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In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC. The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal. [ABSTRACT FROM AUTHOR]

Women seeking a vaginal birth after a caesarean section (VBAC) frequently want to keep their subsequent labour and birth free from intervention. Water immersion (WI) during labour is potentially an effective tool for women having a VBAC for its natural pain-relieving properties. However, negotiating access to WI can be difficult, especially in the context of VBAC. To explore women's experiences of negotiating WI for labour and birth in the context of VBAC. This Grounded Theory study followed Strauss and Corbin's framework and analytic process. Twenty-five women planning or using WI for their VBAC labour or birth were recruited from two midwifery practices and a social media group across Australia. Participants were interviewed during pregnancy and/or postnatally. 'Taking the reins', the core category explaining the women's experiences of assuming authority over their birth, comprised five categories: 'Robbed of my previous birth experience'; 'My eyes were opened'; 'Water is my tool for a successful VBAC'; 'Actioning my choices and rights for WI', and 'Empowered to take back control'. 'Wanting natural and normal' was the driving force behind women's desire to birth vaginally. Two mediating factors: Having someone in your corner and Rules for birth facilitated or hindered their birth choices, respectively. The women became active participants in their healthcare by seeking information and options to keep their birth experience natural and normal. Support from other women and advocacy in the form of continuity of midwifery care was crucial in successfully negotiating WI for their VBAC when navigating the complex health system. [ABSTRACT FROM AUTHOR]

• A vaginal birth after caesarean (VBAC) is associated with fewer complications for both mother and baby compared to a repeat caesarean. • Little is known on the safety and success of planning a VBAC in midwifery led settings such as birth centres and home birth, compared to obstetric led settings. • Findings of this review show that planning VBAC in midwifery led settings is associated with increased vaginal birth and a reduction in interventions such as instrumental birth and caesarean section. Adverse perinatal outcomes are rare, and further research is required to draw conclusions on these risks. • This research will contribute to the limited knowledge base available to midwives, obstetricians and women planning vaginal birth after Caesarean (VBAC), enabling them to make more informed choices regarding planned place of birth. There is a limited knowledge base available to midwives, obstetricians and women planning vaginal birth after caesarean (VBAC), impeding their ability to make informed choices regarding planned place of birth. A VBAC is associated with fewer complications for both mother and baby, but little is known on the safety and success of planning a VBAC in midwifery led settings such as birth centres and home birth, compared to obstetric led settings. To synthesise the findings of published studies regarding maternal and neonatal outcomes with planned VBAC in midwifery setting compared to obstetric units. PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were systematically searched on 16/08/2022 for all quantitative research on the outcomes for women planning VBAC in midwifery led settings compared to obstetric led settings in high income countries. Included studies were quality assessed using the CASP Checklist. Binary outcomes are incorporated into pairwise meta-analyses, effect sizes reported as risk ratios with 95 % confidence intervals. A τ² estimate of between-study variance was performed for each binary outcome analysis. Other, more heterogeneous outcomes are narratively reported. Two high-quality studies, out of 420 articles, were included. VBAC planned in a midwifery-led setting was associated with a statistically significant increase in unassisted vaginal birth (RR=1.42 95 % CI 1.37 to 1.48) and decrease in emergency caesarean section (RR= 0.46 95 % CI 0.39 to 0.56) and instrumental birth (RR= 0.33 95 % CI 0.23 to 0.47) compared with planned VBAC in an obstetric setting. There were no significant differences in uterine rupture (RR= 1.03 95 % CI 0.52 to 2.07), admission to special care nursery (RR= 0.71 95 % CI 0.47 to 1.23) or Apgar score of 7 or less at 5 min (RR= 1.16 95 % CI 0.66 to 2.03). Planning VBAC in midwifery led settings is associated with increased vaginal birth and a reduction in interventions such as instrumental birth and caesarean section. Adverse perinatal outcomes are rare, and further research is required to draw conclusions on these risks. [ABSTRACT FROM AUTHOR]

Women are offered the choice of vaginal birth or elective repeat caesarean section as although the absolute risks of major morbidity or mortality are lower with elective repeat caesarean in the short term, the risks of multiple caesareans such as invasive placental disorders and intra-abdominal adhesion formation, increase with the number of caesareans performed. Guiding patients in the clinic through this decision making process can be challenging but the use of a checklist can be of help. The most pertinent risk of vaginal birth after caesarean section is uterine rupture as it can give little warning to the clinician and can be catastrophic to mother and baby. Therefore, appropriate selection of patients and managing women labouring with a uterine scar is of utmost importance. [ABSTRACT FROM AUTHOR]

Objective: Data regarding the risks of obstetrical anal sphincter injury (OASI) among women who never delivered vaginally undergoing a trial of labor after cesarean (TOLAC) are scarce. We aimed to evaluate the risk factors and the rate of OASI among women undergoing TOLAC who never delivered vaginally.Study Design: A retrospective cohort study of all women undergoing a TOLAC and never delivered vaginally between 3/2011 and 6/2020. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to earliest gestational age in which OASI has occurred. A further comparison was made between the study cohort and a cohort of primiparous women undergoing a vaginal delivery, including gestational ages at which OASI has occurred in that cohort.Results: During the study period there were 2061 TOLACs among women without prior vaginal delivery. Of these, 76 % (1566/2061) had a successful vaginal delivery. Overall, 22/2061 (1.1 %) cases of OASI occurred. There was no difference in maternal demographic, obstetrical and medical history characteristics between the study groups. The mean gestational age at TOLAC was lower in the OASI group (390/7 ± 12/7 vs. 395/7 ± 12/7, p = 0.012). In multivariable regression analysis, gestational age was negatively associated with OASI [adjusted odds ratio, 95 % (confidence interval) 0.95 (0.91-0.99), for each day increase in gestational age)]. The rate of OASI in the study cohort did not differ from the rate of OASI among primiparous women during the same study period (347/27975, 1.2 %, p = 0.686).Conclusion: Gestational age at delivery is the only predictor of OASI among women with no prior vaginal deliveries undergoing a TOLAC. The incidence of OASI in this population is 1.1 % and does not differ from that of primiparous women. [ABSTRACT FROM AUTHOR]

Objective: To compare the success of the double-balloon catheter (DBC) versus prostaglandin gel (PGE2) for induction of labour in women with one previous caesarean section.Design: Retrospective cohort study using routinely collected maternity data in a Tertiary NHS hospital, North West England, UK. Women with a live singleton cephalic pregnancy induced using DBC or PGE2 after one previous birth by caesarean section from 1st April 2017 to 1st July 2019 were included. The core outcomes assessed were the inability to perform artificial rupture of membranes, requirement of oxytocin, vaginal birth and uterine rupture.Results: 208 women met the inclusion criteria, 127 were induced using the DBC and 81 using PGE2. The two groups were well matched for demographics and characteristics. Women induced for prolonged ruptured membranes with PGE2 were excluded from the study leaving 127 managed with DBC and 69 with PGE2. There were no significant differences observed between the two groups. Vaginal birth rates were 52.7% for the DBC and 66.6% for the PGE2 (relative risk 0.79 (confidence interval 0.63-1.00); P = 0.05). A single uterine rupture was reported following DBC usage.Conclusions: The DBC and PGE2 appear to be equally effective for induction of labour in women with one previous caesarean section. [ABSTRACT FROM AUTHOR]

Objective: Prior vaginal delivery (VD), including vaginal birth after cesarean (VBAC), is one of the greatest predictors of successful trial of labor after cesarean (TOLAC) and uterine rupture. We aimed to evaluate VBAC and uterine rupture rates associated with TOLAC in women with VD prior to cesarean delivery (CD) or with prior VBAC, and the cumulative effect of the number of prior VD's.Study Design: This retrospective study included women having TOLAC between 2005-2019. The study compared the caesarean and uterine rupture rates of TOLAC in women with only prior VD as compared to women with only prior VBAC. Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Receiver operating characteristic (ROC) and decision tree analyses (chi-square automatic interaction detection algorithm) was conducted to evaluate the influence of the number of prior VD's on the likelihood of successful TOLAC.Results: Overall, 9,038 women met the inclusion criteria. Women with prior VBAC and prior VD showed significantly higher rates of successful VBAC compared to those with no prior VD or prior VBAC (96 % and 86 % vs 76 %; p < 0.01). However, women with prior VBAC but not women with prior VD showed significantly lower rates of uterine rupture compare to women with no prior VD or VBAC (0.1 % vs 0.6 % and 0.6 %; p < 0.01). The prevented fraction of TOLAC success was significantly higher in women with prior VBAC than that of women with VD prior to CD (83 % vs. 42 %, p < 0.01). ROC curve showed that the number of prior VBACs was a better predictor of TOLAC success and uterine rupture than the number of prior VD's. However, each single variable was found to have low positive predictive value (PPV) and requires other variables to improve the prediction. Finally, decision tree analysis demonstrated significant association between TOLAC success rate and prior VBAC, prior VD, and CD indications, without any association with the number of prior deliveries.Conclusion: Prior VBAC has some prediction value for TOLAC success and uterine rupture. However, it has low PPV as a single variable and requires other variables to improve the prediction. The number of prior VDs is not improving prediction. [ABSTRACT FROM AUTHOR]

Objective: Over the past few decades, the rate of repeat cesarean deliveries (CD) have taken on pandemic proportions. As part of the global effort to reduce the rate of CD, trail of labor (TOL) following one and even two previous CDs is encouraged. We aimed to evaluate maternal and neonatal outcomes of parturients attempting a TOL after two previous CDs, in which a strict departmental protocol was adopted.Study Design: A retrospective cohort study of TOL following CD (TOLAC) at a single tertiary center, between 2005 and 2019. Various maternal and neonatal outcomes were assessed, in which parturients attempting TOL after two CD were compared to those after one previous CD. TOL after two CDs was permitted only to those parturients who fulfilled all the criteria of our department's protocol. A univariate analysis was initially conducted and was then followed by a multivariate analysis.Results: A total of 11,620 TOLAC were identified, of which 515 (4.4 %) were after two previous CDs. Overall, vaginal delivery rates were high, however, following two CDs the rate was lower than following one CD (83.1 % vs. 88.5 %, p < 0.01). Rates of uterine rupture, peripartum hysterectomy, and postpartum hemorrhage did not differ significantly between the groups. Neonatal results following two CDs were less favorable (specifically, one minute APGAR, neonatal care unit admissions and mechanical ventilation rates), yet, when controlling for potential confounders, an independent association between neonatal composite outcome and TOL following two CDs was not demonstrated.Conclusion: For parturients with a history of two CDs, when a strict protocol for selecting appropriate candidates is followed, TOL is a reasonable alternative to repeat CD and is associated with favorable maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive. The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not. An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied. Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear. It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions. [ABSTRACT FROM AUTHOR]

Knowledge about labour characteristics of women achieving successful vaginal birth after caesarean section (VBAC) might be used to improve labour and birth management. This study examined sociodemographic and labour process-related factors regarding a) differences between countries, b) the comparison of successful VBAC with unplanned caesarean section, and c) predictors for the success of planned VBAC in three European countries. We analysed observational data collected within the OptiBIRTH trial, a cluster-randomised controlled trial. Fifteen study sites in Ireland, Italy and Germany, five in each country. 790 participants going into labour for planned VBAC. Descriptive statistics and random-effects logistic regression models were applied. The pooled successful VBAC-rate was 74.6%. Italy had the highest proportion of women receiving none of the four intrapartum interventions amniotomy (ARM), oxytocin, epidural or opioids (42.5% vs Ireland: 26.8% and Germany: 25.3%, p < 0.001). Earlier performance of ARM was associated with successful VBAC (3.50 hrs vs 6.08 hrs, p = 0.004). A positive predictor for successful vaginal birth was a previous vaginal birth (OR=3.73, 95% CI [2.17, 6.44], p < 0.001). The effect of ARM increased with longer labour duration (OR for interaction term=1.06, 95% CI [1.004, 1.12], p = 0.035). Higher infant birthweight (OR per kg=0.34, 95% CI [0.23, 0.50], p < 0.001), ARM (reference spontaneous rupture of membranes (SROM), OR=0.20, 95% CI [0.11, 0.37], p < 0.001) and a longer labour duration (OR per hour=0.93, 95% CI [0.90, 0.97], p < 0.001) decreased the odds of a vaginal birth. Women with a previous vaginal birth, an infant with a lower birth weight, SROM and a shorter labour duration were most likely to have a successful vaginal birth. If SROM did not occur, an earlier ARM increased the odds of a vaginal birth. Labour progress should be accelerated by fostering endogenous uterine contractions. With slow labour progress and intact membranes, ARM might increase the chance of a vaginal birth. [ABSTRACT FROM AUTHOR]

Objective: Caesarean section is increasing in prevalence and with it the proportion of women going into their next pregnancy with a scar on their uterus. For women considering vaginal birth after caesarean (VBAC), accurate information about the associated risks is required.Study Design: The cohort comprised 192,057 women who had a vaginal delivery of a singleton, term, cephalic infant between the 1st April 2013 and the 31st March 2014 in England: 182,064 women who were having their first baby, and 9993 women who were having a second baby after a previous caesarean delivery. Their risk of an obstetric anal sphincter injury (OASI) was compared using a mixed-effects logistic regression model, adjusting for maternal age, use of instrument, episiotomy, prolonged labour, shoulder dystocia, and demographic factors.Results: The OASI rate was 5.0% in primiparous women, 5.8% in secondiparous women undergoing VBAC after previous elective caesarean, and 7.6% in secondiparous women undergoing VBAC after previous emergency caesarean. Women having a VBAC for their second baby following an emergency caesarean section in their first delivery had a higher rate of OASI than primiparous women (adjusted OR 1.31; 95% CI: 1.20, 1.43), For women with a previous elective delivery, the rates are similar to those for primiparous women.Conclusion: Women having a VBAC after emergency caesarean have a higher rate of OASI than primiparous women. This is important in the counselling of women considering VBAC. [ABSTRACT FROM AUTHOR]

Objective: This study investigated how health care provider communication of risk information, and women's role in decision-making, influenced women's preferences for mode of birth after a previous caesarean birth.Methods: Women (N = 669) were randomised to one of eight conditions in a 2 (selectivity of risk information) × 2 (format of risk information) × 2 (role in decision making) experimental design. After exposure to a hypothetical decision scenario that varied information communicated by an obstetrician to a pregnant woman with a previous caesarean birth across the three factors, women were asked to decide their preferred hypothetical childbirth preference.Results: Women provided with selective information (incomplete/biased toward repeat caesarean) and relative risk formats (ratio of incidence being compared e.g. 2.5 times higher), perceived lower risk for caesarean and were significantly more likely to prefer repeat caesarean birth than those provided with non-selective information (complete/unbiased) and absolute risk formats (incidence rate e.g. 0.01 per 100). Role in decision-making did not significantly influence childbirth preferences CONCLUSIONS: Modifiable aspects of healthcare provider communication may influence women's decision-making about childbirth preferences PRACTICE IMPLICATIONS: Optimised communication about risks of all options may have an impact on over-use of repeat CS. [ABSTRACT FROM AUTHOR]

Objective: External cephalic version is commonly not performed in women with a previous cesarean section. Fear of uterine rupture and cesarean section in labor are prominent. The risks, however, of these are unclear. This study aims to document the safety and efficacy of external cephalic version in women with a prior cesarean section in a series of 100 consecutive attempts, and to perform a literature of the existing literature.Study Design: This is a retrospective cohort study of prospectively collected data of external cephalic version attempts in women at term with a previous cesarean section, and a literature review of previously published series. External cephalic version was performed by one of 3 experienced operators, with salbutamol tocolysis if appropriate, using ultrasound to visualize the fetal heart and place of fetal parts.Results: 100 women with a prior cesarean section underwent external cephalic version over a 16-year period in one institution. 68% had no previous vaginal delivery. The external cephalic version success rate was 50%, and 30 (63.8%) of these subsequently delivered vaginally. There were no cases of uterine rupture or other complications. A literature review of series containing a total of 549 cases revealed no cases of uterine rupture or perinatal death.Conclusions: External cephalic version in women with a prior cesarean section is safe but enables a vaginal birth in only about a third of women. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess, if the biomechanical properties of the lower uterine segment (LUS) in women with a previous cesarean section (CS) can be determined by ultrasound (US) elastography. The first aim was to establish an ex-vivo LUS tensile-stress-strain-rupture(break point) analysis with the possibility of simultaneously using US elastography. The second aim was to investigate the relationship between measurement results of LUS stiffness using US elastography in-/ex-vivo with results of tensile-stress-strain-rupture analysis, and to compare different US elastography LUS-stiffness-measurement methods ex-vivo.Study Design: An explorative experimental, in-/ex-vivo US study of women with previous CS was conducted. LUS elasticity was measured by point Shear Wave Elastography (pSWE) and bidimensional Shear-Wave-Elastography (2D-SWE) first in-vivo during preoperative examination within 24 h before repeat CS (including resection of the thinnest part of the LUS = uterine scar area during CS), second within 1 h after operation during the ex-vivo experiment, followed by tensile-stress-strain-rupture analysis. Pearson's correlation coefficient and scatter plots, Bland-Altman plots and paired T-tests, were used.Results: Thirty three women were included in the study; elastography measurements n = 1412. The feasibility of ex-vivo assessment of LUS by quantitative US elastography using pSWE and 2D-SWE to detect stiffness of LUS was demonstrated. The strongest correlation with tensile-stress-strain analysis was found in the US elastography examination carried out with 2D-SWE (0.78, p < 0.001, 95%CI [0.48, 0.92]). The laboratory experiment illustrated that, the break point - as a surrogate marker for the risk of rupture of the LUS after CS - is linearly dependent on the thickness of the LUS in the scar area (Coefficient of correlation: 0.79, p < 0.001, 95%CI [0.55, 0.91]). Two extremely stiff LUS-specimens (outlier or extreme values) rupture even at less stroke/strain than would be expected by their thickness.Conclusion: This study confirms that US elastography can help in determining viscoelastic properties of the LUS in women with a previous CS. The data from our small series are promising. However whether individual extreme values of high stiffness and consecutive restricted biomechanical resilience can explain the phenomenon of rupture during TOLAC in cases of LUS with adequate thickness remains a question which prospective trials have to analyze before US elastography can be introduced into clinical practice. [ABSTRACT FROM AUTHOR]

Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase. The national caesarean section (CS) rate in the UK is almost 25%, having increased by 5.7% in the last 10 years. A rising primary CS rate is a significant contributor to this trend. The latest available data show that almost 1 in 5 women in the world now give birth by CS. The World Health Organisation states that, when medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean sections are associated with short and long-term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. There are two standard care pathways for women having childbirth following previous CS – Vaginal Birth After Caesarean (VBAC) or Elective Repeat CS (ERCS). Attempting a VBAC is a safe and appropriate choice that must be offered to most women who have had a prior caesarean delivery. Approximately 70–75% of women who attempt VBAC will have a successful vaginal delivery. Focused antenatal counselling sessions highlighting the risks and benefits of VBAC vs ERCS may impact upon the pathway a woman chooses. Continued counselling and discussion of relative risks versus benefits will also encourage patient choice and help support the woman throughout antenatal and intrapartum periods. [ABSTRACT FROM AUTHOR]

The cesarean delivery rate in the United States has risen steadily over the past 5 decades such that approximately one in three women now undergo cesarean section. The rise in repeat operations and accompanying decline in trial of labor after cesarean (TOLAC) have been major contributors to this phenomenon. The appropriate use of TOLAC continues to be a topic of interest with the recognition that most women with a history of prior cesarean are candidates for trial of labor. The NICHD MFMU Network Cesarean Registry conducted from 1999 to 2002 provided contemporary data concerning the risks and benefits of TOLAC, which in turn have helped inform practitioners and women considering their options for childbirth following cesarean delivery. [ABSTRACT FROM AUTHOR]

Valence band anticrossing (VBAC) model has been used to explain the strong reduction in band gap as well as the increase in spin–orbit splitting energy with increasing bismuth incorporation in InAs 1− x Bi x , InSb 1 − x Bi x and InP 1− x Bi x . This effect is shown to be due to the restructuring of the valence band as a result of the anticrossing interaction of the extended states of the valence band of the host semiconductor with the Bi related impurity states. The anticrossing interaction causes the splitting of the light hole (LH), heavy hole (HH) and spin–orbit split-off (SO) bands into E + and E − sub bands. The upward movement of the LH/HH and SO E + energy level is responsible for the reduction in bandgap and increase in spin–orbit splitting energy in bismides. The calculated values of the band gap reduction show good agreement with available experimental results. Band dispersion relations for these bismides in the Λ , Δ , and Σ directions are also calculated using the k ⋅ p method. [ABSTRACT FROM AUTHOR]

The reduction in band gap as well as the increase in spin–orbit splitting energy in GaSb 1− x Bi x and GaP 1−x Bi x are explained by the Valence Band Anticrossing (VBAC) model. This restructuring of the valence band is due to the interaction of the Bi related impurity levels with the extended states of the valence band of the host semiconductor. The band gap reduction in GaSb 1− x Bi x and GaP 1− x Bi x calculated using VBAC model are respectively 40.2 meV and 206 meV/at% Bi. A comparison of the theoretical and experimentally obtained values of band gap in GaSbBi shows good agreement. Valence band structure for GaPBi is obtained by the extrapolation of the parameters used for modeling of the GaSbBi system. The upward movement of the spin–orbit split-off E + energy level in GaSbBi by 19.2 meV/at% Bi is also responsible for the suppression of Auger recombination processes making it a potential candidate for near and mid-infrared optoelectronic applications. [ABSTRACT FROM AUTHOR]

Caesarean section (CS) has evolved from a procedure with considerable morbidity and mortality risks into one that is safe enough to be considered as a matter of maternal choice in high resource countries. Improvements in operative techniques, anaesthesia, intensive care, blood transfusion services and availability of antibiotics have all contributed to improved safety of the procedure for pregnant women. Rates of CS are rising all over the world and so are the rates of vaginal birth after caesarean (VBAC). Attempting a VBAC is a safe and appropriate choice that must be offered to most women who have had a prior caesarean delivery. Approximately 70–75% of women who attempt VBAC will have a successful vaginal delivery. However VBAC is associated with risks for both mother and the baby. The possibility of uterine rupture in labour ranges from 3 to 7 per 1000 pregnancies while the risk of perinatal death or severe morbidity should uterine rupture occur is higher with trial of vaginal delivery than with repeat caesarean delivery. These risks and the associated medico-legal sequelae have resulted in revised national and international guidelines with focus on antenatal counselling, individualised risk assessment as well as stringent facility and personnel requirements to conduct VBAC. [ABSTRACT FROM AUTHOR]

Aim Vaginal birth after caesarean (VBAC) is a relatively safe alternative to repeat caesarean birth in the proper context. This important decision to undergo an elective caesarean versus VBAC is ultimately a decision of the mother. The purpose of our study was to assess the quality of online information in relation to VBAC collected using the most common search engine: Google. Methods The 10 most common hit sites for the keywords “VBAC” and “Vaginal birth after caesarean” were evaluated using the search engine Google. The quality of websites was rated based on the Silberg scale for accountability, the modified Abbott's criteria for presentation and the SMOG index for readability. The content of each website was compared to the Society of Obstetricians and Gynecologists of Canada (SOGC) guidelines for VBAC. Findings 13 out of 20 identified websites met the adequate criteria for accountability, with 85% of the websites indicating authorship. 11 websites were deemed aesthetically agreeable. The target audience, assessed by the readability score, was notably above the non-medical population with an average SMOG index score of 14.75. Only half of the websites contained recommendations, as detailed by the SOGC guidelines. Conclusion Almost all sites target a higher academic level, making it beyond the comprehension of the general population. Woman friendly web-assessment tools should be provided to enable pregnant women to take an active role in their decision making. [ABSTRACT FROM AUTHOR]

Abstract: Objective: vaginal birth after caesarean (VBAC) is a controversial issue with strong opinions for and against. The means in which women work through the different opinions and options using the internet should be of interest to midwives, obstetricians and policy makers. The aim of this study was to examine how women use English language internet blog sites to discuss the option of VBAC and what factors influence these women''s decision to have a VBAC or repeat caesarean section. Design: a qualitative study using internet blog sites as the source of data was undertaken. Google alerts were created to search for the term VBAC in internet blogs. These alerts were sent to the first author''s email account daily for a one-year period (November 2007 to October 2008) and downloaded. The content was analysed using thematic analysis. Findings: there were 311 blogs mentioning the word VBAC in the one-year period. Most of the blog sites and discussion originated from the USA. There were more blogs written during the Northern Hemisphere winter months than during other seasons. The main theme identified was a dichotomy in philosophical framework women held about birth; that is a ‘motherbirth’ or ‘childbirth’ framework. Whether women eventually wrote that they chose a VBAC or repeat caesarean or the extent to which they pursued their birth choice depended on whether they came from a perspective that a ‘good parent sacrifices themselves for their baby (prioritises the baby) and takes no risks’ (childbirth) or that ‘giving birth matters to the woman and a happy, healthy mother is a happy healthy baby (mother and baby have equal priority)’ (motherbirth). Several themes were identified including: surviving the damage; inadequate bodies; choice and control; fearing and trusting birth; negotiating the system; and minimising or overestimating risk. Key conclusion: women filtered their decision making regarding VBAC through a belief system that prioritises according to their personal approaches. Implications for clinical practice: blogging may be providing a valuable insight into factors that inform decision making and may provide a forum of information and support for women who have experienced a caesarean section. [Copyright &y& Elsevier]

Abstract: Objective: To compare birth recommendations for pregnant women with a prior cesarean produced from a decision model using absolute risks vs. one using subjective interpretation of the same risks: (1) a multiattribute decision model based on patient prioritization of risks (subjective risk) and (2) a hybrid model that used absolute risks (objective risk). Study Design and Setting: The subjective risk multiattribute model used the Analytic Hierarchy Process to elicit priorities for maternal risks, neonatal risks, and the delivery experience from 96 postnatal women with a prior cesarean. The hybrid model combined the priorities for delivery experience obtained in the first model with the unadjusted absolute risk values. Results: The multiattribute model generated more recommendations for repeat cesarean delivery than the hybrid model: 73% vs. 18%, (P-value <0.001). The multiattribute model favored repeat cesarean because women heavily prioritized avoiding any risk (even rare risk) to the infant. The hybrid model favored the trial of labor because of lower probabilities of risk to the mother and its high success rate of vaginal birth after cesarean. Conclusion: This study highlights the importance of patients and clinicians discussing the patient''s priorities regarding the risks and other nonclinical considerations that may be important to her in the birthing decision. [Copyright &y& Elsevier]

Abstract: The authors studied the presence of substance P (SP) and vasoactive intestinal polypeptide (VIP) and their related fibers in the lower uterine segment (LUS) in 133 women undergoing cesarean sections (CS) during active labor. These were divided into 2 groups: women undergoing repeat or first CSs. Specimens were collected from the LUS and were evaluated by light microscopy and by immunohistochemistry, for the morphometrical quantification of the SP and VIP fibers in the LUS. The SP amount was higher in the post-CS scar, while the VIP amount decreased: nerve fibers contained an SP amount of up to 13±2.6C.U., while nerve fibers contained a VIP amount of up to 7±1.9C.U. The SP amount counts 10±1.5% of the total Bodian fibers, and the ratio of the VIP is 10±1.8% of their total amount. In normal conditions only 6.61C.U. of the Bodian surface is occupied by SP related nerve fibers in contrast to 6.63C.U. of the total surface by VIP; the amount of SP increased up to 13±2.6C.U., while it decreased in the LUS previous scars. The SP levels are higher in repeat CS, while the VIP levels are reduced in the LUS. The increase of SP is probably linked to the attempt to achieve cervical ripening in a post-CS LUS, with the possible consequences of dystocia during vaginal birth after CS. Nevertheless, the decrease of VIP probably affects the relaxation of the internal uterine orifice, compromising the LUS formation and cervical ripening. [ABSTRACT FROM AUTHOR]

The promulgation of the immediately available physician standard has contributed to the rapid decline in vaginal birth after cesareans (VBACs). While having an immediately available obstetrician during a VBAC trial will reduce risk, it is not clear that similar advantage wouldn''t also accrue to women without uterine scars. However, many hospitals can''t staff up to that standard. In this article we suggest 1) set a goal of providing an immediately available team for all women in labor, 2) tailor informed consent to women''s unique risks– unique because of their own risk profile (e.g., previous scar, hypertension, etc) or unique because of characteristics of the birthing site (e.g. a team is or is not available), 3) in smaller hospitals, if an immediately available team cannot be routinely provided, consideration should be given to bringing in a team for the occasional patient requesting a trial, and to allowing labor for lower risk trials. [Copyright &y& Elsevier]

Childbirth is almost always a wonderful and joyous experience. Parents often begin planning for their baby before they are pregnant. They develop their birth plan and look forward to holding their perfect baby. Sometimes this is just not what happens. Something may occur at conception or during the pregnancy, which causes their joy to shatter, and they experience the most dreadful grief. There are some occasions when problems arise during labor. Although an infrequent occurrence, it adds sorrow and anger to the situation. The case study presented here is that kind of happening. There were mistakes made in recognition of deterioration of the fetal well-being. This lack of recognition and treatment resulted in death of the long awaited baby who would have added joy and not grief to this family. [Copyright &y& Elsevier]

Uterine rupture is the most serious complication for women undergoing trial of labor (TOL) after prior cesarean delivery. While rates of uterine rupture vary significantly according to a variety of clinically associated risk factors, the absolute risk for this complication ranges between 0.5 and 4 percent. Previous vaginal delivery and prior successful vaginal birth after cesarean delivery confer the lowest risk of rupture on women attempting TOL. In contrast, multiple prior cesareans, short interpregnancy interval, single layer uterine closure, prior preterm cesarean, labor induction and augmentation have all been suggested in some studies as factors which may increase the rate of uterine rupture. While considering these risk factors is important in counseling women regarding childbirth following cesarean delivery, the infrequency of uterine rupture coupled with relatively weak associations for most risk factors has prevented the development of an accurate prediction tool for uterine rupture. Preliminary studies suggest that sonographic evaluation of the uterine scar may hold some promise for identifying women at risk. [Copyright &y& Elsevier]

There have been multiple observational studies that have assessed the probability that a woman who undertakes a trial of labor after a previous cesarean delivery will have a vaginal birth. These studies have demonstrated a population-level probability of a successful vaginal birth after cesarean (VBAC) that ranges between 60% and 80%. However, within a population the chances for success of a given individual may vary to a significant degree on the basis of particular demographic characteristics and obstetric history. This review summarizes the different characteristics that have been prominently associated with successful VBAC as well as the different attempts that have been made to develop accurate prediction models for successful VBAC. [Copyright &y& Elsevier]

Objective: The purpose of this study was to assess the maternal morbidity associated with attempted vaginal birth after cesarean (VBAC) in twin gestations using a large, nationwide sample of deliveries. Study design: Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, a representative sample of discharges from non-Federal hospitals, for the years 1993 to 2002. Patients admitted nonemergently for the delivery of twin gestations who had a history of previous cesarean delivery were selected. Patients that either delivered vaginally or who had discharge codes that indicated labor before cesarean delivery were defined as the trial of labor group, while patients who had a cesarean delivery without discharge codes that indicated labor were defined as the elective cesarean group. Various complications of delivery were analyzed for each group. Results: We identified 4705 women who underwent an elective cesarean delivery and 1850 women who underwent a trial of labor. For women who had a trial of labor, 836 (45.2%) delivered vaginally. The rate of uterine rupture was higher in the trial of labor group than in the elective cesarean group (0.9% vs 0.1%, P < .001), and the rate of wound complications was lower (0.6% vs 1.3%, P < .02). The rates of other complications including hysterectomy, transfusion, major postpartum infection, thromboembolism, uterine dehiscence, and pelvic hematoma were not significantly different between the 2 groups. Conclusion: Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies. [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to use multivariable methods to develop clinical predictive models for the occurrence of uterine rupture by using both antepartum and early intrapartum factors. Study design: This was a planned secondary analysis from a multicenter case-control study of uterine rupture among women attempting vaginal birth after cesarean (VBAC) delivery. Multivariable methods were used to develop 2 separate clinical predictive indices-one that used only prelabor factors and the other that used both prelabor and early labor factors. These indices were also assessed with the use of Receiver operating characteristic curves. Results: We identified 134 cases of uterine rupture and 665 noncases. No single individual factor is sufficiently sensitive or specific for clinical prediction of uterine rupture. Likewise, the 2 clinical predictive indices were neither sufficiently sensitive nor specific for clinical use (receiver operating characteristic curve [area under the curve] 0.67 and 0.70, respectively). Conclusion: Uterine rupture cannot be predicted with either individual or combinations of clinical factors. This has important clinical and medical-legal implications. [ABSTRACT FROM AUTHOR]

Systematic study on the incorporation effect of dilute Bismuth (Bi) in zinc blende (ZB) phase Indium Arsenide (InAs) is performed taking the full-potential linearized augmented plane wave (FPLAPW) basis sets, the Perdew-Burke-Ernzerh of generalized gradient approximation (PBEsol) exchange correlation (XC) functional, Modified Becke-Johnson (mBJ) potential in the density functional theory (DFT) computation and valence band anticrossing (VBAC) model. Comparatively larger atomic sized Bi impurity in InAs leads to increment in the lattice constant, non-linear reduction of bulk modulus, decrease the bandgap by 31.17 meV/Bi%, and increase the spin-orbit coupling splitting energy (Δ S O ) by 18.35 meV/Bi%. A consistent redshift in the optical spectra towards the > 3 μm region is observed for increasing Bi concentration, which makes InAs 1-x Bi x a suitable candidate for the atmospheric infrared transmission windows at 3–5 and 8–12 μm. A reasonably higher value of Δ S O compared to the direct bandgap mitigate the Auger like non-radiative recombination losses in LASERs and Photodetectors. Computed thermoelectric properties like Seebeck coefficient and electrical conductivity reflects the superiority of Bi incorporation in InAs. Nevertheless, Bi impurity leads to reduction in carrier effective mass in InAs 1-x Bi x , which opens up the possibility to utilize it in High Electron Mobility Transistors (HEMTs) devices. [ABSTRACT FROM AUTHOR]

Background: Women who seek vaginal birth after cesarean delivery may find limited in-hospital options. Increasing numbers of women in the United States are delivering by vaginal birth after cesarean delivery out-of-hospital. Little is known about neonatal outcomes among those who deliver by vaginal birth after cesarean delivery in- vs out-of-hospital.Objective: The purpose of this study was to compare neonatal outcomes between women who deliver via vaginal birth after cesarean delivery in-hospital vs out-of-hospital (home and freestanding birth center).Study Design: We conducted a retrospective cohort study using 2007-2010 linked United States birth and death records to compare singleton, term, vertex, nonanomolous, and liveborn neonates who delivered by vaginal birth after cesarean delivery in- or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth-setting risk differences. Analyses were stratified by parity and history of vaginal birth. Sensitivity analyses that involved 3 transfer status scenarios were conducted.Results: Of women in the United States with a history of cesarean delivery (n=1,138,813), only a small proportion delivered by vaginal birth after cesarean delivery with the subsequent pregnancy (n=109,970; 9.65%). The proportion of home vaginal birth after cesarean delivery births increased from 1.78-2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures, 23 [0.02%] vs 6 [0.19%; P<.001]; Apgar score <7, 2859 [2.68%] vs 139 [4.42%; P<.001; Apgar score <4, 431 [0.4%] vs 23 [0.73; P=.01]). A similar, but nonsignificant, pattern of increased risk was observed for neonatal death and ventilator support among those neonates who were born in the out-of-hospital setting. Multivariate regression estimated that neonates who were born in an out-of-hospital setting had higher odds of poor outcomes (neonatal seizures [adjusted odds ratio, 8.53; 95% confidence interval, 2.87-25.4); Apgar score <7 [adjusted odds ratio, 1.62; 95% confidence interval, 1.35-1.96]; Apgar score <4 [adjusted odds ratio, 1.77; 95% confidence interval, 1.12-2.79]). Although the odds of neonatal death (adjusted odds ratio, 2.1; 95% confidence interval, 0.73-6.05; P=.18) and ventilator support (adjusted odds ratio, 1.36; 95% confidence interval, 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by vaginal birth after cesarean delivery in out-of-hospital settings had higher odds of neonatal morbidity and death compared with women of higher parity. Women who had not birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery had higher odds of neonatal morbidity and mortality compared with women who had birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery. Sensitivity analyses generated distributions of plausible alternative estimates by outcome.Conclusion: Fewer than 1 in 10 women in the United States with a previous cesarean delivery delivered by vaginal birth after cesarean delivery in any setting, and increasing proportions of these women delivered in an out-of-hospital setting. Adverse outcomes were more frequent for neonates who were born in an out-of-hospital setting, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availability of in-hospital vaginal birth after cesarean delivery and suggests that there may be benefit associated with increasing options that support physiologic birth and may prevent primary cesarean delivery safely. Results may inform evidence-based recommendations for birthplace among women who seek vaginal birth after cesarean delivery. [ABSTRACT FROM AUTHOR]

A gravida 10 para 9, after one Cesarean section (CS) followed by four vaginal deliveries was admitted at term without uterine contractions complaining of abdominal pain. The type of uterine scar was unknown. Severe bradycardia was observed at admission and an emergency Cesarean section was performed. A complete uterine rupture was revealed, the fetus in intact membranes and placenta were found in the abdominal cavity. [Copyright &y& Elsevier]

Objective: We investigated the effect of interpregnancy body mass index (BMI) change on success of term vaginal birth after cesarean (VBAC) among normal, overweight and obese women. Study Design: Using 1992-2009 Washington State birth certificate data linked with hospitalization records, we conducted a population-based retrospective cohort study of nulliparous women (BMI ≥18.5 kg/m2) with a primary cesarean in their first birth and a term trial of labor in their second. Interpregnancy weight change (difference between first and second prepregnancy BMIs) was categorized as maintenance (<1 BMI unit change), loss (≥1 unit), moderate gain (≥1 and <2 units), high gain (≥2 units). We estimated relative risks of VBAC success using generalized linear models with a log-link function, adjusting for maternal age, race/ethnicity, nativity, marital status, education, smoking, primary cesarean indication, interpregnancy interval, birth year for second birth, and prenatal care adequacy. Results: Among 8302 women who attempted a term trial of labor, 65% had a successful VBAC. Women with normal BMI before their first pregnancy experienced an 8% decrease in VBAC success with moderate gain (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87–0.98) and a 12% decrease in success with high gain (RR, 0.88; 95% CI, 0.83–0.93), compared with normal weight women who maintained weight. Weight loss increased VBAC success in women who were overweight (RR, 1.12; 95% CI, 1.01–1.25) or obese before their first delivery (RR, 1.24; 95% CI, 1.04–1.49), compared with overweight and obese women, respectively, who maintained weight. Conclusion: Women can improve their chance of successful VBAC through interpregnancy weight management. [Copyright &y& Elsevier]

Objective: The purpose of this study was to estimate the effect of gestational age at the time of prior cesarean on maternal morbidity in women attempting vaginal birth after cesarean delivery (VBAC). Study Design: A retrospective cohort study of women attempting VBAC, comparing women with a prior cesarean delivery ≤ 34 completed weeks to women with a prior cesarean delivery > 34 weeks. The primary outcome was maternal morbidity, including uterine rupture. Univariable, stratified, and multivariable analyses were used to estimate the effect of a prior cesarean performed at ≤ 34 weeks on maternal morbidities. Results: Of 19,474 women with 1 prior cesarean, 12,535 attempted VBAC and 508 of those had a previous cesarean ≤ 34 weeks. Study groups had similar risks of uterine rupture (adjusted OR [AOR], 1.5; 95% CI, 0.7-3.5; P = .32) and composite morbidity (AOR, 0.9; 95% CI, 0.5-1.8; P = .81). Conclusion: Prior cesarean delivery at ≤ 34 weeks'' gestation does not appear to increase the risk of maternal morbidity in a subsequent VBAC attempt. [Copyright &y& Elsevier]

Objective: To compare maternal and neonatal outcomes after successful and failed trials of labor after cesarean in women at term, excluding uterine ruptures, and to examine predictors of successful and failed trials of labor. Study Design: Matched maternal and neonatal data from 1993-1999 in women with singleton term pregnancies with prior cesarean undergoing trial of labor were reviewed. Women with uterine rupture were excluded. Maternal and neonatal outcomes were analyzed for successful and failed trials. Predictors of success and failure were examined. Results: 1284 women and their neonates were available for analysis. 1094 (85.2%) had a vaginal birth and 190 (14.8%) underwent repeat cesarean. Failed trials of labor were associated with higher incidence of choriamnionitis (25.8% vs. 5.5%, P<.001), postpartum hemorrhage (35.8% vs. 15.8%, P<.001), hysterectomy (1% vs. 0%, P=.022), neonatal jaundice (17.4% vs.10.2%, P=.004) and composite major neonatal morbidities (6.3% vs. 2.8%, P=.014). Conclusion: Failed trial of labor in women at term with prior cesarean is associated with increased maternal and neonatal morbidities. [Copyright &y& Elsevier]