Predicting the success of vaginal birth after caesarean delivery: a retrospective cohort study in China
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Objectives To develop a nomogram to predict the likelihood of vaginal birth after caesarean section (VBAC) among women after a previous caesarean section (CS). Design A retrospective cohort study. Setting Two secondary hospitals in Guangdong Province, China. Participants Inclusion criteria were as follows: pregnant women with singleton fetus, age ≥18 years, had a history of previous CS and scheduled for trial of labour after caesarean delivery (TOLAC). Patients with any of the following were excluded from the study: preterm labour (gestational age <37 weeks), two or more CSs, contradictions for vaginal birth, history of other uterine incision such as myomectomy, and incomplete medical records. Primary outcome measure The primary outcome was VBAC, which was retrospectively abstracted from computerised medical records by clinical staff. Results Of the women who planned for TOLAC, 84.0% (1686/2006) had VBAC. Gestational age, history of vaginal delivery, estimated birth weight, body mass index, spontaneous onset of labour, cervix Bishop score and rupture of membranes were independently associated with VBAC. An area under the receiver operating characteristic curve (AUC) in the prediction model was 0.77 (95% CI 0.73 to 0.81) in the training cohort. The validation set showed good discrimination with an AUC of 0.70 (95% CI 0.60 to 0.79). Conclusions TOLAC may be a potential strategy for decreasing the CS rate in China. The validated nomogram to predict success of VBAC could be a potential tool for VBAC counselling.Keywords:
Nomogram
Medical record
Uterine rupture
Women who have a vaginal delivery after a caesarean section face three times the risk of uterine rupture than those who have a second caesarean section, a new report has said ( New England Journal of Medicine 2001;345:3-8).
The study bolsters the old adage, “Once a caesarean section, always a caesarean section.” Moreover, the risk of rupture was five times greater …
Uterine rupture
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Caesarean delivery
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Objective: To explore the delivery mode for repregancy after caesarean section.Methods: Clinical data of 158 cases with repregancy after caesarean section admitted from Oct 2000 to Oct 2010 were retrospectively analyzed,including delivery mode,delivery outcome and maternal and neonatal complication,including 115 with a second caesarean section served as observation group 1,and 43 with vaginal delivery after caesarean section served as observation group 2.Another 158 cases with pregnancy after caesarean section were selected as control group,including 115 with caesarean section and 43 with vaginal delivery.The delivery mode,delivery outcome and maternal and neonatal complication were compared.Results: In observation group,66 had vaginal delivery,in which 43 had successful surgery(65.2%);115 had caesarean section with successful rate as 72.8%.There was no significant difference in incidence of neonatal asphyxia,hemorrhage during delivery and uterine rupture and neonatal weight between observation group 2 and control group(P0.05).The bleeding volume of patients with a second caesarean section was more than patients with vaginal delivery.The average hospitalization duration was significantly longer(P0.01) and the incidences of hemorrhage,severe adhesion and poor incision healing were significantly higher in caesarean section group(P0.05).Conclusions: Caesarean section is not the only option for delivery of patients with one caesarean section.Vaginal delivery under strict monitoring is safe.
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To assess whether maternal request for elective caesarean section was in fact obstetrician driven a postal questionnaire was undertaken in the North Thames Region. One hundred and thirtyfour consultants who undertook NHS obstetrics replied to the questionnaire. Only one (0.8%) offered elective caesarean section to all women, and all suggested trial of scar in selected cases. Eighty-three (61.9%) of respondents felt that maternal request had significantly increased their caesarean section rate. It is concluded that maternal request for caesarean section is not obstetrician led, but patient driven.
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Summary The treatment of 158 grossly infected patients in late labour has been reviewed. The morbidity and mortality following Caesarean section in such cases is high compared to vaginal delivery by destructive operation. Vaginal delivery by destructive operation in skilled hands is safer, although cases have to be carefully judged and selected. Caesarean section is not refused if the fetus is alive even in the presence of infection and it is the best method of treatment when the lower segment is on the verge of rupture, even if the fetus is dead.
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Perinatal mortality
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Caesarean delivery
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Summary: A retrospective analysis was made of 456 patients who had previously undergone Caesarean section and who were considered suitable for a trial of labour. Sixty percent of patients had a vaginal delivery. Patients with obstructed labour or failure to progress as the indication for primary Caesarean section were significantly more likely to require a repeat operation but 44% of these patients still achieved a vaginal delivery. Patients who had had a vaginal delivery prior to, or subsequent to, the Caesarean section had a low incidence of repeat Caesarean section. X‐ray pelyimetry was of limited value in predicting outcome. Intravenous oxytocin was used in 17% of patients. No uterine rupture occurred and no fetal mortality resulted directly due to the trial of labour. Trial of labour following Caesarean section is a safe procedure when conducted in an appropriate hospital setting.
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To review literature about mode of delivery in fetuses affected with congenital heart disease (CHD). Search in PubMed, EMBASE, clinicaltrials.org and reference list limited from January 2000 to February 2019. Key words were: congenital heart disease, vaginal delivery, Caesarean section, planned Caesarean section, neonatal mortality. From each article, the following data were analysed: mode of delivery, gestational age at delivery, and indication for emergency Caesarean section. PRISMA guidelines were followed. From 9 articles, 5217 fetuses were with CHD pooled. Aneuploidies were present in 12.1% of cases and extracardiac anomalies were detected in 15.2% of cases. Prematurity complicated 27.5% of pregnancies. Induction of labour was performed in 31.3% of term pregnancies. Mode of delivery was vaginal delivery in 2901/5217 (55.6%) cases and Caesarean section in 2316/5217 (44.4%) cases. In all but one study, i.e. 1866 fetuses affected with CHD, Caesarean section was classified as planned or emergency Caesarean. The former occurred in 971 (52.0%) of cases, whereas emergency Caesarean section was necessary in 895 (48.0%) fetuses. Non-reassuring fetal heart rate represented the main indication for emergency Caesarean section in 66.0% of Caesarean section performed during labour. Mode of delivery was not stratified according to the type of CHD and there was no comparison between neonatal outcomes following vaginal delivery and planned Caesarean section. Neonatal death occurred in 500/5217 (9.5%) of fetuses with CHD. In fetuses with CHD, vaginal delivery is successful in approximately half of cases. However, abnormal heart rate might occur in about 66% of cases, for which emergency Caesarean section is necessary. Limitations of literature include mode of delivery not stratified for type of CHD, prenatal and postnatal diagnosis of CHD not compared with regard to mode of delivery, neonatal morbidity not compared between planned Caesarean section and vaginal delivery, how extracardiac anomalies impact on mode of delivery.
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Summary In a retrospective review of 333 pregnancies in women who had 1 previous Caesarean section, 244 (73.3%) underwent a trial of scar, and 89 (26.7%) had an elective Caesarean section. In the trial of scar group 197 (80.7%) had a vaginal delivery and 47 (19.3%) required an emergency Caesarean section. The success of the trial was favourably influenced by a nonrecurring indication for the original Caesarean section, a previous vaginal delivery, and a smaller baby. Maternal morbidity was greater in the groups requiring a Caesarean section, whether elective or emergency. Those patients delivered vaginally spent significantly less time in hospital. In 2 of the 244 patients (0.8%) who underwent a trial of scar the previous lower segment scar was found at Caesarean section to have dehisced or ruptured.
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Objective Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. Design Cohort study. Setting University Hospital. Population All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 ( n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour ( n = 1011). Methods Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. Main outcome measure Incidence of uterine rupture. Results Uterine rupture occurred in 0.3% in the previous caesarean section—induction group versus 0.3% in the previous caesarean section—spontaneous labour group ( P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group ( P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. Conclusion Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.
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Women who have had a previous caesarean section, then have a trial of labour at their second delivery, have an increased risk of uterine rupture compared with women who have a repeat caesarean section without labour, report US researchers this week.
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