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Background Both a trial of labor after cesarean (TOLAC) and elective repeat cesarean delivery (ERCD) are reasonable choices after a cesarean delivery, with differing risks and benefits. This study explores the impact of patient health literacy and primary language on the decision to pursue a TOLAC and on decision quality. Methods This is a secondary analysis of the Prior Cesarean Decision (PROCEED) trial, which examined the effect of a patient-centered decision support tool on rates of TOLAC and decision quality. Logistic regression was performed to estimate the association of limited health literacy (Newest Vital Sign score ≤4/6) and non-English primary language (NEPL) with TOLAC. Decision quality was assessed by calculating mean scores for decision-quality scales and using linear regression to estimate adjusted mean differences (aMD) by health literacy and NEPL. Results Among 1455 participants, 44.6% underwent TOLAC, and 71.0% of those with a TOLAC had a vaginal birth after cesarean (VBAC). Limited health literacy was associated with lower odds of TOLAC (aOR 0.60, 95% CI [0.38, 0.93]). For decision quality, limited health literacy was associated with similar scores for decisional conflict, shared decision-making, decision self-efficacy and decision satisfaction, but lower knowledge scores (3.9 vs. 5.4; aMD -0.7, 95% CI [-1.0, -0.5]). Compared to participants whose primary language was English ( n =1043), those with NEPL ( n =255) had similar odds of TOLAC (aOR 1.08, 95% CI [0.69, 1.68]), but greater decisional conflict (20.9 vs. 16.7; aMD 3.9, 95% CI [1.4, 6.3]) and lower decision self-efficacy (88.6 vs. 90.9; aMD -3.3, 95% CI [-5.6, -1.1]) and decision satisfaction (4.6 vs. 4.7; aMD −0.1, 95% CI [-0.2, 0.0]). Conclusions In this study of pregnant people with a prior cesarean and no prior VBAC, those with limited health literacy had lower odds of TOLAC and lower knowledge scores about risks and benefits of TOLAC vs. ERCD. While those with NEPL had similar odds of TOLAC, they had lower decision quality scores compared to those with those with English as a primary language. These findings indicate factors that may result in less effective counseling related to delivery options after prior cesarean and may contribute to differences in approach to delivery and decision quality.

Background Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. Methods OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. Results The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p  = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. Conclusions Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances. Trial registration The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254 .

Objective There have been limited reports on the duration of labor progression in pregnant women undergoing vaginal birth after cesarean (VBAC). This study aimed to investigate the duration of labor progression during VBAC in Hubei, China. Methods A total of 359 pregnant women undergoing VBAC were enrolled as the VBAC group, meeting the following criteria: singleton pregnancy, gestational age ≥ 37 weeks, live birth, history of cesarean delivery, and a willingness to attempt a vaginal delivery. At the same time, 359 primiparas successfully undergoing vaginal delivery were randomly enrolled in the control group at a 1:1 ratio. Subsequently, the durations of the first, second, and third stages of labor were comparatively analyzed between the two groups. Results The duration of the first, second, and total stages of labor in the VBAC group was significantly shorter than that in the control group ( p  < 0.05). There was no significant difference in the duration of the third stage of labor between the two groups ( p  > 0.05). The amount of blood loss, the rate of postpartum hemorrhage (PPH), and episiotomy were higher in the VBAC group than in the control group ( p  < 0.05). The rate of labor analgesia and intrapartum fever in the VBAC group was significantly lower than that in the control group ( p  < 0.05). Conclusion The duration of labor progression of the first, second, and total stages of VBAC is shorter than that in primiparous women in our observation in China.

postdate pregnant women with one previous caesarean section that are planned for vaginal birth after caesarean sections are faced with adverse pregnancy outcomes. This trial was conducted to determine the effect of serial membrane sweeping from 38 weeks gestation in pregnant women planned for vaginal birth after caesarean section. this randomized controlled trial (RCT) was conducted on 90 women at 38 weeks with one previous caesarean section. In the study group, membranes sweeping commenced at 38 weeks and repeated weekly till labour onset. If no labour onset at 41 weeks and 3 days, elective caesarean section was done. In the control group, patients awaited labour onset till 41 weeks and 3 days, after which elective caesarean section was done. Data collected were analyzed using the Statistical Package for Social Sciences (SPSS ver. 22). All analyses were done at p<0.05. labour onset before 41 weeks and 3 days was statistically significantly higher in the study group compared to the control group (RR= 1.5; 95% CI: 1.1 - 2.0; P=0.006). Likewise, successful vaginal birth after caesarean section was statistically significantly higher in the study group (RR=1.7; 95% CI: 1.2-2.5; P = 0.001). serial membrane sweeping from 38 weeks gestation has significant beneficial effect on labour onset and successful vaginal delivery in women with one previous caesarean section.

ObjectiveTo assess the views of women after a first caesarean section (CS) on their birth experience, preference for future mode of birth and willingness to participate in a randomised controlled trial on mode of birth in a future pregnancy.DesignQuestionnaire survey.SettingTwo tertiary maternity centres Ireland, Galway University Hospital, Galwayand the National Maternity Hospital, Dublin.ParticipantsWomen with one previous CS.MethodsEligible women consented to participate, and postal surveys were forwarded. Results were collected and analysed. Results were compared between women who had elective operations and women who had emergency operations.Primary outcome measuresThe satisfaction levels of women after a first caesarean, their preference for mode of birth in a future pregnancy and their willingness to participate in a randomised trial on mode of birth.ResultsThere were 347 completed surveys of 633 women who consented to participate (54.8%), of whom 285 and 62 had emergency and elective caesarean deliveries, respectively. In general, satisfaction ratings with the delivery were greater than 90%, with similar levels of satisfaction with the care received from doctors and midwives. Women who an emergency procedure expressed lower satisfaction levels with the information about the caesarean and the debriefing received afterwards than women who had a planned operation (p<0.05). For future mode of birth, 39.5% expressed a preference for vaginal birth after caesarean (VBAC) in a subsequent pregnancy, and 80% said they would consider involvement in a randomised trial in a future pregnancy.ConclusionDebriefing and counselling women after a CS is an important part of pregnancy care and can significantly impact on a woman’s overall birth experience. A significant proportion of this cohort considered VBAC as a future birth option. These data indicate that a randomised trial on mode of birth after caesarean would be viewed positively by women in our population.

Purpose To evaluate the efficacy of inducing labor using a double-balloon catheter and vaginal prostaglandin E2 (PGE2) sequentially, in comparison with vaginal PGE2 alone after previous cesarean section. Methods A total of 264 pregnant women with previous cesarean section undergoing labor induction at term were included in this prospective multicentre cohort study. Induction of labor was performed either by vaginal PGE2 gel or double-balloon catheter followed by vaginal PGE2. The primary outcome measure was the cesarean section rate. Results The cesarean section rate was 37 % without any statistically significant difference between the two groups (PGE2: n  = 41, 37 % vs. balloon catheter/PGE2: n  = 41, 42 %; P  = 0.438). The median (range) number of applications of PGE2 [2 (1–10) versus 1 (0–8), P  < 0.001] and the total amount of PGE2 used in median (range) mg [2 (1–15) vs. 1 (0–14), P  = 0.001] was less in the balloon catheter/PGE2 group. Factors significantly increasing risk for cesarean section were “no previous vaginal delivery” (OR 5.391; CI 2.671–10.882) and “no oxytocin augmentation during childbirth” (OR 2.119; CI 1.215–3.695). Conclusions The sequential application of double-balloon catheter and vaginal PGE2 is as effective as the sole use of vaginal PGE2 with less applications and total amount of PGE2.

Worldwide, numbers of repeat cesarean sections continue to rise. Although there is a multitude of evidence about the safety of a vaginal delivery attempt after one cesarean section, data is scarce regarding the risks of one compared to two prior procedures. This study aims to determine whether vaginal childbirth is less safe and successful for both mother and child in patients with a history of two cesarean sections compared to those with only one. This retrospective cohort study included all patients with a history of one or two prior cesarean deliveries who gave birth at term at Goethe University Frankfurt between 2014 and 2021. Maternal and neonatal morbidity, as well as rates of success for vaginal birth and uterine rupture, were compared between the groups. Of the 1967 women studied, 1697 gave birth after one previous cesarean section, while 270 had a history of two prior cesarean sections. There was no significant increase in maternal or fetal morbidity in women with two previous cesarean sections compared to one. However, the success rate of a vaginal delivery was lower in the group with two prior cesareans (27/79, 34.2%) than in the group with one (696/989, 70.3%). The rate of complete uterine rupture was higher in patients with two cesareans who underwent cesarean section after onset of labor (CSAOL-2: 3/89, 3.4%) compared to none in the CSAOL-1 group (0/492, 0.0%; p = 0.004). Maternal and fetal morbidity remained comparable across groups, with NICU admission rates of 11.2% (CSAOL-1) vs. 5.6% (CSAOL-2), and maternal transfusion rates of 0.86% (VBAC-1) vs. 6.45% (VBAC-2). In the context of patient autonomy regarding the timing of delivery, offering the patient the choice of different delivery modes after two previous cesareans appears to be safe with respect to maternal and fetal risks. An individualized consultation and thorough counseling are essential, but the opportunity for different delivery options should be respected and supported.

To develop and validate prediction models for obstetric anal sphincter injury (OASI) in three birth scenarios (first vaginal delivery, vaginal birth after cesarean section and second vaginal delivery). Antenatal and intrapartal predictors were included in the models to construct a web-based, interactive, easy-to-use calculator. All 45 maternity units in Sweden participated in the study, with 609,916 first and second deliveries in gestational week ≥37 + 0 with singleton pregnancies and cephalic presentations between 2009 and 2017. The outcome was OASI, defined as a third- or fourth-degree perineal injury involving the external or internal anal sphincter muscles, or both. We analyzed the relative contribution of predictors with Nagelkerke's R2 (R2N) after minimization of the Bayesian Information Criterion for the predictor selection in a logistic regression with OASI as the binary outcome. Model performance was evaluated according to overall measures, discriminative ability, and calibration, with optimism-correction by a bootstrap procedure. OASI occurred in 25,245 women (4.1%). There were 54 relevant, possible predictors, and 47 predictors were kept as candidates for the final models. We included 28, 40, and 46 predictors for the three scenarios, respectively. Infant birth weight was identified as the primary predictor, contributing 31%–45% of the R2N in the full prediction models, which had R2N values of 9.3%, 7.4%, and 12.9% for each scenario. In two-para women, obstetric information from the first birth was important at the second birth, accounting for 50% of the total predictive information. A sphincter injury in the first vaginal delivery strongly predicted a repeat injury (R2N, 40%). Vacuum delivery in the first and second vaginal delivery contributed 33% and 29% of R2N, respectively. By incorporating information on fetal biometry and labor events, the performance of the models increased substantially (eg, R2N increased from 1.7% to 9.3% in the first scenario). An online calculator was developed (www.sphinctercalc.com). Fetal birth weight is the crucial predictor of sphincter injury, supporting efforts to assess fetal biometrics through imaging techniques. This also applies to obstetric interventions, particularly vacuum delivery, provided that there are alternatives to act upon. The proposed online calculator requires further international validation and refinement before it can be widely used clinically and for women's shared decision-making. A third- or fourth-degree vaginal tear (also known as obstetric anal sphincter injury) occurs in about six in 100 women having their first vaginal birth and may lead to loss of bowel control or holding in wind. This study analyzed existing data from thousands of women who had already delivered 1 or 2 children to build a prediction model that can be used prospectively by health-care professionals and pregnant women to assess a woman's individual risk of having a third- or fourth-degree tear to be able to prevent it occurring. [Display omitted] •Prospective high-quality registry data for predicting anal sphincter injury.•Antenatal and intrapartum predictors were key to the dynamic model.•Emphasizing the vital role of fetal biometry and labor interventions.•Our findings support efforts to promote antenatal access to fetal biometrics.•Interactive calculator for personalized risk assessment www.sphinctercalc.com.

Jan Blustein and Jianmeng Liu examine the evidence linking caesarean delivery with childhood chronic disease and say that guidelines on delivery should be reviewed with these risks in mind

Introduction Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor. Material and Methods This retrospective cohort study of the four largest delivery units in Stockholm during 2012–2015 included 1150 women with one previous cesarean section with induction of labor. Inclusion criteria: women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. Primary outcome: mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). Secondary outcomes: induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0. Results Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64–17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women. Conclusions Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased. There is an increased risk of cesarean section for women with induction of labor after one previous cesarean section if the reason for the previous cesarean section was labor dystocia. Previous vaginal delivery is a positive predictive factor for a vaginal birth after a previous cesarean section.