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Background: Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery which has yet to receive ample attention in adolescents. The aim of this study was to describe risk for OASI in adolescent mothers compared to adults. We further attempted to compare risk factors for OASI between these two age groups.Methods: We performed a retrospective cohort study between 2003 and 2019. Primiparous women who delivered vaginally, 21 years and younger were compared to women ages 26-35. Excluded were preterm, multifetal, non-vertex, cesarean deliveries as well as intrauterine fetal death. Rate of OASI as well as obstetric and labor characteristics of women with OASI, were compared between groups. Finally, risk factors were assessed for each group separately. Univariate and multivariate logistic regression model were performed.Results: Final analysis was performed on 5113 nulliparous adolescents and 13,845 nulliparous in the 26-35 age group. Allocation to study groups was according to OASI - Sixty-seven adolescents (1.3%) had a 3rd or 4th degree perineal tear and were defined as the OASI group, while 5046 patients (98.7%) did not have such a tear. In the adult group, 199 out of 13,845 patients (1.4%) were diagnosed with OASI. Occurrence of OASI did not differ between groups (p = 0.510). Comparison of women with OASI in the adolescent group vs. adult group found differences with regard to operative vaginal delivery, (20.9% vs. 36.2%, respectively; p = 0.023) and meconium stained amniotic fluid (9.1% vs. 21.3%, respectively; p = 0.027). Following multivariate analysis the only parameter independently associated with OASI in the adolescent age group was head circumference ≥ 90th percentile with an adjusted odds ratio of 3.08 (CI 1.48-6.38, p = 0.003). In the adult group the similar analysis revealed operative vaginal delivery (OR = 2.44, CI 1.72-3.47, p < 0.001) and a birthweight≥90th percentile (OR = 2.23, CI 1.19-4.18, p = 0.012) to be independent risk factors for OASI.Conclusion: Adolescents have similar risk for OASI compared to adults but differ in risk factors leading to OASI. Head circumference ≥ 90th percentile was found to be associated with OASI in this age group. [ABSTRACT FROM AUTHOR]

Importance: Gestational diabetes is associated with several poor health outcomes.Objective: To update the 2012 review on screening for gestational diabetes to inform the US Preventive Services Task Force.Data Sources: MEDLINE, EMBASE, and CINAHL (2010 to May 2020), ClinicalTrials.gov, reference lists; surveillance through June 2021.Study Selection: English-language intervention studies for screening and treatment; observational studies on screening; prospective studies on screening test accuracy.Data Extraction and Synthesis: Dual review of titles/abstracts, full-text articles, and study quality. Single-reviewer data abstraction with verification. Random-effects meta-analysis or bivariate analysis (accuracy).Main Outcomes and Measures: Pregnancy, fetal/neonatal, and long-term health outcomes; harms of screening; accuracy.Results: A total of 76 studies were included (18 randomized clinical trials [RCTs] [n = 31 241], 2 nonrandomized intervention studies [n = 190], 56 observational studies [n = 261 678]). Direct evidence on benefits of screening vs no screening was limited to 4 observational studies with inconsistent findings and methodological limitations. Screening was not significantly associated with serious or long-term harm. In 5 RCTs (n = 25 772), 1-step (International Association of Diabetes and Pregnancy Study Group) vs 2-step (Carpenter and Coustan) screening was significantly associated with increased likelihood of gestational diabetes (11.5% vs 4.9%) but no improved health outcomes. At or after 24 weeks of gestation, oral glucose challenge tests with 140- and 135-mg/dL cutoffs had sensitivities of 82% and 93%, respectively, and specificities of 82% and 79%, respectively, against Carpenter and Coustan criteria, and a test with a 140-mg/dL cutoff had sensitivity of 85% and specificity of 81% against the National Diabetes Group Data criteria. Fasting plasma glucose tests with cutoffs of 85 and 90 mg/dL had sensitivities of 88% and 81% and specificities of 73% and 82%, respectively, against Carpenter and Coustan criteria. Based on 8 RCTs and 1 nonrandomized study (n = 3982), treatment was significantly associated with decreased risk of primary cesarean deliveries (relative risk [RR], 0.70 [95% CI, 0.54-0.91]; absolute risk difference [ARD], 5.3%), shoulder dystocia (RR, 0.42 [95% CI, 0.23-0.77]; ARD, 1.3%), macrosomia (RR, 0.53 [95% CI, 0.41-0.68]; ARD, 8.9%), large for gestational age (RR, 0.56 [95% CI, 0.47-0.66]; ARD, 8.4%), birth injuries (odds ratio, 0.33 [95% CI, 0.11-0.99]; ARD, 0.2%), and neonatal intensive care unit admissions (RR, 0.73 [95% CI, 0.53-0.99]; ARD, 2.0%). The association with reduction in preterm deliveries was not significant (RR, 0.75 [95% CI, 0.56-1.01]).Conclusions and Relevance: Direct evidence on screening vs no screening remains limited. One- vs 2-step screening was not significantly associated with improved health outcomes. At or after 24 weeks of gestation, treatment of gestational diabetes was significantly associated with improved health outcomes. [ABSTRACT FROM AUTHOR]

Background: Keloid scars are more than just disfiguring cosmetically; many are also pruritic and painful. They also often result in severe emotional distress. This study aimed to investigate the effects of Allium cepa extract, allantoin and heparin topical application on Cesarean section (C-section) scars and keloid prevention. Patients and Methods: This study is a prospective clinical trial study was conducted in Salah Al-Deen general Hospital during the period from 1st Jan-10th June 2021 & included 90 pregnant women who delivered with C/S and divided into 3 groups: Group A: 30 patient advised to use Topical Allium cepa extract, allantoin and heparin group for prevention of scare formation. Group B: 30 patients advised to use Topical Allium cepa extract, allantoin and heparin group (30 patients) for treatment of early keloid. Group C: control group (30 patients) were not advised to use proposed gel for the study as a control group. The study groups assessed 3 times: at base line at removal of stiches, 2nd visit at 6th week, 3rd visit at 12th week. Observer and Patient Scar Assessment Scale (OPSAS): was used for patient assessment. Results: The mean total patient score at 6 week examination was lower among group A, and B than group C, (11.4±2.3), (11.7±1.7), (18.5±2.9) respectively. Also the mean total patient score at 12 week examination the mean total patient score was lower among group A, and B than group C, (9.5±1.9), (8.4±1.1), (15.8±3.6) respectively. Patient POSAS score women's in group B had better improvement at 6 week and 12 week decreased in scores about (-9.67), & (-12.97) respectively. Conclusions: Prophylactic use of the gel is effective in reducing scarring and better results were obtained for the pigmentation and vascularity, after surgical removal of the primary caesarean scar. [ABSTRACT FROM AUTHOR]

Background: The promotion of vaginal birth after cesarean section (VBAC) is the best method for the reduction of repeated cesarean sections. Nonetheless, the decisional conflict which often results from inadequate patient involvement in decision making, may lead to delayed decision making and regret about the choices that were made. The present study aimed to determine the effect of shared decision making on the mode of delivery and decisional conflict and regret in pregnant women with previous cesarean section.Methods: This randomized clinical trial was conducted on 78 pregnant women with a previous cesarean section referring to community health centers in Torbat-e Jam, Iran, in 2019. They were randomly assigned to two groups of intervention and control. During weeks 24-30 of pregnancy, the Decisional Conflict Scale (DCS) was completed by pregnant mothers. Apart from the routine care, the experimental group received a counseling session which was held based on the three-talk model of shared decision making. This session was moderated by a midwife; moreover, a complementary counseling session was administered by a gynecologist. During weeks 35-37 of pregnancy, DCS was completed, and the Decision Regret Scale (DRS) was filled out for both groups at the 8th weeks postpartum and they were asked about the mode of delivery. Data were analyzed in SPSS software (version 19) using the Mann-Whitney, Chi-squared and Fisher's exact tests. p-value less than 0.05 was considered statistically significant.Results: After the intervention, the decisional conflict score was significantly lower in the shared decision making (SDM) group, compared to that in the control group (14.90 ± 9.65 vs. 25.41 ± 13.38; P < 0.001). Moreover, in the SDM group, the rate of vaginal birth was significantly higher than that in the control group (P < 0.001). Two month after the delivery, the mean score of decision regret was lower in the SDM group, in comparison to that in the control group (15.67 ± 23.37 vs. 27. 30± 26.75; P = 0.007).Conclusions: Based on the results of the study, shared counseling can be effective in the reduction of decisional conflict and regret, as well as rate enhancement of VBAC. Therefore, it can be concluded that this counseling method can be used in prenatal care to reduce the rate of repeated cesarean section.Trial Registration: IRCT20190506043499N1; Name of the registry: Iranian Registry of Clinical Trials; Registered 10. August 2019. URL of registry: https://en.irct.ir/trial/39538. Date of enrolment of the first participant to the trial: August 2019. [ABSTRACT FROM AUTHOR]

Background: Evidence-based medicine has shown that successful vaginal birth after cesarean (VBAC) is associated with fewer complications than an elective repeat cesarean. Although spontaneous vaginal births and reductions in cesarean delivery (CD) rates have been advocated, the risk factors for VBAC complications remain unclear and failed trials of labor (TOL) can lead to adverse pregnancy outcomes.Methods: To construct an antepartum predictive scoring model for VBAC. Retrospective analysis of charts from 1062 women who underwent TOL at no less than 28 gestational weeks with vertex singletons and no more than one prior CD.Results: We constructed our scoring model based on the following variables: maternal age, previous vaginal delivery, interdelivery interval (time between prior cesarean and the following delivery), presence of prior cesarean TOL, dystocia as prior CD indication, intertuberous diameter, maternal predelivery body mass index, gestational age at delivery, estimated fetal weight, and hypertensive disorders. Previous vaginal delivery was the most influential variable. The nomogram showed an area under the curve of 77.7% (95% confidence interval, 73.8-81.5%; sensitivity, 78%; specificity, 70%; cut-off, 13 points). The Kappa value to judge the consistency of the results between the predictive model and the actual results was 0.71(95% confidence interval 0.65-0.77) indicating strong consistency. We used the cut-off to divide the VBAC women into two groups according to the success of the TOL. The maternal and neonatal outcomes such as labor time, number of deliveries by midwives, postpartum hemorrhage, uterine rupture, neonatal asphyxia, puerperal infection were significantly different between the two groups.Conclusions: Our predictive scoring model incorporates easily ascertainable variables and can be used to personalize antepartum counselling for successful TOLs after cesareans. [ABSTRACT FROM AUTHOR]

Background: Clinical interventions known to reduce the risk of caesarean delivery include routine induction of labour at 39 weeks, caseload midwifery and chart audit, but they have not been compared for cost-effectiveness.Objective: To assesses the cost-effectiveness of three different interventions known to reduce caesarean delivery rates compared to standard care; and conduct a budget impact analysis.Methods: A Markov microsimulation model was constructed to compare the costs and outcomes produced by the different interventions. Costs included all costs to the health system, and outcomes were quality-adjusted life years (QALY) gained. A budget impact analysis was undertaken using this model to quantify the costs (in Australian dollars) over three years for government health system funders.Results: All interventions, plus standard care, produced similar health outcomes (mean of 1.84 QALYs gained over 105 weeks). Caseload midwifery was the lowest cost option at $15 587 (95% confidence interval [CI] 15 269, 15 905), followed by routine induction of labour ($16 257, 95% CI 15 989, 16 536), and chart audit ($16 325, 95% CI 15 979, 16 671). All produced lower costs on average than standard care ($16 905, 95% CI 16 551, 17 259). Caseload midwifery would produce the greatest savings of $172.6 million over three years if implemented for all low-risk nulliparous women in Australia.Conclusions: Caseload midwifery presents the best value for reducing caesarean delivery rates of the options considered. Routine induction of labour at 39 weeks and chart audit would also reduce costs compared to standard care. [ABSTRACT FROM AUTHOR]

The rate of cesarean section has increased in a very fast way in the last three decades all around the world. In Romania, the rate has dramatically increased after 1990. Romania occupies the third position in Europe with a rate of 37% of cerean sections from the total number of births. This paper aim is to illustrate ways for reducing the number of caesarean surgeries in Romania and it is based on both analysis of multiple scientific papers and author's own experience. Results. We will identify the causes of cesarean surgery that can be avoided in such a way that birth can occur naturally. In general, among the most discussed clinical situations is listed the high-risk pregnancy and the second caesarean section. In order to reduce this worrying cessation rate, more interventions in the current health system are needed: better medical staff training as well as better communication and collaboration between the patient and the doctor in assessing all the risks of doing so operations. Conclusions. The high percentage of cesarean operations in Romania can be reduced by providing better and quality services to pregnant women. [ABSTRACT FROM AUTHOR]

The article discusses various issues related to labour and gynecology as of 2019. Topics include a study in Great Britain on the termination of pregnancy using mifepristone followed by misoprostol, the non-clinical interventions recommended by the World Health Organization to reduce unnecessary caesarean sections, the enactment of the Safe Motherhood and Reproductive Health Rights Act to protect women's rights in Nepal.

Objective: Labor dystocia is an intransigent, high-profile issue in obstetric care. Amniotic fluid lactate (AFL) reflects the uterine metabolic status. High levels associate with subsequent need for operative intervention due to dystocia. In sports medicine, it is known that lactic acid can affect muscular performance and can be decreased by bicarbonate given orally before physical activity.Material and Methods: Two hundred dystocic deliveries were included. At the confirmation of dystocia, the AFL-level was analyzed. Deliveries were randomized to an intake of bicarbonate or not. In the "non-bicarbonate-group", stimulation with oxytocin was started immediately. In the "bicarbonate-group", bicarbonate was given; and oxytocin was started 1 hour after the intake. New sampling of AF was performed after 1 hour in both groups.Outcome Measured: if an oral intake of bicarbonate changes the AFL levels and enhances delivery outcome in dystocic deliveries.Results: Bicarbonate decreases the AFL levels (p < .001). The spontaneous vaginal delivery rate after treatment with bicarbonate was increased (p = .007), without affecting the fetal outcome.Conclusions: An increase of spontaneous vaginal deliveries resulted from bicarbonate ingestion by dystocic women. A decreased level of AFL-level was shown. This simple, low cost treatment has the potential to improve maternal morbidity and satisfaction worldwide. [ABSTRACT FROM AUTHOR]

Objective: To identify the frequency of cesarean delivery for non-obstetric indications before and after the introduction of specific measures to lower the rate of elective cesarean, and to evaluate the effectiveness of the introduced measures.Methods: In the present single-center retrospective cohort study at University Hospital Trnava, Trnava, Slovak Republic, the frequency of elective cesarean was evaluated before (January 1, 2010, to December 31, 2014) and after (January 1, 2015, to December 31, 2016) the implementation of specific measures applied in January 2015 to confirm the indications for primary cesarean delivery. The frequency of elective cesarean delivery for non-obstetric indications was compared between the two periods.Results: Before the intervention in 2015, 229 (2.9%) of 7768 women had elective cesarean deliveries for non-obstetric indications. After implementation of the intervention, the frequency decreased to 27 (0.8%) of 3203 women (P<0.001).Conclusion: The frequency of cesarean delivery for non-obstetric indications was reduced significantly by introducing specific reasonable measures. These included all non-obstetric indications for cesarean delivery being approved by a leading specialist of the related department, close cooperation with professionals from other specialties, and, additionally, staff attending professional educational lectures. [ABSTRACT FROM AUTHOR]

This study describes a retrospective analysis of all women admitted for induction of labour (IoL), carrying a viable singleton foetus, after 34 + 0 weeks of gestation. We aimed to evaluate if foetal sex has an impact on the rate of caesarean delivery following labour induction. Our results demonstrate that among the 1062 women who met the inclusion criteria, 49% (521/1062) were carrying a male foetus. Other than a lower rate of Oxytocin use for the female sex pregnancies, there were no significant differences in pre-labour and labour characteristics between male or female sex pregnancies. There was no difference in caesarean delivery rate between groups (14.4% vs. 14.2%, male vs. female, respectively, p = .505). We concluded conclude that foetal sex does not impact the caesarean delivery rate among women undergoing IoL, regardless of the indication for induction and the indication for the caesarean delivery. Impact statement Male sex foetuses are at increased risk for adverse perinatal outcomes including, among others, an increased risk for caesarean delivery. The possible contribution of male sex to caesarean delivery after labour induction has not been specifically explored. Following induction of labour, there is no difference in failed induction or caesarean delivery rate between male and female sex pregnancies. Induction of labour may be safely employed for both male and female foetuses. [ABSTRACT FROM AUTHOR]

Medical conditions associated with pregnancy are continuously rising therefore the obstetrician is more often required to indicate termination of pregnancy for various medical reasons. Termination of pregnancy at term or near term, before spontaneous labor may be easy but sometimes can create difficulties. The following study proposes to present the induction of labor method with misoprostol at term, analysis of results, various associations between obstetrical parameters and mode of delivery including Apgar score at 1 minute. We also present cardiotocography (CTG) traces associated with induction of labor (IOL) with prostaglandins and management. We would like to emphasize the importance of careful case selection that can be induced, the surveillance protocol of an induced labor and the attitude suitable for each individual case. Apart from permanent efforts to decrease the primary caesarean section rate including maternal request cesarean section, we must be aware of the existence of this group of women with various medical conditions that request IOL, for whom we are ethical and medical responsible to offer the chance of a natural vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective: To examine the outcomes of vaginal birth after cesarean (VBAC) in women, in spontaneous labor, delivering after 37 weeks' gestation at an institution where trial of labor after a previous cesarean delivery (TOLAC) is encouraged and management of labor is standardized.Methods: This retrospective cohort study included 3071 women with one previous cesarean only and no vaginal delivery who underwent a trial of labor from 2001 to 2011. Women were managed using the standardized "active management of labor" intrapartum protocol. Outcomes and characteristics of women who delivered vaginally were compared with those who required cesarean delivery.Results: In spontaneous labor in their second pregnancy, those who attempted TOLAC had a 72.5% (1611/2222) rate of successful VBAC. Women who had a successful VBAC had smaller babies (3584 ± 452 g versus 3799 ± 489 g; p < 0.0001) at earlier gestations than those who had a repeat intrapartum cesarean delivery. They also required less intrapartum intervention, such as oxytocin augmentation (14.5% [234/1611] versus 41% [251/611]; p < 0.0001) and epidural anesthesia (64.8% [1044/1611] versus 82.8% [506/611]; p < 0.0001). The rate of uterine rupture was 0.54% (12/2222), while the rate of peri-partum hysterectomy was 0.18% (4/2222).Conclusion: This study shows that serious complications associated with TOLAC are rare providing intrapartum care and decision-making is made simple for the benefit of staff and patients alike. This is achieved through a standardized labor management protocol. [ABSTRACT FROM AUTHOR]

Introduction: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates.Material and Methods: Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate.Results: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates.Conclusions: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to determine whether trial of labor after cesarean (TOLAC) is associated with increased risk of adverse outcomes for small-for-gestational-age (SGA) neonates.Methods: This secondary analysis of a multicenter prospective observational study evaluated SGA neonates born to women with a single prior cesarean delivery. Nonanomalous, singleton pregnancies delivered at 24-41 weeks were included. The primary exposure was whether women underwent planned cesarean versus attempted TOLAC. Log-linear regression models were developed to characterize the relationship between TOLAC and neonatal outcomes. The primary outcome was a composite measure of neonatal morbidity and/or mortality, including death, respiratory complications, treated hypoglycemia, sepsis, neonatal intensive care unit (NICU) admission and hospital stay >5 days.Results: Of 1009 patients identified, 258 underwent repeat cesarean; 751 attempted TOLAC. Controlling for age, race, body mass index, smoking, maternal disease, prior vaginal birth after cesarean, corticosteroids, prematurity and nonreassuring fetal status as indication for delivery, the composite adverse outcome was similarly likely in both groups (adjusted risk ratio (RR) 0.99, 95% confidence interval (95% CI) 0.88-1.12, p = 0.93).Conclusions: SGA infants born to women who TOLAC have similar neonatal outcomes to those who deliver by planned repeat cesarean. We conclude that TOLAC is an acceptable option for women with a prior cesarean and suspected SGA neonates. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to reduce the rate of cesarean section (CS) in severe pregnancy-induced hypertension (PIH) by introducing a set of indicative criteria for CS.Methods: Labor induction was attempted in Japanese patients (n = 41) with severe PIH after 34 weeks of gestation. Vital signs and symptoms that may increase the risk of serious complications were defined. Following the appearance of one or more signs or symptoms, labor induction was suspended and CS was performed. The impact of using specific indicative criteria was evaluated by comparing the CS rate among patients who delivered before and after the criteria were introduced.Results: Labor induction was attempted in 36 of 41 patients. Among the 36 patients in whom vaginal delivery was started, 12 patients required CS, and the remaining 24 patients succeeded in vaginal delivery. The introduction of specific indicative criteria for CS was associated with a significant reduction in the CS rate, from 95% (43/45) to 41% (17/41).Conclusions: Unnecessary CS may be avoided by defining the limits of safe labor induction. [ABSTRACT FROM AUTHOR]

Aims: The aim of our study was to compare the onset and duration of sensory and motor block, hemodynamic effects, neonatal outcome and adverse effects of isobaric levobupivacaine and hyperbaric bupivacaine in parturients undergoing elective lower segment cesarean section. Methodology: Clinical records of parturients, who had undergone elective cesarean section and who had received either isobaric levobupivacaine 2 ml or hyperbaric bupivacaine 2 ml, and fulfilled inclusion and exclusion criteria were reviewed retrospectively and sorted out in two groups of 30 each. Variables investigated included demographic profile, ASA grading, block characteristics, hemodynamic parameters, neonatal apgar score and any anesthesia related complications. Results: One hundred and forty medical records were evaluated. Demographic profile, block characteristics and anesthesia related complications were similar in both of the groups and statistically insignificant. There was more drop in systolic blood pressure in bupivacaine group at second (p=0.001) and fourth minute (p=0.006), when compared to levobupivacaine group. Conclusion: Isobaric levobupivacaine is a good alternative to hyperbaric bupivacaine for subarachnoid block due to its better hemodynamic stability in cesarean sections. [ABSTRACT FROM AUTHOR]

Objective: To determine the obstetric and perinatal outcome of pregnancies with singleton breech presentation, and to scrutinize the causes of increasing incidence of cesarean section in breech presentation. Design: Analytical Observational study. Place and duration: Department of obstetrics and gynecology Fatima hospital Baqai university campus from Jan 2010 to Oct 2011. Patients & Methods: This study includes 135 patients with singleton breech presentation = 34 weeks of gestation, were analyzed in detail with help of designed performa. Patients were categorized in three groups. Groups a, who had elective C-section, group b. who underwent emergency caesarean section or had C-section after failed trial of vaginal delivery and group c. who had vaginal breech delivery. Elective caesarean section was done in those cases that had some other indications for carrying out this procedure apart from breech presentation. Trial of vaginal breech delivery was planned for all multiparous women except those falling in group A. All antepartum fetal demise, twin pregnancies and placenta previa of major degree were excluded. Results: Of 135 women, 7(5%) underwent prelabour cesarean, and 128(95%), had trial of vaginal delivery, of whom 117(91.5%) delivered vaginally. Significantly more infants weighing> 3.5kg were selected for prelabour and intrapartum cesarean than vaginal delivery. Two neonates had Apgar score< 7 at 5 minutes but both were normal neurologically. There were no nonanomalous perinatal death and no case of significant trauma or neurological dysfunction. Two infants died due to lethal anomalies. Conclusion: Trial of vaginal breech delivery in well counselled patients, still taken as an appropriate option without compromising prenatal and maternal outcome. It also decreases the rate of cesarean section. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to analyze how the progression of cervical dilatation in active labor can be predicted by digital assessment in low-risk pregnant women, in spontaneous labor at term.Material and Methods: This prospective observational study was performed on 328 women with singleton term gestations experiencing midwife-led labor according to local protocols, progressing to full dilatation and spontaneous delivery without any medical intervention. Mixed nonlinear models were adopted to (i) model individual cervical data into centile curves and (ii) calculate the time needed to gain 1 cm in cervical dilatation (TNG1cm ) modeled as a function of current dilatation. We correlated the first and the last TNG1cm on parturients with at least four cervical data points.Results: TNG1cm showed large variations, both before and after 6 cm. This variability of natural progression of cervical curves described by the 10th and 90th centiles exceeded the differences observed in published curves from cohorts homogeneous for parity, weight and ethnicity. There was no significant correlation between the first and the last TNG1cm . Neonatal base excess was not significantly different in women with TNG1cm <10th centile and >90th centile.Conclusions: The rate of cervical dilatation, traced by parsimonious nonlinear mixed models, is largely unpredictable in the case of spontaneous naturally progressing labor, even when possible larger individual variability is excluded by prudent clinical rules. Future research in labor and delivery should be focused on the diagnosis of the causes that lie behind apparently erratic cervical changes. [ABSTRACT FROM AUTHOR]

Objective: Over the past two decades, the incidence of cesarean section in most countries has increased. Cesarean section increases the risk of death and complications in the mother and fetus. Educational interventions based on behavior change models can play an important role in reduce the rate of cesarean section. The aim of our study is investigation the effect of educational intervention based on BASNEF Model on decreasing of cesarean section rate among pregnant women in Khomain County, from June to November 2013. Materials and methods: In this interventional study, 140 nulliparous women who were in their last trimester of pregnancy were randomly allocated to case and control groups. Data gathering instrument was a questionnaire based on BASNEF framework. Data were analyzed by SPSS 14 software. Results: The scores of knowledge, attitudes, subjective norms, and enabling factors in the intervention group than the control group showed a significant difference (p < 0.001). After the study, it was found that 18 women (25.7%) in case group and 42 women (60%) in the control group underwent cesarean section. By Chi-square test showed that the difference in the type of delivery between the two groups was statistically significant (p < 0.001). Conclusion: Design and implement curriculum based on BASNEF can be effective in reducing elective cesarean section. [ABSTRACT FROM AUTHOR]

Objective To evaluate national cesarean section ( CS) rates and other obstetric indicators after a concerted action to reduce CS rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding. Design Retrospective observational population-based study. Setting Portugal. Population Births occurring in Portugal between 2000 and 2014. Methods Governmental sources were used to obtain data on national CS, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean ( VBAC), hypoxia-related complications and perineal lacerations were retrieved for state-owned hospitals. Main outcome measures CS, perinatal and maternal mortality, instrumental vaginal delivery, VBAC, hypoxia-related complications and perineal lacerations. Results After a continuous rise between 2000 and 2009, national CS rates declined significantly over the following 5 years (36.6% vs. 33.1%, time trend p ≤ 0.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery, VBAC and perineal lacerations increased, while the incidence of hypoxia-related complications decreased. Conclusions A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding, was followed by a significant reduction in national CS rates, as well as an improvement in most related obstetric indicators. There may be an association between the reported intervention and the observed changes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess whether outpatient cervical ripening at 41 0/7 weeks of gestation with the nitric oxide donor isosorbide mononitrate reduces cesarean delivery rates in nulliparous women with an unfavorable cervix. METHODS: We recruited nulliparous pregnant women with a Bishop score less than 6 in a randomized, multicenter, double-blind, placebo-controlled trial. Women received 40 mg vaginal isosorbide mononitrate or a placebo at 41 0/7, 41 2/7, and 41 4/7 weeks of gestation. They returned home between visits. At 41 5/7 weeks of gestation, for women who had not yet given birth, labor was induced with oxytocin or prostaglandins, depending on cervical status. We needed 685 women per group to detect a 25% reduction in the cesarean delivery rate, the primary outcome measure, from 25% in the placebo group to 18.75% in the isosorbide mononitrate group (1-β = 0.8, α = 0.05, two-sided). RESULTS: The NOCETER (NO donors for reduction of CEsareans at TERm) trial was a negative study. The cesarean delivery rate was 27.3% (185/678) in the isosorbide mononitrate group and 27.2% (186/684) in the placebo group (relative risk 1.00, 95% confidence interval [Cl] 0.84-1.19). None of the maternal secondary efficacy outcomes differed between groups. Side effects were more common among women receiving isosorbide mononitrate than in the placebo group (78.8% [534/678] compared with 27.9% [191/684], relative risk 2.82, 95% Cl 2.49-3.20). Composite perinatal morbidity did not differ between groups. CONCLUSION: Outpatient cervical ripening with vaginal isosorbide mononitrate for prolonged pregnancy in nulliparous women does not reduce cesarean delivery rate. [ABSTRACT FROM AUTHOR]

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery. [ABSTRACT FROM AUTHOR]

In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate. [ABSTRACT FROM AUTHOR]

Objective To develop and internally validate a model that predicts the outcome of an intended vaginal birth after caesarean ( VBAC) for a Western European population that can be used to personalise counselling for deliveries at term. Design Registration-based retrospective cohort study. Setting Five university teaching hospitals, seven non-university teaching hospitals, and five non-university non-teaching hospitals in the Netherlands. Population A cohort of 515 women with a history of one caesarean section and a viable singleton pregnancy, without a contraindication for intended VBAC, who delivered at term. Methods Potential predictors for a vaginal delivery after caesarean section were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques. Main outcome measures Predictors for VBAC. For model validation, the area under the receiver operating characteristic curve (AUC) for discriminative capacity and calibration-per-risk-quantile for accuracy were calculated. Results A total of 371 out of 515 women had a VBAC (72%). Variables included in the model were: estimated fetal weight greater than the 90th percentile in the third trimester; previous non-progressive labour; previous vaginal delivery; induction of labour; pre-pregnancy body mass index; and ethnicity. The AUC was 71% (95% confidence interval, 95% CI = 69-73%), indicating a good discriminative ability. The calibration plot shows that the predicted probabilities are well calibrated, especially from 65% up, which accounts for 77% of the total study population. Conclusion We developed an appropriate Western European population-based prediction model that is aimed to personalise counselling for term deliveries. [ABSTRACT FROM AUTHOR]

Objective To develop a patient decision aid (Pt DA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean ( VBAC) with the elicitation of patient preferences and evidence-based information. Design A Pt DA was developed and pilot tested using the International Patients Decision Aid Standards ( IPDAS) criteria. Setting Obstetric health care in the Netherlands. Population A multidisciplinary steering group, an expert panel, and 25 future users of the Pt DA, i.e. women with a previous caesarean section. Methods The development consisted of a construction phase (defini-tion of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. Main outcome measures Usability, clarity, and relevance. Results The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The Pt DA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness ( n = 7) were not evaluated. Conclusions An evidence-based Pt DA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the Pt DA enhances the quality of decision-making on mode of birth after caesarean section. [ABSTRACT FROM AUTHOR]

Objective To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends. Design A retrospective cohort study of singleton deliveries from a national administrative database. Setting The English National Health Service between 1 April 2000 and 31 March 2012. Population A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth. Methods Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors. Main outcome measure The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears. Results The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia. Conclusions Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation. [ABSTRACT FROM AUTHOR]

In the article, the authors discusses the prevention of the first cesarean delivery. They cite the forum organized by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists to tackle the concept of preventing the first cesarian delivery. They claim that cesarian delivery is the most commonly performed major surgery in the U.S.

A vaginal delivery has a profound impact on the pelvic floor with the potential for significant functional sequelae. There is an increasing trend among obstetricians to perform a caesarean section to preserve pelvic floor function. This in turn has contributed to an increasing caesarean section rate, both in South Africa and internationally. What impact does vaginal delivery have on pelvic floor dysfunction and can we prevent these problems by resorting to an abdominal delivery? When it comes to preventing urinary incontinence, caesarean section has been shown to be protective; reducing the risk by about 50%, but the effect appears to dissipate with time. For faecal incontinence, caesarean delivery has only a marginal impact with one study showing that 167 caesarean sections need to be done to prevent one case of faecal incontinence. Forceps delivery appears to double the risk of faecal and urinary incontinence compared to normal vaginal delivery. In terms of sexual function, caesarean section is associated with a sensation of better vaginal tone for both partners but no difference in any other parameters. Vaginal delivery is significantly associated with pelvic organ prolapse, with the risk rising with increased vaginal parity. caesarean section is strongly protective against the development of prolapse. This should be viewed in the context of an increased mortality rate for elective caesarean section, with one study showing this to be about 3.6 times that of vaginal delivery. Every women embarking on a caesarean delivery to protect her pelvic floor should be counselled by her obstetrician about the limitations and risks of this procedure. [ABSTRACT FROM AUTHOR]

Se presenta un artículo de opinión del tema de la realización de las cesáreas en las mujeres con la desproporción céfalo-pélvica cuando no se ha documentado oficialmente la desproporción. Se afirma que la decisión es la responsabilidad del obstetra pero se opina que los médicos deban tomar la decisión con más documentación y con más cuidado.

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McGrath P, Phillips E, Vaughan G. International Journal of Nursing Practice 2010; 16: 274–281 Vaginal birth after Caesarean risk decision-making: Australian findings on the mothers' perspective The purpose of this paper is to explore, from the mothers' perspective, the decision-making experience with regard to subsequent birth choice for women who had previously delivered by Caesarean section. A qualitative methodological approach was taken to the exploration of mothers' knowledge of the risks of vaginal birth after Caesarean (VBAC) or elective Caesarean following a prior birth by Caesarean section. This paper presents the insights provided by the four women who chose VBAC. The health professionals' attitude to birth, and thus the support they offer to mothers, is predominantly pro-Caesarean. In view of the declining numbers of VBACs and the fact that the clinical literature documents risks for both elective Caesarean and VBAC, it is important for health professionals to be very sensitive and balanced in the information and support offered for the VBAC birth option. [ABSTRACT FROM AUTHOR]

El artículo presenta las opiniones del autor sobre su papel como Director y Profesor de ginecología y obstetricia en el Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INper). Entre los temas analizados se incluyen diversas obras de doctor Jorge Arturo Cardona Pérez en INper, el redujo de los casos de cesáreas por debajo de la semana 39 y las investigaciones realizadas para mejorar la salud de los bebés prematuros.

There is scant research available on the psycho-social aspects of births subsequent to Caesarean Section (CS). In particular, there is little psycho-social research available in regard to women who seek to have a Vaginal Birth After Caesarean (VBAC). To address this lack of information in the literature, this article explores, from a phenomenological perspective, the reasons motivating women to try for a VBAC, from the perspectives of four women who have tried for or achieved a VBAC. The findings indicate that these mothers differed to other women interviewed in the study who opted for repeat CS. The VBAC mothers expressed a strong belief in the importance of a natural birth as the best start for their infant, strived to reduce where possible drug interventions during labour and birth and believed in the importance of breastfeeding. The VBAC mothers viewed achieving a natural birth as a significant aspect of their femininity and a major life event for a woman. [ABSTRACT FROM AUTHOR]

The article presents a study which estimates the success rates and risks of an attempted vaginal birth after cesarean (VBAC) delivery. In this paper, the authors had selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. With this, it has been found that women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts.

With rising Caesarean section (CS) rates, more women are having to consider the choice between an elective CS and a vaginal delivery (VBAC) in their subsequent pregnancy. This paper argues that there is an unmet need for clinicians to provide sufficient information to women in this position, so that the woman's choice can be an informed one. Consent should be evidence-based, but there are currently no published random-allocation studies comparing VBAC with elective repeat CS. However the available evidence could be better used by clinicians to facilitate informed choice. [ABSTRACT FROM AUTHOR]

The article reports on a study which developed a graphic nomogram model based on factors available at the first prenatal visit predicting chance of successful vaginal birth after cesarean delivery for individual patients who undergo a trial of labor. Factors identifiable at the first prenatal visit were used.

The article reports on a study that identifies a group of clinical factors that could be used to accurately predict failure in women attempting vaginal birth after cesarean (VBAC). Information about material history and outcomes of the index pregnancy are collected. A multivariable prediction model for the outcome of VBAC failure is developed using univariable and multivariable statistical methods.

Female pelvic floor dysfunction is integral to the woman's role in the reproductive process, largely because of the unique anatomic features that facilitate vaginal birth and also because of the trauma that can occur during that event. Interventions such as primary elective cesarean delivery have been discussed for the primary prevention of pelvic floor dysfunction; however, existing data about potentially causal factors limit our ability to evaluate such strategies critically. Here we consider the conceptual principles of epidemiologic function and the availability of data that are necessary to make informed recommendations about prevention opportunities for pelvic floor dysfunction at delivery. Available epidemiologic data on pelvic floor dysfunction suggest that there may be substantial opportunities for the primary prevention of pelvic organ prolapse at delivery. Although definitive recommendations await further epidemiologic studies of the potential risk and benefits of obstetric practice change, it is hoped that this discussion will provide a novel, quantitative framework for the assessment of pelvic floor dysfunction prevention opportunities. [ABSTRACT FROM AUTHOR]

The article aims to assess trends in vaginal birth after cesarean (VBAC) delivery in California. It compares neonatal and maternal mortality rates among women who attempted VBAC delivery or who undergone repeat cesarean delivery before and after the revision of the more-restrictive guidelines for VBAC delivery. The findings revealed that attempted VBAC deliveries decreased significantly from 24% to 13.5% after guideline revision.

Background: In July 1999, The American College of Obstetricians and Gynecologists (ACOG) issued Practice Guideline number 5 on vaginal birth after cesarean section (VBAC) and trial of labor (TOL). This updated guideline recommends that a physician be immediately available during a TOL in the rare case of complications. We examined the effect this new guideline would have on physician’s VBAC/TOL practices in Utah. Objective: 1) Explore physician knowledge of ACOG Practice Guideline number 5; 2) Evaluate change in physician’s VBAC practices in the previous 12 months; 3) Evaluate physician’s ability to comply with ACOG Practice Guideline number 5 recommendations by rural, suburban, and urban location. Methods: In spring 2001, we surveyed by mail all physicians practicing obstetrics in Utah. Questions included demographics, hospital data, VBAC/TOL practice patterns and awareness of ACOG Practice Guideline number 5. Physicians were classified as urban, suburban, or rural by their primary delivery hospital. Results: We found 97% of obstetricians and 79% of family physicians were aware of ACOG Practice Guideline number 5. Forty-five percent of all physicians reported a decline in VBAC practices in the preceding 12 months. Urban physicians’ use of VBAC/TOL decreased the least, followed by rural and suburban. Eighty-seven percent of physicians had C/S “immediately” available during TOL: urban physicians 100%, suburban 88%, and rural physicians 76%. Emergency C/S delivery was performed fastest at urban hospitals, slower at suburban, and slowest at rural hospitals. Conclusion: Physicians use of VBAC/TOL has changed. TOL is offered less by obstetrical providers in Utah and more repeat C/S are performed since 1999 when ACOG updated this policy guideline. This decline has been more noticeable in suburban and rural hospitals and is consistent with recent national trends. Many rural physicians are unable to comply with ACOG Practice Guideline number 5 recommendations. [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. Study design: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. Results: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11–2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% C1 1.17–4.37). Conclusion: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to compare vaginal birth after cesarean (VBAC) success and uterine rupture rates between preterm and term gestations in women with a history of one prior cesarean delivery. Our hypothesis was that preterm women undergoing VBAC were more likely to be successful and have a lower rate of complications than term women undergoing VBAC. METHODS: We reviewed medical records of women with a history of a cesarean delivery who either attempted a VBAC or underwent a repeat cesarean delivery from 1995 through 2000 in 17 community and university hospitals. We collected information on demographics, medical and obstetric history, complications, and outcome of the index pregnancy. The primary analysis was limited to women with singleton gestations and one prior cesarean delivery. Statistical analysis consisted of bivariate and multivariable techniques. RESULTS: Among the 20,156 patients with one prior cesarean delivery, 12,463 (61%) attempted a VBAC. Mean gestational ages for the term and preterm women were 39.2 weeks and 33.9 weeks of gestation, respectively. The VBAC success rates for the term and preterm groups were 74% and 82%, respectively (P < .001). Multivariable analysis showed that the VBAC success was higher (adjusted odds ratio 1.54, 95% confidence interval 1.27–1.86) in preterm gestations. A decreased risk of rupture among preterm gestations was suggested in these results (adjusted odds ratio 0.28, 95% confidence interval 0.07–1.17; P = .08). CONCLUSION: Preterm patients undergoing a VBAC have higher success rates when compared with term patients undergoing a VBAC. Preterm patients undergoing VBAC may have lower uterine rupture rates. [ABSTRACT FROM AUTHOR]

Background: To assess pregnancy course and outcome after conservative treatment of a cesarean scar pregnancy. Methods: During an 8-year period, 15 cases of cesarean scar pregnancies were diagnosed at our institution. Seven of the 14 patients for whom we successfully preserved the uterus became pregnant within 3 years after termination of the scar pregnancy. The year of diagnosis, conservative method and gestational age for these five patients were recorded. Delivery method, time interval between the scar pregnancy and subsequent pregnancy, and maternal and neonatal outcome were evaluated. Results: Seven pregnancies (eight live and one dead baby) were noted. The mean interval between the ectopic pregnancy and subsequent pregnancy was 13.3 months (range 0-34 months). One patient, who became pregnant 3 months after the scar pregnancy was found, suffered uterine rupture at 38.3 weeks' gestational age. Two patients with placental accrete, and one of them who continued the existing intrauterine twin pregnancy after transvaginal sono-guided aspiration of the scar pregnancy received a cesarean hysterectomy at 32 weeks of gestation. The remaining four pregnancies were uneventful, followed by early cesarean sections at 36 weeks. Conclusion: The results of this first series of seven subsequent pregnancies after conservative treatment of scar pregnancies are promising. An early cesarean section before over-extension of the uterus and spontaneous labor can help to prevent uterine rupture. Placenta accrete is another severe morbidity of these patients in addition to uterine rupture. Thus a cesarean hysterectomy may be the choice of treatment. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the association between preinduction modified Bishop's score and obstetric outcome, including successful vaginal birth after prior cesarean (VBAC) and uterine rupture in patients with a previous cesarean undergoing induction of labor. Study design: Medical records of all patients who had an induction of labor after a previous cesarean in our institution between 1988 and 2002 were reviewed, Patients were divided into 4 groups according to the modified Bishop's score (0 to 2, 3 to 5, 6 to 8, and 9 to 12). The rates of successful YBAC, symptomatic uterine rupture, and other obstetric outcomes were evaluated in each group. Multivariate regression analyses were performed to adjust for confounding factors. Results: Out of 685 women included in the study, 187 (27.3%) had a modified Bishop's score <2, 276 (40.3%) of 3 to 5, 189 (27.6%) of 6 to 8, and 33 (4.8%) of 9 to 12. The rate of successful YBAC significantly correlated with the modified Bishop's score (57.5%, 64.5%, 82.5%. and 97.0%, respectively, P < .001). However, the rate of uterine rupture was not statistically significant between the groups (2.1%, 1.8%, 0.5%, 0.0%, P = .48). After adjusting for confounding variables, a modified Bishop's score ≥ 6 remained associated with successful VBAC (odds ratio [OR] 2.07, 95% CI 1.28-3.35, P < .001). Conclusion: The modified Bishop's score before induction of labor is an independent factor associated with successful VBAC. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To apply published scoring systems retrospectively to patients who had undergone a trial of labor after cesarean delivery to estimate whether there was a score at which a trial of labor should be discouraged. METHODS: Patients with 1 previous cesarean delivery who then delivered between January 1, 1998, and December 31, 1998, were studied. An investigator blinded to outcome assigned scores using 3 different scoring systems. Student t test, χ², analysis of variance, and receiver operating curve analysis were performed. P < .05 was significant. RESULTS: Seventy-six percent (117/153) of trial of labor patients had a vaginal birth after cesarean delivery. Successful vaginal birth after cesarean delivery patients had significantly different mean scores using all 3 scoring systems, but none of the systems accurately predicted failed trial of labor resulting in cesarean delivery. Unfavorable scores were associated with high rates of major complications. CONCLUSIONS: An unfavorable score predicting a high rate of complications and more failed trials of labor may help in counseling patients considering trial of labor. A better system to predict the success or failure of trim of labor is needed. [ABSTRACT FROM AUTHOR]

Vacuum extractors have replaced forceps for many situations in which assistance is required to achieve vaginal delivery.Compared with metal-cup vacuum extractors, soft-cup devices are easier to use and cause fewer neonatal scalp injuries; however, they detach more frequently. Vacuum extractors can cause neonatal injury. These devices should be employed when indicated, usually for a nonreassuring fetal heart tracing or failure to progress in the second stage of labor. Complications may be minimized if the physician recognizes contraindications to the use of vacuum extraction. Complete documentation is essential. [ABSTRACT FROM AUTHOR]

Background: There is widespread concern about increasing proportion of births by caesarean section. Many factors can affect the likelihood of success of vaginal birth after caesarean section. The purpose of this study was to evaluate the effect of birth weight on the success of labour in women with previous one caesarean section. Material & Methods: This cross-sectional study was carried out in department of Obstetrics & Gynaecology, Women and Children Hospital, Abbottabad, from March 2012 to March 2013. One hundred women were includ- ed who had previous one caesarean section and were now in their pregnancy with single fetus at term. These women were in spontaneous labor and consented to undergo trial of scar. Patients were grouped according to birth weight as Group-1 <3 Kg, Group-2 with 3.1-3.5 Kg and Group-3 with 3.6-0 Kg. Age in years, period of gestation in weeks and birth weight were recorded. Results: The mean age of patients was 28.9 (range 25 to 40 years). The mean gestation was 38(37 to 41 weeks). Out of 100 parturient, 59 (59%) had birth weight 2.5-3 Kg while 25(25%) had 3.1-3.5 Kg and only 16(16%) had birth weight 3.6-4 Kg. The overall success rate for vaginal delivery after previous caesarean was highest for Group-1, and lowest for Group-3, suggesting a strong correlation of birth weight with success of vaginal birth after caesarean section. Conclusion: The chances of success of vaginal birth after caesarean section increases with lowering birth weight. [ABSTRACT FROM AUTHOR]

Objectives. Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians. Methods. A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice. Results. The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education. Conclusions. This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm. [ABSTRACT FROM AUTHOR]