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Background: Most German hospitals do not offer a trial of labour after two caesarean sections (TOLA2C). TOLA2C is claimed to be associated with too many complications, above all the high risk of uterine rupture. The objective of this study is to review our experience with TOLA2C, with special attention paid to the risk and probability of uterine ruptures. Secondary outcomes include comparing neonatal and maternal outcomes in the group of TOLA2C with the group of elective repeat caesarean section (ERCS) and to assess the success rate for vaginal birth after two caesarean sections (VBAC-2). Methods: The retrospective cohort study was conducted in a community hospital in North Rhine-Westphalia. Inclusion criteria were all pregnant women with two caesarean sections in their medical history, with a current vertex singleton pregnancy and the absence of morphological abnormalities of the foetus, who gave birth in our facility between January 2015 and June 2021. Descriptive statistics were calculated and Kolmogorov-Smirnov tests, Mann-Whitney U tests, Fishers exact tests, Chi2 –tests and t-tests for independent samples were performed. Results: A total of 91 cases were included in the TOLA2C-group. These were compared to 99 cases that, within the same time frame, had an elective repeat caesarean section (ERCS-group). There was no statistically significant difference found in the neonatal outcome between the two groups (except for the neonatal pH-value: p 0.024). The hospital stay was significantly shorter in the TOLA2C-group, while maternal complication rates were almost similar (13.2% in the TOLA2C-Group, vs. 16.2% in the ERCS-Group). The success rate for TOLA2C was 55%. No complete uterine rupture was found, but in three cases an incomplete rupture (3.3% rate for incomplete uterine ruptures) occurred, but had no influence on the neonatal outcome. Conclusion: TOLA2C is not associated with a worse maternal or neonatal outcome compared to ERCS, and especially the risk of complete uterine ruptures seems to be low. TOLA2C should be more widely offered to suitable patients who are motivated for it. [ABSTRACT FROM AUTHOR]

To evaluate differences in reproductive and neonatal outcomes on the basis of the time interval from cesarean delivery to subsequent frozen embryo transfer (FET). Retrospective cohort. Multicenter fertility practice. Women undergoing autologous elective single embryo transfer FET after prior cesarean delivery. Time from prior cesarean delivery to subsequent FET. live birth (LB). A total of 6,556 autologous elective single embryo transfer FET cycles were included. Frozen embryo transfer cycles were divided into eight groups on the basis of the time interval from prior cesarean delivery to subsequent FET in months. A secondary analysis was then performed with time as a continuous variable. The proportion of LBs did not differ significantly across all time interval groups and over continuous time (range: 40.0%–45.6%). The mean gestational age at the time of delivery did not significantly differ as the time between prior cesarean delivery and subsequent FET increased (range: 37.3–38.4). When time was evaluated continuously, the proportion of preterm births was higher with a shorter time between cesarean delivery and subsequent FET. The mean birth weight ranged from 3,181–3,470g, with a statistically significant increase over time. However, the proportions of extremely low birth weight, very low birth weight, and low birth weight did not significantly differ. There were no significant differences in reproductive outcomes on the basis of the time interval from cesarean delivery to FET, including LB. The proportion of preterm deliveries decreased with a longer time between cesarean delivery and FET. Differences in mean neonatal birth weight were not clinically significant because the proportion of low birth weight neonates was not significantly different over time. Although large, this sample cannot address all outcomes associated with short interpregnancy intervals, particularly rarer outcomes such as uterine rupture. When counseling patients, the timing of FET after cesarean delivery must be balanced against the risks of increasing maternal age on reproductive and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Background: Rates of cesarean birth (CBs) are steadily increasing and account for 36.7% of all births in New South Wales (NSW), with primary cesareans driving the increase. NSW Health guidelines recommend women attempt a vaginal birth after a previous CB (VBAC); however, rates of VBAC are decreasing, particularly within the private hospital setting. This study aimed to determine the rates of adverse outcomes for women who planned a VBAC (pVBAC) compared with women who planned an elective repeat CB (pERCB) at one private hospital in Sydney, Australia. Method: This retrospective data review evaluated patient records over a 10‐year period (2010–2019). Records (n = 2039) were divided into four groups: pVBAC, pVBAC + EMCB, labor + ERCB (lab + ERCB), and pERCB. The incidence of adverse maternal and neonatal outcomes is reported as counts and percentages. Regression and chi‐squared tests were used to compare groups. Significance was determined at a p‐value of <0.05. Results: Overall, very low rates (N = 148, 7.3%) of women had a VBAC compared with a repeat CB at this private hospital over the 10‐year period. The incidence of adverse outcomes was low regardless of study group. Outcomes differed significantly between groups for postpartum hemorrhage (pERCB seven times less likely than VBAC group) and special care nursery admission (pVBAC + EMCB is 4.6 times more likely than in the VBAC group). Conclusion: Overall, it is safe to attempt a VBAC at this private hospital, and labor after a cesarean should be recommended, yet very few women had a VBAC at the study site. The incidence of adverse outcomes was low compared with other published research. [ABSTRACT FROM AUTHOR]

Background: Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases. Methods: This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor. Results: The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70–0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74–1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself. Conclusions: After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration. [ABSTRACT FROM AUTHOR]

In the case of placenta previa‐accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low‐transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post‐TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post‐TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To evaluate hemostatic efficacy, complications, and subsequent pregnancy outcomes in women with placenta previa who underwent combined vertical compression sutures in the lower uterine segment and intrauterine balloon tamponade (Hot‐Dog method) to achieve hemostasis after cesarean section.We retrospectively reviewed data for 117 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between 29 and 38 weeks' gestation. Treatments were as follows: (1) conventional—intravenous oxytocin administration after placental detachment and suturing of bleeding points at the detachment site as needed (conventional group) (n = 47). (2) Intrauterine balloon tamponade alone (balloon group) (n = 41). (3) Vertical compression sutures + intrauterine balloon tamponade (Hot‐Dog group) (n = 29).The placenta accreta spectrum prevalence was significantly higher in the balloon and Hot‐Dog groups versus the conventional group. The prevalence of anteriorly located placenta was significantly higher in the Hot‐Dog versus balloon groups. Intraoperative and total blood loss were significantly higher in the Hot‐Dog versus conventional groups. Postoperative blood loss was significantly lower in the Hot‐Dog versus balloon groups. Fewer additional procedures for managing postoperative hemorrhage were required in the Hot‐Dog versus conventional and balloon groups. The number of subsequent pregnancies in the conventional, balloon, and Hot‐Dog groups was 11 (23.4%), 8 (19.5%), and 4 (13.8%), respectively; all resulted in live births at term without serious obstetric complications.The Hot‐Dog method is a straightforward and safe hemostasis technique for placenta previa that preserves fertility and controls severe bleeding. [ABSTRACT FROM AUTHOR]

Objective This article identifies how mode of delivery and the presence of labor affect the initiation and effectiveness of breastfeeding. Study Design This is a retrospective cohort study of breastfeeding success after vaginal delivery, cesarean section after labor, and scheduled cesarean section in term, singleton deliveries in nulliparous patients at a large academic institution from 2017 to 2018. Exclusion criteria included major postpartum complications requiring admission to the surgical intensive care unit or neonatal intensive care unit, general anesthesia, and major fetal anomalies. Breastfeeding success in the immediate postpartum period, defined as the first 2 to 3 days postpartum prior to hospital discharge, was measured by the presence of breastfeeding, the need for formula supplementation, the average number of breastfeeding sessions per day, the average amount of time spent at each breastfeeding session, the average number of newborn stools and wet diapers produced daily, and the neonatal percentage in weight loss over the first 2 to 3 days of life. Multivariable linear and logistic regression were used to assess the association between mode of delivery and markers of breastfeeding success after adjusting for potential confounders. A Tukey's post hoc analysis with pairwise comparisons was performed to assess differences in breastfeeding outcomes between vaginal delivery, scheduled cesarean section, and cesarean section after labor. Results A total of 2,966 women met inclusion criteria during the study period, 1,936 (65.3%) of whom underwent spontaneous vaginal delivery, 415 (14.0%) of whom delivered by scheduled cesarean section, and 615 (20.7%) of whom underwent cesarean section after labor. There were significant differences in maternal age, obesity, race/ethnicity, insurance status, gestational age at delivery, birth weight, and 1-minute Apgar's score less than 7 between vaginal delivery, scheduled cesarean section, and cesarean section after labor. There were also significant differences between indication for oxytocin, type of anesthesia, and postpartum hemorrhage between the three groups. After controlling for these factors, women who underwent vaginal delivery were more likely to have infants with decreased need for formula supplementation (adjusted odds ratio [aOR] = 1.71, 95% confidence interval [CI]: 1.52–1.93) and were less likely to switch from breast to formula feeding (aOR = 1.71, 95% CI: 1.04–1.31) in comparison to women who delivered via cesarean section in labor or scheduled cesarean section. The infants of these women also had an increased number of breastfeeding sessions on average (β = 0.06, p = 0.002), required fewer number of daily formula feedings (β = 0.14, p < 0.001), and experienced a smaller percentage in neonatal weight loss over the first 2 to 3 days of life (β = 0.18, p < 0.001) compared to those born after cesarean section and cesarean section after labor. These women comparatively required less time at each breastfeeding session (β = 0.06, p = 0.005), and produced fewer wet diapers and stools on average (β = 0.12, p < 0.001 and β = 0.12, p < 0.001, respectively). On post hoc analysis with pairwise comparisons, and on separate sensitivity analysis of only women who underwent cesarean delivery, there was no difference in breastfeeding outcome measures between scheduled cesarean section and cesarean section in labor. Conclusion Women who deliver by cesarean section, despite the presence or absence of labor, are less likely to maintain exclusive breastfeeding postpartum and are more likely to require formula supplementation. These women may need more support with breastfeeding after surgery in order to experience similar benefits for neonatal growth and weight gain. Key Points Women who deliver by cesarean section are less likely to maintain exclusive breastfeeding. Women who deliver by cesarean section are more likely to require formula supplementation. Women may need more support with breastfeeding after cesarean delivery. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. Methods: A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. Results: Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. Conclusions: This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the possible association between acute fetal stress during labor and maternal blood levels of osteopontin (OPN), white blood cells, sedimentation, and C-reactive protein (CRP). Methods: The study included women with a term pregnancy (37 weeks or more) who had a cesarean section during the active phase of labor. The study included 30 term pregnancies who underwent cesarean section for fetal distress and 30 pregnant women who underwent cesarean section for other indications (prior uterine surgery, head-pelvis incompatibility, large baby, non-progressing plot) as a control group. The levels of OPN and other inflammatory markers (leukocytes, sedimentation, CRP) in the maternal venous blood of 60 pregnant women were compared, and whether there was a significant association between the groups was investigated. Results: OPN levels in the fetal stress group were higher than those in the control group, and the difference was statistically significant (p=0.008). There was no statistically significant difference in white blood cell, blood sedimentation, and CRP levels between the two groups (p>0.005). Conclusion: Placental inflammation plays a role in the etiology of fetal stress, and OPN may be released because of fetal stress. The increase in OPN in maternal blood during labor may be an important marker for predicting fetal stress. [ABSTRACT FROM AUTHOR]

This article's emphasis is on the holistic care of women who are assessed as suitable for and amenable to vaginal birth after Caesarean section (VBAC) in the South African state health sector context. It is beyond its scope to deal with the minutiae of VBAC conduct, operative conduct of repeat Caesarean section (CS), or management of uterine rupture. It is also beyond the scope of the article to reflect on practices, which are accepted in other healthcare contexts. The intention is not to promote VBAC over elective repeat CS, but rather to assist healthcare workers with providing high-quality holistic care. The goal is that women with previous CS are given access to the mode of delivery, which is safest for them and their fetus, while minimising adverse psychological effects of previous and future negative birth experiences. [ABSTRACT FROM AUTHOR]

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery. [ABSTRACT FROM AUTHOR]

Background Vaginal birth after caesarean section (VBAC) is an alternative to a caesarean section (CS) in the absence of repeat or new indications for primary CS. There is a knowledge gap regarding the trend and successful VBAC in Ethiopia. Therefore this systematic review and meta-analysis aimed to assess the trend, pooled prevalence of successful VBAC and its predictors in Ethiopia. Methods Electronic databases (SCOPUS, CINAHL, Embase, PubMed and Web of Science), Google Scholar and lists of references were used to search works of literature in Ethiopia. Stata version 14 was used for analysis and the odds ratios of the outcome variable were determined using the random effects model. Heterogeneity among the studies was assessed by computing values for I2 and p-values. Also, sensitivity analyses and funnel plots were done to assess the stability of pooled values to outliers and publication bias, respectively. Results A total of 12 studies with a sample size of 2080 were included in this study. The overall success rate of VBAC was 52% (95% confidence interval 42 to 65). Cervical dilatation ≥4 cm at admission, having a prior successful vaginal delivery and VBAC were the predictors of successful VBAC. Conclusions Meta-analyses and sensitivity analyses showed the stability of the pooled odds ratios and the funnel plots did not show publication bias. The pooled prevalence of successful VBAC was relatively low compared with existing evidence. However, the rate was increasing over the last 3 decades, which implies it needs more strengthening and focus to decrease maternal morbidity and mortality by CS complications. Promoting VBAC by emphasizing factors favourable for its success during counselling mothers who previously delivered by CS to enhance the prevalence of VBAC. [ABSTRACT FROM AUTHOR]

• Women undergoing trial of labour following two previous caesareans (TOLA2C) are more likely to develop endometritis or sepsis postnatally. • Women undergoing TOLA2C are more likely to have a longer postnatal stay. • Neonates of women undergoing TOLA2C are more likely to have Apgar scores less than seven and require neonatal unit admission. • The best predictor of successful vaginal delivery following TOLA2C is a prior successful vaginal birth after caesarean. To assess the (i) predictors of and associated rates of success and; (ii) maternal and perinatal outcomes of women undergoing trial of labour after two previous caesarean sections (TOLA2C). This retrospective cohort study collected data from two regional obstetric centres with 12,000 deliveries per annum collectively. The population included singleton pregnancies undergoing (i) TOLA2C, (ii) elective repeat caesarean section following two caesarean sections (ERCS) and (iii) trial of labour after one caesarean section (TOLA1C). Data was collected electronically from 2013 to 2021. Statistical analysis included Fisher exact and Kruskal-Wallis test to compare unpaired samples alongside univariate and multivariable logistic regression. The primary outcome measure was maternal and perinatal outcome. The three groups included; n = 146 TOLA2C, n = 206 ERCS and n = 99 TOLA1C. TOLA2C had a success rate of 65 % compared to 74 % for TOLA1C (p = 0.16). The optimal predictor of successful TOLA2C was previous successful TOLA1C OR 8.65 (95 % CI 2.75–38.41). TOLA2C was associated with greater risk of endometritis and/or sepsis postnatally compared to the other two groups [10.3 % (n = 15) versus 0.5 % (n = 1) and 3 % (n = 3) for ERCS and TOLA1C respectively p < 0.01]. It was also associated with longer maternal hospital stay [2.4 days (+/-1.8) versus 1.8 (+/-0.8) and 1.8 (+/-1.7) p < 0.01], a greater proportion of neonates with Apgar scores less than 7 (p =<0.01) and higher rates of neonatal unit admission [14 % (n = 20) versus 5 % (n = 11) versus 4 % (n = 4) (p =<0.01)]. Women considering trial of labour following two caesarean sections should be counselled regarding the potential increased risk of endometritis, sepsis and adverse neonatal outcome. [ABSTRACT FROM AUTHOR]

Background: Almost a third of all deliveries now involve a caesarean section (CS). Trial of labor after caesarean (TOLAC) followed by vaginal birth after caesarean (VBAC) is crucial for lowering the total caesarean rate since repeat caesarean is the most prevalent single rationale for caesarean. Aim: this study was conducted to assess the incidence, and maternal and neonatal outcomes of vaginal birth after caesarean section. Methods: This retrospective cohort study was conducted at the obstetrics and gynecology department in of Beni-Suef General Hospital. The data was obtained from the files of each patient. The collected data included reported history taking, clinical examinations, preoperative and postoperative investigations, details of previous deliveries, and maternal and fetal outcomes of vaginal delivery following caesarean section. The success rate of TOLAC was (84.9%) while the failure rate was (15.1%). Results: The rate of succeeded VBAC was (1.6%) while the rate of CS was (38%) from all deliveries in 2016 and 2017. There was a difference between succeeded VBAC group and failed group regarding the history of previous vaginal delivery, number, causes, type, indications of prior CS(s), duration between CS and current pregnancy, presentation, medical disorders, fetal heart rate (FHR), Apgar score and need for neonatal intensive care unit (NICU) admission. Conclusion: Regarding VBAC precautions, factors that improve success are previous lower segment CS, previous vaginal delivery, cephalic presentation, a single full-term fetus of average weight, good maternal health (free of medical disorder), the patient is in an active phase of the first stage of labor and previous vaginal delivery. VBAC became one of the solutions to avoid the complications of ERCD as there are fewer complications, shorter hospital stays, faster recovery, avoidance of major surgery, and reduced risk of NICU admission. [ABSTRACT FROM AUTHOR]

ObjectiveTo describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors.MethodsWe invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts.ResultsAmong the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC.ConclusionOur findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

Background & aim: Trial of labor after cesarean (TOLAC) to achieve vaginal delivery is considered acceptable in women with one previous cesarean. This study was performed to compare the success rate and maternal and neonatal outcomes of TOLAC after one and two previous cesarean sections.Methods: This cross-sectional study was conducted in September 2018 and March2020 by convenience sampling on 339 pregnant women with a history of one or two previous cesarean sections in Mashhad. TOLAC was performed for all eligible participants, if cesarean section performed due to any reason, it was considered a failed TOLAC. Maternal and neonatal outcomes by a check list were recorded during TOLAC and one week later. Data were analyzed by SPSS (version 24). Results: TOLAC was successful in 301 cases (94.1%), but 19 (5.9%) underwent cesarean section. Maternal age, parity, and frequency of comorbidities were significantly higher in those with two previous cesarean sections compared to those with one previous cesarean section (P0.05). Conclusion: Considering standard precautions in patient selection, TOLAC has a high enough success rate to justify recommending it to the selected women with one or two previous cesarean section.

Background Objectives Search strategy Selection criteria Data collection and analysis Main results Conclusions Vascular Ehlers‐Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.To systematically review the literature data on the complications in pregnancy associated with vEDS.We searched the Pubmed Medline and Embase databases for articles using the following terms “vascular Ehlers‐Danlos syndrome” or “vEDS” AND “pregnancy”.Women with vEDS.We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation. [ABSTRACT FROM AUTHOR]

This article discusses the complications that can arise from a previous caesarean section, specifically focusing on the caesarean scar defect. It emphasizes the importance of recognizing and managing these complications, as they can occur even after a successful vaginal birth after caesarean section. The article describes the anatomical changes of the caesarean scar defect and its relationship with placenta accrete spectrum disorder. It also addresses the management of these complications during pregnancy, including a technique for myometrial uterine repair. The article provides case studies to demonstrate how knowledge of scar anatomy can be used to manage complications related to the caesarean scar defect. The authors suggest the potential benefit of dedicated teams in Obstetrics and Gynecology departments to manage scar complications and improve outcomes. [Extracted from the article]

Purpose: We hypothesized that among obese patients with a history of cesarean birth, a TOLAC is associated with decreased composite maternal adverse outcomes (CMAO) compared to planned repeat low transverse cesarean section (RLTCS). Methods: In this population-based cross-sectional study using the National Birth Certificate database from 2016 to 2020, we compared obese patients who attempted TOLAC at term (≥ 37 weeks estimated gestational age) to planned RLTCS. The primary outcome was a CMAO, defined as delivery complications, including intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or maternal blood transfusion. Results: Overall, 794,278 patients met inclusion criteria for the study; 126,809 underwent a TOLAC, and 667,469 had a planned RLTCS. The overall CMAO was significantly higher for patients undergoing TOLAC (9.0 per 1000 live births) compared to RLTCS (5.3 per 1000 live births; aRR 1.64, 95% CI 1.53–1.75). Conclusion: This data demonstrate that in obese patients with prior cesarean birth, a trial of labor is associated with increased maternal morbidity when compared to a planned repeat cesarean birth. [ABSTRACT FROM AUTHOR]

Background: Australia's caesarean rate is higher than Organisation for Economic Co‐operation and Development (OECD) average, and is rising. Vaginal birth after caesarean (VBAC) is safe for selected women. Midwifery continuity of care (CoC) is associated with higher rates of vaginal birth compared to other models; however, impacts on VBAC attempts and success are unknown. Aims: The primary aim was to determine if there is a difference in achieving VBAC between CoC and non‐CoC (NCoC) models. The secondary aim was to determine if there is a difference in the proportion of women attempting VBAC between these models. Materials and Methods: Retrospective review of antenatal records and birthing data of all women who birthed in 2021 with one or more previous caesareans. Women were included if they had two or fewer caesareans. Women were excluded if contraindications to VBAC existed. Results: There were 142/1109 (12.8%) women who had previous caesareans and were eligible to attempt VBAC. There were 47/109 (43.1%) women who attempted vaginal birth after one caesarean with 78.7% success. After one caesarean, women in CoC were more likely to achieve VBAC than NCoC (45.2% vs 26.1%; relative risk (RR) 1.76, 95% CI 1.04–3.00), although when stratified by private and midwifery CoC models, women in midwifery CoC models were more likely to be successful (private RR 0.69, 95% CI 0.23–2.07 vs midwifery RR 2.48, 95% CI 1.50–4.11). Women in CoC were more likely to attempt VBAC (54.7% vs 34.8%; RR 1.57, 95% CI 1.02–2.41), and receive counselling about VBAC (92.5% vs 62%; RR 1.48, 95% CI 1.41–3.11). Conclusion: CoC improves the rate of attempted and successful VBAC through several factors, including increased counselling and greater provision of birth choices. [ABSTRACT FROM AUTHOR]

Background: Vesicouterine fistula (VUF) is a iatrogenic injury in the vast majority of cases. The worldwide increase of cesarean delivery rates is expected to lead to increased complications. Objectives: To assess current evidence on VUF pathogenesis and surgical management. Search Strategy: Pubmed and Embase databases were searched from January 2000 to January 2023 using relevant key words. Selection Criteria: Only original articles including either transabdominal or transvaginal surgical routes for post‐cesarean VUF repair, in English language, were included. Data Collection and Analysis: Two authors independently screened the references for eligibility, data extraction, and assessment of methodologic quality. All available surgical outcomes were recorded. Main Results: Of the 1160 studies retrieved, 67 were selected for analysis. Most of these were case reports, case series, or observational cohort studies including a total of 284 patients. The majority (78.6%) of patients had more than one cesarean section, and approximately 10% of them experienced an overt bladder injury and/or uterine rupture at the time of cesarean delivery. The supratrigonal part of the bladder was most commonly involved (92.5%). The majority of patients (88.8%) underwent delayed VUF repair through laparotomy. Length of stay and blood loss were significantly less in patients treated via a minimally invasive approach (P < 0.001 and P = 0.02, respectively). Most patients had double‐layer bladder repair and single‐layer uterine repair. The overall success rate was 100% on first attempt for each independent combination of different surgical approaches and techniques. Live birth following VUF repair was reported in 23 patients. Conclusions: Paying close attention to surgical details is crucial to reduce the incidence of this complication and recurrence rates. Double‐layer bladder closure and delayed timing of repair of VUF are recommended. Synopsis: Delayed repair of vesicouterine fistula avoiding endometrial exposure and using a double‐layer bladder closure are the most important surgical tenets of vesicouterine fistula repair. [ABSTRACT FROM AUTHOR]

Background: Cesarean section (CS) is among the most common obstetric operations globally, and recent research shows a rise in the prevalence of CS. Maternal morbidity and mortality related to CS is a major public health concern across the world. This necessitates a study of the impact of recurrent CSs on mother morbidity. Patients and Methods: This Cross-sectional study was carried out on 165 women in the Department of Obstetrics and Gynecology, Zagazig University Hospitals by analyzing the data and records of all women who underwent multiple repeated CSs. The women were allocated according to the number of CSs into 3 groups, the maternal outcomes and complications as adhesions, hysterectomy, or blood transfusion requirements of all groups were examined retrospectively. Results: The current study included a total of 165 participants. Our results revealed that the most frequent complication was adhesion ~59.39%, followed by intraoperative hemorrhage and need for blood transfusion (19.4%), and the less frequent complication was endometritis and no maternal death. There was a significant difference between the groups regarding maternal age, BMI, hospital stay, and operative time, while no significance was found in pre/postoperative hemoglobin. Conclusions: Our results endorse our assumption that the risk of maternal complications increases as the number of CSs increases. There is no clear absolute threshold for the number of CSs, but a total of 4 or more cesarean deliveries was identified as the critical level for most of the major complications. Adhesions were the most prevalent complication in our research group, followed by intraoperative hemorrhage. To reduce related problems, the number of CSs must be reduced. The patient should be advised that vaginal birth after CS is an option. [ABSTRACT FROM AUTHOR]

Background: Globally, cesarean birth rates are rising, and while it can be a lifesaving procedure, cesarean birth is also associated with increased maternal and perinatal risks. This study aims to describe changes over time about the mode of birth and perinatal outcomes in second‐pregnancy women with one previous cesarean birth in the Netherlands over the past 20 years. Methods: We conducted a nationwide, population‐based study using the Dutch perinatal registry. The mode of birth (intended vaginal birth after cesarean (VBAC) compared with planned cesarean birth) was assessed in all women with one previous cesarean birth and no prior vaginal birth who gave birth to a term singleton in cephalic presentation between 2000 and 2019 in the Netherlands (n = 143,146). The reported outcomes include the trend of intended VBAC, VBAC success rate, and adverse perinatal outcomes (perinatal mortality up to 7 days, low Apgar score at 5 min, asphyxia, and neonatal intensive care unit admission ≥24 h). Results: Intended VBAC decreased by 21.5% in women with one previous cesarean birth and no prior vaginal birth, from 77.2% in 2000 to 55.7% in 2019, with a marked deceleration from 2009 onwards. The VBAC success rate dropped gradually, from 71.0% to 65.3%, across the same time period. Overall, the cesarean birth rate (planned and unplanned) increased from 45.2% to 63.6%. Adverse perinatal outcomes were higher in women intending VBAC compared with those planning a cesarean birth. Perinatal mortality initially decreased but remained stable from 2009 onwards, with only minimal differences between both modes of birth. Conclusions: In the Netherlands, the proportion of women intending VBAC after one previous cesarean birth and no prior vaginal birth has decreased markedly. Particularly from 2009 onwards, this decrease was not accompanied by a synchronous reduction in perinatal mortality. [ABSTRACT FROM AUTHOR]

Background: Cesarean birth (CB) rates have been increasing rapidly globally, including in Bangladesh. This study aimed to assess national trends in CB rates and to investigate associated factors in Bangladesh. Methods: We analyzed data from the five most recent Bangladesh Demographic and Health Surveys (BDHS) between 2003 and 2018. A total of 27,328 ever‐married women aged 15–49 who had a live birth in the 2 years preceding the survey were included in this study. We estimated the prevalence of CB from 2003 to 2018, as well as changes in the prevalence. Logistic regression analysis was used to measure the association between dependent and independent variables. Results: The overall prevalence of CB among Bangladeshi mothers was 3.99% in 2003–04; this rate increased to 33.22% in 2017–18. The annual percentage change in CB rate was 16.34% from 2004 to 2017–18, which is alarming relative to the World Health Organization's cesarean birth recommended threshold. Several factors, such as maternal age, maternal and paternal education, working status of the mother, maternal BMI, age at first pregnancy, antenatal care (ANC) use, administrative division, and wealth status, had a significant influence on the rising rate of CB in Bangladesh. Conclusions: This study documents the alarming rate of CB increase in Bangladesh since 2003. It is critical that authorities implement more effective national monitoring measures to identify the causes of this dramatic increase and work to mitigate the rate of unnecessary CB in Bangladesh. [ABSTRACT FROM AUTHOR]

This document is a comprehensive guide on the perioperative management of patients in the surgical intensive care unit (SICU). It covers various topics such as pain management, resuscitation and hemodynamic management, prevention of complications, management of hematologic disorders, evaluation of antimicrobial regimens, and blood glucose management. The document also provides information on pharmacotherapy for specific conditions and populations, including trauma, neurologic injury, transplant patients, and patients with traumatic brain injury. It discusses the role of pharmacists in the treatment and prevention of gastrointestinal complications, as well as the prevention and treatment of acute kidney injury. Additionally, the document addresses blood transfusion and resuscitation, transfusion reactions, venous thromboembolism prophylaxis, and the perioperative management of antithrombotic therapy. The guideline emphasizes a systems-based approach and the involvement of pharmacists in providing comprehensive care. [Extracted from the article]

Objective Methods Results Conclusions To investigate whether women undergoing their first vaginal delivery after a previous cesarean section (secundiparous) are at increased risk for obstetric anal sphincter injury (OASI) compared with primiparous women.A retrospective cohort study of 85 428 women who delivered vaginally over a 10‐year period in a single tertiary medical center. Incidence of OASI, risk factors, and clinical characteristics were compared between primiparous women who delivered vaginally and secundiparous women who underwent their first vaginal birth after cesarean section (VBAC). A multivariable logistic regression analysis was used to study the association between VBAC and OASI.Overall, 36 250 primiparous and 1602 secundiparous women were enrolled, 309 of whom had OASI. The rates of OASI were similar among secundiparous women who had VBAC and primiparous women who underwent vaginal delivery (15 [0.94%] vs 294 [0.81%], P = 0.58). The proportions of third‐ and fourth‐degree tears were also similar among secundiparous and primiparous women who experienced OASI (87% vs 91.5%, and 13% vs 8.5%, respectively, P = 0.68). Furthermore, the rates of OASI were similar in both study groups, although secundiparous women who underwent VBAC had higher rates of birth weights exceeding 3500 g (414 [25.8%] vs 8284 [22.8%], P = 0.016), and higher rates of vacuum‐assisted deliveries (338 [21%] vs 6224 [17.2%], P < 0.001). A multivariate logistic regression analysis failed to establish a statistically significant association between VBAC and OASI (odds ratio 0.672, 95% confidence interval 0.281–1.61, P = 0.37).No increased risk for OASI was found in secundiparous women who underwent VBAC compared with primiparous women at their first vaginal birth. [ABSTRACT FROM AUTHOR]

Background: The impact of hypertrophic cardiomyopathy (HCM) on cardiovascular and obstetrical outcomes in pregnant women remains unclear, particularly in Asian populations. This study aimed to evaluate the maternal cardiovascular and obstetrical outcomes in Korean women with HCM. Methods: Using data from the Korean National Health Insurance Service database, we identified women who gave birth via cesarean section or vaginal delivery after being diagnosed with HCM between 2006 and 2019. Maternal cardiovascular and obstetrical outcomes were assessed based on the trimester of pregnancy. Results: This study included 122 women and 158 pregnancies. No maternal deaths were noted; however, 21 cardiovascular events, such as hospital admission for cardiac problems, including heart failure and atrial fibrillation (AF), new-onset AF or ventricular tachycardia (VT) occurred in 14 pregnancies (8.8%). Cardiac events occurred throughout pregnancy with a higher occurrence in the third trimester. Cesarean sections were performed in 49.3% of the cases, and all cardiovascular outcomes occurring after delivery were observed in patients who had undergone cesarean sections. Seven cases involved preterm delivery, and two of these cases were accompanied by cardiac events, specifically AF. Pre-existing arrhythmia (AF: odds ratio (OR): 7.44, 95% confidence interval (CI): 2.61–21.21, P < 0.001; VT: OR: 31.61, 95% CI: 5.85–172.77, P < 0.001) was identified as a predictor for composite outcomes of cardiovascular events or preterm delivery. Conclusions: Most pregnant women with HCM were well-tolerated. However, cardiovascular complications could occur in some patients. Therefore, planned delivery may be necessary for selected patients, especially the women with pre-existing arrhythmias. [ABSTRACT FROM AUTHOR]

Introduction: The global incidence of caesarean section (CS) deliveries has exceeded the recommended threshold set by the World Health Organization. This development is a matter of public health concern due to the cost involved and the potential health risk to the mother and the neonate. We sought to investigate the prevalence, indications, maternal and neonatal outcomes and determinants of CS in private health facilities in Ghana. Method: A retrospective cross-sectional analysis was conducted using data from women who delivered at the Holy Family Hospital from January to February 2020 using descriptive and inferential statistics, with a significance level set at p<0.05. Results: The prevalence of CS was 28.70%. The primary indications of C/S include previous C/S, foetal distress, breech presentation, pathological CTG and failed induction. Significant associations were found between CS and breech presentation (AOR = 4.60; 95%CI: 1.22–17.38) p<0.024, previous CS history (AOR = 51.72, 95% CI: 11.59–230.70) p<0.00, and neonates referred to NICU (AOR = 3.67, 95% CI: 2.10–6.42) p<0.00. Conclusion: The prevalence of caesarean section (CS) deliveries was higher than the WHO-recommended threshold. Major indications for CS included previous CS, fetal distress, and failed induction. Significant risk factors for CS were previous CS history, breech presentation, and neonates referred to NICU. [ABSTRACT FROM AUTHOR]

Purpose: The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. Methods: A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. Results: 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0–7.7) vs. 4.6 (3.0–6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. Conclusion: Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up. [ABSTRACT FROM AUTHOR]

Purpose: To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. Methods: A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. Results: During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). Conclusion: Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients. [ABSTRACT FROM AUTHOR]

Adenomyosis is a benign condition commonly encountered in patients with infertility. While the definitive surgical management is hysterectomy, conservative surgical management is gaining attention in patients desiring future fertility. This review explores whether the surgical treatment of adenomyosis affects fertility outcomes for patients trying to conceive. The PubMed and Medline databases were searched using the keywords: "adenomyosis", "surgery", "radiofrequency", "infertility", "pregnancy", "sterility", "conception", "miscarriage", and "endometrial receptivity". Abstracts were screened, and relevant articles were selected for review. This review reveals that surgery appears to improve fertility outcomes with or without medical therapy; however, the risk of uterine rupture remains high and the best technique to reduce this risk is still not known. More studies are needed to formulate the best surgical approach for preserving fertility in treating adenomyosis and to establish standardized guidelines. [ABSTRACT FROM AUTHOR]

Introduction: Tranexamic acid (TXA) injections, known for their antifibrinolytic properties, are gaining wider acceptance as a treatment for postpartum hemorrhage (PPH) on a global scale. Aims and objectives: The purpose of this study was to evaluate the effectiveness of TXA and its potential side effects in preventing PPH following vaginal birth. Materials and methods: This randomized controlled trial, conducted in a multispecialty hospital in Belagavi, India, involved 210 term patients over 1 year from January to December 2019. Subjects were randomly assigned into two cohorts using computer-based randomization. Each cohort received 10 prophylactic units of oxytocin. One group received 1 gm of intravenous TXA, while the other received 10 mL of normal saline intravenously within 2 minutes after delivery. Blood loss was measured using calibrated drapes, and mean changes in hemoglobin (Hb) and packed cell volume (PCV) were assessed from pre-delivery to postnatal day 2. Data assessment was carried out using the statistical program R i386 3.6.3. Results: Patients in the research had an average age of 23.43 years with a standard deviation (SD) of 3.26 years. The occurrence of PPH was observed in 5 individuals (4.85%) in the TXA group and 12 individuals (11.21%) in the placebo group (p= 0.0912). Furthermore, the mean blood loss was significantly lesser in the TXA group, measuring 250.10 mL with an SD of 133.54 mL, compared to 334.2 mL with an SD of 141.78 mL in the placebo group (p < 0.0001). Conclusion: Tranexamic acid can serve as a supplementary treatment alongside uterotonics during the third stage of labor, given its demonstrated clinical effectiveness and safety in preventing PPH. [ABSTRACT FROM AUTHOR]

Background: The growing prevalence of Cesarean Sections (CS), particularly repeated CS, is a major issue in contemporary midwifery. This study seeks to gain a comprehensive understanding of the experiences of pregnant women and specialists with vaginal delivery after CS, as well as the obstacles that may arise. Materials and Methods: From March 2020 to May 2021, 10 women, 12 midwives, and 8 obstetricians and obstetricians affiliated with Qom University of Medical Sciences were interviewed to investigate the experiences and challenges associated with Vaginal Birth After Cesarean section (VBAC). We used the content analysis method, and the sampling was purposive. Semi-structured interviews were conducted to collect data, which were then analyzed using qualitative content analysis based on conventional content analysis. Results: The results show that subcategories "individual aspects of VBAC" and "family-social aspects of VBAC" formed "positive aspects of VBAC." Subcategories "self-efficacy" and "decision-making participation" formed the "empowerment for the woman." Subcategories "technical team challenges" and "woman's challenges" formed the main category of "upcoming challenges." Conclusions: Positive relationships, choice-making ability, and self-confidence impact a woman's decision to choose VBAC. Informing women of alternative delivery options after a CS and pursuing their dreams increases the likelihood of successful VBAC. [ABSTRACT FROM AUTHOR]

• Generally, placenta previa (PP) and specifically major PP is a well-established risk factor during pregnancy, and is associated with the highest maternal and perinatal complication rates. • The presence of PP substantially increases the patient's risk for invasive placentation or placenta accreta spectrum (PAS). When pregnancies are complicated by both types of abnormal placentation (PP with PAS), a much higher risk of worse maternal outcomes is typically expected. • Moreover, evidence suggests that previous CS increases the risks of both PP and PAS, up to more than 67 % by 5th. repeated CS and PP will develop abnormal placentation (PAS). • This study aimed to find out the maternal outcomes of major PP (with or without PAS) among patients with history of "previous CS-one or more". To compare maternal characteristics and outcomes among patients having major placenta previa (PP) with and without previous cesarean section (CS). And to determine if previous CS alone is a risk factor for associated adverse maternal outcomes in these patients. This is a retrospective analysis including two groups of major PP patients, with previous CS (n = 184) and without CS (n = 115); who were admitted to Abha Maternity and Children's Hospital over the last ten-years (January 2012–December 2021), Aseer region, Saudi Arabia. Compared to those without previous CS, major PP patients with previous CS had significantly advanced ages with higher mean numbers of gravidity and parity, but significantly less rates of previous uterine surgery and IVF pregnancies. Moreover, they were more likely to acquire higher rates of adverse maternal outcomes. In the same way, these patients had an increased Odds Ratios of cesarean hysterectomy (OR of 20.462), urinary tract injuries (OR of 12.361), associated PAS (OR of 4.375), moderate/ heavy intra-operative bleeding (OR of 2.153) and the need for transfusion of 3+ units of packed RBCs (OR of 1.849). (1) Patients with combined existence of major PP and previous CS had significantly higher rates of adverse maternal outcomes (2) Alone, prior CS in major PP patients increased the Odds Ratios of cesarean hysterectomy, urinary tract injuries, diagnosis of PAS, excessive intra-operative bleeding and repeated packed RBCs transfusions. (3) Among our PP patients with previous CS, the increased rate and OR of PAS diagnosis could in-part explain the adverse maternal outcomes. [ABSTRACT FROM AUTHOR]

Background & Objective: Vaginal birth after Cesarean (VBAC) is often offered as an option after a single cesarean section (CS). To evaluate the success rate of vaginal birth after two cesarean sections (VBAC-2). Materials & Methods: We searched MEDLINE, EMBASE, PubMed, Scopus, using search terms (cesarean OR cesarean OR caesarean OR caesarian) AND ("Vaginal birth after cesar Keywords: Vaginal birth after Cesarean, Cesarean section, Maternal, Fetal outcomesean" OR VBAC) AND (two OR Twice OR second OR multiple). Two independent reviewers performed the study selection, and abstracted and tabulated data and pooled estimates were obtained. Meta-analyses were performed using Open-meta and Comprehensive Meta-Analysis. Results: Mean success rate of VBAC-2 was 72% (2174 out of 3020 cases) with a range of 24-90%. The mean hysterectomy rate was 0.43% ranging from 0% to 1.7%. Our meta-analysis showed no significant difference between VBAC-2 and CS-3 in the case of hysterectomy, with a pooled odds ratio (OR) of 0.699, but with a wide confidence interval (95% CI was 0.347-1.407). VBAC-2 being associated with 2-fold increased risk of perinatal mortality compared to CS-3. Conclusion: Vaginal delivery is a suitable option for women with two previous cesarean sections; the outcomes are significantly more favorable for women with a history of vaginal birth. [ABSTRACT FROM AUTHOR]

Background: Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group. Methods: This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 – December 2015) and after (January 2018 – December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit. Results: Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality. Conclusions: This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes. [ABSTRACT FROM AUTHOR]

Background: Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery. Methods: Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived. Results: Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50–69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50–69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation. Conclusions: Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram. Trial registration: Retrospectively registered. [ABSTRACT FROM AUTHOR]

Objective: To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14–28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS). Methods: A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h. Results: A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair. Conclusion: Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management. Synopsis: Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section. [ABSTRACT FROM AUTHOR]

Background: Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture. Methods: Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively. Results: In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1–40+3 weeks), and the average bleeding volume was 1896.97 ml (200–6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%). Conclusions: The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture. [ABSTRACT FROM AUTHOR]

Background: One of the procedures that is carried out the most frequently globally is the Caesarean section (CS). The introduction of enhanced recovery (ER) for planned CS to enable earlier discharge is receiving a lot of interest. The aim of this study was to assess the enhanced recovery protocols versus the standard care in elective cesarean section and to introduce enhanced recovery protocols to Zagazig University maternity hospitals and Al-Ahrar Teaching Hospital to decrease hospital stays and opioid use. Methods: This non-randomized controlled trial included patients attending Zagazig University Hospitals and Al-Ahrar Teaching Hospital for elective caesarean sections in the period between September 2018 and August 2019. The number of patients included in the study was 96 patients classified into two groups. A general clinical examination, laboratory investigations, and radiological studies were done. A Cesarean section for all patients of both groups was performed. Results: Regarding the opiates used during the process of recovery for pain control in both groups, the overall mean of both groups was 0.25 ± 0.342 amp. and 1.156 ± 0.463 amp. in group (a) and group (b) respectively, where there was a significant statistical difference between the two groups. Conclusions: When enhanced recovery after surgery (ERAS) protocols are used in elective cesarean sections, patients treated with these protocols benefit from earlier ambulation, earlier resumption of intestinal sounds, earlier oral intake tolerated, decreased catheterization time, decreased amounts of opiates used and their obvious side effects, an improved satisfaction score, and decreased pain. [ABSTRACT FROM AUTHOR]

Background Research comparing the efficacy of phenylephrine and norepinephrine in managing post spinal hypotension among pregnant patients is limited. Objective To assess the effectiveness of phenylephrine and norepinephrine bolus doses in treating hypotension during elective cesarean section under spinal anesthesia in pregnant females hypothesizing similar neonatal outcomes. Materials and Methods: The present randomized controlled study is a single-centre, tertiary care hospital based study conducted on 90 pregnant women with singleton pregnancies experiencing postspinal hypotension during cesarean section. Patients received intravenous phenylephrine (50 µg) or norepinephrine (4 µg) for hypotension treatment, defined as = 20% drop in baseline systolic BP or absolute value < 100 mmHg. Primary outcome measure was umbilical artery pH while secondary measures were Apgar scores, hypotensive episodes, vasopressor requirements, cardiac complications, maternal outcomes. Results: Umbilical artery pH did not differ between phenylephrine and norepinephrine groups (8.26 ± 0.06 vs. 8.27 ± 0.06, respectively; P = 0.93). Median hypotensive episodes were higher with norepinephrine (2[1to3] vs.1 [1to2], P=0.014). Apgarscores, va so press ordoses, BP trends, and maternal complications were similar. Phenylephrine group had lower heart rates (P = 0.026); one had bradycardia (HR < 50 bpm) vs. none with norepinephrine (P = 1.000). Conclusions In pregnant women undergoing elective cesarean section, phenylephrine (50 µg) and norepinephrine (4 µg) bolus doses for spinal anesthesia-induced hypotension are equally effective with similar neonatal and maternal outcomes. [ABSTRACT FROM AUTHOR]

Background Determining how women make sense of their birth preferences with metaphor analysis will be an important step in determining perceptions about birth options. Objective The aim of this study is to examine the perceptions of women who had cesarean section regarding the concept of "cesarean birth" and "Vaginal birth after cesarean section" with metaphor analysis. Materials and Methods: This study is a qualitative research based on the philosophy of Husserl's phenomenology, which was carried out between June and November 2022. Within the scope of the research, 50 women who had a cesarean section were interviewed face to face. The metaphor form prepared in line with the international literature was used to determine women's perceptions of the concept of "Cesarean section" and "Vaginal birth after cesarean section". Results 25 metaphors for cesarean birth and 28 metaphors for vaginal birth after caesarean section were identified. Considering the common features and analogy aspects of the metaphors obtained, three themes were determined within the scope of cesarean section and vaginal birth after caesarean section. Conclusions This study took a unique approach to revealing women's birth experiences and perceptions. Vaginal birth after caesarean section is a very valuable birth method for women who have had a cesarean section and are curious about the feeling of vaginal birth. [ABSTRACT FROM AUTHOR]

Objectives: To study risk factors for shoulder dystocia (ShD) among women delivering <3500 g newborn. Methods: A retrospective case–control study of all term live‐singleton deliveries during 2011–2019. Women with neonatal birthweight <3500 g were included. We compared cases of ShD to other deliveries by univariate and multivariable regression. Results: There were 79/41 092 (0.19%) cases of ShD among neonates <3500 g. In multivariable regression analysis, the following factors were independently associated with ShD; operative vaginal delivery (odds ratio [OR] 2.78; 95% confidence interval [CI]: 1.28–6.02, P = 0.009), vaginal birth after cesarean (VBAC, OR 2.74; 1.22–6.13, P = 0.010), sonographic abdominal circumference to biparietal diameter ratio (3.73 among ShD vs. 3.62, OR 1.35; 95% CI: 1.12–1.63, P = 0.001) and sonographic abdominal circumference to head circumference ratio (1.036 among ShD vs. 1.011, OR 3.04; 95% CI: 1.006–9.23, P = 0.049). Conclusions: There is an association between operative vaginal delivery and ShD also in deliveries <3500 g. Importantly, the proportions between the fetal head and abdominal circumference are a better predictor of ShD than the newborn fetal weight and VBAC is associated with ShD. Synopsis: Shoulder dystocia <3500 g have a certain clinical and gestational risk factor. [ABSTRACT FROM AUTHOR]

Objective: To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. Methods: A retrospective single‐center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not. Results: Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699). Conclusion: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks. Synopsis: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for both the mother and neonate. Oxytocin use does not affect these risks. [ABSTRACT FROM AUTHOR]

• All women are administered uterotonic drugs for preventing postpartum hemorrhage. • Carbetocin given by an intravenous bolus is better than intramuscular oxytocin. • Intramuscular ergometrine + oxytocin is also better than intramuscular oxytocin. • Oxytocin works best when given by an intravenous bolus than intramuscularly. To perform a network meta -analysis to specify the route of administration that maximises the effectiveness of each of the available prophylactic uterotonics without increasing the risk for side effects. Literature searches on 12th September 2022 included: CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. The reference lists of the retrieved study records were also searched. Population: Randomized controlled trials involving women in the third stage of labour after a vaginal or caesarean delivery in hospital or community settings. Interventions: Systemically administered prophylactic uterotonics of any route and dose for primary postpartum hemorrhage prevention. Comparison: Any other prophylactic uterotonic, or a different route or dose of a given uterotonic, or placebo, or no treatment. Outcomes (primary): postpartum hemorrhage ≥ 500 mL and ≥ 1000 mL. Risk of bias and trustworthiness assessments were performed, according to Cochrane's guidance. Direct, indirect and network meta -analyses were conducted, and results were summarized either as risk ratio or mean difference with 95% confidence intervals for dichotomous and continuous outcomes, respectively. The certainty of generated evidence was assessed according to the GRADE approach. Cumulative probabilities were calculated and the surface under the cumulative ranking curve was used to create a ranking of the available drugs. One hundred eighty-one studies involving 122,867 randomised women were included. Most studies were conducted in hospital settings in lower-middle income countries and involved women delivering vaginally. When compared with intramuscular oxytocin, carbetocin (RR 0.58, 95 % CI 0.40–0.84) and oxytocin (RR 0.75, 95 % CI 0.59–0.97) by an intravenous bolus, and intramuscular ergometrine plus oxytocin combination (RR 0.71, 95 % CI 0.56–0.91) are probably more effective in preventing primary postpartum hemorrhage. Intramuscularly administered oxytocin and carbetocin by an intravenous bolus have a favourable side effects profile. Generated evidence was generally moderate and global inconsistency was low. Carbetocin and oxytocin by an intravenous bolus, and intramuscular ergometrine plus oxytocin combination are probably the top uterotonics for primary postpartum hemorrhage prevention. Large scale studies exploring different routes of administration for available prophylactic uterotonics, and women's views should be conducted. [ABSTRACT FROM AUTHOR]

Background & Aim: The high prevalence of cesarean section in most developed countries, exceeding 50%, has led to detrimental effects on maternal and child health. Vaginal birth after cesarean (VBAC) is a beneficial way to reduce cesarean rates. This study aimed to determine the effect of theory of planned behavior-based training on the intention and behavior of VBAC in pregnant women with previous cesarean section. Methods & Materials: In this randomized controlled trial study, a convenience sample of 70 pregnant women with a history of cesarean section, referred to comprehensive health centers in Ardabil in 2020, were randomly assigned to either the intervention or control group. The intervention group received four weekly education sessions based on the theory of planned behavior structures, while the control group received standard care. Data were collected using a researcher-developed questionnaire at three time points: before, immediately after, and four weeks after the intervention. Data analysis was conducted using SPSS software version 16, employing independent t-test, Fisher’s exact test, chi-square test, and repeated measures ANOVA at a 95% confidence level. Results: Repeated measures ANOVA revealed significant differences in mean scores of attitude, subjective norm, perceived behavior control, intention, and awareness over time between the intervention and control groups (P<0.001). However, the educational intervention did not lead to a behavior change. Conclusion: Based on the findings, it is imperative for health planners to focus on providing organizational support and fostering a positive attitude among obstetricians and midwives to prioritize the implementation of VBAC. [ABSTRACT FROM AUTHOR]

This article discusses the diagnosis of isthmocele, a uterine defect that occurs at the site of a previous cesarean section or other uterine surgeries. It affects up to 70% of women with a history of cesarean sections and can cause symptoms such as abnormal uterine bleeding and abdominal pain. Accurate diagnosis is important as isthmocele has been linked to complications in future pregnancies. Transvaginal ultrasonography is the primary diagnostic method, and the study suggests that performing the ultrasound during the secretive phase of the menstrual cycle provides clearer visualization of the isthmocele. Surgical correction can be done depending on the size of the defect. [Extracted from the article]

A 35-year-old woman at 36 weeks and 4 days gestation with known complete anterior placenta previa and no other medical history presented for routine obstetric follow-up. She reported increasing fatigue in the prior week but otherwise endorsed no new concerns. She denied recent vaginal bleeding or discharge, abdominal pain, contractions, or extremity swelling. On evaluation, her BP was 126/74 mm Hg with a heart rate of 72 beats per min. The results from the physical examination were normal. There was a category II fetal heart rate tracing and a 6/10 biophysical profile (ie, no fetal breathing movements, nonreactive nonstress test), which prompted referral to the hospital. On admission, sonogram confirmed cephalic presentation and redemonstrated complete anterior placenta previa with no evidence of hemorrhage. She received antenatal steroids and was scheduled for a cesarean section delivery. She received bupivacaine spinal anesthesia for the procedure. The surgical procedure progressed with a low transverse uterine incision and subsequent delivery of the baby with no complications noted. Immediately after delivery of the baby and during gentle traction of the placenta, the patient experienced rapid cardiovascular collapse in the form of hypotension and bradycardia. [ABSTRACT FROM AUTHOR]

To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. Academic tertiary hospital. A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (β-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the β-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower β-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches, our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP. [ABSTRACT FROM AUTHOR]

Previous models for prediction of vaginal birth after cesarean (VBAC) relied on race and ethnicity, raising concern for bias. In response, the Maternal-Fetal Medicine Units Network (MFMU) created a new prediction model without race and ethnicity for individuals with one prior cesarean delivery. We performed a secondary analysis of the MFMU Cesarean Registry database to evaluate whether the MFMU VBAC prediction model without race and ethnicity could accurately predict VBAC for individuals with two prior cesarean deliveries. Overall, 353 individuals were included and 252 (71%) had VBAC. An area under the curve for the receiver operating curve of 0.74 (95% CI, 0.69-0.80) was reported for the predicted probabilities for VBAC, indicating that the model can be used for prediction of VBAC in this population. [ABSTRACT FROM AUTHOR]