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Background

For women who have a caesarean section in their preceding pregnancy, two care policies for birth are considered standard: planned vaginal birth and planned elective repeat caesarean. Currently available information about the benefits and harms of both forms of care are derived from retrospective and prospective cohort studies. There have been no randomised trials, and recognising the deficiencies in the literature, there have been calls for methodologically rigorous studies to assess maternal and infant health outcomes associated with both care policies.

The aims of our study are to assess in women with a previous caesarean birth, who are eligible in the subsequent pregnancy for a vaginal birth, whether a policy of planned vaginal birth after caesarean compared with a policy of planned repeat caesarean affects the risk of serious complications for the woman and her infant.

Methods/Design

Design: Multicentred patient preference study and a randomised clinical trial.

Inclusion Criteria: Women with a single prior caesarean presenting in their next pregnancy with a single, live fetus in cephalic presentation, who have reached 37 weeks gestation, and who do not have a contraindication to a planned VBAC.

Trial Entry & Randomisation: Eligible women will be given an information sheet during pregnancy, and will be recruited to the study from 37 weeks gestation after an obstetrician has confirmed eligibility for a planned vaginal birth. Written informed consent will be obtained. Women who consent to the patient preference study will be allocated their preference for either planned VBAC or planned, elective repeat caesarean. Women who consent to the randomised trial will be randomly allocated to either the planned vaginal birth after caesarean or planned elective repeat caesarean group.

Treatment Groups: Women in the planned vaginal birth group will await spontaneous onset of labour whilst appropriate. Women in the elective repeat caesarean group will have this scheduled for between 38 and 40 weeks.

Primary Study Outcome: Serious adverse infant outcome (death or serious morbidity).

Sample Size: 2314 women in the patient preference study to show a difference in adverse neonatal outcome from 1.6% to 3.6% (p = 0.05, 80% power).

Clinical Trial Registration

ISCTRN5397431

Objective

To determine if a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL).

Study Design

Using a previously published prediction model, we categorized women with one prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach.

Results

Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P<.001), but not elective repeat cesarean section (ERCS) (P >.05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (RR 2.2, 95% CI [1.5, 3.1]) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the two groups (RR 0.8, 95% CI [0.5, 1.2]). The results were similar for neonatal morbidity..

Conclusion

A prediction model for VBAC provides information regarding the chance of TOL-related morbidity, and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.

Vaginal birth after caesarean section (VBAC) is being increasingly considered as an alternative to elective repeat section, in order to help reduce overall caesarean rates and achieve improved perinatal outcomes. This review examines the evidence for the safety of VBAC compared to the traditional practice of “Once a caesarean, always a caesarean.” It appears that the incidence of uterine rupture is much lower than previously thought (less than 1%), and that the rates of overall fetal and maternal mortality improve with the use of VBAC. A number of associated treatments such as epidural anesthesia and oxytocin use are also examined.

Summary

The objective of this study was to determine whether, and to what degree, the change in the vaginal birth after caesarean (VBAC) rate is due to a change in the characteristics of the obstetric population, the undertaking of a trial of labour (TOL), or the tendency to abandon a TOL once it has been initiated. All women with one prior low transverse caesarean and a vertex singleton gestation at term were identified in a registry of caesarean deliveries occurring at 8 academic centers during a four-year period (1999 – 2002). Women were classified by their predicted chance of VBAC and year-to-year differences were analyzed. Of the 9643 women who met criteria for analysis, 5334 (55.3%) underwent a TOL. From 1999 to 2002, the VBAC rate underwent a steady decline: 51.8% to 45.1% to 37.4% to 29.8% (P < .001). Although there were some changes in the characteristics of the population that predispose to successful VBAC, as well as some reduction in the chance that a VBAC is successful once a TOL is undertaken, the most pervasive reason for this decline was that women became increasingly likely to forego a TOL, regardless of their likelihood of vaginal delivery. Based on these results, it appears that the change over time in the VBAC rate is multifactorial, although the greatest change has been a decrease in the frequency with which women undertake a TOL, and this change is observed in all categories of the chance of a successful TOL.

Background

Vaginal birth after Caesarean section (VBAC) is a relevant question for a large number of women due to the internationally rising Caesarean section (CS) rate. There is a great deal of research based on quantitative studies but few qualitative studies about women's experiences.

Method

A metasynthesis based on the interpretative meta ethnography method was conducted. The inclusion criterion was peer-review qualitative articles from different disciplines about women's experiences of VBAC. Eleven articles were checked for quality, and eight articles were included in the synthesis.

Results

The included studies were from Australia (four), UK (three), and US (one), and studied women's experience in relation to different aspects of VBAC; decision-making whether to give birth vaginally, the influence of health professionals on decision-making, reason for trying a vaginal birth, experiences when choosing VBAC, experiences of giving birth vaginally, and giving birth with CS when preferring VBAC. The main results are presented with the metaphor groping through the fog; for the women the issue of VBAC is like being in a fog, where decision-making and information from the health care system and professionals, both during pregnancy and the birth, is unclear and contrasting. The results are further presented with four themes: ‘to be involved in decision about mode of delivery is difficult but important,’ ‘vaginal birth has several positive aspects mainly described by women,’ ‘vaginal birth after CS is a risky project,’ and ‘own strong responsibility for giving birth vaginally'.

Conclusion

In order to promote VBAC, more studies are needed from different maternity settings and countries about women's experiences. Women need evidence-based information not only about the risks involved but also positive aspects of VBAC.

Background

The caesarean section rate continues to rise globally. A caesarean section is inarguably the preferred method of delivery when there is good evidence that a vaginal delivery may unduly risk the health of a woman or her infant. Any decisions about delivery method in the absence of clear medical indication should be based on knowledge of outcomes associated with different childbirth methods. However, there is lack of sold evidence of the short-term and long-term risks and benefits of a planned caesarean delivery compared to a planned vaginal delivery. It also is important to consider the economic aspects of caesarean sections, but very little attention has been given to health care system costs that take into account services used by women for themselves and their infants following hospital discharge.

Methods and design

The Ontario Mother and Infant Study III is a prospective cohort study to examine relationships between method of delivery and maternal and infant health, service utilization, and cost of care at three time points during the year following postpartum hospital discharge. Over 2500 women were recruited from 11 hospitals across the province of Ontario, Canada, with data collection occurring between April 2006 and October 2008. Participants completed a self-report questionnaire in hospital and structured telephone interviews at 6 weeks, 6 months, and 12 months after discharge. Data will be analyzed using generalized estimating equation, a special generalized linear models technique. A qualitative descriptive component supplements the survey approach, with the goal of assisting in interpretation of data and providing explanations for trends in the findings.

Discussion

The findings can be incorporated into patient counselling and discussions about the advantages and disadvantages of different delivery methods, potentially leading to changes in preferences and practices. In addition, the findings will be useful to hospital- and community-based postpartum care providers, managers, and administrators in guiding risk assessment and early intervention strategies. Finally, the research findings can provide the basis for policy modification and implementation strategies to improve outcomes and reduce costs of care.

Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.

Design Randomised trial, conducted from May 2004 to August 2006.

Setting Four maternity units in south west England, and Scotland.

Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded.

Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.

Main outcome measures Total score on decisional conflict scale, and mode of delivery.

Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.

Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section.

Trial Registration Current Controlled Trials ISRCTN84367722.

Purpose

To determine the effects of vaginal birth after cesarean (VBAC) versus repeated cesarean sections (RCS) after a primary cesarean section (CS), on the rate of intraoperative and postpartum maternal morbidity.

Patients and methods

This is a retrospective population-based cohort study. During the study period (1988–2005) there were 200,012 deliveries by 76,985 women at our medical center; 16,365 of them had a primary CS, of which 7429 women delivered a singleton infant after the primary CS, met the inclusion criteria, were included in our study, and were followed for four consecutive deliveries. Patients were divided into three study groups according to the outcome of their consecutive delivery after the primary CS: VBAC (n = 3622), elective CS (n = 1910), or an urgent CS (n = 1897). Survival analysis models were used to investigate the effect of the urgency of CS and the numbers of pregnancy predating the primary CS on peripartum complications.

Results

Women who failed a trial of labor had a higher rate of uterine rupture than those who had a VBAC. Patients who delivered by CS had a higher rate of endometritis than those giving birth vaginally. The rate of cesarean hysterectomy and transfer to other departments increased significantly at the fourth consecutive surgery (P = 0.02 and P = 0.003, respectively). VBAC was associated with a 55% reduction in the risk of intrapartum complications in comparison to a planned CS (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.22–0.89. A greater maternal parity at the time of primary CS was associated with lower intrapartum and postpartum morbidities (HR 0.44; 95% CI: 0.24–0.79; HR 0.54; 95% CI: 0.47–0.62, respectively).

Conclusions

(1) A successful VBAC is associated with a reduction in the intrapartum complications; and (2) maternal morbidity increases substantially from the fourth consecutive cesarean delivery.

Objective

To analyze the success rate of VBAC (Vaginal birth after cesarean section) with reference to various factors and derive simple and easily usable prognostic factors to predict successful VBAC.

Methods (Study Design)

In this retrospective observational study, 162 women who had undergone successful trial of labor were analyzed to study the factors which contributed to successful trial of labor over a study period of one year. Maternal age, prior antenatal visits, prior obstetric history, neonatal weight and interconceptional period were studied with reference to outcome of VBAC. Success of VBAC when compared with prior indication for CS was studied. The role of instrumental deliveries for VBAC was analyzed. Maternal and perinatal mortality and morbidity were assessed. Chi square test was used to analyze the significance of each factor.

Results

Success rate of VBAC was 75%. Maternal age, prior antenatal care, prior vaginal delivery, neonatal weight and interconceptional period were all statistically significant predictors (P<0.001) of successful VBAC. Instrumental deliveries were helpful in successful VBAC and can be used prophylactically to cut short second stage. VBAC had no adverse maternal or perinatal outcome.

Conclusion

VBAC can be successfully tried in all women with prior cesarean section by careful selection and employing simple predictive factors.

The authors examined the association between hospital volume of vaginal delivery after cesarean (VBAC) and VBAC failure, uterine rupture, and maternal morbidity. This study was a secondary analysis of a retrospective cohort study from 1995 to 2000. Trained nurses extracted medical records of more than 25,000 women with a prior cesarean delivery from 17 community and tertiary care hospitals. Detailed Information was obtained for each patient. The study sample included 12,844 women with prior cesarean who attempted vaginal delivery with singleton births. Annual hospital VBAC volume was divided into terciles. Primary outcomes included VBAC failure, uterine rupture, and a composite of maternal morbidity. We used multivariable logistic regression to assess the association between hospital VBAC volume and adverse VBAC outcomes controlling for confounders. We did not find evidence of an association between hospital VBAC volume and the likelihood of adverse outcomes in VBAC after adjustment for patient mix. Other risk factors consistent with prior research were identified, including induction of labor, ≥ 2 prior cesarean deliveries, preeclampsia, diabetes and large birth weight. Prior vaginal delivery was protective against adverse VBAC outcomes. The risk of adverse outcomes in VBAC in low volume hospitals was comparable to that in high volume hospitals.

Objectives

To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.

Design

Population based birth cohort study, using ethnographic and epidemiological methods.

Setting

Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.

Participants

5304 women who gave birth in any of the city's hospitals in 1993.

Main outcome measures

Birth by caesarean section or vaginal delivery.

Results

In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.

Conclusions

Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

What is already known on this topicWomen's preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveriesWhat this study addsIn Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient

Background

Caesarean section is a commonly performed operation worldwide. It has been found to increase rates of maternal infectious morbidities more than five times when compared to vaginal delivery. Provision of intravenous prophylactic antibiotics 30 to 60 minutes prior to caesarean section has been found to reduce post-caesarean infection tremendously. Many centers recommend provision of a single dose of antibiotics, as repeated doses offer no benefit over a single dose.

At Bugando Medical Centre post caesarean infection is among the top five causes of admission at the post-natal ward. Unfortunately, there is no consistent protocol for the administration of antibiotic prophylaxis to patients who are designated for caesarean section. Common practice and generally the clinician’s preference are to provide repeated dosages of antibiotic prophylaxis after caesarean section to most of the patients. This study aims to determine the comparative efficacy of a single dose of gentamicin in combination with metronidazole versus multiple doses for prevention of post caesarean infection.

Methods/Design

The study is an interventional, open-label, two-armed, randomized, single-center study conducted at Bugando Medical Centre Mwanza, Tanzania. It is an ongoing trial for the period of seven months; 490 eligible candidates will be enrolled in the study. Study subjects will be randomly allocated into two study arms; “A” and “B”. Candidates in “A” will receive a single dose of gentamicin in combination with metronidazole 30 to 60 minutes prior to the operation and candidates in “B” will receive the same drugs prior to the operation and continue with gentamicin and metronidazole for 24 hours. The two groups will be followed up for a period of one month and assessed for signs and symptoms of surgical site infection.

Data will be extracted from a case record form and entered into Epi data3.1 software before being transferred to SPSS version 17.0 for analysis. The absolute difference in proportion of women who develop surgical site infection in the two study arms will be the effectiveness of one regime over the other.

Trial registration

Current Controlled TrialsISRCTN44462542.

OBJECTIVE: To determine (a) the proportion of women undergoing elective repeat cesarean section without a trial of labour who were eligible for such a trial by the 1986 guidelines of the panel of the National Consensus Conference on Aspects of Cesarean Birth, (b) whether vaginal birth after cesarean section (VBAC) was discussed with these women and (c) the reasons cited for not having a trial of labour. DESIGN: Chart audit. SETTING: Level 2 perinatal care centre in a general teaching hospital. PATIENTS: All 313 women with a history of previous cesarean section who gave birth at the centre during 1989. RESULTS: Only 93 (30%) of the 313 women underwent a trial of labour. According to the 1986 guidelines 71% were eligible. A further 13% would have been eligible according to the revised 1991 guidelines. Of the 220 women who underwent elective repeat cesarean section, only 24 (11%) had a discussion of VBAC noted in their hospital charts. However, of all 117 patients whose charts indicated discussion of VBAC 93 (79%) chose to try it. Most of the women had either questionable indications or no indication noted for undergoing repeat cesarean section. CONCLUSION: Most of the women who underwent repeat cesarean section were eligible for a trial of labour. However, few charts noted a discussion of VBAC. Further physician and patient education is necessary to promote the appropriate use of VBAC and repeat cesarean section.

Aim: To validate a previously developed prediction model for vaginal birth after cesarean (VBAC) using a Japanese cohort.

Methods: We performed a cohort study of all term pregnant women with a vertex position, singleton gestation, and one prior low transverse cesarean delivery attempting a trial of labor between April 1985 and March 2010. Variables necessary for the prediction of successful VBAC were maternal age, pre-pregnancy body mass index, ethnicity, prior vaginal delivery, prior VBAC, and indication for prior cesarean delivery. They were extracted from medical records and put into the formula that calculates an individual woman's predicted VBAC success rate. The predicted rates were then partitioned into deciles and compared with the actual VBAC rates. The predictive ability of the model was assessed with a receiver operating characteristic and the area under the curve (AUC) was determined.

Results: Seven hundred and twenty-five women who met the inclusion criteria had complete data available, of which 664 (91.6%) had VBAC. The predicted probability of VBAC, as calculated by the regression equation, was significantly higher in those who had a successful trial of labor (median 80.1%, interquartile range 71.5-88.7) than those who did not (median 69.4%, interquartile range 59.9-78.9, P<0.001). The predictive model had AUC of 0.80, which was comparative to the originally described one. When the predicted rates were each deciles of over 70%, the actual success rates were more than 90%.

Conclusion: The previously published prediction model for VBAC developed in the USA is also available to Japanese women.

Objective To determine the factors associated with an increased risk of perinatal death related to uterine rupture during attempted vaginal birth after caesarean section.

Design Population based retrospective cohort study.

Setting Data from the linked Scottish Morbidity Record and Stillbirth and Infant Death Survey of births in Scotland, 1985-98.

Participants All women with one previous caesarean delivery who gave birth to a singleton infant at term by a means other than planned repeat caesarean section (n = 35 854).

Main outcome measures All intrapartum uterine rupture and uterine rupture resulting in perinatal death (that is, death of the fetus or neonate).

Results The overall proportion of vaginal births was 74.2% and of uterine rupture was 0.35%. The risk of intrapartum uterine rupture was higher among women who had not previously given birth vaginally (adjusted odds ratio 2.5, 95% confidence interval 1.6 to 3.9, P < 0.001) and those whose labour was induced with prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factors were also associated with an increased risk of perinatal death due to uterine rupture. Delivery in a hospital with < 3000 births a year did not increase the overall risk of uterine rupture (1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with ≥ 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04).

Conclusion Women who have not previously given birth vaginally and those whose labour is induced with prostaglandin are at increased risk of uterine rupture when attempting vaginal birth after caesarean section. The risk of consequent death of the infant is higher in units with lower annual numbers of births.

A case-control study using UK data estimates the risk of uterine rupture in subsequent deliveries amongst women who have had a previous caesarean section.

Background

Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.

Methods and Findings

A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16–7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62–6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00–15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2–4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75–189).

Conclusions

Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section.

Please see later in the article for the Editors' Summary

Editors' Summary

Background

Uterine rupture is a serious complication of pregnancy in which the wall of the uterus (womb) tears during pregnancy or early labor. Signs and symptoms of uterine rupture include fetal heart rate abnormalities, abdominal pain, and vaginal bleeding. If uterine rupture happens during labor, the woman must have an immediate caesarean section (surgical delivery of her baby) to save both her life and that of her baby. The woman's womb and nearby organs can be damaged at rupture or removed during surgery and she may need a blood transfusion because of severe bleeding. Moreover, her baby may develop respiratory distress syndrome and other life-threatening complications. In high income countries, uterine rupture most commonly occurs in women who have delivered a previous pregnancy by caesarean section. In a caesarean section, the baby is delivered through a cut made through the abdominal wall and the uterine wall. The stretching that occurs during pregnancy or the strong contractions of labor can tear the scar left by this cut, resulting in uterine rupture.

Why Was This Study Done?

Women who have had a caesarean delivery are generally encouraged to try to deliver subsequent babies vaginally. However, recent reports of an increased risk of complications (morbidity) and death (mortality) due to uterine rupture are thought to reduce women's willingness to attempt vaginal birth after caesarean (VBAC) in some countries. In the UK, for example, where one in four babies is delivered by caesarean section, a previous caesarean delivery is one of commonest reasons for a repeat section. Obstetricians (doctors who care for women during child birth) need to know as much as possible about the incidence of uterine rupture and about the risk factors for it so that they can advise women who have had a previous caesarean section about their delivery options. In this national case-control study (a study that compares the characteristics of people with and without a specific condition), the researchers estimate the incidence of uterine rupture in the UK by intended mode of delivery and investigate and quantify the risk factors for and outcomes of uterine rupture.

What Did the Researchers Do and Find?

The researchers used the UK Obstetric Surveillance System (UKOSS) to identify all the women in the UK who had a uterine rupture over a 13-month period (159 women, 139 of whom had had a previous caesarean delivery). Controls for the study were women who had not had a uterine rupture but who had previously delivered by caesarean section. Overall, the incidence of uterine rupture was 0.2 per 1,000 maternities. In women with a previous caesarean delivery, 2.1 and 0.3 per 1,000 maternities ended in uterine rupture in women planning vaginal delivery and caesarean delivery, respectively. Amongst women who had had a previous caesarean delivery, the risk of uterine rupture was greater among those who had had two or more previous caesarean deliveries or a caesarean delivery less than 12 months previously, or whose labor was induced. Two women died following uterine rupture (a case fatality of 1.3%) and 18 babies died around the time of birth (a perinatal mortality rate of 124 per 1,000 live births; the UK perinatal mortality rate is 7.5 per 1,000 live births). 15 of the women who had a uterine rupture had their womb removed, 10 had other organs damaged, and nearly half had other complications; 19 of the surviving babies had health problems.

What Do These Findings Mean?

These findings indicate that, in the UK, although uterine rupture is associated with significant mortality and morbidity, it is a rare occurrence even among women who have had a previous caesarean delivery and are planning a vaginal delivery. They also indicate that, for women who have previously had a caesarean section, the risk of rupture increases with the number of previous caesarean deliveries, with a short interval since the last caesarean section, and with labor induction. Although the researchers may not have identified all the women who had a uterine rupture during the study period or may have identified only the worst cases, these findings provide valuable information about the factors that obstetricians need to consider when advising women who have previously had a caesarean section and when managing their labor.

Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001184.

This study is linked to a PLoS Medicine Research Article by Caroline Crowther and a PLoS Medicine Perspective by Catherine Spong

Wikipedia has a page on uterine rupture (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)

The American Congress of Obstetricians and Gynecologists has information sheets for patients on caesarean sections and on vaginal birth after caesarean delivery

The Royal College of Obstetricians and Gynaecologists in the UK has information for women on birth after previous caesarean

Childbirth Connection, a US-based not-for-profit organization, provides information about caesarean sections and about vaginal birth after caesarean

The National Childbirth Trust, a UK charity, provides information for parents on all aspects of pregnancy and birth, including caesarean sections and vaginal birth after caesarean delivery

The UK charity Healthtalkonline has personal stories from women making decisions about birth after a caesarean section

A personal story of uterine rupture during an attempted VBAC is available

The UK Obstetric Surveillance System studies rare disorders of pregnancy in the UK

Repeat cesarean delivery (CD) rates among US Hispanic women are the highest of all racial/ethnic groups (90%). Vaginal birth after cesarean (VBAC) is an alternative delivery method, but requires medical records documentation of a non-vertical incision and favorable conditions in the current pregnancy. VBAC rates for Hispanic women are extremely low. This study explores the birth histories and medical records access among Hispanic women in California, taking into account the potential role of immigration on access to VBAC. Study aims are to describe for a sample of Hispanic women: (1) CD and VBAC histories as well as history of vaginal delivery preceding CD; and (2) medical records access, among women who had previous births in Mexico. Chart review was conducted for prenatal patients from three safety net clinics in two California counties with large Mexican migrant populations between August, 2003 and February 2004—during which VBAC was widely available in these two counties to determine: obstetric histories, CD details, birthplace and whether or not medical records had been requested/obtained for CD. 355 multiparous Hispanic women were included. Thirty-three percent had a previous CD, almost two-thirds (64%) had only one CD. Over half of the women (55%) with 2+ births and CD history also reported a vaginal birth history. Medical records for CD were infrequently requested (29%). Of those requested, records were received for 77% of women with a US CD, compared with 13% of women with Mexican CD histories. Policies to address: (1) VBAC opportunities for low risk women, such as those with prior vaginal births and one CD, and (2) overcoming limited medical records access, could mitigate against unnecessary CD and associated medical expenditures and risks for future complications.

Background

Rates of caesarean section are progressively increasing in many parts of the world. As a result of psychosocial factors there has been an increasing tendency for pregnant women without justifiable medical indications for caesarean section to ask for this procedure in China. A critical examination of this issue in relation to maternal outcomes is important. At present there are no clinical trials to help assess the risks and benefits of caesarean section in low risk women. To fill the gap left by trials, this indication-matched cohort study was carried out to examine prospectively the outcomes of caesarean section on women with no absolute obstetric indication compared with similar women who had vaginal delivery.

Methods

An indication-matched cohort study was undertaken to compare maternal outcomes following caesarean section with those undergoing vaginal delivery, in which the two groups were matched for non-absolute indications. 301 nulliparous women with caesarean section were matched successfully with 301 women who delivered vaginally in the Maternal and Children's Hospitals (MCHs) in Shanghai, China. Logistic regression model or binomial regression model was used to estimate the relative risk (RR) directly. Adjusted RRs were calculated adjusting for propensity score and medical indications.

Results

The incidence of total complications was 2.2 times higher in the caesarean section group during hospitalization post-partum, compared with the vaginal delivery group (RR = 2.2; 95% CI: 1.1-4.4). The risk of haemorrhage from the start of labour until 2 hours post-partum was significantly higher in the caesarean group (RR = 5.6; 95% CI: 1.2-26.9). The risk of chronic abdominal pain was significantly higher for the caesarean section group (RR = 3.6; 95% CI: 1.2-10.9) than for the vaginal delivery group within 12 months post-partum. The two groups had similar incidences of anaemia and complicating infections such as wound complications or urinary tract infection.

Conclusions

In nulliparous women who were at low risk, caesarean section was associated with a higher rate of post-partum morbidity. Those requesting the surgical procedure with no conventional medical indication, should be advised of the potential risks.

Objective

To estimate the effect of birth-weight difference between the current and index pregnancy on VBAC failure in patients whose prior cesarean was for cephalopelvic disproportion (CPD).

Methods

This was a retrospective cohort study of women with one cesarean for CPD, comparing the rate of VBAC failure in women whose infant was smaller, the same, or larger in the VBAC attempt compared to cesarean. The primary outcome was VBAC attempt failure, defined as a patient that attempted VBAC but subsequently required a cesarean for any indication. Univariable, stratified, and multivariable analyses were used.

Results

Of 13,706 patients attempting VBAC, 1,511 had one prior cesarean for CPD. Compared to patients with the same birth weight, a lower birth weight had fewer failed VBAC attempts (adjusted odds ratio (29.6% vs 37.8%, AOR) 0.7, 95% confidence interval (CI) 0.5-1.0) and a higher birth weight had more failed VBAC attempts (54.5% vs 37.8%, AOR 2.0, 95% CI 1.5-2.8).

Conclusions

Birth-weight difference has a moderate effect on the rate of VBAC success in patients whose prior cesarean was for CPD.

Objectives To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery.

Design Prospective population based cohort study.

Setting ALSPAC (the Avon longitudinal study of parents and children).

Participants 14 663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992.

Main outcome measure Edinburgh postnatal depression scale score ≥ 13 at eight weeks postnatal on self completed questionnaire.

Results Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P = 0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P = 0.46, and 0.89, 0.68 to 1.18, P = 0.42, respectively).

Conclusions There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.

A total of 2176 consecutive patients who had had one previous caesarean section were studied retrospectively. A repeat elective caesarean section was performed in 395 (18.2%). Labour started spontaneously in 1363 patients, 301 of whom were given oxytocin to accelerate inert labour, and was induced by amniotomy and infusion of oxytocin in 418 women; 1618 of these 1781 patients (90.8%) delivered vaginally. Patients who had had a previous vaginal delivery were more likely to deliver vaginally again. Those women in whom the initial caesarean section had been performed during labour before the cervix was 4 cm dilated were less likely to deliver vaginally than those who had progressed further in labour or those who had had an elective caesarean section. Similarly, those who received oxytocin to stimulate inert labour were more likely to require a repeat caesarean section than those who did not. The uterine scar ruptured in only eight (0.45%) of the 1781 patients allowed into labour. The risk of rupture of the scar was not increased by the use of oxytocin alone either to induce or to accelerate labour. The combination of oxytocin to accelerate labour and epidural analgesia to provide pain relief, however, was associated with an increased incidence of scar rupture. Labour may be safely allowed in women who have had a previous caesarean section, most of whom will deliver vaginally. Induction of labour does not increase the risk of either a repeat caesarean section or rupture of a uterine scar.

Repeat cesarean section is a major factor contributing to the rising cesarean section rate. Although vaginal birth after a previous cesarean section (VBAC) is advocated in most cases, it has not yet been adopted as widespread policy. In a case-control study we compared 400 women in Quebec who underwent VBAC with 1600 women who had a repeat cesarean section from 1985 to 1987 in an attempt to identify factors that favour vaginal delivery. Using both simple and multiple logistic regression analyses we examined the effect of independent variables linked to the patients (two variables), the attending physicians (seven) and the hospitals (two) on the dependent variable (type of birth) with the use of odds ratios. We found that the physician characteristics related to type of practice and the degree of hospital specialization were significant factors in predicting the type of delivery. Women who gave birth vaginally were more likely than those who had a repeat cesarean section to be attended by a physician with a specialized practice and to give birth in a hospital providing an intermediate or high level of care. This suggests that VBAC is still perceived as a high-risk option and is managed by only a minority of specialized obstetricians.

Summary

Objective

To determine Ghanaian women's preferred mode of delivery and opinion of caesarean section after caesarean delivery.

Design

A cross sectional study of women who recently delivered by caesarean section prior to hospital discharge.

Setting

Two teaching hospitals in Ghana: Komfo Anokye Teaching Hospital, Kumasi, and Korle-Bu Teaching Hospital, Accra.

Respondents

154 patients who delivered by caesarean section between the 1st and 31st August, 2003 were interviewed. Of the 154 initiating the interview, 151 completed, and 145 had complete data.

Main Outcome Measures

Delivery preference and general opinion of caesarean delivery.

Results

The majority of women interviewed indicated that they preferred vaginal delivery (55%). Despite preference for vaginal delivery among these women who had delivered by caesarean section, the majority had a generally positive opinion of caesarean section (53%).

Conclusion

Ghanaian women with experience of caesarean delivery prefer vaginal delivery.

Background

The rate of caesarean sections is increasing worldwide, yet medical literature informing women with uncomplicated pregnancies about relative risks and benefits of elective caesarean section (CS) compared with vaginal delivery (VD) remains scarce. A decision board may address this gap, providing systematic evidence-based information so that patients can more fully understand their treatment options. The objective of our study was to design and pre-test a decision board to guide clinical discussions and enhance informed decision-making related to delivery approach (CS or VD) in uncomplicated pregnancy.

Methods

Development of the decision board involved two preliminary studies to determine women's preferred mode of risk presentation and a systematic literature review for the most comprehensive presentation of medical risks at the time (VD and CS). Forty women were recruited to pre-test the tool. Eligible subjects were of childbearing age (18-40 years) but were not pregnant in order to avoid raising the expectation among pregnant women that CS was a universally available birth option. Women selected their preferred delivery approach and completed the Decisional Conflict Scale to measure decisional uncertainty before and after reviewing the decision board. They also answered open-ended questions reflecting what they had learned, whether or not the information had helped them to choose between birth methods, and additional information that should be included. Descriptive statistics were used to analyse sample characteristics and women's choice of delivery approach pre/post decision board. Change in decisional conflict was measured using Wilcoxon's sign rank test for each of the three subscales.

Results

The majority of women reported that they had learned something new (n = 37, 92%) and that the tool had helped them make a hypothetical choice between delivery approaches (n = 34, 85%). Women wanted more information about neonatal risks and personal experiences. Decisional uncertainty decreased (p < 0.001) and perceived effectiveness of decisions increased (p < 0.001) post-intervention.

Conclusion

Non-pregnant women of childbearing age were positive about the decision board and stated their hypothetical delivery choices were informed by risk presentation, but wanted additional information about benefits and experiences. This study represents a preliminary but integral step towards ensuring women considering delivery approaches in uncomplicated pregnancies are fully informed.

Objective

To estimate the rate of vaginal birth after cesarean delivery (VBAC) success in diabetic women based on White’s Classification.

Methods

This is a secondary analysis of an observational study conducted at 19 medical centers of women attempting VBAC. Diabetic women with singleton gestations, one prior cesarean delivery, and cephalic presentation who underwent a trial of labor (TOL) were included. VBAC success rates, maternal and neonatal complications were compared based on White’s Classification.

Results

Of 11,856 women who underwent trial of labor, 624 met all study criteria (Class A1=356, A2=169, B=70, C=21, D, R, or F=8). VBAC success in each group was: A1=68.5% (95% confidence interval [CI] 63.4%–73.3%), A2=55% (95% CI 47.2%–62.7%), B=70% (95% CI 57.9%–80.4%), C=47.6% (95% CI 25.7%–70.2%), D/F/R=12.5% (95% CI 0.3%–52.7%). Maternal and neonatal complications were rare, and not found to be different between groups.

Conclusion

Our study provides estimates for VBAC success based on White’s classification and indicates a relatively low rate of perinatal complications after VBAC attempt for diabetic women.