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Background During the last decades, the rate of caesarean section is increasing and this can increase the mortality and morbidity. Up to one third of the caesarean sections are attributed to the elective repeat caesarean section (ERCS). This study aims to evaluate attitudes and factors affecting the choice of pregnant women with one previous caesarean section regarding their mode of delivery in their second pregnancy. By assessing these attitudes, this study can help the efforts in developing strategies to increase the rates of vaginal delivery. Material and methods A cross-sectional design was conducted by a structured questionnaire on 166 pregnant women who had delivered once by caesarean section for their first pregnancy and were in the third trimester of their second pregnancy. Any women with an absolute indication for caesarean section was excluded. The study comprises women who attend the clinic at our center in Northern of Jordan. Proper statistical tests were performed to assess the association between the choice of delivery and selected demographic and clinical factors. Results About 55.4% responded that they would choose ERCS (n = 92) and the remaining participants chose trial of labour after caesarean section (TOLAC) (n = 74). Fear of pain was the most common reason for choosing caesarean section, accounting for 55.4%. Interestingly, our study did not show a significant association between the mode of delivery and demographic factors, such as age, educational level and occupation. The single independent significant factor influencing patients’ choice that our study revealed was “being informed about the complications of TOLAC”. The choice of TOLAC was almost four times higher for those participants who had been informed about the complications, compared to those who had not been informed. Conclusion Proper counselling is a main factor that affected the patients’ choice toward the mode of delivery. Proper pain management may encourage patients to choose TOLAC because fear of pain was a main reason that patients requested ERCS instead of TOLAC., Highlights • Pregnants with a previous caesarean section has the right to choose TOLAC or ERCS. • Pregnants should be aware about the risks and benefits for each mode of delivery. • Proper counselling pain management are the main factors affect their choice. • Knowledgeable pregnant women tend to choose TOLAC over ERCS.

Objective To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET. Design Randomised controlled trial. Setting Two labour wards, in a university tertiary hospital and a central hospital. Population A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation. Methods Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour. Main outcome measures Primary outcome: rate of operative deliveries. Secondary outcomes duration of labour, amount of oxytocin given, adverse neonatal outcomes. Results Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84-1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section. Conclusions IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration. Tweetable abstract IT (versus ET) reduced oxytocin use in high-risk labours but did not influence operative delivery rate or adverse neonatal outcomes.

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

Objective To identify the characteristics of women and maternity units associated with elective repeat caesarean delivery (ERCD) in women eligible for trial of labour after caesarean (TOLAC). Design Cross-sectional study. Setting France. Population and sample Using data from the 2010 French National Perinatal Survey, a representative sample of births in France (n = 14 681 women), we studied two groups of women with prior caesarean section: (i) women eligible for TOLAC according to guidelines (n = 1179) and (ii) a subgroup of these women without any medical characteristics that might indicate ERCD (n = 575). Methods Associations were analysed by multilevel logistic regression. Main outcome measures Adjusted odds ratios. Results Among the 1584 women with a previous caesarean, 1179 (74.4%) were eligible for TOLAC according to guidelines (group 1); 490 (41.6%) had ERCD. Risk of ERCD increased with increasing maternal age and body mass index, pre-existing condition and suspected macrosomia and decreased with previous vaginal deliveries. Among the unit characteristics, private status (aOR = 2.3, 95% CI 1.3–4.1) and low level of care (aOR = 2.5, 95% CI 1.4–4.5]) were independently associated with a higher risk of ERCD after adjustment on patient/pregnancy characteristics. The variability of ERCD rate between hospitals was mainly (78%) explained by the status and level of care, and not (0%) by patient/pregnancy characteristics. Associations with unit characteristics were similar for group 2. Conclusion For women eligible for TOLAC, the rate of ERCD is high and not in agreement with guidelines. Some characteristics of women are associated with ERCD, but the main determinants are at the unit level, which suggests that non-medical reasons are involved in the decision process. Tweetable abstract Elective repeat caesarean in women eligible for trial of labour mainly depends on maternity unit characteristics.

Pregnant women with a history of previous Caesarean section face the decision either to undergo an elective repeat Caesarean section (ERCS) or to attempt a trial of labour with the goal of achieving a vaginal birth after Caesarean (VBAC). Both choices are associated with their own risks of maternal and neonatal morbidity. We aimed to determine the external validity of a prediction model for the success of trial of labour after Caesarean section (TOLAC) that could help these women in their decision-making.We used a perinatal database including 185,437 deliveries from 32 obstetrical centres in Quebec between 2007 and 2011 and selected women with one previous Caesarean section who were eligible for a TOLAC. We compared the frequency of maternal and neonatal morbidity between women who underwent TOLAC and those who underwent an ERCS according to the probability of success of TOLAC calculated from a published model of prediction.Of 8508 eligible women, including 3113 who underwent TOLAC, both maternal and neonatal morbidities became less frequent as the predicted chance of VBAC increased (P0.05). Women undergoing a TOLAC were more likely to have maternal morbidity than those who underwent an ERCS when the predicted probability of VBAC was less than 60% (relative risk [RR] 2.3; 95% CI 1.4 to 4.0); conversely, maternal morbidity was not different between the two groups when the predicted probability of VBAC was at least 60% (RR 0.8; 95% CI 0.6 to 1.1). Neonatal morbidity was similar between groups when the probability of VBAC success was 70% or greater (RR 1.2; 95% CI 0.9 to 1.5).The use of a prediction model for TOLAC success could be useful in the prediction of TOLAC success and perinatal morbidity in a Canadian population. Neither maternal nor neonatal morbidity are increased with a TOLAC when the probability of VBAC success is at least 70%.

To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean.Retrospective cohort study.19 US hospitals from the Consortium on Safe Labor.Of 2225 twin sets ≥36 weeks' gestation.Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes.Maternal and neonatal outcomes.Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [OR 2.5, 95% confidence interval (CI) 1.4-4.5] and blood transfusion (OR 1.9, 95%CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95%CI 1.05-14.5; B: OR 3.9, 95%CI 1.3-12.3).Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases.

SUMMARY Retrospective analysis of medical records and individual case review was undertaken at 11 major obstetric hospitals for a 5 year period from July 1992 to June 1997 to investigate rates of vaginal birth after Caesarean section (VBAC), the occurrences of uterine rupture, and the outcomes for mother and infant following rupture. Total deliveries were 234,015, of which 21,452 or 9.2% were associated with one or more previous Caesarean sections. Within this scar group, 5419 patients or 25.3% were delivered vaginally. There were 62 cases of significant uterine rupture with no maternal deaths. Perinatal mortality with rupture was 25% and serious maternal complications (usually hysterectomy) occurred in 25% of those with uterine rupture. In women attempting vaginal delivery after a previous lower segment Caesarean section, the uterine rupture rate was estimated at 0.3%, with 0.05% experiencing a perinatal death and 0.05% requiring a hysterectomy. Although VBAC rates in Australia remain lower than many overseas reported series, rates are increasing. While rupture continues to be associated with serious adverse outcomes, the incidence of rupture during trial of labour is low and appears to be associated with a better outcome than rupture of an unscarred uterus.

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 Ultrasonography has been used to examine the scarred uterus in women who have had previous caesarean sections in an attempt to assess the risk of rupture of the scar during subsequent labour. The predictive value of such measurements has not been adequately assessed, however. We aimed to evaluate the usefulness of sonographic measurement of the lower uterine segment before labour in predicting the risk of intrapartum uterine rupture. Methods In this prospective observational study, the obstetricians were not told the ultrasonographic findings and did not use them to make decisions about type of delivery. Eligible patients were those with previous caesarean sections booked for delivery at our hospital. 642 patients underwent ultrasound examination at 36-38 weeks' gestation, and were allocated to four groups according to the thickness of the lower uterine segment. Ultrasonographic findings were compared with those of physical examination at delivery Findings The overall frequency of defective scars was 4·0% (15 ruptures, 10 dehiscences). The frequency of defects rose as the thickness of the lower uterine segment decreased: there were no defects among 278 women with measurements greater than 4·5 mm, three (2%) among 177 women with values of 3·6-4·5 mm, 14 (10%) among 136 women with values of 2·6-3·5 mm, and eight (16%) among 51 women with values of 1·6-2·5 mm. With a cutoff value of 3·5 mm, the sensitivity of ultrasonographic measurement was 88·0%, the specificity 73·2%, positive predictive value 11·8%, and negative predictive value 99·3%. Interpretation Our results show that the risk of a defective scar is directly related to the degree of thinning of the lower uterine segment at around 37 weeks of pregnancy. The high negative predictive value of the method may encourage obstetricians in hospitals where routine repeat elective caesarean is the norm to offer a trial of labour to patients with a thickness value of 3·5 mm or greater.

Objective To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery. Design Retrospective follow up study. Setting Medical Centre Leeuwarden, The Netherlands. Participants All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 1986–1998. Methods Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour. Results Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour. Conclusions In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.

Summary. The relationships between prior obstetrical complications and subsequent trial of labour and vaginal birth after Caesarean (VBAC) success likelihood were examined among a cohort of Washington State women with a first livebirth via Caesarean delivery and a second livebirth between 1987 and 1993 (n = 10 110). Overall, 64% of the cohort undertook a labour trial, and 62% of those who attempted VBAC delivery were successful, for an overall VBAC rate of 40%. Women with fetal macrosomia, cephalopelvic disproportion, prolonged labour, diabetes, or placental problems in the first pregnancy were less likely to undergo a labour trial in the second pregnancy than those without these factors, while women with prior induced labour, genital herpes, fetal distress, or breech presentation were more likely to attempt vaginal birth. Approximately half of women with prior macrosomia, labour problems, or chronic medical conditions who attempted VBAC succeeded, as did three-quarters of women with prior breech presentation or placental conditions. Overall VBAC rates were around 33% for women with previous fetal macrosomia, labour problems, or chronic medical conditions, and 45‐55% among those with herpes, fetal distress or breech presentation at the first birth. Trial of labour should especially be encouraged among women without prior labour problems.