Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

Effects of ADIET communication and delivery rehearsal on anxiety, labor process, and outcomes in vaginal trial delivery

BACKGROUND

In recent years, the obstetrics department has advocated vaginal delivery to reduce the rate of cesarean sections. However, in clinical practice, pregnant women are prone to anxiety before childbirth, making it difficult to perform a vaginal trial delivery smoothly. The combined approach of ADIET communication and delivery rehearsal for vaginal trial delivery can provide a reference for reducing prenatal anxiety, shortening labor duration, facilitating a smooth delivery, and ensuring the safety of both mothers and babies.

AIM

To analyze the effect of AIDET communication combined with labor rehearsal on vaginal trial delivery.

METHODS

A study conducted between January 2023 and December 2023 included 200 vaginal trials. Women were randomly assigned to an observation group (100 women), which received ADIET communication plus delivery intervention, and a control group (100 women), which received routine communication plus delivery intervention. This study aimed to compare antenatal anxiety status as measured using the Maternal Anxiety Scale, labor duration, delivery efficacy as assessed using the simplified Chinese version of the Childbirth Self-Efficacy Inventory, and delivery outcomes.

RESULTS

After the intervention, the observation group had a lower Maternal Anxiety Scale score and higher Childbirth Self-Efficacy Inventory score (P < 0.05) than the control group (P < 0.05), whereas the observation group had higher natural delivery, cesarean delivery, vaginal delivery, and neonatal asphyxia rates (P < 0.05).

CONCLUSION

For women undergoing vaginal trial delivery, a combination of AIDET communication and delivery rehearsal can relieve prenatal anxiety, enhance delivery efficiency, shorten labor duration, and somewhat improve delivery outcomes.

Supporting Labor After 2 Cesarean Births

Labor after cesarean (LAC) is a safe alternative for pregnant persons who have had 1 or 2 previous cesarean births (CBs) and have no contraindication to vaginal birth. When compared with repeat CB, vaginal birth after cesarean (VBAC) reduces short- and long-term health complications and morbidity and should therefore be presented as an option. Despite recommendations from the American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists in support of LAC, not all pregnant persons who are candidates have access to this option. In some areas, provider hesitancy and institutional guidelines limit the availability of LAC, especially after more than one CB. Midwives are uniquely positioned to advocate for this birthing option through the use of shared decision-making. In the antepartum period, birth decision aids, VBAC calculators, and continued dialogue allows for pregnant persons to make informed choices meeting their unique health needs and goals. This clinical rounds article highlights the safety of labor in a pregnant person with a history of 2 prior CBs. As presented in this case, when LAC includes the need for induction of labor, the use of a transcervical balloon catheter for cervical ripening and judicious use of oxytocin are safe, evidence-based options. Ultimately, LAC can offer pregnant persons an increased sense of autonomy and control over their labor and birth, which improve both satisfaction and outcomes, consistent with the family- and person-centered hallmarks of midwifery care.

Safety of a trial of labor after cesarean in kidney and liver transplant recipients: A multicenter cohort study

OBJECTIVE

To evaluate the trends, safety, and feasibility of a trial of labor after cesarean (TOLAC) among kidney and liver transplant recipients.

METHODS

This was a retrospective cohort study using the Transplant Pregnancy Registry International. It included recipients of a kidney or liver transplant with a live-birth pregnancy ≥20 weeks following a prior cesarean, with births between 1967 and 2019 from 289 hospitals, primarily in North America. The primary outcomes of severe maternal morbidity (SMM) and neonatal composite morbidity were compared between those with repeat cesarean deliveries (RCDs), vaginal births after cesarean (VBACs), and failed TOLAC. Multivariable regression was conducted to calculate odds ratios and 95% confidence intervals.

RESULTS

The 243 deliveries included in this study were composed of 80.7% RCDs, 10.3% VBACs, and 9.1% with failed TOLAC, with similar demographics between groups. There was no significant difference in incidence of SMM (RCD, 1.0%; VBAC, 4.0%; failed TOLAC, 0%; P = 0.48) or neonatal composite morbidity (RCD, 15.2%; VBAC, 11.5%; failed TOLAC, 4.5%; P = 0.45) between groups. No cases of uterine rupture or neonatal death occurred. Trends in TOLAC demonstrate that the TOLAC rate has declined from 35% in 1989-1994 to 13% in 2014-2019.

CONCLUSIONS

In this cohort of transplant recipients, TOLAC resulted in successful vaginal delivery over half the time, and did not increase the risk of maternal or neonatal morbidity compared with RCD. We encourage offering transplant recipients a trial of labor after appropriate counseling to decrease the overall rate of cesarean delivery and morbidity in this high-risk population.

How labor induction methods have evolved throughout history, from the Egyptian era to the present day: evolution, effectiveness, and safety

Induction of labor (IOL) is currently used for one in 10 pregnancies globally. Methods used for induction have shown major changes over time. Medical interventions trace their origins back to ancient civilizations, with evidence suggesting that they began over 5000 years ago in ancient Egypt. During this era, the Egyptians employed natural remedies such as castor oil and date fruits for the IOL. These early practices highlight the rich history and long-standing tradition of using natural substances in medical treatments, laying the foundation for the development of modern obstetric practices. After that, Hippocrates practiced mammary stimulation and mechanical cervical dilatation about 2500 years ago in Greece. Since then, there has been a marked change, especially over the last century, with the development of safer and more effective methods. Mechanical methods were the main method until the early 20th century, which were then substituted by pharmacological methods with more experiments in the mid to late 20th century. Nowadays, effectiveness, safety, cost, and client satisfaction are the main determinants of the methods used. This review summarizes how labor induction practices have evolved from the Egyptian era to the present-day randomized controlled trials and meta-analysis evidence, paying attention to their effectiveness, safety, and future directions.

Trial of labour after two caesarean sections (TOLA2C) and risk of uterine rupture, a retrospective single centre study

BACKGROUND

Most German hospitals do not offer a trial of labour after two caesarean sections (TOLA2C). TOLA2C is claimed to be associated with too many complications, above all the high risk of uterine rupture. The objective of this study is to review our experience with TOLA2C, with special attention paid to the risk and probability of uterine ruptures. Secondary outcomes include comparing neonatal and maternal outcomes in the group of TOLA2C with the group of elective repeat caesarean section (ERCS) and to assess the success rate for vaginal birth after two caesarean sections (VBAC-2).

METHODS

The retrospective cohort study was conducted in a community hospital in North Rhine-Westphalia. Inclusion criteria were all pregnant women with two caesarean sections in their medical history, with a current vertex singleton pregnancy and the absence of morphological abnormalities of the foetus, who gave birth in our facility between January 2015 and June 2021. Descriptive statistics were calculated and Kolmogorov-Smirnov tests, Mann-Whitney U tests, Fishers exact tests, Chi2 -tests and t-tests for independent samples were performed.

RESULTS

A total of 91 cases were included in the TOLA2C-group. These were compared to 99 cases that, within the same time frame, had an elective repeat caesarean section (ERCS-group). There was no statistically significant difference found in the neonatal outcome between the two groups (except for the neonatal pH-value: p 0.024). The hospital stay was significantly shorter in the TOLA2C-group, while maternal complication rates were almost similar (13.2% in the TOLA2C-Group, vs. 16.2% in the ERCS-Group). The success rate for TOLA2C was 55%. No complete uterine rupture was found, but in three cases an incomplete rupture (3.3% rate for incomplete uterine ruptures) occurred, but had no influence on the neonatal outcome.

CONCLUSION

TOLA2C is not associated with a worse maternal or neonatal outcome compared to ERCS, and especially the risk of complete uterine ruptures seems to be low. TOLA2C should be more widely offered to suitable patients who are motivated for it.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.