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Objective To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle—a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). Methods A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician–patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. Results The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. Conclusions A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

Objective To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. Methods Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. Results The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. Conclusion The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Background The advanced maternal age rate increases in developed countries. Older women have more pre-existing condition than youngest women and develop more frequently obstetrical pathologies responsible for a higher rate of caesarean delivery before labour and labour induction. For aged nulliparous without pathology who experience spontaneous labour, there is few data on the mode of delivery and on physiological labour according to maternal age. Objective To compare the intrapartum caesarean delivery rate according to maternal age, for nulliparous with planned vaginal delivery and spontaneous labour at term. Methods Retrospective cohort in a single academic institution between January 2000 and June 2017. All nulliparous women with planned vaginal delivery with live singleton in cephalic presentation at and after 37 weeks of gestation with spontaneous labour were included (n = 10,611). Two groups were compared: nulliparous women aged 20–34 and nulliparous women aged 35 and over. The main outcome was the intrapartum caesarean delivery rate. A subgroup analysis was performed for nulliparous with more advanced maternal age defined as women over 40. Results Among the 10,611 women included in this analysis, 8,993 (84.8%) were aged 20–34 and 1,618 (15.2%) were aged over 35. From the latter 367 (22.7%) were over 40 years old. The intrapartum caesarean delivery rate was similar between women aged between 20 and 34 and women aged over 35 (10.8% compared to 8.8%; cOR 0.91, 95% CI 0.76–1.08; aOR 0.91, 95% CI 0.76–1.09). The indications of caesarean were similar in both groups. No differences were found between both groups for mean labour duration (430.9 min for the [20–34] years group compared to 428.0 min for the over 35 years group, p = 0.654). The subgroup analysis performed on nulliparous with more advanced maternal age yielded similar results. Conclusion For nulliparous at term in spontaneous labour, an advanced maternal age was not associated with an increased intrapartum caesarean delivery rate.

Objective Biomechanics of pelvic floor muscles is becoming an important field of research in understanding a complex process of labour. Current evidence indicates that the levator ani stretches to allow passage of the fetus through the birth canal. We sought to identify properties of the functional female pelvic floor during pregnancy that could help to predict the mode of delivery, especially in women who underwent caesarean section in the past. Methods A single centre prospective cohort study of pregnant women in the 3rd trimester attending antenatal clinic. Participants were categorised into three groups: 1. nulliparous, 2. previous one vaginal delivery and 3. previous one caesarean section who chose a trial of labour in their current pregnancy. All women underwent ultrasonographic evaluation of their pelvic floor muscles. Distensibility and the mode of delivery were assessed in participants’ current pregnancies. The primary outcome was the mode of delivery. ANOVA test was used for statistical analysis. Results 133 women were included: 55 nulliparous, 52 primiparous (previous one vaginal birth), and 26 primiparous (previous one LSCS and planned for vaginal delivery after caesarean (VBAC)). Participants were scanned at an average gestation of 32 weeks. The inter-observer reliability test for puborectalis distensibility was good (kappa 0.75). Overall, women who delivered vaginally had a more distensible puborectalis muscle than those who delivered by emergency LSCS regardless of their previous type of delivery. Women who underwent a successful VBAC had less distensible pelvic floor muscles compared to their nulliparous and primiparous counterparts (who delivered vaginally in the past). Conclusion These results support our basic conceptual theory of puborectalis muscle distensibility influencing the mode of delivery and endorse application of dynamic pelvic floor ultrasound in future studies. We identified measurable differences in the functional female pelvic anatomy aiding a better understanding of physiology of the labour. There are trends towards lesser distensibility in women who delivered by LSCS.

To compare the demographic and clinical characteristics between women who chose elective repeat Caesarean section (ERCS) versus trial of labour after Caesarean section (TOLAC) in St. John's, Newfoundland and Labrador (NL).We conducted a retrospective case control study of women with live singleton gestations delivering at term in St. John's, NL between January 1, 2001 and December 31, 2014. Inclusion criteria were women who had a previous single lower segment Caesarean section (LSCS). TOLAC, successful TOLAC, and VBAC rates were calculated. Demographic and clinical characteristics were compared between women who chose ERCS versus TOLAC. Univariate analyses and multiple logistic regression analyses were performed, and adjusted odds ratios (aOR) and 95% CIs were calculated.A total of 1579 women were included, of whom 160 (10.1%) chose TOLAC, with 107 resulting in successful VBAC (67% successful TOLAC rate). The overall VBAC rate was 6.8%. Women who chose ERCS compared with those who chose TOLAC were more likely to be obese (aOR 3.20, 95% CI 1.85-5.54, P 0.001), less likely to have had GA at delivery greater than 40 weeks (aOR 0.13, 95% CI 0.08-0.21, P 0.001), less likely to have had a previous vaginal delivery (aOR 0.40, 95% CI 0.20-0.80, P 0.001), and less likely to have had the previous CS for breech presentation (aOR 0.51, 95% CI 0.33-0.80, P = 0.003).The overall TOLAC and VBAC rates in St. John's are low when compared with reported national rates. The successful TOLAC rate is within the expected range reported in the literature. Differences exist between women who chose ERCS compared with TOLAC.

Objective To explore nulliparous women's perceptions of decision making regarding mode of delivery under China's two-child policy. Design Qualitative descriptive design with in-depth semi-structured interviews. Setting Postnatal wards at a tertiary specialized women's hospital in Shanghai, China. Participants 21 nulliparous women 2–3 days postpartum were purposively sampled until data saturation. Methods In-depth semi-structured interviews were conducted between October 8th, 2015 and January 31st, 2016. Results Two overarching descriptive categories were identified: (1) women's decision-making process: stability versus variability, and (2) factors affecting decision making: variety versus interactivity. Four key themes emerged from each category: (1) initial decision making with certainty: anticipated trial of labour, failed trial of labour, ‘shy away' and compromise, anticipated caesarean delivery; (2) initial decision making with uncertainty: anticipated trial of labour, failed trial of labour, ‘shy away' and compromise; (3) internal factors affecting decision making: knowledge and attitude, and childbirth self-efficacy; and (4) external factors affecting decision making: social support, and the situational environment. Conclusion and implications for practice At the initial period of China's two-child policy, nulliparous women have perceived their decision-making process regarding mode of delivery as one with complexity and uncertainty, influenced by both internal and external factors. This may have implications for the obstetric setting to develop a well-designed decision support system for pregnant women during the entire pregnancy periods. And it is recommended that care providers should assess women's preferences for mode of delivery from early pregnancy and provide adequate perinatal support and continuity of care for them.

Objective To determine the proportion of women in Robson group 5 (RG5) who were eligible for a trial of labour after Caesarean (TOLAC) and, among eligible candidates, identify determinants of having a TOLAC and subsequent vaginal delivery (VD). Methods This population-based cohort study used data derived from the Nova Scotia Atlee Perinatal Database. Deliveries from 1998–2014 to women in RG5 (≥1 previous CS with a singleton term cephalic fetus) were included. Eligibility for a TOLAC was based on SOGC criteria. Multivariable logistic regression was used to identify characteristics independently associated with TOLAC and VD. The characteristics associated with VD were used in a logistic model to predict the theoretical probability of VD in women who did not have a TOLAC. Results Of the 15 111 deliveries in RG5, 75.3% were by CS. Of the 14 763 eligible women, 5488 (37.2%) had a TOLAC, of which 3739 (68.1%) resulted in VD. Predictors of VD included high area–level income and either a CS without labour or a spontaneous VD in the preceding pregnancy. While mode of previous delivery also predicted TOLAC among eligible women, high area–level income was associated with reduced odds of TOLAC. The probability of VD in women who did not undergo TOLAC was estimated to be 47.1%, and the lowest CS rate attainable in RG5 was estimated at 46.3%. Conclusions Sociodemographic factors such as income and previous mode of delivery were associated with the rates of TOLAC and subsequent VD in eligible women, and suggest that the Caesarean section rate in RG5 could be safely reduced.

Objective To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section. Outcome Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. Evidence MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. Recommendations 1.Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section (II-2B). 2.The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (II-2B). 3.For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is available. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A). 4.Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely Caesarean section (III-B). 5.In the case of a TOL after Caesarean, an urgent laparotomy should be set-up immediately to facilitate delivery as quickly as possible (III-C). 6.Continuous electronic fetal monitoring of women attempting a TOL after Caesarean section is recommended (II-2A). 7.Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A). 8.Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (II-2A). 9.Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B). 10.Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate counselling (II-2B). 11.Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean section (II-2A). 12.A Foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A). 13.The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture (II-2B). 14.Multiple gestation is not a contraindication to TOL after Caesarean section (II-2B). 15.Diabetes mellitus is not a contraindication to TOL after Caesarean section (II-2B). 16.Suspected fetal macrosomia is not a contraindication to TOL after Caesarean section (II-2B). 17.Women delivering within 18 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B). 18.Postdatism is not a contraindication to a TOL after Caesarean section (II-2B). 19.Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, a TOL after Caesarean section can be offered (II-2B). Validation These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

Polyhydramnios is associated with an increased risk of cesarean section. The aetiology of polyhydramnios and the characteristics of the labour may be confounding factors. The objective was to study the characteristics and mode of delivery in case of pregnancy complicated with idiopathic polyhydramnios.This retrospective matched and controlled study included all pregnant women with idiopathic polyhydramnios (amniotic index25cm or single deepest pocket8cm) diagnosed at the 2nd or 3rd trimester and persistent at term delivery (37weeks of pregnancy) in our institution. We excluded pregnancies in which the polyhydramnios could be explained by infection, gestational diabetes, congenital malformation, abnormal karyotype, placental anomalies, alloimmunization as well as pregnancies in which an amniocentesis for the purpose of diagnosis had not been performed. Data were gathered from a tertiary care university hospital register from 1998-2015. Cases of polyhydramnios were matched with the following two women who presented for labour management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index. The main outcome measure was the risk of cesarean section. Univariate and multivariate adjusted analysis were performed.We identified 108 women with idiopathic polyhydramnios and compared them with 216 matched women. Among them, 94 and 188 attempted a trial of labour. Maternal age, mean term delivery and birthweight were 31 years, 39+5weeks gestation and 3550 g. We did not observe differences in maternal characteristics, epidural analgesia and rate of abnormal fetal heart tracing. Induced labour and non-vertex presentations (forehead, bregma, face) were more frequent in the polyhydramnios group (respectively 57.9% versus 27.8%, P0.05 and 7.8% versus 1%, P0.05). Cesarean section rate was higher in the case of polyhydramnios in the overall population (45.4% versus 8%, P0.05) and remained higher after exclusion of cases of induced labour and non-vertex presentation (38.4% versus 3.8%, P0.05). Amniotomy was more frequent in pregnancies with polyhydramnios (55.8% versus 39.1%, P0.05). After adjustment for matching and confounding variables, polyhydramnios was found to be a risk factor for cesarean section (OR 21.02; CI 95% 8.004-55.215, P0.01).Idiopathic polyhydramnios increased the risk of prolonged first stage of labour, non-vertex presentation and cesarean section.

Objectives To understand the current attitudes and practice patterns of prenatal and intrapartum care providers regarding Trial of Labour After Cesarean Section (TOLAC) and to assess misconceptions regarding eligibility and risks of TOLAC. Methods A survey was developed based on published TOLAC literature, validated by a statistician, and piloted amongst university-affiliated faculty. French and English versions were distributed via the SOGC mailing list. Practicing obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics, correlational and multiple regression analysis. Results The response rate was 33.7% (381/1130 eligible participants) with representation from every Canadian province and territory. Obstetricians/Gynecologists (239, 63%), Family Physicians (100, 26%) and Midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although the majority of respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin compared with cervical foley or amniotomy for induction and offering TOLAC to patients with an unknown uterine scar. Providers in Alberta and Saskatchewan reported more comfort offering TOLAC to patients with more than one previous cesarean section compared to other provinces. Two hundred and nine participants (62%) reported that they had at least one patient with a uterine rupture, with the minority (13, 6%) resulting in litigation. Conclusions This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Objectives This quality improvement (QI) initiative was designed to identify gaps between evidence-based and/or hospital recommendations for TOLAC labour management, and clinical practice. Methods Viable, singleton pregnancies from January 1, 2016 to December 31, 2018 undergoing TOLAC were extracted from the electronic medical record. Sixty (60) randomly selected charts were reviewed for 1) consent 2) induction methods 3) oxytocin use 4) continuous fetal monitoring 5) admission indication 6) exam regularity 7) duration of dystocia prior to decision for cesarean section (CS) 8) maternal complications. Results Institutional VBAC rate was 71%. Documented consent to TOLAC on admission was present in 50% of cases. Oxytocin augmentation was used in 38% of cases and the median max dose was 4 [IQR 3-7.5] mU/min. Delays in initiating oxytocin were identified in 47% of those patients. Decisions to deliver by CS were made after a median time of 5h 40 min [IQR 3h 30m – 6h35m] of failure to progress despite adequate contractions. After this decision, median time to delivery was 1h 11m [IQR 57m–2h 16m]. Complications included post-partum hemorrhage (5%) and chorioamnionitis (6.7%). Surgical injury occurred in 10% of intrapartum CS. Peri-partum complications were associated with delay in oxytocin implementation ((1) = 9.80, p Conclusions Areas for QI were identified in 1) consent, 2) duration of dystocia prior to decision for CS and delay to CS delivery, 3) peri-partum complications. We recognize the potential use of this as a tool to identify areas for QI and prospective study.

Objectives To study the efficacy of a trial of labour after caesarean (TOLAC) bundle in decreasing caesarean delivery (CD) rates across five hospitals. Methods Five hospital sites participated, two tertiary-care centres and three community hospitals. Annual delivery rates ranged from 2500 to 7500 per site. A before and after study design was employed. The bundle consisted of three main interventions: (1) education for health care providers, (2) a TOLAC decision aid, and (3) patient educational tools. A one-year chart review determined baseline CD rates in eligible TOLAC patients, according to SOGC guidelines. The bundle interventions were then introduced every four to six months and CD rates were monitored. Obstetrics staff were provided their individual CD rates using an audit-and-feedback approach prior to introduction of the next intervention. Results Baseline CD rate was 77% (1730 out of 2244 eligible patients). Following the introduction of the bundle, the CD rate decreased to 71% (1497 out of 2096 eligible patients). This is a statistically significant 6% decrease in the CD rate, Χ²(1) = 18.29, p Conclusions This TOLAC bundle can decrease CD rates without negatively impacting uterine rupture or NICU admission rates. The interventions can be easily adapted for use in different hospitals and practice environments.

Objectives To develop and implement a Trial of Labour After Cesarean section (TOLAC) bundle—a group of interventions aimed to decrease the cesarean section (CS) rate in women with a prior CS (Robson 5). Methods A TOLAC bundle was developed including (1) educational rounds for health care providers, (2) a physician-patient TOLAC decision aid, and (3) patient-centered handouts and videos. A before-and-after study design was employed. A one-year chart review determined baseline CS rates in Robson 5 patients at a tertiary care academic center, according to SOGC guidelines. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was introduced every four to six months and modified based on provider feedback. Obstetrics staff physicians were provided with their individual CS rates using an audit-and-feedback approach prior to introduction of the next intervention. Results Baseline CS rate was 70.9% (175 out of 247 eligible patients). Following the introduction of the bundle, the CS rate decreased to 61.2% (131 out of 214 eligible patients). This is a 9.7% decrease in the CS rate, χ²(1) = 4.77, p = 0.029. Also, a significant increase in induction rate was noted, from 4.9% pre-intervention to 10.7% post-intervention, p = 0.017. There was no significant decrease in the vaginal birth after CS rate or increase in uterine rupture or NICU admission rates. Conclusions A TOLAC bundle consisting of provider education, a TOLAC decision aid, and patient resources, combined with audit and feedback, has the ability to decrease CS rates in Robson 5 patients.

Primarily, to assess the performance of three statistical models in predicting successful vaginal birth in patients attempting a trial of labour after one previous lower segment caesarean section (TOLAC). The statistically most reliable models were subsequently subjected to validation testing in a local antenatal population.A retrospective observational study was performed with study data collected from the Northern Ireland Maternity Service Database (NIMATs). The study population included all women that underwent a TOLAC (n=385) from 2010 to 2012 in a regional UK obstetric unit. Data was collected from the Northern Ireland Maternity Service Database (NIMATs). Area under the curve (AUC) and correlation analysis was performed.Of the three prediction models evaluated, AUC calculations for the Smith et al., Grobman et al. and Troyer and Parisi Models were 0.74, 0.72 and 0.65, respectively. Using the Smith et al. model, 52% of women had a low risk of caesarean section (CS) (predicted VBAC72%) and 20% had a high risk of CS (predicted VBAC60%), of whom 20% and 63% had delivery by CS. The fit between observed and predicted outcome in this study cohort using the Smith et al. and Grobman et al. models were greatest (Chi-square test, p=0.228 and 0.904), validating both within the population.The Smith et al. and Grobman et al. models could potentially be utilized within the UK to provide women with an informed choice when deciding on mode of delivery after a previous CS.

Objectives Classical cesarean section may be associated with increased short- and long-term risks. The objectives of this study were to review the following systematically: first, the short-term maternal and infant risks with preterm classical compared with low transverse cesarean sections; and second, the risk of spontaneous or early-labour uterine rupture. Data sources Medline, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from January 1980 to July 2018. Study selection A total of 772 studies were independently screened by two reviewers, and 91 full texts were reviewed. The review included nine studies comparing outcomes after preterm classical versus low transverse cesarean section and 15 studies addressing subsequent pregnancy outcomes. Data synthesis Our primary short-term outcomes were maternal death and intensive care unit (ICU) admission. For subsequent pregnancies, our primary outcome was the risk of spontaneous or early-labour uterine rupture. The data were synthesized using random effects, and odds ratios (ORs) and 95% confidence intervals (CIs) were generated. There were no significant differences between preterm classical and low transverse cesarean sections in the odds of maternal death (OR 2.38; 95% CI 0.15–38.07) or ICU admission (adjusted OR 2.38; 95% CI 0.42–13.35). A subgroup from 28 to 31 weeks gestation had increased risks of endometritis, transfusion, and ICU admission with the classical incision. The low vertical incision was associated with a lower odds of organ injury than was the low transverse incision. The incidence of uterine rupture following the classical incision without a trial of labour was 1%. Conclusion Preterm classical cesarean section is not associated with significantly increased risks, but data are scarce. Subsequent uterine rupture risk when not planning a trial of labour is 1%.

Objective The purpose of this study was to evaluate pregnancy outcomes in a cohort of women with a placental edge between 11 and 20mm from the internal cervical os, and to determine the likelihood of a successful vaginal delivery when trial of labour is attempted in these women. Methods We carried out a prospective observational study of women with singleton pregnancies and a placental edge between 11 and 20mm from the internal cervical os (identified by transvaginal sonography) who underwent a trial of labour. Results Fourteen women with the above characteristics underwent a trial of labour during the study period. The mean interval (± SD) from ultrasound to delivery was 17.2±9.6 days. Thirteen women (92.9%) delivered vaginally with no complications, and only one woman (7.1%) required an emergency Caesarean section for intrapartum bleeding. The risks of antepartum and postpartum hemorrhage were 21.4% and 14.3%, respectively. Conclusion Having a placental edge more than 10mm from the internal os, measured by transvaginal sonography near term, justifies allowing a trial of labour and carries a low risk of subsequent obstetrical hemorrhage.

Pregnant women with a previous Caesarean section face making the decision to undergo an elective repeat Caesarean section or to attempt a trial of labour with the goal of achieving a vaginal birth after Caesarean (VBAC). One of the key factors in counselling these women is the probability of a successful VBAC. We aimed to validate a prediction model for VBAC success.We performed an analysis of women at term with one prior low-transverse Caesarean section and a live cephalic singleton pregnancy who attempted a trial of labour after Caesarean (TOLAC) at 32 hospitals in Quebec between 2008 and 2012. The individual TOLAC probabilities of success were calculated without regard to ethnicity, using a prediction model previously developed in the United States. The predictive ability of the model was assessed using receiver operating characteristic curves and the area under the curve (AUC). In addition, a calibration curve was generated by plotting the predicted and observed VBAC rates.Of 3113 eligible women who underwent TOLAC, we found an overall rate of VBAC of 75.3%. Beyond a predicted probability of 40%, both observed and predicted TOLAC success rates were similar. The accuracy of the model was high (AUC = 0.72; 95% CI 0.70 to 0.74, P0.001) as was the correlation between observed and predicted probabilities of TOLAC success (R² = 0.98). Finally, for women requiring induction of labour, observed and predicted probabilities were similar for a predicted probability ≥ 70%.It is possible to estimate VBAC success accurately in Quebec using a validated prediction model from the United States. This model may be used in practice without regard to ethnicity as a primary method to refine counselling during antepartum visits for women with a prior Caesarean section.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 8 - p. 803-816

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 8 - p. 782-787

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 6 - p. 497-511

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. # 2010 Australian College of Midwives. Published by Elsevier Australia (a division of Reed

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 39 - N° 3 - p. 238-245

Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Validation This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1.Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2.Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3.Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4.With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5.Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1.For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2.Contraindications to labour include a.Cord presentation (II-3A) b.Fetal growth restriction or macrosomia (I-A) c.Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d.d. Clinically inadequate maternal pelvis (III-B) e.Fetal anomaly incompatible with vaginal delivery (III-B) 3.Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000g. (II-2B) Labour Management 4.Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5.Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6.In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7.Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8.A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9.The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10.A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11.The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12.An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13.The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14.The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15.Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16.Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17.At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18.Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19.Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres. (III-B) 20.The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21.In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22.The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23.Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24.Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25.The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26.Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)

To determine differences between family physicians and obstetricians in rates of trial of labour (TOL) attempt, vaginal birth after Caesarean section (VBAC) success, and maternal-fetal complications.We undertook a database evaluation study in an urban Quebec secondary care hospital centre that serves a multiethnic population. Study subjects were pregnant women with at least one previous Caesarean section (CS), who delivered singletons at St. Mary's Hospital Center between January 1995 and December 2003. Outcomes were rates of TOL attempt, of VBAC success and failure, and of uterine rupture or dehiscence.Of 32 500 singleton deliveries, 3694 (11.4%) women met study criteria. Of these, 3493 (94.6%) were patients of obstetricians, and 201 (5.4%) were patients of family physicians. The TOL attempt rate was 50.6% (1768) and 81.1% (163) for obstetricians and family physicians, respectively (P 0.001). For women having TOL, the VBAC success rate was 64.3% for obstetricians and 76.1% for family physicians (P = 0.002). Rates of uterine rupture or dehiscence in the combined failed and successful VBAC groups were 2.9% for obstetricians and 4.3% for family physicians (P = 0.33) whereas in the failed VBAC group the rates were 7.9% versus 17.9% for the family physicians (P = 0.04). Within delivery outcomes for successful and failed VBAC there were no differences in maternal characteristics and newborn outcomes by physician group.More patients of family physicians than of obstetricians attempted TOL and had successful VBAC. Newborn outcomes were similar in the two groups, except that in the failed VBAC group, the family doctors had slightly higher uterine rupture or dehiscence rates; given the low power of this study, further studies are needed to confirm and explain this result. Also, given the similarity in patient profiles, the differences in delivery outcomes may be attributable to differences in physician practice styles.

To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean.Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history.A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason.Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.

The purpose of this article was to perform a critical analysis of publications having estimated the utility of X-ray pelvimetry, in order to allow tangible and useful conclusions for the clinical practice. X-ray pelvimetry was proposed in 3 indications: trial of labour among patients with a history of caesarean section, breech presentation, suspicion of cephalopelvic disproportion. The large majority of these publications are retrospective studies, studying a low number of patients and especially without control groups or randomisation. Their contradictory results and their methodological weaknesses do not allow any conclusion. Published randomised trials are exceptional. Among patients with a history of caesarean section, there is only one randomised trial; it demonstrates that ante-partum X-ray pelvimetry is not necessary prior to a trial labour in women with one previous caesarean section. It increases the caesarean section rate and is a poor predictor of the outcome of labour. There is also only one randomised trial which evaluated the interest of X-ray pelvimetry in patients with a breech presentation: the use of pelvimetry in breech presentation at term does not significantly reduce the overall caesarean-section rate, and does not improve the neonatal issues. However, it allows better selection of the delivery route, with a significantly lower emergency Caesarean-section rate. Finally, the only one randomised trial having studied the utility of X-ray pelvimetry for the prediction of cephalopelvic disproportion shows that pelvimetry is a poor predictor of the outcome of labour, has no influence on the neonatal issues and increases the caesarean sections rate. Furthermore, although radiation exposure during a X-ray pelvimetry is very weak, diagnostic X-ray studies during any stage of gestation have been shown to increase the risk of childhood cancer in the irradiated fetus. In the rare cases where pelvimetry is useful (trial of labour with a breech presentation), it is thus careful to perform a MRI pelvimetry.

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.

Objective: To compare maternal and neonatal outcomes in twin gestations with a vertex presenting first twin undergoing either an elective repeat Caesarean section or a trial of labour subsequent to having had a Caesarean delivery in a prior pregnancy. Methods: Maternal and newborn data from 1980 to 1999 in twin gestations, having I or more previous lower-segment Caesarean section(s) and a vertex presentation of the first twin, were analyzed from the Nova Scotia Atlee Perinatal Database. Categorical data were compared using chi-square or Fisher exact tests and continuous data by the Student t test. Logistic regression was used to control for covariates. Results: Of the 121 women eligible for the data analysis, 38 chose to have a trial of labour, and 28 delivered vaginally with no uterine ruptures, scar dehiscences, maternal deaths, or increase in neonatal morbidity or mortality reported. Two Caesareans in the trial-of-labour group were for the delivery of the second twin. Women choosing elective Caesarean section had a higher incidence of infectious morbidity (p = 0.04). Conclusion: In twin pregnancies with twin A presenting as a vertex, a cautious trial of labour may be an effective and safe alternative to elective repeat Caesarean section. Further research on a trial of labour after previous Caesarean section in twin gestations is warranted, as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.

Objective: To determine antenatal factors that may predict successful vaginal birth after Caesarean (VBAC). Data Sources: The MEDLINE database was searched for all English-language articles describing the impact of various factors on outcomes when VBAC is attempted. Articles reviewed included published abstracts, retrospective and prospective studies, and meta-analyses. Criteria for Study Selection: Studies were included if they reported both a control group of pregnant women without the factor under evaluation and a study group with this factor, both undergoing a trial of labour (TOL). Other criteria included accountability for all individuals enrolled at study outset, and vaginal delivery rates in both study and control groups stated or easily calculated. Results: A nonrecurrent indication for previous Caesarean section (CS), such as breech presentation or fetal distress, is associated with a much higher successful VBAC rate than recurrent indications, such as cephalopelvic disproportion (CPD). Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS. Prior vaginal deliveries are excellent prognostic indicators of successful VBAC, especially if the vaginal delivery follows the prior CS. A low vertical uterine incision does not seem to adversely affect VBAC success rates as compared to a low transverse incision. Maternal obesity and diabetes mellitus adversely affect VBAC outcomes. Fetal macrosomia does not appear to be a contraindication to VBAC, as success rates exceeding 50% are achieved and uterine rupture rates are not increased. Twin gestation does not preclude VBAC. Post-dates pregnancies may deliver successfully by VBAC in greater than two-thirds of cases. Conclusion: There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.

Dystocia, or poor progress in labour, is the most common reason for Caesarean section in nulliparous patients. It has contributed significantly not only to rising emergency Caesarean section rates but also to an increase in the number of elective procedures performed because many women choose not to try for a vaginal delivery after one unsuccessful attempt. This article describes three case scenarios which highlight these problems and endeavours to provide a rational clinical approach to them, based on currently available evidence.

Objective: To determine the clinical outcome of vaginal birth after caesarean section (VBAC) in a Dutch population with a low overall caesarean section (CS) rate of 6.5%. Study Design: Prospective population based cohort study of 252 patients with a previous caesarean section (CS). Outcome parameters were trial of labour (TOL), success rate and VBAC rate. Results: The TOL rate in the study cohort was 73%, success rate 77%, VBAC rate 56%. The reason for the previous CS influenced success rate. Complications, morbidity and mortality were not different between elective, emergency CS and TOL group, except for a higher incidence of haemorrhage more than 500 ml in the elective CS compared to the TOL group (29% versus 17%, relative risk (RR) 1.74 (1.15–2.34)). Conclusions: In this Dutch study the success rate is comparable to rate in US study reports. Increase of the VBAC rate can mainly be achieved by increasing the number of women attempting TOL.

This review of vaginal birth after caesarean (VBAC) focuses on practical issues that will be useful for the physician in training and the obstetrician in clinical practice. Although VBAC has long been a common practice in many European nations, the same has not been true in North America. As recently as 1970 essentially all hospitals in the United States maintained a policy that women with a history of previous caesarean delivery would undergo repeat caesarean operations for any and all subsequent births. Although VBAC rates in many nations increased dramatically in the 1980s and 1990s, many aspects of trial of labour (also known as trial of scar) remain controversial at the dawn of the 21st century.

Objectives: to identify the incidence of risk factors for and the tools to predict and diagnose uterine wall disruptions. To elaborate on the perinatal and maternal prognosis and on the future reproductive potential of patients who suffered uterine wall disruptions. Method: this is a comprehensive review of the evidence published over the past decade in the English language. Publications were retrieved through Medline search, categorized as to topic and evaluated as to quality of evidence. Results: in contrast to the incidence of uterine rupture in the developing world, the incidence in the developed world is low (0.04%). Grand multiparity, dysfunctional labour and fetal malpresentations remain the major risk factors for uterine wall disruption in the unscarred uterus. Undertaking a trial of labour in the previously scarred uterus is identified as the major risk factor for uterine rupture. Evidence supports the recommendation of a cautionary and highly selective approach to the use of oxytocin to correct dysfunctional labour at any phase, and in the use of prostaglandin for ripening the cervix and induction of labour. Use of epidural anaesthesia, fetal macrosomia, type of lower uterine segment scar (vertical or horizontal) and previous Caesarean section for cephalopelvic disproportion do not seem to be important risk factors. Evidence is lacking as to the safety of trials of labour in multifetal pregnancies. Past history of a previous vaginal birth after Caesarean section (VBAC) seems to be reassuring. Sonography emerges as having a role in evaluating the potential for uterine rupture in labour. Use of partographs in labour could help to reduce the risk of uterine rupture. The most consistent sign of uterine wall disruption in labour is a non-reassuring fetal heart pattern, the severity of which seems to correlate well with the degree of disruption and fetal expulsion. Expediting delivery within 18 minutes of a non-reassuring fetal heart rate pattern carries a good neonatal prognosis, but maternal reproductive potential, while possible, will become guarded. Conclusion: while rare, uterine wall disruption may carry high rates of perinatal morbidity and mortality and maternal morbidity. In the past decade, risk factors have been better defined, with trials of labour after a previous Caesarean section being the most prominent of the risk factors. Overzealous advocacy of such trials cannot be supported. Trials of labour after previous Caesarean section need to be undertaken on a selective basis. Evidence is needed about the safety of trials of labour when certain conditions prevail, including those pertaining to the use of oxytocin, prostaglandin, trials involving patients with more than one previous Caesarean section, and the multifetal pregnancy. Sonography and partographs seem to have potential roles as tools that might help in the selection of candidates for a safe trial of scar and identify women at increased risk for uterine wall disruption.

Summary • Delivery should be in a unit with experienced staff and the appropriate support facilities. • Continuous fetal-heart-rate monitoring is mandatory and should continue after the delivery of the presenting infant. • Ultrasound is important for the antenatal diagnosis of multiple pregnancy, estimating fetal weights in the preterm and determining the presentations of the fetuses. • There is an increased incidence of dysfunctional labour in twin pregnancy and oxytocin augmentation can be used safely if required. • There is very little recent evidence, and what is available is mainly retrospective, on which to base the decision regarding the mode of delivery of multiple gestations. • A trial of labour is recommended for vertex-vertex twins, regardless of gestation. • A trial of labour may be allowed for vertex-nonvertex twins, including those weighing less than 1500 g. • Breech extraction of second twins weighing more than 1500 g appears to be safe and is associated with fewer complications than external cephalic version. • Elective caesarean section is recommended for breech first twins in view of the risks of entanglement and those inherent in vaginal delivery of breech singletons. • Monoamniotic twins should be delivered by elective caesarean section. • There is no need to limit the inter-twin delivery time provided continuous fetal-heart-rate monitoring of the second twin is possible and satisfactory. • Delayed-interval delivery of multiple gestations when the first fetus has delivered very prematurely appears to be associated with improved outcome for the remaining fetus(es) if there is no indication for simultaneous delivery. • Vaginal delivery of twins after previous lower-segment caesarean section may be attempted in appropriately selected women. • Triplets and higher order multiple gestations are probably best delivered by elective caesarean section.

Objective: The study was conducted to compare maternal and neonatal outcome of two groups of nulliparae with breech presentations, who were selected for vaginal delivery by protocols differing only in their use of X-ray pelvimetry. Study Design: We reviewed all term singleton breech deliveries of nulliparous patients who were eligible for vaginal trial of labour in our Centre between 1992 and 1994. In Group A ( n =85) X-ray pelvimetry was performed, and in Group B ( n =70) it was not. Obstetric management was otherwise similar. Admission to the two departments was on alternate days. Results: The rate of caesarean section was similar in both groups (Group A, 36.4% vs. Group B, 42.8%; P >0.05), however, the indications for caesarean section differed. Neonatal outcome was similar in both groups. Maternal febrile morbidity was higher in Group B patients, especially those who underwent caesarean section after a trial of labour. Conclusion: X-ray pelvimetry in nulliparae with breech presentation is associated with reduced maternal febrile morbidity, but does not improve neonatal outcome.

Objective: Because difficult vaginal delivery is more frequent with macrosomic fetuses, some authors recommend routine caesarean section for the delivery of fetuses>4500 g. The purpose of this study was to evaluate the appropriateness of this recommendation, in particular, to analyze maternal and fetal complications according to the mode of delivery. Method: Maternal and neonatal records of 100 infants with weights of at least 4500 g were identified retrospectively from January 1991 to December 1996. Outcome variables included the mode of delivery and the incidence of maternal and perinatal complications. Results: The study sample consisted of 100 infant and mother pairs. Macrosomic fetuses represented 0.95% of all deliveries during this period and only ten were >5000 g. Mean birth weight was 4730 g (maximum, 5780 g). Gestational diabetes was present in nineteen patients. Diabetes was present in three patients. A trial of labour was allowed in 87 women, and elective caesarean delivery was performed in thirteen patients. The overall cesarean rate, including elective caesarean delivery and failed trial of labour, was 36%. Of those undergoing a trial of labour, 73% (64/87) delivered vaginally. Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) and it was the most frequent complication in our series. There were five cases of Erb's palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia. Maternal complications with vaginal delivery of macrosomic infants included a high incidence of lacerations requiring repair (eleven cases). No complications were noticed in the patients who had a caesarean section. Conclusion: Vaginal delivery is a reasonable alternative to elective cesarean section for infants with estimated birth weights of less than 5000 g and a trial of labour can be offered. For the fetuses with estimated birth weight >5000 g, an elective caesarean section should be recommended, especially in primiparous women.

Summary Background Pelvimetry is widely used in women with breech presentation at term to select those for whom planned vaginal delivery is appropriate. However, its clinical value has never been established. We evaluated pelvimetry in a randomised controlled trial. The main outcome measures were the elective and emergency caesarean-section rates and the early condition of the neonate. Methods Magnetic-resonance (MR) pelvimetry was done on 235 women. The women were then randomly assigned to two groups–for the study group (n=118), the pelvimetry results were reported to the responsible obstetricians, who used them as the basis for decisions on whether to schedule elective caesarean or trial of labour; for the control group (n=117), the pelvimetry results were not disclosed until 8 weeks post partum, and decisions about obstetric management were made on the basis of clinical factors only. Findings 35 women (15 [13%] study group, 20 [17%] control group) had abnormalities on pelvimetry. The overall caesarean-section rates did not differ significantly between the study and control groups (50 [42%] vs 59 [50%], p=0·24) but the emergency caesarean-selection rate was significantly lower in the study group than in the control group (22 [19%] vs 41 [35%], p=0·0052). The mean 1 min Apgar scores in the study and control groups were 8·1 and 8·0 (p=0·93) and the mean 3 min scores 9·5 and 9·4, respectively (p=0·28). There were no significant differences in the early neonatal outcome for infants born vaginally, by emergency caesarean section, or by elective caesarean section in the two groups, except for a significantly lower Apgar score in the six infants born vaginally to control-group women who had pelvic abnormalities. Interpretation The use of MR pelvimetry in breech presentation at term did not significantly reduce the overall caesarean-section rate. However, it allowed better selection of the delivery route, with a significantly lower emergency caesarean-section rate. Neonatal outcome was not compromised by use of the pelvimetry data.

Objective: Vaginal delivery after previous caesarean section is widely accepted in Western countries. Is a trial of labour in rural Africa also safe for mother and child? Study Design: In a case control study in rural Zimbabwe the outcome of labour of 281 women who had one or more previous caesarean sections was compared with 4501 women who had no previous caesarean section. Maternal and perinatal mortality, the percentage of vaginal birth and factors related to the achievement of vaginal delivery were studied. Data were tested for statistical significance with a Mantel-Haenszel equation for odds ratio's. Results: No elective caesarean sections were performed. After previous caesarean section, 124 (44%) out of 281 women had a vaginal birth. One scar rupture occurred in a woman with thyrotoxicosis. Perinatal and maternal outcome did not differ significantly between cases and controls. A history of more than one previous caesarean section (Odds Ratio (OR) = 10.0; 95% Confidence Interval (CI 95% ) = 4.4–23.8) or a previous caesarean section for cephalopelvic disproportion (OR = 6.2; CI 95% 3.2–12.0) increased the risk for a repeat caesarean section significantly. Conclusion: A policy to allow all women a trial of labour after a previous caesarean section did not increase adverse pregnancy outcome. Also in rural Africa it seems rational to encourage a trial of labour after one or more previous caesarean sections.

Objective: the objective of this study was to determine current attitudes and practices of obstetricians in Canada regarding the management of breech presentation at term. Methods: a survey was sent to 307 obstetricians across Canada to determine their views on trial of labour for frank and non-frank breech presentation at term, use of external cephalic version, acquisition of skills by residents, influence of the medico-legal climate, and participation in a randomized controlled trial of Caesarean section versus planned vaginal delivery for breech presentation at term. Results: most obstetricians surveyed were from teaching hospitals and from hospitals in Ontario or the Western provinces. The response rate was 65 percent. Almost all of the respondents (96%) were supportive of a trial of labour for the frank breech, and many were supportive of a trial of labour for the non-frank breech presentation. Most (68%) performed external cephalic version, although 52 percent considered their success rate to be less than 50 percent. Most of the respondents (69%) did not feel that residents were acquiring the necessary skills to manage a trial of labour and vaginal delivery for the frank breech presentation at term. Many (46%) indicated that the medico-legal climate had a major influence on clinical decision making. Most respondents (58%) were willing to ask patients to be entered into a randomized controlled trial of Caesarean section versus planned vaginal delivery, and most (78%) indicated that they would be prepared to change their practice based on the results of such a trial. Conclusions: most obstetricians surveyed would support a trial of labour in selected pregnancies.

Study Methods: A retrospective chart review was conducted on patients who underwent a hysterectomy subsequent to a NovaSure ablation over a four year time frame in one community based hospital. Detailed analysis was performed on 203 charts. Results: Of the 1994 women who underwent NovaSure ablation 226 (11%) subsequently had a hysterectomy. The Novasure procedure was unable to be performed in 23 patients and those charts were excluded. The primary indication for hysterectomy was bleeding in 117 (58%). Other indications include pain in 31 (15%), pain and bleeding in 45 (22%), and other, prolapse, and cancer 10 (5%). New onset pain was reported in 45 (22%) patients following NovaSure and 16 (8%) underwent a hysterectomy solely due to new onset pain. Of the 164 pathology reports that commented on the endometrium, 88 (54%) showed active endometrium, 10 (6%) inactive or atrophic, 52(32%) fibrosis, scarring, or “postablative changes”. 14 (9%) had both scarring and residual active endometrium. Conclusion: Bleeding is the most common reason for Novasure failure. However, new onset pain following the NovaSure procedure is a significant burden for 22% of patients. The finding of post ablative scarring and fibrosis was not found universally in those with new onset pain, nor was it consistently noted in those patients with a bleeding component, making it difficult to attribute it as a consistent or common cause of the pain. O-OBS-PhD-108 FACTORS OBSTETRICIANS, FAMILY PHYSICIANS AND MIDWIVES CONSIDER WHEN COUNSELLING PREGNANT WOMENWITH A PREVIOUS CESAREAN SECTION (CS) ON DELIVERY METHOD C. Kurtz Landy York University, 4700 Keele St., HNES 312A, Toronto, Ontario, M3J 1P3, Canada W. Sword, S. McDonald, A. Biringer, J. Cramp, J. Dawdy, P. Angle, C. Cunningham, M. Heaman, M. Morris, H. McDonald, H. Shannon, J. Blake Objectives: Repeat CSs are major contributors to the high rate of CS in Canada. Maternity care providers have a strong influence on women’s decision to have a planned repeat CS or trial of labour (TOL), yet little is known about factors providers consider when counselling women. This study examined factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOL, on delivery method. Study Methods: We used a qualitative descriptive approach and conducted in-depth telephone interviews with 39 maternity care providers in Ontario. A semi-structured interview schedule guided the interviews. Data was analyzed using qualitative content analysis. Results: Maternity care providers considered systems, clinical, and personal factors when counselling women. System factors of concern to obstetricians included the availability of anesthesiologists and time needed to mount emergency CSs; and oncall providers’ support for TOL. All providers identified clinical factors, i.e. women’s characteristics that increased or decreased the likelihood of successful TOL(e.g., BMI); as well as women’s risk tolerance related to both modes of delivery. All providers considered women’s preferences. Women’s preferences were particularly important to the midwives. Midwives described that some women sought their care for a TOL believing midwives could make vaginal delivery possible when physicians couldn’t, or when obstetricians refused to support a TOL. Providers’ negative clinical experiences 490 l MAY JOGC MAI 2016 also influenced their counselling. Convenience of delivery method was considered by some. Conclusion: Effectively addressing systems, clinical and personal factors providers consider when counselling women on delivery methods may assist in decreasing non medically indicated elective repeat CS rates. O-OBS-MFM-MD-113 CORRELATION OF ESTIMATED FETAL WEIGHT WITH NEONATAL BIRTH WEIGHT AT BORDERLINE VIABILITY N. Ladhani Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada S. Hughes, J. Nguyen, J. Barrett Objectives:We sought to determine the correlation between estimated fetal weight and neonatal birth weight in live-birth deliveries between 23+0 and 25+6 weeks gestational age at a major Canadian tertiary care centre. Predicting the likelihood of morbidity and mortality in neonates delivered at the extreme of prematurity, namely 23+0 to 25+6 weeks gestational age, is an important part of counseling in this population. Physicians rely on a number of sonographic markers to establish an estimated fetal weight (EFW) composite which they use as a surrogate marker to predict true birth weight. Study Methods: A retrospective cohort study was conducted at Sunnybrook Health Sciences Centre. We sampled patients retrospectively through records of all patients delivering singleton pregnancies at gestational ages of 23+0 to 25+6 weeks between January 2003 and December 2013 inclusive, who had an ultrasound scan less than 2 weeks prior to delivery. We collected information regarding maternal demographics, ultrasound parameters, and neonatal characteristics. Results: Two hundred and forty-seven deliveries, with an average birth weight of 679g, were includded. Median maternal age was 32 years (16-46years); median gravidity was 2. The mean interval between ultrasound (measuring fetal biometry) and birth was 3.24 days. Estimated fetal weight was moderately correlated with live birth weight (r1⁄40.63). Conclusion: Estimates of fetal weight correlate moderately with live birth weight in neonates born at 23+0 to 25+6 weeks. Developing a better understanding of the utility of EFW in assessing extremely premature neonates will help guide physicians’ and families’ decision-making during this difficult periviable period W-GYN-JM-094 THE MIND-BODY CONNECTION AFTER SURGERY FOR PELVIC FLOOR DISORDERS: FACT OR FICTION? M. Larouche Providence Health St. Paul’s Hospital, 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada L. Brotto, N.A. Koenig, T. Lee, G.W. Cundiff, R. Geoffrion Objectives: To determine the association between depression and anxiety symptoms, and patient-centered outcomes after surgical treatment for pelvic floor disorders (PFD). Study Methods: Prospective cohort of 50 women undergoing inpatient surgery for PFDs at a single tertiary care center. Preoperative validated questionnaires included Beck’s Depression Inventory-II (BDI-II), Beck’s Anxiety Inventory (BAI), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Floor Distress Inventory (PFDI20). Women were asked about their post-surgical goals at baseline. All questionnaires were readministered at 6 weeks postoperatively

Objective. The objective of this study was to determine the views of women regarding entry into a proposed multicentre, multinational, randomized controlled trial of planned Caesarean section versus planned vaginal birth for a breech presentation at term. Methods: Sixty-two pregnant women less than 30 weeks gestation were recruited from their private obstetricians' offices. Written information was provided about the proposed trial. Their views regarding participation were then collected. Results: Of those women recruited (n=62), 37 (60%) responded YES or NOT SURE to participation in the proposed trial (95% confidence interval, 48 to 72%). Of those who said NO (n=25), 14 (56%) preferred to have a Caesarean section, four (16%) preferred a vaginal delivery, and nine (36%) commented on having difficulty with the concept of randomization. Of those who said YES (n=11), most commented that they wished to participate in the trial in order to help other women in the future. Conclusions: Many women are agreeable to considering participation in a randomized trial of elective Caesarean section versus trial of labour for a breech presentation at term. The concept of randomization continues to be difficult for potential trial participants.

This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section in Ontario for women with a previous cesarean section or a breech presentatio. Using data from multiple sources—surveys of obstetricians, and hospital administrators, and hospital record statistics, the authors attempt to assess the response of obstetricians to pressure to change their practice. This pressure comes principally from the Canadian Consensus Conference Statement on Cesarean Birth, released in June 1986 and subsequently endorsed by a number of professional organizations. The Statement provides clear guidelines for the management of labour in women with previous cesarean section or a breech presentation. The findings present a number of interpretive challenges. Based on their response to hypothetical cases obstetricians are favourably disposed to considering a trial of labour for women with previous cesarean section and breech presentation. However, both their reported practices, as well as hospital statistics indicate the continued high prevalence of cesarean section, though there is a small decline in cesareans for previous cesarean section. There was no evidence that hospitals lacked appropriate facilities for a trial of labour or had unduly restricted formal policies. Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questioned on the actual details of the recommendations, obstetrician's recall was surprisingly low. Respondents tended to err in the direction of choosing more conservative measures than those recommended by the Statement. The authors consider several possible interpretations for the differences: physicians perceptions of the complexity of their own cases compared to the hypothetical scenarios; difficulties encountered in implementing new procedures such as trial of labour; the inhibiting effect of their conservative interpretation of the Consensus Statement recommendations; convenience and income issues; fear of litigation; and, patient preferences.