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Introduction: An antenatal scoring system for vaginal birth after caesarean section (VBAC) categorises patients into a low or high probability of successful vaginal delivery. It enables counselling and preparation before labour starts. The current study aims to evaluate the role of Grobman nomogram and the Kalok scoring system in predicting VBAC success in Singapore. Methods: This is a retrospective study on patients of gestational age 37 weeks 0 day to 41 weeks 0 day who underwent a trial of labour after 1 caesarean section between September 2016 and September 2017 was conducted. Two scoring systems were used to predict VBAC success, a nomogram by Grobman et al. in 2007 and an additive model by Kalok et al. in 2017. Results: A total of 190 patients underwent a trial of labour after caesarean section, of which 103 (54.2%) were successful. The Kalok scoring system (AUC [area under the curve] 0.740) was a better predictive model than Grobman nomogram (AUC 0.664). Patient’s age odds ratio [OR] 0.915, 95% CI [confidence interval] 0.844–0.992), body mass index at booking (OR 0.902, 95% CI 0.845–0.962), and history of successful VBAC (OR 4.755, 95% CI 1.248–18.120) were important factors in predicting VBAC. Conclusion: Neither scoring system was perfect in predicting VBAC among local women. Further customisation of the scoring system to replace ethnicity with the 4 races of Singapore can be made to improve its sensitivity. The factors identified in this study serve as a foundation for developing a population-specific antenatal scoring system for Singapore women who wish to have a trial of VBAC. Keywords: Antenatal scoring system, caesarean section, obstetrics and gynaecology, trial of labour after caesarean section, vaginal birth after caesarean section

The factors associated with the outcome of trial of labour after one previous Caesarean Section; a retrospective cohort study. A retrospective observational study was performed on all eligible consecutive singleton pregnancies planned for trial of labour after one previous Caesarean Section (TOLAC) over a period of 18 months to study the success rate of vaginal birth after Caesarean Section (VBAC) and to find out the factors associated with successful and failed TOLAC. All of the data were entered in electronic format and the data was analysed in detail. Of the 1324 women studied, the VBAC rate was 65.3% and the incidence of scar rupture was 0.5%. The composite adverse maternal (postpartum haemorrhage and intensive care admission) and foetal outcome (still birth, 5-minute APGAR7 and NICU admission) was more in the failed TOLAC group. Various demographic, clinical and obstetric factors were studied in detail between the successful and failed TOLAC groups. The favourable Bishop Score (4) was independently associated with successful TOLAC (OR 4.3; 95% CI 3.3-5.6

Összefoglaló. Bevezetés: Az új koronavírus (SARS-CoV-2) okozta pandémia számos változást eredményezett életünk minden területén, így a debreceni Szülészeti és Nőgyógyászati Klinikán is. Célkitűzések: A koronavírus-járvány többek között a terminus körüli elektív szülésindukciók gyakorlatának megváltoztatását igényelte. A bevezetett új szakmai eljárásrendeknek, járványügyi intézkedéseknek, a megyei kórházi funkciót ellátó debreceni Kenézy Kórház Szülészeti Osztálya és a Szülészeti Klinika összevonásának, illetve a megváltozott jogi környezetnek a szülészeti ellátásra kifejtett együttes hatásait elemezzük. Módszerek: Helyi protokollokat és részletes eljárásrendeket készítettünk és vezettünk be. 1. Szülésindukció. 2. Szülésindukció cervixérlelést igénylő esetekben. 3. A szülés módjának megválasztása előzményi császármetszés után. 4. A császármetszés utáni hüvelyi szülést támogató, terminus körüli gondozási protokoll. A protokollok bevezetését követő első 9 hónap szülészeti mutatóit (szülésszám, császármetszések aránya, perinatalis kimenetel, szülésindukciók aránya és sikeressége) vizsgáltuk és hasonlítottuk össze a megelőző időszak debreceni adataival, illetve az országos szülészeti mutatókkal. Eredmények: Klinikánkon a császármetszés aránya 2020-ban 33,5%-ra csökkent, a protokollok bevezetése óta pedig 30,7%, miközben a 2020. évi magyarországi arány 40,3%. Az összes szülés 20%-a volt 2020-ban szülésindukció, melyek közül 74% végződött hüvelyi szüléssel, míg ugyanez 2019-ben 11% indukcióból 47%-nak adódott. A havi szülésszám 2020. január és 2021. január között folyamatosan emelkedett (250-ről 450-re), a havi császármetszési arány pedig 41%-ról 25%-ra csökkent. Mindezen változások mellett 2019-ről 2020-ra csökkent mind a perinatalis mortalitás (6,3‰-ről 4,2‰-re), mind a szülés után a Neonatalis Intenzív Centrumba történő felvételek aránya (14,8%-ról 13,5%-ra). Következtetések: A bemutatott tényezők együttes hatásaként – elsődlegesen a megfelelő és következetesen betartott protokolloknak köszönhetően – a szülésindukciók aránya és sikeressége jelentősen növekedett, a császármetszések aránya szignifikánsan csökkent, javuló perinatalis morbiditási és mortalitási mutatók mellett. Orv Hetil. 2021; 162(21): 811–823. Summary. Introduction: The pandemic caused by the new coronavirus (SARS-CoV-2) has catalized several changes in many fields of our lives, and also at the Department of Obstetrics and Gynecology of the University of Debrecen, Hungary. Objectives: We wanted to analyse the compound effect of our new local protocols regarding elective labour inductions at term, the coronavirus pandemic and the resulting infection control measures, the merging of the Obstetrics and Gynecology Ward of the Kenézy County Hospital of Debrecen and the University Department of Obstetrics and Gynecology, and also the change of the legal environment. Methods: Local protocols were introduced: 1. Labour induction. 2. Cervical ripening in labour induction. 3. Choosing the route of delivery after cesarean. 4. Management of pregnancy around term in the case of planned trial of labour after cesarean. We compared the obstetrical data (number of deliveries, cesarean section rate, perinatal outcome and the rate and success rate of labour inductions) before and after the implementation of the protocols. The results were also compared to the Hungarian national database. Results: The annual cesarean rate at our department dropped to 33.5% in 2020. In the first 9-month period, after the introduction of the new reforms, the cesarean rate decreased to 30.7%, whereas the Hungarian national rate was 40.3% in 2020. At our department, 20% of all the deliveries were induced and 74% of them led to vaginal deliveries in 2020, while in 2019 only 11% of deliveries were labour inductions, and 47% of these cases were vaginal deliveries. The monthly number of deliveries was rising constantly between January 2020 (250 deliveries) and January 2021 (450 deliveries), and the monthly cesarean rate decreased from 41% to 25%. Comparing the data of 2019 and 2020, the annual perinatal mortality rate dropped from 6.3‰ in 2019 to 4.2‰ in 2020. Neonatal morbidity, as measured by admissions to the neonatal intensive care unit, also decreased (14.8% in 2019 and 13.5% in 2020). Conclusions: As a compound result of the described factors, but mainly due to the new protocols, both the rate and the success rate of labour inductions increased significantly, while the cesarean rate decreased with improving perinatal mortality and morbidity. Orv Hetil. 2021; 162(21): 811–823.

BACKGROUND: Customized clinical and administrative interventions in the form of a care pathway tool can improve VBAC outcomes and reduce the alarming rise in caesarean sections globally. OBJECTIVE: To determine the effect of a locally tailored clinical pathway tool on VBAC outcomes in a private hospital in India. METHODS: A pre- and post-implementation study was conducted in a private hospital in India. All women with one previous caesarean section term pregnancy and cephalic presentation were included at baseline from January 2013 to December 2015 (Phase 1) and from January 2016 to December 2018 (Phase 2) after ongoing implementation of a clinical pathway tool by all providers. Background characteristics and clinical outcomes in both phases were reviewed retrospectively from case files. RESULTS: Overall 223 (13.42%) women among 1661 total births and 244 (11.62%) women among 2099 total births were included in Phase 1 and Phase 2, respectively. Total number of women who underwent trial of labour (TOLAC) increased from 36.77% to 64.34% (P

Background: The mode of delivery of a parturient is influenced by previous caesarean section (CS) scar. Objective: The objective of the study is to evaluate the pregnancy outcomes of a parturient with one previous caesarean delivery that was managed in Mile Four hospital, Abakaliki, Nigeria. Materials and Methods: A 5-year retrospective study of women with one previous CS who delivered in Mile Four hospital between January 2011 and December 2015 was done. IBM SPSS version 20 was used for data analysis, and data were represented using frequency tables, charts, and Chi-square. The level of significance was set at an alpha level of 0.05. Results: Three hundred and twenty-two (322) women with one previous CS were selected for a trial of labor after A C/S (TOLAC). More than half of the women (53.1%) had successful TOLAC while 46.9% had a repeat CS. Of the 53.1% of women who had a successful TOLAC, One hundred and forty-one patients had spontaneous vertex delivery. Seventeen women (9.9%) on the TOLAC arm had a ruptured uterus, while seven patients (4.6%) failed the TOLAC group had uterine dehiscence. Haemorrhage was the most common maternal complication. Severe asphyxia and perinatal death were present in 5.9% and 5.3% of neonates on TOLAC arm, respectively. Conclusion: Trial of labour after a CS can result in an excellent outcome in a well-selected patient. The success rate of 53.1% in our study is encouraging. However, adequate intrapartum monitoring is recommended to reduce maternal and fetal complications.

Objective To create a new and simple model for predicting the likelihood of vaginal birth after cesarean (VBAC) section using variables available at the time of admission. Materials and methods A prospective observational study was performed at a tertiary care centre in Haryana over a period of 12 months (January 2018 - December 2018) in pregnant women attending the labour room with one previous cesarean section fulfilling the criteria for undergoing trial of labour after cesarean (TOLAC). The sample size was 150. A VBAC score was calculated for each patient using a new prediction model that included variables available at the time of admission such as maternal age, gestational age, Bishop's score, body mass index, indication for primary cesarean section, and clinically estimated fetal weight. The results of the VBAC scores were correlated with outcomes i.e. successful VBAC or failed VBAC. The chi-square test and Student's t-test was used for comparison among the groups. Descriptive and regression analysis was performed for the study variables. Results Out of 150 TOLAC cases, 78% had successful VBAC and the remainder (22%) had failed VBAC. The observed probability of having a successful VBAC for a VBAC score of 0-3 was 34%, 4-6 was 68%, 7-9 was 90%, and ≥10 was 97%. The prediction model performed well with an area under the curve of 0.77 (95% CI: 0.68 to 0.85) of the receiver operating characteristics receiver operating characteristic curve. Conclusion The present study shows that the proposed VBAC prediction model is a good tool to predict the outcome of TOLAC and can be used to counsel women regarding the mode of delivery in the current and subsequent pregnancies. Further studies of this model and other such models with different permutations and combinations of variables are required.

Introduction: The prevalence of cesarean deliveries is high in many parts of world. Vaginal birth after cesarean section (VBAC) is a trial of vaginal delivery in selected cases of a previous CS in a well equipped hospital. It offers distinct advantages over a repeat caesarean section, since the operative risks are completely eliminated, the hospital stay is much shorter and expenses involved are much less. Objectives: To study the maternal and perinatal outcomes among women with previous Cesarean section at a tertiary care centre. Materials and Methods: This prospective study was carried out over a period of 12 months. 979 pregnant women with previous caesarean section were recruited in study. A detailed history was taken and mode of delivery decided as per the standard protocol. 636 patients underwent elective repeat LCSC.343 patients were given trial of labour out of which 226 delivered vaginally. Maternal and neonatal outcomes were noted Result: The rate of successful VBAC was 65.89%. Most common indications of repeat caesarean section were fetal distress and failure to progress. Post op maternal and neonatal complications were significantly more in repeat caesarean section group. Incidence of infectious morbidity was also higher in repeat cesarean group than VBAC group. Conclusion: Fetal morbidity and mortality due to trial of labor is comparable with the women laboring without a scar, trial of labour may be encouraged. women given trial of labour with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management of previous one or two CS. Keywords: VBAC, TOLAC, Emergency cesarean section, Perinatal morbidity.

Background In line with global trends, India has witnessed a sharp rise in caesarean section (CS) deliveries, especially in the private sector. Despite the urgent need for change, there are few published examples of private hospitals that have successfully lowered their CS rates. Our hospital, serving private patients too, had a CS rate of 79% in 2001. Care was provided by fee-for-service visiting consultant obstetricians without uniform clinical protocols and little clinical governance. Consultants attributed high CS rate to case-mix and maternal demand and showed little inclination for change. We attempted to reduce this rate with the objective of improving the quality of our care and demonstrating that CS could be safely lowered in the private urban Indian healthcare setting. Methods We hired full-time salaried consultants and began regular audit of CS cases. When this proved inadequate, we joined an improvement collaborative in 2011 and dedicated resources for quality improvement. We adopted practice guidelines, monitored outcomes by consultant, improved labour ward support, strengthened antenatal preparation, and moved to group practice among consultants. Results Guidelines ensured admissions in active labour and reduced CS (2011 to 2016) for foetal heart rate abnormalities (23 to 5%; p p p p p Conclusions It is feasible to substantially reduce CS rate in private healthcare setting of a middle-income country like India. Ideas such as moving to full-time attachment of consultants, joining a collaborative, improving labour ward support, providing resources for data collection, and perseverance could be adopted by other hospitals in their own journey of moving towards a medically justifiable CS rate.

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.

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.

Elective caesarean section (CS) is the safest means of delivering the litter in bitches in specific situations. Timeously performing elective pre-parturient CSs at a fixed time would be convenient and prevent emergency CSs and foetal demise. This review proposes a method of performing elective pre-parturient CSs which is safe for both the bitch and puppies. Brachycephaly, small litters and large litters, preceding litter delivered by CS and trial of labour after a preceding CS are identified as factors increasing the need for CS whereas emergency CS is identified as factor increasing foetal demise. The first day of cytological dioestrus more precisely predicts the day of onset of spontaneous parturition than the first day of the LH surge or the dates during oestrus on which progesterone (P4) first exceeds 6 nM or 16 nM. Foetal biparietal diameter at the time of onset of spontaneous parturition varies too much to accurately predict readiness for CS. During the last few days of gestation, P4 with cut-off concentrations at 15.8, 8.7 and 3.18 nM, but not plasma cortisol concentrations, hold promise as predictors of onset of parturition and when to perform pre-parturient CSs. A protocol associating medetomidine hydrochloride as premedicant with propofol as induction agent and sevoflurane as maintenance is safe for scheduled CS and yields good maternal and puppy survival rates at delivery, 2 hr and 7 days after CSs. Clinicians have to pay attention to the haematocrit of bitches at the time of cervical dilatation which is at the lower end of the normal reference ranges for non-pregnant dogs and to the decline in haematocrit during CS (as a proxy for blood loss) which is approximately 7% for both parturient (open cervix) and pre-parturient (closed cervix) CSs. Pre-parturient CSs can be scheduled and performed 57 days after onset of cytological dioestrus with puppy survival rates of 99%. Collectively, these studies provide a protocol to safely perform elective CSs in a large proportion of the obstetric population at a convenient time of the day but more research is required with larger numbers to establish whether this practice is routinely safe and safe in all breeds.

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 Uterine rupture is a rare obstetric emergency, and the rate of rupture has increased over time with the rising rate of caesarean section (CS) and trial of labour after CS (TOLAC). Aim To determine the prevalence, and maternal and neonatal complications associated with complete uterine rupture at a New Zealand (NZ) tertiary referral hospital over an 11-year period. Material and methods This is a retrospective, observational study. Waikato Hospital records of patients with uterine rupture occurring between 2008 and 2018 were reviewed for risk factors, delivery outcomes, and maternal and neonatal complications. Results There were 32 patients with complete uterine rupture in 38 182 births, conferring a prevalence of 8.4 per 10 000 births (95% CI 5.9-11.8). Of the 29 cases occurring during labour, 83% of patients were multiparous, 59% previously had one or two CS; patients with an unscarred uterus had lower rates of emergency CS and high rates of postpartum haemorrhage than patients with a scarred uterus. There were no maternal deaths although three patients required peripartum hysterectomy, 63% required blood transfusion and there were five (16%) perinatal deaths. Conclusion The prevalence of uterine rupture in this NZ tertiary hospital is comparable to other developed countries. There was no maternal mortality but there was a 16% perinatal death rate. Patients with spontaneous labour and an unscarred uterus were not exempt from this rare complication. There is a need to manage labour judiciously in all patient groups and to maintain a high level of suspicion for uterine rupture.

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: The purpose of this study was to compare maternal and perinatal outcomes in a trial of labour after caesarean (TOLAC) and an emergency repeat caesarean delivery (ERCD). Design: A one-year prospective observational study at a tertiary care centre. Methods: Selection of candidates for Vaginal Birth after caesarean section (VBAC) was based on the 2010 American College of Obstetricians and Gynecologists’ (ACOG) recommendation. The maternal outcome was measured using the VBAC success rate, maternal complications, and the number of days spent in the hospital. The perinatal outcome was measured using the 5 minute Apgar score and the need for neonatal intensive care unit (NICU) admission. Results: Vaginal delivery was trialled on 250 patients. The success rate for VBAC was 169/249. (67.9 percent). Repeat CS was required for 80/249 (32.1%) of the patients. Cases with a Bishop score greater than 6 had a higher rate of vaginal delivery (89.6%) than cases with a Bishop score \(\le\)6 (17.4 %) (p=0.01). Spontaneous labour had better VBAC success rate (91.8%) than induced labour (55.5%) (p=

Vaginal birth after caesarean (VBAC) is an option to avoid major abdominal surgery and many consequences related to repeated caesarean delivery. In the last years, many efforts have been made to increase the number of patients attempting trial of labour after caesarean (TOLAC). The aim of our study was to identify the most important factors associated with the success of VBAC. A retrospective study was conducted in two Italian referral centres. Subjects included were singleton and morphologically normal pregnancy with previous C-section. Subjects with an inter-pregnancy interval shorter than 18 months, a large for gestational age baby, a pregnancy complicated with gestational diabetes and a previous unclassified uterine scar were excluded. The characteristics of the subjects were compared and a logistic regression was performed to evaluate variables associated with successful VBAC. Of the 300 patients included, 224 (74.7%) achieved VBAC while 76 (25.3%) underwent C-section after failed TOLAC. The number of previous C-sections was not significantly associated with the success of TOLAC. Factors positively associated with achievement of VBAC were previous vaginal delivery (OR of 6.88 for one and 9.68 for more than one) and oxytocin implementation (OR 3.32). No maternal and neonatal adverse events occurred. Our results show that attempting VBAC is a feasible option in referral centres after adequate evaluation of the potential factors affecting the probability of success. A careful record of obstetrical history and management of labour can provide clinicians useful information to counsel women before and during labour.

Aims and objectives This research was conducted to explore the effectiveness of employing the healthcare failure mode and effect analysis method in the management of trial of labour after caesarean, with the aims of increasing vaginal birth after caesarean section rate and reducing potential risks that might cause severe complications. Background Previously high caesarean section rate in China and the "two children" policy leads to the situation where multiparas are faced with the choice of another caesarean or trial of labour after caesarean. Despite evidences showing the benefits of vaginal birth after caesarean, obstetricians and midwives in China tend to be conservative due to limited experience and insufficient clinical routines. Thus, its management needs further optimisation in order to make the practice safe and sound. Design A prospective quality improvement programme using the healthcare failure mode and effect analysis. Methods With the structured methodology of healthcare failure mode and effect analysis, we determined core processes of antepartum and intrapartum management, conducted risk priority numbers and devised remedial protocols for failure modes with high risks. The programme was then implemented as a clinical routine under the agreement of the institutional review board and vaginal birth after caesarean success rates were compared before and after the quality improvement programme, both descriptively and statistically. Standards for Quality Improvement Reporting Excellence 2.0 checklist was chosen on reporting the study process. Results Seventy failure modes in seven core processes were identified in the management process, with 14 redressed for actions. The 1-year follow-up trial of labour after caesarean and vaginal birth after caesarean rate was increased compared with the previous 3 years, with a vaginal birth after caesarean rate of 86.36%, whereas the incidence of uterine rupture was not compromised. Conclusions The application of healthcare failure mode and effect analysis can not only promote trial of labour after caesarean and vaginal birth after caesarean rate, but also maintaining a low risk of uterine rupture. Relevance to clinical practice This modified vaginal birth after caesarean management protocol has been shown effective in increasing its successful rate, which can be continued for further comparison of severe complications to the previous practice.

Introduction: Cesarean section rate has been on a continuous rise since 1970. When trial of scar is done, 30- 80% of women with one previous lower segment caesarean section can achieve vaginal delivery. Identification of the determinants of the success of TOLAC help in selecting the patients with favorable factors and hence improving the success rate of TOLAC with minimum possible complications. Materials and Methods: This study was planned from January 2015 to December 2015. Case files of previous one cesarean pregnancies were reviewed retrospectively in two groups: VBAC group and RCS group. Results: There were 9.8% (N-488) previous one cesarean pregnancies out of which 67% (327) underwent TOLAC. VBAC happened in 71.56% and RCS in 28.44%. Malpresentation, fetal distress, CPD and Failed induction were the indications of primary cesarean which had significantly more number of VBAC as compared to RCS (p value the spontaneous onset of labour was compared to induced labour. The mean admission bishops score of VBAC group was 6.952.72 and that of RCS group was 3.87 2.54 (p value- 0.000). Also the mean birth weight of the VBAC group was 2.660.53 and that of RCS group was 2.800.47 (p value- 0.027). Conclusion: Malpresentation, fetal distress, CPD and failed induction are the most important indications of primary cesarean section which have better chances of VBAC. Spontaneous onset of labour, admission bishops score and birth weight has significant affecton the outcome of TOLAC. Keywords: Trial of labour after cesarean (TOLAC), Vaginal birth after cesarean (VBAC), Repeat cesarean section (RCS), Previous one cesarean section, Determinants of success of TOLAC, Trial of labour after cesarean (TOLAC), Vaginal birth after cesarean (VBAC), Repeat cesarean section (RCS), Previous one cesarean section, Determinants of success of TOLAC.

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.

This study was designed to evaluate maternal and obstetrical factors associated with a successful trial of labour after one caesarean section (TOLAC) as well as evaluating the associated fetal and maternal outcomes and to determine the rate of vaginal delivery and repeated C/S. A prospective cross-sectional study was done on 237 women with previous one C/S then patients were selected for the trial of labour based on the department protocol. Those who were chosen for TOL were strictly monitored & observed for the progress of labour and the outcomes were recorded in terms of mode of delivery, maternal & fetal complications and were analysed and compared with those who had repeated C/S. Seventy-three (30.8%) patient was delivered by elective C/S without trial, 109 (46%) of the patients who were admitted to labour room delivered vaginally while 55 (23.2%) delivered by emergency C/S. It has been found that maternal BMI of (

Introduction: World medical community has raised concerns over the rising caesarian rates. Materials and Methods: This was a prospective, cross-sectional, hospital-based study to determine factors responsible for a woman’s choice of delivery, that is, caesarian delivery (CD) or vaginal delivery (VD). Pregnant women attending antenatal clinics, were interviewed with a structured questionnaire, and data was analyzed. Results and Discussion: 266 responses were analyzed, wherein, 186 women preferred VD and 80 women preferred CD. The characteristics of women who chose CD as their preferred mode of delivery, were compared with the women who chose VD as their preferred mode of delivery. Age, religion, occupation, and economic status did not influence a women’s choice of delivery. Factors strongly related included educational status, wherein, more educated women were likely to prefer CD. Contrary to popular perception gravida, para, number of miscarriages or living children did not influence the choice of delivery. 90% of women who had previous CD, preferred CD for this delivery, they were not aware of the option for trial of labour after caesarian. 49% (n = 45) of the 91 patients delivering in private hospitals underwent CD, as compared to only 13% (n = 11) of the 85 patients delivering in government hospitals. The high caesarian rates in private hospitals is partly driven by caesarian delivery on maternal request. Conclusion: Counsel the pregnant women regarding the process and benefits of normal VD, as well as the risks of unnecessary CD can influence patient decision-making and decrease CD rates. Keywords: Caesarian, Vaginal delivery, Preference, Mode of delivery.

Background: Low-lying placentas are positioned close to the internal os of the cervix. The preferred way of delivery within this group is unclear. Objectives: To review the literature on the success of a vaginal delivery with a low-lying placenta. Search strategy: We searched OVID EMBASE and MEDLINE for studies on vaginal delivery with a low-lying placenta. Data collection and analyses: Data was extracted on successful vaginal delivery and emergency caesarean section due to haemorrhage. We distinguished between different distances between the cervical os and the placenta (internal os distance, IOD); 0–10, 11–20, and >20 mm. A meta-analysis of proportions was made for successful vaginal delivery and emergency caesarean section at every cut-off value. Maternal morbidity (i.e. antepartum blood loss, postpartum haemorrhage and blood transfusion) at different cut-off values was evaluated. Main results: Of the 999 articles retrieved, 10 articles met our inclusion criteria. A vaginal delivery was successful at an IOD of 0–10 mm in 43%, at an IOD of 11–20 mm in 85%, and at an IOD of >20 mm in 82%. A shorter IOD had a higher chance of antepartum haemorrhage, whereas a larger IOD needed postpartum blood transfusion more often. Postpartum haemorrhage did not depend on IOD. Conclusion: A low-lying placenta is not a contraindication for a trial of labour, and the morbidity in these women is not increased. However, women with a low-lying placenta have a higher chance of an emergency caesarean section compared with women with a placenta outside the lower uterine segment. Therefore, shared decision-making is mandatory in case of a trial of labour. Tweetable abstract: This systematic review demonstrates the possibility of a vaginal delivery in women with a low-lying placenta within 20 mm of the cervix.

This study aimed to estimate the impact of third-trimester ultrasound with measurement of the lower uterine segment thickness (LUST) and estimation of fetal weight (EFW) on maternal and perinatal morbidity among women with a prior cesarean delivery.We performed a secondary analysis of the QUARISMA trial, including women who delivered at term after one prior cesarean delivery in tertiary care centres. Major and minor maternal and perinatal morbidities were compared between centres that had introduced LUST and EFW measurements into routine practice and those that had not, using generalised estimating equations and adjusted odds ratios (aOR). In a secondary analysis, we compared women who underwent a trial of labour with and without LUST and EFW measurements.We observed a significant reduction in major perinatal morbidity (aOR 0.52; 95% CI 0.28-0.96, P = 0.04), minor perinatal morbidity (aOR 0.49; 95% CI 0.25-0.96, P = 0.04), and minor maternal morbidity (aOR 0.56; 95% CI 0.34- 0.94, P = 0.03) but no significant difference in major maternal morbidity (aOR 0.40; 95% CI 0.04-3.69, P = 0.42) in the 2 centres that had introduced third-trimester ultrasound with EFW and LUST measurements (1458 women), compared with the 4 centres (1247 women) that had not. Among women who underwent a trial of labour, we observed a reduction in major perinatal morbidity (aOR 0.25; 95% CI 0.11-0.54, P0.001) and a lower rate of uterine rupture (0% vs. 0.3%, P = 0.045) with LUST and EFW measurements.Third-trimester ultrasound with EFW and LUST measurement is associated with a significant reduction in major perinatal morbidity in women with a prior cesarean delivery.

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENTWhat is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors.What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS.What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

Development of anuria in the setting of post-caesarean section is a cause of concern for surgeons, and it requires rapid evaluation for detecting its possible etiology and the initiation of appropriate treatment. When the cause of anuria is not immediately apparent in a hemodynamically stable patient, one must rule out other possible differentials as part of the diagnostic process. In this report, we present a rare case of a patient undergoing a trial of labour after a caesarean section, who had a Foley catheter accidentally placed and inflated in the right ureter, instead of the bladder. This led to apparent anuria, which was not identified until the patient's caesarean section had been completed. We also seek to shed light on a method for safely removing a ureteral Foley with a blocked inflation channel.

Objective: to compare the vaginal birth rate in women with previous one lower segment caesarean section when induced at 40 weeks compared to expectant management till 41 weeks. Design: A randomized controlled trial Setting: Department of Obstetrics and Gynaecology, JIPMER, a tertiary care teaching institution in the south of India. Population or Sample: Low-risk women with previous one single lower segment caesarean section with a singleton foetus in vertex presentation and eligible for a trial of labour (TOLAC) at 40 weeks gestation. Methods: Block randomization to two groups of thirty each. The induction group was induced at 40 weeks with low dose oxytocin infusion or ripening with a single application of a single balloon Foley catheter followed by oxytocin infusion 24 hours later. The expectant group was managed in the hospital with maternal and foetal surveillance and induced at 41 weeks if they had not delivered by then. Main Outcome Measures: Vaginal birth after caesarean section (VBAC). Results: The demography and pregnancy variables were comparable in the two groups. Twenty out of thirty women (66.67%) had a successful vaginal birth after caesarean section in the induction group compared to ten out of 30 (33.33%) in the expectant group. This difference was significant (RR 2.0, 95% CI: 1.13-3.52; P=0.016) Conclusions: Among low-risk women with previous one lower segment caesarean section willing and eligible for TOLAC, the successful VBAC rate is significantly higher among those induced at 40 weeks compared to those managed expectantly till 41 weeks.

ObjectiveThe rates of caesarean section (CS) in Ethiopian private hospitals are high compared with those in public facilities, and there are limited descriptions of groups of women contributing to these high rates. The objective of this study was to describe the groups contributing to increased CS rates using the Robson classification in two major private hospitals in eastern Ethiopia.DesignCross-sectional study.SettingTwo major private hospitals in eastern Ethiopia.ParticipantsAll women who gave birth from 9 January 2019 to 8 January 2020 in two major private hospitals in eastern Ethiopia.Primary and secondary outcome measuresThe primary outcome was the Robson 10 Group Classification System. The secondary outcome was indication for CS as recorded in the medical files.ResultsOf 1203 births in both hospitals combined during the study period, 415 (34.5%) were by CS. Women with a uterine scar due to previous CS (group 5), single cephalic term multiparous women in spontaneous labour (group 3) and single cephalic term nulliparous women in spontaneous labour (group 1) were the leading groups contributing 33%, 27.5% and 17.1%, respectively. The leading documented indications were fetal compromise (29.4%), previous CS (27.2%) and obstructed labour (12.3%).ConclusionMore than three-fourths of CS were performed among Robson groups 5, 3 and 1, indicating inadequate trial of labour after CS or management of labour among relatively low-risk groups (3 and 1). Improving management of spontaneous labour and strengthening clinical practice around safely providing the option of vaginal birth after CS practice are strategies required to reduce the high CS rates in these private facilities.