) after one previous caesarean were compared with having an elective repeated caesarean section (ERCS) without labour in low-resource settings.Design: A prospective 4-year observational study.Setting: Senegal and Mali.Sample: A cohort of 9712 women with one previous caesarean delivery.Methods: Maternal and perinatal outcomes were compared between 8083 women who underwent a TOL and 1629 women who had an ERCS. Perinatal and maternal outcomes were then stratified according to the presence or absence of risk factors associated with vaginal birth after caesarean section. These outcomes were adjusted on maternal, perinatal and institutional characteristics.Main Outcome Measures: The risks of uterine rupture, maternal complication and perinatal mortality associated with TOL after one previous caesarean as compared with ERCS, RESULTS: The risks of hospital-based maternal complication [adjusted odds ratio (OR) 1.52; 95% CI 1.09-2.13; P = 0.013] and perinatal mortality (adjusted OR 4.53; 95% CI 2.30-9.92; P < 0.001) were significantly higher in women with a TOL compared with women who had an ERCS. However, when restricted to low-risk women, these differences were not significant (adjusted OR 0.90, 95% CI 0.55-1.46, P = 0.68, and adjusted OR 1.13; 95% CI 0.75-1.86; P = 0.53, for each outcome, respectively). Uterine rupture occurred in 25 (0.64%) of 3885 low-risk women compared with 70 (1.66%) of 4198 women with unfavourable risk factors.Conclusion: Low-risk women have no increased risk of maternal complications or perinatal mortality compared with women with one or more unfavourable factors.Tweetable Abstract: Low-risk women have a lower risk of maternal complications or perinatal mortality compared with high-risk women. [ABSTRACT FROM AUTHOR]

Objective: To assess the success rate of vaginal delivery among women with twin pregnancies; the Twin Birth Study has shown that vaginal delivery and caesarean section are equally safe for twin delivery but >40% of the planned vaginal delivery group delivered by caesarean section.Design: A retrospective cohort study.Setting: A tertiary medical centre.Population: A total of 2194 women with twin pregnancies not complicated with very low birthweight.Methods: Planned mode of delivery was documented in the woman's electronic record upon entering the delivery room. Information regarding maternal age at delivery, parity, gestational age, presentation, previous history of caesarean delivery, birthweight and Apgar score was collected from the obstetric electronic charts.Main Outcome Measured: Rate of vaginal twin delivery.Results: Of the 2194 women included, 1311 twin pregnancies had planned caesarean delivery and 883 underwent a trial of labour. Of the 883 women who underwent a trial of labour, the rate of vaginal delivery was 86.9%, whereas the rates of caesarean delivery and combined vaginal-caesarean delivery were 11.1% and 2.0%, respectively. Presentation of second twin, gestational age and maternal age did affect the chances of success. Nulliparity [odds ratio (OR) 2.38, 95% confidence interval (95% CI) 1.4-4.05], Foley induction of labour (OR 2.33, 95% CI 1.38-3.91) and body mass index >30 kg/m(2) (OR 1.76, 95% CI 1.03-3) were independent risk factors for caesarean delivery.Conclusions: The rate of vaginal delivery among women with twin pregnancies who undergo labour can be high, especially in women who laboured spontaneously and have delivered before.Tweetable Abstract: The rate of vaginal delivery of twins can be high, especially in women who have delivered before. [ABSTRACT FROM AUTHOR]

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

Objective To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean. Design Retrospective cohort study. Setting 19 US hospitals from the Consortium on Safe Labor. Population Of 2225 twin sets ≥36 weeks' gestation. Methods Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar <7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes. Main outcome measures Maternal and neonatal outcomes. Results Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [ OR 2.5, 95% confidence interval ( CI) 1.4-4.5] and blood transfusion ( OR 1.9, 95% CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar <7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95% CI 1.05-14.5; B: OR 3.9, 95% CI 1.3-12.3). Conclusion Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases. [ABSTRACT FROM AUTHOR]

Background: To analyse the mode of delivery in trial of labour (TOL), incidence of successful vaginal deliveries and indications of repeat caesarean section (CS). Materials and Methods: Prospective selective study. Study population consisted of 367 pregnant women with previous one lower segment caesarean section (LSCS) in reproductive age group. These were grouped in to three groups, Group 1 (n = 239): Women, who were elected for repeat CS without a TOL. Group 2 (n = 76): Women, who were given TOL and delivered vaginally. Group 3 (n = 52): Women, who were given a TOL but due to failed trial, had to be taken for emergency repeat section. The maternal and foetal outcome was studied in all the groups. Statistical Method Used: The data was entered in the Microsoft excel worksheet, values expressed as mean ± SD. Chi-square test was done to compare the categorical variables among the groups. ANOVA (one-way analysis of variance) was done to compare the baseline characteristics of patients and time to delivery among the groups. Results: Out of 128 women who were given TOL, 76 (59.37%) vaginal birth after caesarean (VBAC) occurred, out of which 40 (52.63%) had spontaneous vaginal deliveries without augmentation of labour and 36 (47.36%) subjects had augmentation of labour with artificial rupture of membranes (ARMs) and oxytocin. A total of 52 women (40.62%) underwent emergency LSCS. Conclusion: Proper selection and counselling about clinically significant risks, women can be given TOL with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management of previous one CS in labour. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the outcome of pregnancy in women with previous one cesarean section in relation to vaginal delivery and maternal and perinatal complications. It also aimed at identifying the factors, which can influence the outcome of trial of scar (TOS). Materials and Methods: A retrospective analysis of medical records of 151 women with previous one cesarean section who delivered at the Mafraq Hospital, Abu Dhabi between January- August 2011was carried out. Those women with previous classical cesarean section and those with extreme prematurity were excluded. The collected data were analyzed using SPSS software version 20. Continuous and categorical data were presented in the form of mean, standard deviation and percentage, while proportions were analyzed using the chi-square test. A p-value ⩽0.05 was considered statistically significant. Results: Of the 151 women, 115 were candidates for TOS. Of them, 96 (83.47%) had vaginal birth after cesarean (VBAC) and 19 (16.5%) had a repeat cesarean section. There were four cases of primary postpartum hemorrhage (PPH) and two cases of scar dehiscence in the study group. No significant perinatal morbidity was observed. VBAC rate was significantly more in women who had prior vaginal deliveries, especially in those with previous VBAC. Conclusion: In carefully selected cases, trial of labour (TOL) after a prior cesarean is safe and often successful. A prior vaginal delivery, particularly, a prior VBAC are associated with a higher rate of successful TOL. [ABSTRACT FROM AUTHOR]

Objectives To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section ( VBAC). Design Cohort study using data from Hospital Episode Statistics. Setting English National Health Service. Population Women whose first birth resulted in a live singleton delivery by caesarean section between 1 April 2004 and 31 March 2011, and who had a second birth before 31 March 2012. Methods Logistic regression to estimate adjusted odds ratios ( OR). Main outcome measures Attempted and successful VBAC. Results Among the 143 970 women in the cohort, 75 086 (52.2%) attempted a VBAC for their second birth. Younger women, those of non-white ethnicity and those living in a more deprived area had higher rates of attempted VBAC. Overall, 47 602 women (63.4%) who attempted a VBAC had a successful vaginal birth. Younger women and women of white ethnicity had higher success rates. Black women had a particularly low success rate ( OR, 0.54; 95% confidence interval [ CI], 0.50-0.57). Women who had an emergency caesarean section in their first birth also had a lower VBAC success rate, particularly those with a history of failed induction of labour ( OR, 0.59; 95% CI, 0.53-0.67). Conclusion In this national cohort, just over one-half of women with a primary caesarean section who were eligible for a trial of labour attempted a VBAC for their second birth. Of these, almost two-thirds successfully achieved a vaginal delivery. [ABSTRACT FROM AUTHOR]

Background: Trial of labour is a clinical test to assess the adequacy of pelvis and ability of fetus and mother to withstand labour. If progressive changes in dilation and station do not occur, a cesarean delivery is performed. Objective: Feto-maternal outcome after trial of labour in women with gestational age b/w 37 to 42 weeks. Study Design: Cross sectional study. Setting: Department of Obs/ Gyn unit-I Liaquat University Hospital Hyderabad. Duration of Study: One year from 01-02-2009 to 31-01-2010. Subjects and Methods: 100 pregnant women, with gestational age between 37-42 weeks, who underwent trial of labour at labour ward, Obs/Gyn Unit-1 Liaquat University Hospital, after fulfilling the inclusion criteria were included in the study. Detailed history and examination including abdominal and pelvic examination as well as Ultrasound for fetal well being was performed. Fetal monitoring was done by auscultation and CTG. Partogram was maintained to observe the progress of labour. Those who progressed with trial either delivered normally or with the help of instruments and those who did not progress were delivered by C-section. After delivery, mothers were watched for any postpartum complication and condition of neonates was assessed by APGAR score. Results: Out of 100 women included in this study 58% delivered vaginally, 31 % delivered by cesarean section and 11 % had instrumental deliveries. Labour was induced in 34%, augmented in 34% and 32% had spontaneous labour. 77.0% babies had apgar score > 5(7.1±0.72), 16% < 5(3.68±2.18) and 6% were still birth. 81% mothers had no complication during or after delivery, whereas 19 developed complications and these were 12 Genital tract traumas, 5 postpartum haemorrhage, one uterine rupture and one retained placenta. There was no statistically significant difference (P=0.42) when mode of delivery was compared with the trial of labour. However augmentation of labour was associated with increased rate of maternal complications when maternal outcome was compared with the type of labour (P=0.03). Conclusions: Trial of labour in carefully selected women with high probability to deliver their babies vaginally decreases the rate of LSCS, thereby reducing the maternal morbidity and mortality associated with it. However augmentation of labour is associated with increased rate of maternal complications as compared to spontaneous or induced labour. [ABSTRACT FROM AUTHOR]

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

Objective Compare changes in pelvic organ prolapse ( POP) from 36-38 weeks of gestation to 1 year postpartum after unlaboured cesarean delivery( UCD)and trial of labour ( TOL). Design Prospective observational cohort study. Setting Wenzhou Third People's Hospital, Wenzhou, Zhejiang, China. Population Nulliparous women undergoing UCD or TOL. Methods Pelvic organ prolapse was assessed at 36-38 weeks of gestation, then at 6 weeks, 6 months and 1 year postpartum, using the Pelvic Organ Prolapse Quantification ( POPQ) system. Main outcome measures Postpartum POP status in UCD and TOL determined by POPQ measurements over time. Results Points Aa (Ba) determined the final stage assignment in most cases. Stage II POP was present in 35% and 37% of women in UCD and TOL at 36-38 weeks of gestation. After delivery, the likelihood of stage II POP declined during the first year postpartum in the whole cohort. The TOL group was much less likely to recover from stage II POP compared with the UCD group (odds ratio 0.04, 95% confidence interval 0.01-0.18) after adjustment for POP status at 36-38 weeks of gestation, age, first-trimester body mass index, newborn birthweight, educational level, gravidity and smoking status. With the exception of age, education and gravidity, these covariates were also independent predictors of postpartum POP. Conclusion Factors unique to labour and delivery lead to sustained pelvic floor relaxation postpartum. Pelvic organ prolapse at 36-38 weeks of gestation, and higher first-trimester body mass index also appear to predict long-term POP. Further investigation into mechanisms leading to persistent or progressive POP after TOL are warranted. In addition, caution is needed in generalising the findings due to the single-centre design. [ABSTRACT FROM AUTHOR]

Objective: To examine the delivery mode and neonatal outcome after a trial of external cephalic version (ECV) procedures. Study design: This is an interim analysis of an ongoing larger prospective off-centre randomised trial, which compares a clinical hypnosis intervention against neuro-linguistic programming (NLP) of women with a singleton breech foetus at or after 37 (259 days) weeks of gestation and normal amniotic fluid index. Main outcome measures were delivery mode and neonatal outcome. Results: On the same day after the ECV procedure two patients (2 %), who had unsuccessful ECVs, had Caesarean sections (one due to vaginal bleeding and one due to pathological CTG). After the ECV procedure 40.4 % of women had cephalic presentation ( n = 38) and 58.5 % ( n = 55) remained breech presentation. One patient remained transverse presentation ( n = 1; 1.1 %). Vaginal delivery was observed by 73.7 % of cephalic presentation ( n = 28), whereas 26.3 % ( n = 10) had in-labour Caesarean sections. Of those, who selected a trial of vaginal breech delivery, 42.4 % ( n = 14) delivered vaginally and 57.6 % ( n = 19) delivered via Caesarean section. There is a statistically significant difference between the rate of vaginal birth between cephalic presentation and trial of vaginal breech delivery ( p = 0.009), however, no difference in neonatal outcome was observed. Conclusion: ECV is a safe procedure and can reduce not only the rate of elective Caesarean sections due to breech presentation but also the rate of in-labour Caesarean sections even if a trial of vaginal breech delivery is attempted. [ABSTRACT FROM AUTHOR]

Background A previous caesarean delivery is no longer an indication per se for a subsequent, planned caesarean. We performed this study to identify women suitable for trial of labour after caesarean ( TOLAC), investigating the association between the indication for the first caesarean and the risk of unplanned caesarean in the second pregnancy. Methods We identified women with their first two pregnancies registered in the Swedish Medical Birth Registry 1992-2007. The indications for caesarean in the first pregnancy were determined using a previously published hierarchical system. For each indication group, the rate of caesarean among women with a first caesarean (n = 59 643) and a TOLAC in the second pregnancy was compared with that of primiparae (parity 0) (n = 354 053). Results The TOLAC rate was 69.5%. Among women with TOLAC, the uterine rupture rate was 1.1%. The success rate of TOLAC varied substantially based on the indication for the first caesarean (range 51-83%). Multiple births, breech presentation, and placenta praevia in the first pregnancy were associated with marginally increased odds of unplanned caesarean in the second pregnancy when compared with primiparae (adjusted OR 1.27 [95% CI 1.10, 1.48], 1.42 [1.34, 1.51], and 1.65 [1.17, 2.31]; OR, odds ratio; CI, confidence interval). The indications based on complications during labour/delivery, macrosomia, and maternal diabetes, were associated with substantially increased OR: 3.87 [3.70, 4.06], 4.15 [3.74, 4.61], and 4.62 [3.79, 5.63], respectively. Conclusions Considering the indications for caesarean in the first pregnancy before recommending a TOLAC or a planned caesarean in the second pregnancy may help to lower the rate of unplanned caesarean deliveries. [ABSTRACT FROM AUTHOR]

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

A prospective observational study was conducted at Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, India on 300 pregnant women with one previous caesarean section fulfilling the eligibility criteria for trial of labour, to study the predictive factors and the outcome of trial of labour. The data obtained were analysed according to mode and outcome of labour and was then subjected to statistical analysis. The success rate of trial of labour was found to be 53.6%%. Favourable Bishop's score ( p == 0.000), spontaneous onset of labour ( p == 0.005) and history of previous delivery after caesarean ( p == 0.007) were significantly associated with a successful outcome of trial of labour. Higher chances of vaginal delivery were found with breech as an indication of previous caesarean section, i.e. 67.1%% as compared to 39%% with non-progress of labour as an indication. [ABSTRACT FROM AUTHOR]

Summary: Background: Previous studies assessing the safety of vaginal birth after caesarean section (VBAC) have compared VBAC to elective repeat caesarean section (ERCS), despite the fact that the risks posed by each are considerably different. Explaining the complications of VBAC in a way that is meaningful to women can be challenging, and thus a comparison to a similar group of women who have also not undergone previous vaginal delivery may be a more relevant comparison. Research question: When counselling women undergoing planned VBAC, should a comparison of outcomes be made to women undergoing ERCS, or is a comparison to other nulliparous women undergoing vaginal birth a more valid comparison in terms of risk outcomes? Participants and methods: A retrospective cohort study was undertaken comprising a consecutive cohort of 21,389 women who delivered, stratified by Robson''s criteria into Robson groups 1–5. Those in Robson groups 6–10 were not included. Demographic data and maternal/neonatal outcomes were reviewed, with main outcome measures comprising uterine rupture, post-partum haemorrhage (PPH), 3rd/4th degree tears and neonatal morbidity. Results: There was no increase in PPH, vaginal tears or neonatal complications in the VBAC group when compared to Robson groups 1 and 2 (nulliparous women in spontaneous or induced labour, respectively). Uterine rupture rates were low in all groups, with no correlation identified. Discussion: The maternal and neonatal morbidity associated with VBAC is comparable to primiparous women undergoing a vaginal birth. Conclusion: In demonstrating the low relative morbidity in this comparison, these outcomes may aid in counselling women faced with the choice of VBAC versus ERCS. [Copyright &y& Elsevier]

Introduction: Vaginal birth after caesarean section is currently the preferred method of delivery for pregnant women who had previous one lower segment caesarean section. This common practice warrants some reconsideration in light of recent clinical data on the risks associated with VBAC. Objectives: To evaluate conditions which can achieve successful vaginal birth after one caesarean section. Study Design: Cross-sectional analytic study. Setting: Department of Obstetrics and Gynaecology, Unit-I, Services Hospital, Lahore. Duration of Study with Dates: Study was carried out over a period of six months from 08-06-2006 to 07-12-2006. Subjects and Methods: One hundred pregnant women meeting inclusion criteria were included. During trial of labour patients were closely monitored by vital signs, fetal cardiac activity, lower abdominal pain and tenderness, fetal distress, vaginal bleeding and loss of presenting part. Results: Mean age of the patients was 34.27 + 6.45. According to distribution of cases by parity, maximum number i.e 64 (64.0%) was P 3-6. 79 patients (79.0%) had prior vaginal delivery. Maximum 41.0% patients were due to fetal distress while in 28% indication for previous caesarean were breech presentation. In 71% patient membranes were intact while 29.0% patients presented with per vaginal leaking. 51.0% had dilatation between 3-4cm. VBAC was more successful in patients 58.0% with favourable Bishop score. Conclusions: BMI <20, prior vaginal delivery, non-recurrent indication for previous caesarean, spontaneous onset of labour, cervical dilatation or favourable Bishop score, weight of baby < 3.5kg predict an individual’s likelihood of successful VBAC. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Al-Zirqi I, Stray-Pedersen B, Forsén L, Vangen S. Uterine rupture after previous caesarean section. BJOG 2010;117:809–820. Objective To determine the risk factors, percentage and maternal and perinatal complications of uterine rupture after previous caesarean section. Design Population-based registry study. Population Mothers with births ≥28 weeks of gestation after previous caesarean section ( n = 18 794), registered in the Medical Birth Registry of Norway, from 1 January 1999 to 30 June 2005. Methods Associations of uterine rupture with risk factors, maternal and perinatal outcome were estimated using cross-tabulations and logistic regression. Main outcome measure Odds of uterine rupture. Results A total of 94 uterine ruptures were identified (5.0/1000 mothers). Compared with elective prelabour caesarean section, odds of rupture increased for emergency prelabour caesarean section (OR: 8.63; 95% CI: 2.6–28.0), spontaneous labour (OR: 6.65; 95% CI: 2.4–18.6) and induced labour (OR: 12.60; 95% CI: 4.4–36.4). The odds were increased for maternal age ≥40 years versus <30 years (OR: 2.48; 95% CI: 1.1–5.5), non-Western (mothers born outside Europe, North America or Australia) origin (OR: 2.87; 95% CI: 1.8–4.7) and gestational age ≥41 weeks versus 37–40 weeks (OR: 1.73; 95% CI: 1.1–2.7). Uterine rupture after trial of labour significantly increased severe postpartum haemorrhage (OR: 8.51; 95% CI: 4.6–15.1), general anaesthesia exposure (OR: 14.20; 95% CI: 9.1–22.2), hysterectomy (OR: 51.36; 95% CI: 13.6–193.4) and serious perinatal outcome (OR: 24.51 (95% CI: 11.9–51.9). Induction by prostaglandins significantly increased the odds for uterine rupture compared with spontaneous labour (OR: 2.72; 95% CI: 1.6–4.7). Prelabour ruptures occurred after latent uterine activity or abdominal pain in mothers with multiple or uncommon uterine scars. Conclusion Trial of labour carried greater risk and graver outcome of uterine rupture than elective repeated caesarean section, although absolute risks were low. A review of labour management and induction protocol is needed. [ABSTRACT FROM AUTHOR]

The safety of women undergoing childbirth with prior caesarean delivery is a major public health concern. Most of the earlier studies focused on the success rate of vaginal birth after caesarean section; later focus shifted to maternal and neonatal safety, and presently, each factor that would influence the outcome of trial of labour is being considered on both the success and the safety of vaginal birth following caesarean delivery. The contribution of induction of labour to uterine rupture is not entirely clear. Although large multi-center randomised trials comparing planned elective repeat caesarean delivery vs vaginal delivery following prior caesarean delivery are required for conclusive evidence; current evidence suggests that, in properly selected women, vaginal birth can be safely achieved if adequate facilities to monitor the foetus and immediate caesarean can be performed. Unbiased evidence-based information should be given to patients in making decisions about mode of delivery based on individual characteristics. The purpose of this review is to understand each factor that would influence the success and safety of vaginal birth after caesarean delivery. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine mode of delivery and occurrence of uterine rupture in women with a previous caesarean section (CS) in the Netherlands. Materials and methods: During a 1-year period 38 hospitals in the Netherlands registered prospectively mode of delivery, use of prostaglandins or oxytocin and occurrence of uterine rupture in all women with a previous CS. Results: There were 4569 women with a previous CS. Trial of labour (TOL) was attempted in 71.7%, of whom 76.0% delivered vaginally. The vaginal birth after caesarean (VBAC)-rate was 54.4%. Forty-nine uterine ruptures occurred (1.1%), of which 48 occurred during a TOL (1.5%). There were four perinatal deaths (1.2/1000 TOL) and 3 hysterectomies (0.9/1000 TOL) related to the rupture. Use of prostaglandin E2 alone or combined with oxytocin was significantly associated with an increased risk of uterine rupture (OR 6.8, 95% CI 3.2–14.3, OR 4.8, 95% CI 1.6–14.6, respectively). The same held for augmentation with oxytocin (OR 2.2, 95% CI 1.04–5.0). Conclusion: The success rate of TOL was 76%, resulting in a VBAC rate of 54%. Uterine rupture occurred in 1.5% during a TOL, with a risk of perinatal death of 1.2 per 1000. The risk of uterine rupture increased significantly when labour was induced with prostaglandins alone or combined with oxytocin or when labour was augmented with oxytocin. [Copyright &y& Elsevier]

To estimate maternal age effects on the rates of vaginal birth after caesarean delivery (VBAC), the related maternal complications and patient election to attempt VBAC, we conducted a secondary analysis of a retrospective cohort study of women who were offered VBAC from 1996 to 2000 in 17 community and university hospitals. We used bivariable and multivariable analyses to assess the association between maternal age and the study outcomes. A total of 25 005 patients were included, of whom 13 706 (54.81%) elected to attempt VBAC. After controlling for several confounding variables, using ages 21–34 years as the referent group, women aged 15–20 years were 27% less likely to have a failed VBAC attempt (OR = 0.73 [0.62, 0.87], P < 0.001). Analysing maternal age as a dichotomous variable, women who were of advanced maternal age (≥35 years) were more likely to experience an unsuccessful trial of labour (OR = 1.14 [1.03, 1.25], P = 0.009). In addition, women ≥35 years of age had 39% more risk of experiencing one of the VBAC-related operative complications (OR = 1.39 [1.02, 1.89], P = 0.039). As women increase in age, they are less likely to attempt VBAC and more likely to have an unsuccessful labour trial. While teenage patients do not appear to be at increased risk for VBAC-related complications, patients of advanced maternal age do show an increase in composite VBAC-related operative complication rates. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine maternal and perinatal morbidity and mortality after uterine rupture in the Netherlands. Study Design: All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of uterine rupture between 1st April 2002 and 1st April 2003. For every case, a questionnaire about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed. Results: Eighty-nine percent of all hospitals in the Netherlands participated. Ninety-eight uterine ruptures were registered; 95 after a previous caesarean section (CS) of which 91 occurred during a trial of labour. The fetus was extruded in the abdominal cavity completely in 18 cases and partially in 13 cases. Major complications due to uterine rupture were: perinatal death (n =11, from 94 cases with a viable fetus, 11.7%) and hysterectomy (n =4, 4.1%). Conclusion: These severe complications, perinatal death and hysterectomy, have to be an issue when counselling women on an elective CS and women with a history of a CS on the route of delivery. [Copyright &y& Elsevier]

Summary: Caesarean section (CS) rates continue to rise. Vaginal birth after Caesarean section (VBAC) for a woman needs to be determined on an individual basis. With careful selection, the majority of women (60–80%) will achieve vaginal delivery with minimal risks. There are two randomized controlled trials underway that are likely to have an impact on clinical management of women who have undergone prior Caesarean. The first is the CAESAR study, which will evaluate whether the single or two layers closure of the uterine incision has a significant impact on immediate morbidity and that of future pregnancies. The second is the ACTOBAC trial (A collaborative trial of birth after Caesarean) in which women who have undergone prior Caesarean will be randomized to vaginal versus Caesarean birth. Until data from these studies are available, the evidence to date suggests that for most women who have undergone prior low segment Caesarean a trial of labour should be offered after providing adequate information. The fetal condition and progress of labour should be monitored closely. Prompt resort to emergency CS should be undertaken with signs of fetal compromise or of scar dehiscence. [Copyright &y& Elsevier]

Aim: To compare the breathing patterns of infants born by elective caesarean section to those infants delivered by caesarean section after a failed trial of labour.Methods: Healthy term infants born by caesarean section were studied. The study group (n = 13) had no trial of labour, whereas infants in the control group (n = 13) failed a trial of labour. Polysomnographic study was performed at 36 h of age. Heart and respiratory rate, type and duration of apnoeas, arterial oxygen saturation and lower limb movements were analysed.Results: Term infants born by elective caesarean section had a shorter duration of pregnancy and weighed less. Their heart rate was faster, they had more mixed apnoeas, and during quiet sleep they had more central apnoeas of longer duration.Conclusion: Cardiorespiratory patterns in infants delivered by elective caesarean section are different from those delivered by caesarean section after a failed trial of labour. [ABSTRACT FROM AUTHOR]

Objective: To investigate the safety of a trial of labour (TOL) after two or three previous caesarean sections.Study Design: Retrospective analysis of medical records of women with a history of more than one previous caesarean section who gave birth during a 10-year period (1988-1997) in two large university hospitals in The Netherlands.Results: Women numbering 30,132 gave birth with a hospital caesarean birth rate of 14.8%. There were 246 women with a history of more than one previous caesarean section: 187 (76%) delivered by elective repeat caesarean section (ERCS); 59 (24%) had a trial of labour, of whom 49 (83%) had a vaginal birth. Three uterine ruptures occurred after previous lower segment caesarean sections without maternal or perinatal mortality related to the uterine rupture; only one rupture was during a trial of labour. In the study group there was no maternal mortality. Maternal morbidity did not differ between women with an elective repeat caesarean or a failed trial of labour. Perinatal mortality was not related to the mode of delivery.Conclusion: Elective repeat caesarean section is not the only answer to a woman with two or three previous caesarean sections. A trial of labour can be a safe option for a selected group of women. [ABSTRACT FROM AUTHOR]