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ObjectiveThe aim of this study was to assess the caesarean section (CS) rates using Robson’s 10-Group Classification System among women who gave birth at Hawassa University Referral Hospital in southern Ethiopia.DesignCross-sectional study design to determine CS rate using Robson’s 10-Group Classification System.SettingHawassa University Referral Hospital in south Ethiopia.Participants4004 women who gave birth in Hawassa University Referral Hospital from June 2018 to June 2019.ResultsThe 4004 women gave birth to 4165 babies. The overall CS rate was 32.8% (95% CI: 31.4%–34.3%). The major contributors to the overall CS rates were: Robson group 1 (nulliparous women with singleton pregnancy at term in spontaneous labour) 22.9%; group 5 (multiparous women with at least one previous CS) 21.4% and group 3 (multiparous women without previous CS, with singleton pregnancy in spontaneous labour) 17.3%. The most commonly reported indications for CS were ‘fetal compromise’ (35.3%) followed by previous CS (20.3%) and obstructed labour (10.7%).ConclusionA high proportion of women giving birth at this hospital were given a CS, and many of them were in a low-risk group. Few had trial of labour. More active use of partogram, improving fetal heartbeat-monitoring system, implementing midwife-led care, involving a companion during labour and auditing the appropriateness of CS indications may help to reduce the CS rate.

Objectives To determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. Design Cohort study using linked electronic maternity records. Participants 276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016. Main outcome measure A composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes. Results Multiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25 805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%). Conclusions Nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.

ObjectivesTo develop a nomogram to predict the likelihood of vaginal birth after caesarean section (VBAC) among women after a previous caesarean section (CS).DesignA retrospective cohort study.SettingTwo secondary hospitals in Guangdong Province, China.ParticipantsInclusion criteria were as follows: pregnant women with singleton fetus, age ≥18 years, had a history of previous CS and scheduled for trial of labour after caesarean delivery (TOLAC). Patients with any of the following were excluded from the study: preterm labour (gestational age Primary outcome measureThe primary outcome was VBAC, which was retrospectively abstracted from computerised medical records by clinical staff.ResultsOf the women who planned for TOLAC, 84.0% (1686/2006) had VBAC. Gestational age, history of vaginal delivery, estimated birth weight, body mass index, spontaneous onset of labour, cervix Bishop score and rupture of membranes were independently associated with VBAC. An area under the receiver operating characteristic curve (AUC) in the prediction model was 0.77 (95% CI 0.73 to 0.81) in the training cohort. The validation set showed good discrimination with an AUC of 0.70 (95% CI 0.60 to 0.79).ConclusionsTOLAC may be a potential strategy for decreasing the CS rate in China. The validated nomogram to predict success of VBAC could be a potential tool for VBAC counselling.

OBJECTIVE--To audit the subsequent obstetric management of women who had had one previous baby delivered by caesarean section. DESIGN--Retrospective analysis of a regional obstetric database. SETTING--Data derived from the 17 obstetric units in North West Thames region. SUBJECTS--1059 women who delivered a singleton fetus of at least 37 weeks9 gestation with a cephalic presentation in 1988 who had a history of one previous caesarean section and no other deliveries. MAIN OUTCOME MEASURES--Mode of delivery, postnatal morbidity, and duration of hospital stay. RESULTS--395 (37%) women were delivered by elective repeat caesarean section and 664 (63%) were allowed a trial of labour. Maternal height and birth weight of the previous infant differed significantly between those who were and those who were not allowed to labour. 471 (71%) of those allowed to labour achieved a vaginal delivery. In individual units there was no significant correlation between the proportion of patients allowed to labour and the rate of the successful trial of labour. There was a trend towards greater success rates in units that allowed a longer duration of labour (p less than 0.05) and units with greater use of oxytocin for augmentation of labour (not significant). Both elective and intrapartum caesarean section was associated with a significantly higher rate of postnatal infection than vaginal delivery (14.7% and 16.0% v 3.4%). CONCLUSIONS--In patients with a history of caesarean section there is no evidence that the likelihood of successful vaginal delivery after trial of labour is modified by the proportion of such patients allowed the option of attempted vaginal delivery. Until selection criteria of adequate prognostic value can be identified a more liberal approach to allowing women a trial of labour seems justified.

Background Repeat caesarean section (CS) following previous CS is one of the most significant factors contributing to increasing CS rates globally. Even though trial or labour (TOL) is the recommended option associated with better outcomes for both mothers and babies, TOL rates vary widely through healthcare settings and countries. The aim of this study was to compare the risk of neonatal and infant mortality in women with one previous CS undergoing a subsequent TOL or elective repeat CS. Methods Setting Denmark (1982–2010). The Danish Civil Registration System (CRS) data were used for the current analysis. This is population-based, high-quality, validated data collected continuously on the entire population of Denmark using a unique identifer. Data were obtained from the Medical Birth Register and the National Hospital Register. Women with their first two deliveries between 1982 and 2010 (n = 550,273) were included in the study. The odds of neonatal death ( Results Women with one previous CS undergoing a subsequent TOL had a 68% increased odds of neonatal death (OR 1.68, 95% CI 1.05, 2.68) compared to women having an elective repeat CS in the crude analyses. This remained unchanged in the adjusted analyses (OR 1.68, 95% CI 1.05, 2.69). However, in the later years this increased risk disappeared suggesting a cohort effect (OR 1.15, 95% CI 0.69, 1.91). No increased odds of infant death was found among women with a first CS udergoing a subsequent TOL in the crude (OR 1.08, 95% CI 0.80, 1.45) and adjusted analyses (OR 0.89, 95% CI 0.63, 1.27). Conclusion In the largest study to date we found that women with a first CS and subsequent TOL had a 68% increased odds of neonatal death compared to women with an elective repeat CS. However, this increased odds disappeared in the later years of the cohort, suggesting a cohort effect and the possibility that CS is now a much safer operation and the increased risk in the earlier years of the cohort could be due to underlying medical complications requiring a CS rather than as a result of the CS per se . This information will help expectant parents and healthcare providers to make a more informed decision regarding the optimal mode of delivery in women with one previous CS.

Objective To assess the performance of three different statistical models in predicting successful VBAC. The statistically most reliable model was subsequently subjected to validation testing in a local antenatal population and a cost saving analysis was performed. Materials and methods The study population included all women who had attempted trial of labour after previous Caesarean Section (TOLAC) within a regional UK obstetric unit, between April 2010 and April 2012. A retrospective observational study was performed with study data collected from the Northern Ireland Maternity Service Database (NIMATs) and subjects’ personal medical chart. Statistical analysis was performed using Microsoft EXCEL TM 2007 (v.12)and IBM SPSS statistics TM v. 20.0 (2011). Results Our study included 385 TOLAC subjects. Of the three predictor models evaluated, area under the curve (AUC) calculations determined the Grobman model, was statistically the most reliable (AUC = 0.724 p 2 = 0.88), validating the model within our population. Had this model been utilised ante-natally, it may have led to a 3.4% reduction in costs over two years had women with a 72% predicted probability of successful VBAC been selected. Conclusion The Grobman model could potentially be utilised within the UK antenatal population to give women and clinicians an informed choice when deciding on mode of delivery after 1 previous CS. This could lead to potential cost savings.

Patients with a single previous Caesarean section for non-recurrent cause can have a successful vaginal delivery in >75% cases.1 Elective Caesarean with no medical indication is associated with increased maternal mortality and severe morbidity.2 Uptake of vaginal birth after Caesarean (VBAC) however is dependent on many factors including, maternal perception and choice. Can the authors increase uptake of VBAC in this patient group? Method Patient suitability for VBAC determined by senior obstetrician at 20 weeks, Caesarean for non medical reason only permitted with two consultant9s agreement. Those who did not labour by 41 weeks had cervical assessment – if ARM (artificial rupture of membrane) was feasible, labour was induced; if not Caesarean section performed. Data Collection Retrospective analysis of all patients with single previous Caesarean. Delivery outcomes and maternal and fetal morbidity assessed 6 months pre- and postprotocol change. Results 59% (94/159) had trial of labour (control 46%), of which 77% (72/159) had successful vaginal delivery (control 62%). Spontaneous labour occurred in the majority. 11% were induced with 80% of inductions achieving vaginal birth. 65/159 (41%) had elective Caesarean section (control 54%). There were no cases of uterine rupture or perinatal death. A significant difference (p Conclusion Involving senior obstetricians in discussions with women regarding mode of delivery and active discouragement of Caesarean for non-medical reason, appears to increase VBAC rates.

Introduction Uterine rupture is amongst the preventable obstetric complication that carries severe risks both to mother and baby Aim Critically analyse the notes of women with rupture uterus over a period of 11 years and to reflect and learn from the outcome. Method and Settings Retrospective analysis of case notes of women with confirmed uterine rupture over a period of 11 years from January 2000–December 2011 at Royal Maternity Hospital, Belfast. Results 17 women had confirmed uterine rupture in the study period of which 4 were preterm. All women except for one, had one or more term caesarean sections in past. The median interval between caesarean section and rupture was 3 years. Only 23% of women had induction of labour. Scar tenderness with or without suspicious CTG was the leading reason to suspect rupture. In nearly 70% of women maternal observations remained stable. Scar rupture was suspected only in 65% of women before the surgical intervention. 8 women (47%) had either scar rupture or dehiscence of varying length while remaining 53% had extensions of scar rupture. Conservative management remained the main stay of management. 35% of babies required neonatal care. The study also considered factors like uterine anomalies and surgeries, labour details including postpartum, staff involved etc. Conclusion Trial of labour in previous section with successful outcome has long term implication on maternal health, while at the same time staff providing the care should be educated and trained to suspect the scar problems at early stages and intervene appropriately.

Objective To compare mode of delivery in fetuses with known congenital heart disease (CHD) versus the background rate in non-anomalous fetuses. Methods We examined all cases of prenatally-diagnosed CHD over the 5-year study period, 2007–2011. Data were extracted from computerised patient records. Control data for non-anomalous fetuses were obtained from published hospital records for 2007. Categorical data were analysed using Fisher’s exact test (5% level significant). Results We identified 242 cases of prenatally-diagnosed CHD over the study period. We excluded 25 lethal karyotypes, 7 miscarriages and 1 termination. Of the remaining 209 cases, complete labour records were available for 158 women. There were 146 live births (92%) and 12 antepartum stillbirths at ≥24 weeks (8%). Of the live-born infants with CHD, the perinatal mortality rate was 41 per 1,000. Extra-cardiac defects and non-lethal karyotypic abnormalities were present in 22% (n = 34) and 11% (n = 18) of the cohort respectively. Overall, 23% (34/146) underwent elective caesarean section (CS). The remaining 112 women had a trial of labour, with a 13% (n = 15) intrapartum CS rate. The rate of intrapartum CS for nulliparous women with known CHD was 18% (8/45), which was not different to the rate in nulliparous controls in 2007 (13%; 432/3324; p = 0.27). The equivalent rate in multiparous women was 10% (7/67) in CHD versus 2.4% (80/3392) in controls without previous CS (p = 0.0013). Conclusions The rate of intrapartum CS in fetuses with known CHD is not different to the background rate in nulliparous women but is increased in multips.

The trend to deliver with caesarean section has increased in the recent years. The factors affecting this trend need re-consideration. Most of the women would deliver normally after a trial of labour after previous caesarean section. The obstetricians should abide by ethics in clinical practice, carefully evaluate the indication before every caesarean section, and take an unbiased decision before performing a caesarean section. Trend to deliver with caesarean section (CS) has increased recently. The underlying factors are increased knowledge, availability of facilities and patients’ fear of vaginal birth. Many women are now opting for a caesarean delivery, even when it is not absolutely required. Moreover, some obstetricians find it easy to perform a CS rather than to wait longer in trial of labour. On the basis of the available evidence the concept of a prophylactic caesarean section being outrageous has been shattered by the fact that almost a third of female obstetricians would choose it for themselves. 1 Increased rate of primary caesarean delivery in the United States in recent years, and a declining vaginal birth after caesarean (VBAC) rate has increased the overall rate of caesarean deliveries. 2 Recent increases in the proportion of US women with a prior caesarean delivery mean that an increasing number of women are faced with the choice and associated risks of either VBAC or repeat caesarean delivery. 3 A prior caesarean birth increases the risk of both elective and emergency caesarean births and uterine rupture in a subsequent pregnancy. 4 A trial of labour after prior caesarean delivery is associated with a greater perinatal risk than is elective repeated caesarean delivery without labour, although absolute risks are low. This information is relevant for counselling women about their choices after a caesarean section. 5 Women with a history of a prior caesarean birth may receive conflicting information regarding options in future pregnancies related to the choice of a trial of labour after a caesarean (TOLAC) or having an elective repeat caesarean delivery (ERCD). 6 Need for induction and augmentation of labour are both factors associated with an increased likelihood of unsuccessful vaginal birth and risk of uterine rupture. 4 Trial of labour after caesarean (TOLAC) delivery is currently a hot obstetrical topic owing to the acute rise in the rate of caesarean deliveries, both primary and repeat. 7 Certain labour management practices increase the risk for uterine rupture 2–3 times, although the absolute increase is small from a baseline uterine rupture rate. 8 After accounting for labour duration, induction is not associated with an increased risk of uterine rupture in women undergoing TOLAC. 9 Ultrasonography can be a useful tool for evaluation of the uterus in planning a normal delivery after previous CS. Ultrasound measurements of the CS scar expressed as residual myometrial thickness (RMT) and the change in RMT between the first and the second trimester of pregnancy, can accurately predict a successful trial of labour in patients with one previous CS. 10 To meet patient expectations for a safe and successful outcome with a trial of labour after caesarean delivery (TOLAC), specific management plans, checklists, practical coverage arrangements, and simulation drills are necessary. 11 The reports Health Committee Maternity Services and Changing Childbirth suggested that women should have a pivotal role in their obstetric care. On the basis of the available evidence the concept of a prophylactic caesarean section being outrageous has been shattered by the fact that almost a third of female obstetricians would choose it for themselves. 1 A motherto-be must be explained in detail the benefits and risks of a CS before she opts for or is made to accept the CS for delivery of her child. The obstetrician must neither simply be a technician to receive dictation from her patient, nor should be deciding herself alone about the mode of delivery. The option of CS should be left only for a really deserving case with genuine reasons for a primary or a subsequent CS, and not only because of a previous caesarean section. Excluding a small number of cases who require an elective CS, labour may safely be permitted in women who have had one previous caesarean section, and most will deliver vaginally. 12 Induction of labour does not increase the risk of repeat caesarean section or uterine rupture. Though oxytocin may be administered to augment inefficient labour, the combined use of oxytocin to accelerate labour and analgesia significantly increases the risk of uterine rupture. 12 Obstetricians should abide by ethics in clinical practice and carefully evaluate the indication in every CS and take an unbiased decision before performing CS on demand/request. Although the debate will continue regarding the appropriateness of CS on demand, any discussion of risks and benefits must include the J Ayub Med Coll Abbottabad 2012;24(1) 2 http://www.ayubmed.edu.pk/JAMC/24-1/Editorial.pdf potential for long term risks of repeated CS, including hysterectomy and maternal and foetal death. 13

Introduction The relentless rise in the caesarean section (CS) rate has been associated with a decrease in the vaginal birth after caesarean (VBAC) rate possibly due concerns about the safety of a trial of labour after CS (TOLAC). The purpose of this study was to assess the risk of uterine rupture and maternal and perinatal complications associated with uterine rupture in women undergoing a TOLAC. Methods A retrospective study was performed in a tertiary referral hospital. Records were reviewed for the years 1990-2010. Only women with one previous caesarean section were allowed undergo a trial of labour. Uterine rupture was defined as disruption of the uterine muscle involving the uterine serosa or disruption of the uterine muscle with extension to the bladder or broad ligament. Results From 1990-2009 there were 88,668 multigravidas delivered of a baby weighing >500g and 14,832 had one previous CS. The CS rate increased from 11.3% in 1990 to 25.1% in 2009 and the VBAC rate decreased from 75.0% to 57.1%. There were 30 cases of uterine rupture in women with one previous CS during this time. Uterine rupture was associated with the use of prostaglandin to induce labour (n=2) and oxytocin to induce or augment labour (n=14). There were no maternal deaths or peripartum hysterectomies performed after uterine rupture. There was one perinatal death due to prematurity and one baby with neurological abnormality after uterine rupture. Conclusion VBAC remains a safe mode of delivery for mother and baby with a low risk of uterine rupture.

Objective To assess the association between obesity and successful vaginal birth after caesarean section (VBAC) in women with different ethnic backgrounds and predict the likelihood of VBAC in this group. Methods A retrospective cohort study of hospital birth data determined labour outcomes in VBAC candidates. Outcomes were defined as elective repeat caesarean section (ERCS), VBAC and failed trial of labour (TOL). Univariable and multivariable analysis assessed the relationship between ethnic origin and birth outcomes. Results The cohort included 202 women. Of these, 74 (36.6%) chose ERCS and 128 (63.4%) attempted VBAC. 80 (62.5%) of those women opting for VBAC had vaginal birth and 48 (37.5%) had an emergency caesarean section. The proportion of women choosing VBAC over ERCS was consistent across ethnic groups (>60%), but there was inconsistency in VBAC outcomes between different ethnic groups. Of 47 White women, 32 (68.1%) succeeded in VBAC. Of 65 Black women only 36 (55.4%) were successful. Obesity (body mass index >30 kg/m2) was more prevalent in Black women (30.0% compared to 12.2% in White women). However, of the 22 obese Black women in the cohort, only 40.9% were successful in VBAC compared to 60.0% obese White women. Conclusions The increasing rate of obesity in the UK is having a negative impact on the number of vaginal births. This study highlights the urgent need to provide women attempting VBAC with individualised risk evaluations, especially in the obese. Further work is required to better quantify this effect in order to improve clinical outcomes.

Increasing proportion of births by Caesarean section (CS) is a widespread concern to the general public and health professionals. Evidence suggests that vaginal birth after Caesarean (VBAC) may be more successful in women with previous CS for breech. Other factors thought to influence VBAC outcomes are raised body mass index (BMI), birth weight >4000 g and previous vaginal delivery. Our aim was to ascertain if previous section for breech is an independent favourable factor in VBAC. The delivery rate in our unit in 2008 was 2497. 325 out of the total number of delivery had previous Caesarean section. 153 (47%) of these had repeat CS. Of those who had a trial of labour, 96 (56%) delivered vaginally and 74 (44%) required section. 54 cases analysed showed that seven of the 14 (50%) of those who had section for breech, had successful VBAC whereas 17 (44%) of the 40 women whose previous section was for cephalic presentation, were successful (RR 1.2, 95% CI 0.62 to 2.22). After removing confounding factors such as BMI>30, fetal weight>4000 gm, VBAC was achieved in five of the 10 in the previous breech group and eight out of 23 in those whose previous section was for non breech (RR 1.75, CI 0.69 to 4.37). Conclusion Our initial result suggests that previous CS for breech may be an independent favourable factor for VBAC. However the CI was wide and this may be due to the small number analysed. If our finding is confirmed in larger studies, it would be relevant in counselling patients for VBAC.

A 34 year old pregnant woman (para 4+0, gravida 4) presented because of intrauterine death at 30 weeks after a viral illness. Antepartum haemorrhage occurred during a trial of labour and emergency caesarean section was performed. The patient then had a massive postpartum haemorrhage, which did not respond to intrauterine balloon tamponade. Hysterectomy was performed but bleeding continued. She developed disseminated intravascular coagulation and needed more than 90 units of blood. Haemostasis was achieved after transcatheter embolisation. ### Short answers ### Long answers The World Health Organization’s definition of primary postpartum haemorrhage is the loss …

Editor—In the term breech trial planned caesarean section was associated with a lower risk of death and initial serious morbidity, for singleton breech babies at term, compared with planned vaginal birth, although no benefit of planned caesarean was evident at 2 years of age.1,2 Kotaska does not believe that these results are generalisable and thinks that practitioners must have pushed their comfort level for vaginal breech delivery to achieve a vaginal delivery rate of 57%3. However, this rate was for women having a trial of labour and is similar to rates found in published reports.3 Kotaska also criticises the selection criteria and the intrapartum management of women planning a vaginal breech delivery in the trial, despite the fact that the protocol was developed at a consensus workshop by a group of obstetricians who were recognised in their communities as expert at vaginal breech delivery, and was then vetted by experienced obstetricians worldwide.4 We agree that operators' skill is crucially important in evaluating surgical interventions but continue to believe that randomised controlled trials provide the best evidence as to whether such procedures cause more good than harm.5 We sympathise with practitioners who do not believe that the results of the term breech trial apply to them. No one was more disappointed with the findings of the trial than the participating clinicians themselves who believed in the safety of vaginal breech delivery but were willing to put their vaginal breech delivery skills to the test.

Objective To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section. Design Systematic review. Data sources Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full. Review methods Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic. Results We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10 000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly. Conclusions Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.