Nowadays, with the concept of having two children and rising literacy rate and socioeconomic status of Indian population, neither the patient is willing to take the risk of prolonged trial of normal labour and tolerate neither extremly painful labour pains nor the clinician because of medicolegal issues. So, the trend of having elective cesarean section or taking early decision of cesarean section after a short trial of labour is prevalent. This has lead to a rise in the incidence of previous one cesarean section and the clinician should not forget that “once a cesarean section, always a scar”. Thus, the decision of first cesarean section should always be taken cautiously. There is consensus amongst National Institute for Health and Care Excellence (NICE), Royal College of Obstetrics and Gynecology (RCOG), American College of Obstetrics and Gynecology (ACOG) and National Institutes of Health (NIH) that vaginal birth after cesarean is a clinically safe and acceptable option for women with single previous lower segment cesarean section. VBAC avoids major abdominal surgery, lowers the women’s risk of postpartum morbidity like fever, blood transfusion, infections, shorter hospital stay and encourages earlier breastfeeding and better bonding between mother and neonate.
Abstract: Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation. This study attempts to evaluate factors associated with success of vaginal birth after cesarean section and to compare the maternal and perinatal outcomes between vaginal birth after cesarean section and intrapartum cesarean section in patients who were admitted to hospital during the active or second stage of labor. A retrospective evaluation was made from the results of 127 patients. Cesarean section was performed in 57 patients; 70 attempted trial of labor. The factors associated with success of vaginal birth after cesarean section were investigated. Maternal and neonatal outcomes were compared between the groups. Vaginal birth after cesarean section was successful in 55% of cases. Advanced cervical opening, effacement, gravidity, parity, and prior vaginal delivery were factors associated with successful vaginal birth. The vaginal birth group had more complications (P,0.01), but these were minor. The rate of blood transfusion and prevalence of changes in hemoglobin level were similar in both groups (P.0.05). In this study, cervical opening, effacement, gravidity, parity, and prior vaginal delivery were important factors for successful vaginal birth after cesarean section. The patients’ requests influenced outcome. Trial of labor should take into consideration the patient’s preference, together with the proper setting.
To contain the ever-increasing rate of cesarean deliv- ery, vaginal birth after cesarean section (VBAC) delivery has been promoted since the 1990s. 14 A National Institutes of Health consensus conference in 2010 and the most recent American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin recognized the safety of TOLAC and recommended increased access. 15–17 However, due to the perceived risk of uterine rupture and other complications, obstetricians may be reluctant to undertake VBAC. 18 This situation is especially prominent in Taiwan, even though the Ministry of National Health Insurance (MNHI) in Taiwan enacted a policy. 21 (This policy raised the reimbursement rate by the Ministry of National Health Insurance (MNHI) in Taiwan for VBAC to the same as that for CS) to encourage VBAC in 2005. Given the low rate of VBAC in Taiwan of only 1.5 – 4.0% in recent decades 19 – 21 relative to the rates of 8.5 – 30% in the US 22 and 30 – 50% in European countries, 23 women and obstetricians in general view TOLAC as a relatively risky birthing practice. The very low rate of VBAC in Taiwan might be attributed to the low rate of birth in this country (the crude birth rate dropped from 2.46 in 1981 to 1.18 in 2015), 24 which has indirectly caused underinvest- ment in facilities for vaginal delivery and a general per- ception that VBAC is hazardous. The current study intended to investigate the determinants of VBAC in Taiwan from the viewpoint of obstetricians. The extent to which obstetricians ’ past experiences, risk tolerance, back- ground information, and institutional settings in ﬂ uence the VBAC or elective repeat cesarean surgery (ERCS) deci- sion will be explored.
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During the prenatal counseling of women with one previous cesarean section, the probability of successful vaginal birth is one of the most crucial factors. The his- tory of previous delivery (previous VB before CS, previ- ous VBAC and the indications for previous CS), the characteristics of the pregnant women (age and race), the complications (obesity, diabetes and HDCP), the size of the fetus, the bishop score of the cervix, and the ne- cessity of labor induction should be highly considered, which were associated to the success of VBAC. The cli- nicians should be also aware that uterine rupture could complicate with TOLAC. TOLAC under continuous monitoring by a skilled clinician and at facilities with 24- h surgery services  should be guaranteed to increase the safety of the delivery.
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The marginalization of midwives in the State of Flor- ida and in the United States is another key factor in the uptake of VBAC. Notably, midwives are not even men- tioned in any version of the ACOG guidelines; however, they are included as part of a team approach to caring for women with a previous cesarean in guidelines from both the United Kingdom [35,36] and New Zealand . In this study, the midwives had little control about whether or not they were able to participate in VBACs. Much of their ability to do so was dependent on the set- ting and/or the willingness of the obstetricians they worked with. They were also frustrated by the lack of proactive solutions to the limited access to VBAC in Florida. Many women with a previous cesarean were seeking their care in hopes of having a vaginal delivery. Some of these women were traumatized over their pre- vious cesarean and desired the continuous presence of a supportive caregiver during labor in order to achieve a vaginal birth. Yet, the midwives felt that “ their hands were tied ” in terms of being able to be part of the
Depending on the etiology or indication, a cesarean delivery contributes to short- and long-term risks for both mother and infant [12, 13]. The Society of Obstetri- cians and Gynaecologists of Canada (SOGC) recom- mends that a trial of labor be offered to women with one previous transverse low-segment cesarean section . A woman’s willingness to undergo a trial of labor after cesarean (TOLAC) may be influenced by a multi- tude of factors . While a vaginal birth after a cesarean (VBAC) may be desired by some women, the patient-level benefits associated with a VBAC from avoiding major abdominal surgery and risk of complica- tions in future pregnancies must be weighed against the potential for serious harms such as a failed TOLAC and subsequent maternal and neonatal morbidity including an unplanned repeat cesarean delivery . For women with more than one previous cesarean delivery, a VBAC is likely to be successful, but with an estimated higher risk of uterine rupture (0.2 to 1.5% with a transverse uterine incision, 1.0 to 1.6% with a low-vertical uterine incision) . This SOGC statement is consistent with recommendations from the American College of Obstet- rics and Gynecology (ACOG) [16, 17].
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Appropriateness of using the EQ-5D an the Indian setting The findings of the pilot study at hand indicate that the descriptive system of the EQ-5D-5L was able to depict and differentiate early postpartum QOL in Indian women by birth mode and over time. On average, at least 75% of the women in our study reported slight to extreme problems in four of the five health dimensions assessed by the EQ-5D-5L. The median woman who gave vaginal birth reported slight problems with mobil- ity, self-care, usual activities, and pain or discomfort in the first interview 0–3 days after birth. At a similar post- partum time, the median woman who gave birth by cesarean section reported slight problems only with pain or discomfort and extreme problems with mobility, self-care and usual activities. No problems with anx- iety or depression were reported by the median women in both birth groups, and less than 3% of the women interviewed ever reported more than slight problems with anxiety or depression. Among the women who gave vaginal births, the EQ-5D based QOL measure was lower for women who reported to have had an episiot- omy during birth in comparison to those women who did not have this oftentimes discomforting procedure. Differences in the level of problems, and consequently QOL weights, between women with vaginal births and women with cesarean sections were highest at the time of the first interview which took place within the first three days postpartum. As time progressed, differences in QOL between women with vaginal and cesarean births narrowed and ceased to be statistically discernible at the time of the last follow-up interview when adjust- ing for socioeconomic, pregnancy and birth characteris- tics. Estimating the overall QOL in the first 21 days postpartum, vaginal births were associated with signifi- cantly more QALDs than cesarean sections.
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a vaginal birth. All singleton, term (≥37th week of gesta- tion) fVBAC who delivered at the Department of Gynecology and Obstetrics, Medical Faculty and Univer- sity Hospital in Pilsen, Charles University from January 2012 till December 2016 were included in the study (Additional file 1: Figure S1). The singleton term PVB subsequent to each of the included fVBAC formed the control cohort. The controls were selected on a one-to- one ratio to the VBAC patients. Women who had a vagi- nal birth prior to the index cesarean section, and preg- nancy complicated by intrauterine fetal death, fetal anomalies, stillbirth and those who had intrapartum epi- dural analgesia were excluded from the study. Since the main aim of the study was to assess the influence of the pre- vious labor process, women with epidural analgesia were ex- cluded as it is considered a major confounding factor for labor duration and perineal trauma [16–18]. The use of oxy- tocin for labor induction or augmentation or any form of pharmacologic or mechanical cervical ripening was not con- sidered as exclusion criteria. Prostaglandins were never used for this purpose in fVBAC. The hospital clinical database was used to identify eligible women and their individual health records were used for data collection.
Many demographic and obstetric factors are associated with the likelihood of VBAC. Race and ethnicity are the strongest demographic predictors of vaginal delivery after trial of labor. Hispanic and African American women have lower rates of VBAC than non-Hispanic white women. In addition, increasing maternal age, single marital status, and less than 12 years of education also have been associated with lower rates of VBAC. Women who deliver at rural and private hospitals and the presence of maternal disease such as hypertension, diabetes, asthma, seizures, renal disease, thyroid disease, heart disease also associated with a decreased likelihood of VBAC. Greater maternal height and body mass index below 30 kg/m2 are associated with an increased likelihood of VBAC (Chu, et al., 2006; Carroll, et al., 2003; Cunningham, et al., 2010). Maternal weight has an important relation with the reproductive health of women, as obesity during pregnancy is associated with increased maternal and fetal risk (Stewart, et al., 2007).
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We discovered maternal age, cervical maturity, BMI before pregnant and psychology were major factors influenced vaginal delivery. With the maternal age increased, the odds of complications were increased, the body functions were slightly reduced, so most of them reluctant to trial of labor. Mendoza also identified the maternal age was interrelated with VBAC [20, 21]. One study found once maternal age was more than 35, then the success of VBAC was decrease . While Malede thought maternal age was not related with VBAC . A study revealed cervical opening, effacement, gravidity, parity, and prior vaginal delivery were important factors for successful vaginal birth after cesarean section . Another study showed maternal pre-pregnancy BMI, non-recurring indications of previous cesarean section, good Bishop’s score at the time of admission, spontaneous onset of labor, and neonatal birth weight were associated with more higher probability of VBAC .
Only 2 mothers experienced VBAC complications as post partum hemorrhage (2.7%) and one of them needed transfusion. Post partum hemorrhage occurred in 2.2% of Melamed study population (14). Transfusion rate was 2% in Frass study (23). These findings confirmed the low incidence of hemorrhagic events required transfusion in women undergo VBAC. None of our cases had uterine rupture, as same as Melamed (14). In Ramirez report, uterine rupture frequency was 2.4%, and most cases occurred after induction (23). It seems that selecting women for VBAC is very important, and the risk of life threatening complications of VBAC can be reduce with appropriate criteria (such as previous transverse incision, not using induction for delivery, noting the interval from the previous CS). Some studies proposed that 18 months interval between previous CS and VBAC are adequate (19). Bangal showed that uterine rupture happened in women attempted to have VBAC before 2 years interval from previous C-section (20).
Many systematic reviews evaluated labor induction in women with previous CS using different agents with suc- cessful VBAC in 50% - 70% of women [25-27]. Dino- prostone vaginal tablets are the simplest formulation to administer, but it may need repeated application. Mean- while, the sustained release dinoprostonepessary releases a continuous and predictable dose of dinoprostone at a rate of approximately 0.3 mg/h for 24 h with single va- ginal application. The progressive cervical ripening in- duced by the controlled release of dinoprostone may be more acceptable to patients than the rapid onset of con- tractions observed with dinoprostone vaginal tablets . The present study demonstrated that both forms of va- ginal dinoprostone (1.5 mg tablet and 10 mg sustained release pessary) were efficient in inducing labor among women with previous CS. Our data displayed that the vaginal delivery rate was 67% in the 1.5 mg dinoprostone group A and 64% in the 10 mg dinoprostone sustained release group with no statistical difference. A similar success rate of labor induction was reported by Stock et al.,  who performed a retrospective study on women with one previous CS, in Scotland and United Kingdom over 27 years. The overall vaginal delivery rate was achi- eved in nearly 60% of women attempting labor induction between 39 and 42 weeks (4399/7401). Similarly, Ou- zounian et al.,  performed a retrospective cross-sec- tional cohort study on 6833 patients with prior CS. Of these, 5027 women had spontaneous onset of labor and 1806 women had labor induced with either dinoprostone vaginal tablets or oxytocin. They showed that women with labor induction had an overall successful VBAC in 66.4% of cases. Furthermore, two recent prospective stu- dies had evaluated dinoprostone for labor induction in patients with previous CS and demonstrated a compara- ble successful vaginal rate. On the other hand, Gómez and colleagues  conducted a retrospective study to compare the efficacy and safety profile between the di-
A number of factors influencing the increase of this surgical delivery method include changes in healthcare practice styles, patient preferences, pressures of malprac- tice and demographic influences (e.g., social, economic, cultural) [4–10]. These influences can affect delivery op- tions/choice and may result in complex pregnancies that ultimately require a CD [11, 12]. Short- and long-term morbidity risks for the infant and mother are further in- fluenced by the etiology or indication of their CD; how- ever, overall risk of morbidity and mortality is more positively associated with CD compared to vaginal deliv- ery [13–16]. This risk warrants careful consideration of potential post-operative complications before scheduled CD, a major abdominal surgery. Recent ‘Early Recovery After Cesarean’ (ERAS) for CD guidelines (Part 1–3) have been published to reduce maternal and neonatal morbidity and mortality .
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The objective is the reduction of cesarean sections in primigravidae and the incentive to those pregnant women fit for VBAC, modifying the thought that "once cesarean section always cesarean" (Zaitoun et al., 2013; Chhabra et al., 2006; Madi et al., 2013). At the study site, it is common to indicate a new cesarean section in pregnant women who have two or more previous cesarean sections and in those with a previous cesarean section performed less than two years ago. Current evidence suggests that VBAC should be encouraged for all pregnant women with previous cesarean section longer than 15 months, with at most two previous cesarean sections, absence of traditional contraindications to labor or normal delivery, and adequate maternal pelvis on physical examination (Secretaria de Atenção à Saúde, 2016; American College of Obstetricians and Gynecologists 2010). The frequency of VBAC varies globally. In European countries it is between 29.0% and 55.0%, in the United States and Australia approximately 36.0% and in the United Kingdom 26.0%, rates higher than that found in this study (17.7%), (England NMS-. Hospital Episode Statistics, 2015; Schemann et al., 2015; Alexander et al., 2008). Part of this statistical divergence is due to the variability of the election criteria to consider pregnant women fit to VBAC, who depend on the study site, the protocols of each service, the local physical and socioeconomic structure, factors that limit the comparison of the data. Data from the United States indicate that more than 90.0% of pregnant women with a previous cesarean section were admitted to elective cesarean section.
This study used prospective data from a large cohort of children broadly representative of the general Australian population, gathered over a 9-year period. When accounting for birth factors, social vulnerability, maternal BMI, and breastfeeding, we found few differences in the long- term health and developmental outcomes of children delivered by cesarean delivery compared with those delivered vaginally. The ﬁ nding that children born by cesarean delivery were more likely to have a medical condition at age 2 to 3 years and use prescribed medication at 6 to 7 years are difﬁcult to interpret because these associations were not consistent throughout the 5 waves of the study. Similarly, the association between cesarean delivery and increased child BMI at age 8 to 9 years was a relatively small effect that seemed to be mediated through maternal BMI rather than mode of birth. For children delivered by cesarean delivery, an effect of lower parent-reported quality of life emerged at age 8 to 9 years, but once again this effect was relatively weak and was not present in the earlier age groups. Intriguingly, we did ﬁnd that children delivered by cesarean delivery had better parent-reported global health at 2 to 3 years of age, which contrasted with the lower quality of life ﬁnding at age 8 to 9 years. We also found that these children rated slightly higher on the prosocial scale at the beginning of school at age 6 to 7 years.
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In a population-based cross sectional study of nulliparous women at term, an increased risk of cesarean delivery was noted with increasing BMI. BMI seems to have a dose-response effect on the risk of cesarean delivery . The study noted a six-fold increase in cesarean delivery in extreme morbidly obese group (BMI>50), which is nearly three times that of class I obese women (BMI 30-34.9) . In a cohort of nulliparous women undergoing induction of labor, the risk of cesarean delivery was increased by 17 percent with each 10 kilogram increase in maternal weight . One study examined specifically women undergoing labor induction for pre-eclampsia and noted an increased risk of cesarean delivery with increasing BMI . Obesity and pre-gestational diabetes were noted to be independent risk factors for cesarean delivery . Obese women with comorbiditiesare also noted to have higher cesarean deliveries rates compared to obese women without comorbidities .
Women with previous cesarean section (CS) constitute a high risk group in obstetrics. The present study was done to determine the mode of delivery, various indications for repeat CS, maternal and perinatal outcomes among women with previous CS. A hospital based observational study was done in Pondicherry Institute of Medical Sciences, Puducherry. All pregnant women at ≥34 weeks of gestation with history of previous one lower segment caesarean section (LSCS) and singleton pregnancy in cephalic presentation were enrolled. Study protocol was approved by Institute Ethics Committee. Taking the incidence of repeat CS as 50% among women with previous one CS, a sample size of 96 was calculated. However 103 women were enrolled. Proportions were calculated for categorical variables and chi-square test was applied for significance. Among 44 women who were given trial of labour, 18 (40.9%) delivered vaginally. Most common indication for emergency cesarean section in trial of labour group was scar tenderness (46.2%) followed by non-progress of labour (34.6%). Among women who underwent elective CS, emergency CS and VBAC, the proportion of complications was 10.3%, 8.7% and 11.1% respectively. Almost one-fourth of the newborns had complications (24.3%). 88% of them required NICU admission and 36% had some form of respiratory morbidity. Trial of labour is a reasonable option for properly selected group of pregnant women with prior one LSCS.
after the birth of their baby); and two partners. Women were generally concerned about the safety of their new baby, and lacked confidence in themselves as new mothers regarding their ability to care for their baby. There was a prevailing view that the physical presence and availability of professional support helped alleviate these concerns, and this was especially the case for women having a first baby. Women had anxieties and fears around early parenting and their changing role. Consistent with these views, many women were concerned about any moves to make the postnatal hospital stay shorter, espe- cially for first time mothers. We concluded that any changes to care provision should be evaluated, that women? s views should be taken into account, and that where possible providers should ensure that care is individualised to address each woman? s/family? s particu- lar concerns .
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We extrapolated our findings to the entire U.S. new- born population in 2016. The extrapolation estimated total healthcare expenditure of $271.9 million and incre- mental costs of $177.0 million among 18,872 treated hemolytic NHB newborns as compared with their coun- terparts without NHB during the first month after birth. Our extrapolation assumed our estimates were applic- able to the U.S. newborn population mainly insured by private insurance plans or Medicaid. This projection should be interpreted with caution as privately insured populations tend to have higher socioeconomic status and healthcare expenditures than the Medicaid popula- tion . Further research in the Medicaid newborn population is warranted to examine our assumptions and estimates.
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The risk of infection after post-placental insertion is low, and randomized tri- als have not shown a difference of infection based on the insertion point. Leu- corrhées were found in 29.9% and 37.6% for group 2 and group 1 to 6 months. The examination of vaginal secretions had regained 17.6% of infection in pa- tients in group 2, and 16.2% for group 1. Our rates are substantially higher compared to those found in the literature    . The explanation is that a proportion not negligent of our patients had a history of recurrent infections genital 19% in group 2 and 15% in Group 1. All of these patients had received treatment with anti-infective a good clinical response. No IUD had been with- drawn because of infection (Table 3).