Search Results (12)

Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal–neonatal outcomes between the two groups. Methods: This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally. Results: The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal–neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used. Conclusions: Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC. Full article

Information on the effect of bloody amniotic fluid during labor at term is scarce. This study assessed risk factors and adverse outcomes in labors with bloody amniotic fluid. During the six years of this study, all nulliparas in our institution, with a trial of labor, were included. Multiple pregnancies and preterm deliveries were excluded. Outcomes were compared between the bloody amniotic fluid group and the clear amniotic fluid group. Overall, 11,252 women were included. Among them, 364 (3.2%) had bloody amniotic fluid and 10,888 (96.7%) had clear amniotic fluid. Women in the bloody amniotic fluid group were characterized by shorter duration of the second stage and higher rate of cesarean section due to non-reassuring fetal heart rate. In addition, there were higher rates of low cord pH (<7.1) and NICU admissions in the bloody amniotic fluid group. In multivariate logistic regression analysis, cesarean delivery, cord blood pH < 7.1, and NICU admission were independently associated with increased odds ratio for bloody amniotic fluid. Bloody amniotic fluid at term is associated with adverse outcomes and must be considered during labor. Full article

Natural childbirth after a previous cesarean section is a debated issue despite scientific research and international recommendations. This study aimed to examine the experiences of women giving birth after a previous cesarean section, their preferences, and changes in attitudes towards childbirth after labor. This longitudinal study involved 288 pregnant women who had a previous cesarean section and completed a web-based questionnaire before and after labor, including information about their obstetric history, birth beliefs, and preferred mode of delivery. Among women who preferred a vaginal birth, nearly 80% tried it and 49.78% finished delivery by this mode. Among women declaring a preference for an elective cesarean section, 30% attempted a vaginal birth. Choosing a hospital where staff supported their decision (regardless of the decision) was the most helpful factor in preparing for labor after a cesarean section (63.19%). Women’s birth preferences changed after labor, with women who had a vaginal birth after a cesarean section preferring this mode of delivery in their next pregnancy (89.34%). The mode of birth did not always follow the women’s preferences, with some women who preferred a natural childbirth undergoing an elective cesarean section for medical reasons. A variety of changes were noticeable among women giving birth after a cesarean section, with a large proportion preferring natural birth in their next pregnancy. Hospitals should support women’s birth preferences after a cesarean section (if medically appropriate), providing comprehensive counseling, resources, and emotional support to ensure informed decisions and positive birth experiences. Full article

Background and Objectives: Women with a history of cesarean section are a high-risk group because they are likely to develop uterine rupture during their next pregnancy. Current evidence suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC). Case Description: A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally, underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction, she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was performed. The presumed diagnosis was confirmed during the procedure—a full-thickness rupture of the pregnant uterus was found. The fetus was delivered without signs of life and successfully resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient was discharged 4 days after the cesarean section without significant complications, with a healthy newborn girl. Conclusions: Uterine rupture is a rare but severe obstetric emergency and can be associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC attempt should always be considered, even if it is a subsequent TOLAC. Full article

Background: The efficacy and safety of a cervical ripening balloon (CRB) in women with a previous cesarean section (CS) and unfavorable Bishop score are still controversial. Methods: A retrospective cohort study was performed across six tertiary hospitals from 2015 to 2019. Women with one previous transverse CS, singleton cephalic term pregnancy and BS < 6 were included if submitted to labor induction with a CRB. The main outcome was the rate of vaginal birth after cesarean (VBAC) after CRB ripening. Secondary outcomes were abnormal composite fetal and maternal outcomes. Results: Of the 265 women included, 57.3% had successful vaginal birth. Augmentation improved vaginal delivery (32.2% vs. 21.2%). Intrapartum analgesia was associated with an increased VBAC rate (58.6% vs. 34.5%). Maternal BMI ≥30 and age ≥40 years increased emergency CS rate (11.8% vs. 28.3% and 7.2 vs. 15.9%). Composite adverse maternal outcome occurred in 4.8% of CRB group women and increased to 17.6% when associated with oxytocin. Uterine rupture occurred in one case (0.4%) in the CRB–oxytocin group. Poorer fetal outcome occurred after emergency CS, if compared to successful VBAC (12.4% vs. 3.3%). Conclusions: In women with a previous CS and unfavorable Bishop score, induction of labor with a CRB can be considered safe and effective. Full article

This study aimed to determine whether transvaginal sonographic measurement of cervical length before labor induction can predict successful induction. This retrospective study recruited 138 pregnant women who underwent labor induction at 37–41 weeks of gestation. Cervical length was measured using transvaginal ultrasonography before labor induction. Labor was induced according to the hospital protocol. Age, gestational age (GA), parity, body mass index (BMI), Bishop score, hemoglobin level, maternal disease, and epidural anesthesia were also recorded. Labor induction outcomes, including cesarean section for failed induction, time of induction, and the three labor stages, were assessed. From December 2018 to December 2021, 138 women were recruited for our study, including 120 and 18 women with successful and failed labor induction, respectively. Shorter cervical length (≤3.415 cm, OR = 6.22, 95% CI = 1.75–22.15) and multiparity (OR = 17.69, 95% CI = 2.94–106.51) were associated with successful induction. Higher BMI was associated with failed induction (OR = 0.87, 95% CI = 0.75–0.99). Age, GA, Bishop score, and fetal birth weight were not associated with successful labor induction. The ROC curve showed a cervical length cutoff value of 3.415 cm, revealing 76.8% of the area under the curve. In conclusion, a shorter cervical length (≤3.415 cm) was associated with a higher chance of successful labor induction (76.8%). This parameter might be used to predict the chance of successful labor induction. This information could help better inform clinician discussions with pregnant women concerning the chance of successful labor induction and consequent decision-making. Nevertheless, further large-scale clinical trials are warranted. Full article

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40–0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36–19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65–1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01–20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery. Full article

Background: Vaginal dinoprostone (PGE₂) is currently used as the prostaglandin of choice in many obstetric units. However, few studies have evaluated its safety, especially in women who previously had a cesarean section. Objective: To evaluate the efficacy and safety of PGE₂ in pregnant women who are undergoing induction of labor (IOL), and who have had a previous cesarean section. Materials and Methods: A prospective observational study was conducted in La Mancha Centro Hospital in Alcázar de San Juan, Spain, from 1 February 2019 to 30 August 2020. Obstetric and neonatal outcomes, following IOL with PGE₂, in 47 pregnant women who wanted a trial of labor after cesarean (TOLAC), and 377 pregnant women without a history of cesarean section, were analyzed. The outcomes were analyzed by bivariate and multivariate analyses using binary and multiple linear regression. Results: A total of 424 women were included in this study. The percentage of cesarean sections in the TOLAC group was 44.7% (21), compared with 31.6% (119) in the group without a history of cesarean section (adjusted odds ratio: 1.4; 95% CI: 0.68–2.86). In the multivariate analysis, no statistically significant differences were observed between both groups for obstetric and neonatal outcomes (p > 0.05). However, two uterine ruptures (4.3%) occurred in the group of patients with a history of cesarean section who underwent IOL with PGE₂. Conclusions: The induction of labor with vaginal dinoprostone (PGE₂), in patients with a previous history of cesarean section, was not associated with worse obstetric or neonatal outcomes compared with the group of patients without a history of cesarean section in our study sample. However, further research is needed regarding this IOL method, and it should be used with caution in this population group. Full article

Background: Delivering a child is a very stressful experience for women. Pregnancy and labor entail complex events that are unique to each individual female. The management of labor pain is often done using analgesics and anesthesia, which have been shown to have some side effects. More comprehensive data are needed to provide clinically significant evidence for clinicians to confidently prescribe exercises to patients. This study was done to evaluate the effect of antenatal exercises, including yoga, on the course of labor, delivery, and pregnancy outcomes. Methods: A retrospective study was conducted among 200 primiparous subjects (aged 20–40). A questionnaire was provided to the subjects to obtain their demographic and obstetrical information 6 weeks after delivery, and their hospital records were also assessed for further details. Based on the nature and details obtained for the antenatal exercises, subjects were divided into two groups: control and exercise. Outcome measures included the need for labor induction, self-perceived pain and perceived exertion during labor, duration and nature of the delivery, newborn infant weight, maternal weight gain, history of back pain, and post-partum recovery. The total maternal weight gain (in kilograms) was calculated from weight at 6 weeks after delivery minus the weight at 12–14 weeks of gestation. Back pain during pregnancy and self-perceived labor pain were measured using a visual analog scale (VAS). The overall perceived exertion during labor was measured using an adapted Borg scale for perceived effort. Results: The subjects who followed regular antenatal exercises, including yoga, had significantly lower rates of cesarean section, lower weight gain, higher newborn infant weight, lower pain and overall discomfort during labor, lower back pain throughout pregnancy, and earlier post-partum recovery compared to those who did no specific exercises or only walked during pregnancy. Conclusions: This retrospective study showed that regular antenatal exercises, including yoga, result in better outcomes related to the course of labor, delivery, and pregnancy. These results notably indicated that pregnant women should be active throughout pregnancy and follow a supervised exercise program that includes yoga unless contraindicated. We require further large-scale prospective studies and quasi-experimental trials to confirm the observed findings. Full article

Currently, there is no meta-analysis comparing intravaginal misoprostol plus intracervical Foley catheter versus intravaginal misoprostol alone for term pregnancy without identifying risk factors. Therefore, the purpose of this study is to conduct a systematic review and meta-analysis of randomized control trials (RCTs) comparing concurrent intravaginal misoprostol and intracervical Foley catheter versus intravaginal misoprostol alone for cervical ripening. We systematically searched Embase, Pubmed, and Cochrane Collaboration databases for randomized controlled trials (RCTs) comparing intracervical Foley catheter plus intravaginal misoprostol and intravaginal misoprostol alone using the search terms “Foley”, “misoprostol”, “cervical ripening”, and “induction” up to 29 January 2019. Data were extracted and analyzed by two independent reviewers including study characteristics, induction time, cesarean section (C/S), clinical suspicion of chorioamnionitis, uterine tachysystole, meconium stain, and neonatal intensive care unit (NICU) admissions. Data was pooled using random effects modeling and calculated with risk ratio (RR) and 95% confidence interval (CI). Pooled analysis from eight studies, including 1110 women, showed that labor induction using a combination of intracervical Foley catheter and intravaginal misoprostol decreased induction time by 2.71 h (95% CI −4.33 to −1.08, p = 0.001), as well as the risk of uterine tachysystole and meconium staining (RR 0.54, 95% CI 0.30–0.99 and RR 0.48, 95% CI 0.32–0.73, respectively) significantly compared to those using intravaginal misoprostol alone. However, there was no difference in C/S rate (RR 0.93, 95% CI 0.78–1.11) or clinical suspicion of chorioamnionitis rate (RR 1.22, CI 0.58–2.57) between the two groups. Labor induction with a combination of intracervical Foley catheter and intravaginal misoprostol may be a better choice based on advantages in shortening induction time and reducing the risk of uterine tachysystole and meconium staining compared to intravaginal misoprostol alone. Full article

The rate of vaginal birth after cesarean section (VBAC) is extremely low in Taiwan probably due to the high perceived risk of trial of labor after a cesarean (TOLAC). To promote the benefits associated with vaginal birth, this study provides evidence to potentially assist relevant public authorities adopt appropriate guidelines or optimize health insurance reimbursement policies to achieve a higher VBAC rate. Employing the National Health Insurance (NHI) Claim Data, this study analyzes women’s adoptions of birth-giving methods for those who had previous cesarean section (CS) experiences. Empirical methods include logit, probit, and hierarchical regression models controlling women’s demographics, incentive indicators, as well as hospital and obstetrician characteristics. Taiwan continues to have a decreasing trend in VBAC rate even with an increase in NHI payment for vaginal birth delivery in 2005, which stimulated a surge in VBAC rate only temporarily. Factors that significantly influence women’s adoption of VBAC include institution-specific random effects, weekend admission, comorbidities during pregnancy, and income and fertility of women. Change in service payment from National Health Insurance (NHI) to healthcare providers constitutes an effective policy in directing clinical practices in the short term. Constant and systematic policy review should be undertaken to promote safe and beneficial medical practices. The results of the study suggest that women’s adoption of birth-giving method is dominated by non-medical considerations. Significant institution-specific effects imply that women might not be well-informed regarding their optimal birth-giving choice. Health education and training programs for hospital personnel should be kept up to date to better serve society. Full article

There exist very few studies comparing different postures or postural changes during labor in parturients with epidural analgesia. Aim: To disclose whether the intervention of a multidisciplinary nursing team including a physiotherapist during the second stage of labor improves the obstetric outcome in parturients with epidural analgesia. Design: Prospective randomized trial. Setting: University-affiliated hospital. Population: Women undergoing labor with epidural analgesia after a normal gestation. Methods: 150 women were randomized either to actively perform predefined postural changes during the passive phase of the second stage of labor under the guidance of the attending physiotherapist (study group), or to carry out the whole second stage of labor lying in the traditional supine position (control group). Results: There were significantly more eutocic deliveries (p = 0.005) and, conversely, significantly less instrumental deliveries (p < 0.05) and cesarean sections (p < 0.05) in the study group. The total duration of the second stage of labor was significantly shorter (p < 0.01) in the study group. This was at the expense of the passive phase of the second stage of labor (p < 0.01). Significantly less episiotomies were performed in the study group (31.2% vs 17.8%, p < 0.05). Conclusion: The intervention of a physiotherapist during the second stage of labor significantly improved the obstetric outcome. Full article