Maternal and neonatal characteristics associated with clinical outcomes of TOLAC from 2012-20 in the USA: Evidence from a retrospective cohort study

BACKGROUND

The risks of a few maternal and/or neonatal morbidities are higher with the trial of labour after caesarean (TOLAC) owing to unplanned caesarean delivery. Thus, it is imperative to consider the trade-off between the risk of side effects and the potential benefits before TOLAC utilisation and whether TOLAC should be provided to women with specific characteristics related to previous caesarean delivery. We aimed to investigate maternal and neonatal characteristics associated with TOLAC utilisation, compare maternal and/or neonatal morbidities in TOLAC women with women who chose planned caesarean deliveries, and assess specific characteristics related to maternal and/or neonatal morbidities in women with TOLAC utilisation.

METHODS

In this retrospective cohort study, we used nationwide, linked birth and infant death data in the United States between 2012 and 2020, which covers all 50 states in the US. Poisson regression models using generalised estimating equations yielded adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) of TOLAC utilisation and unsuccessful TOLAC by maternal and neonatal characteristics. Logistic regression models using generalised estimating equations yielded adjusted odds ratios (aORs) with 95% CIs of maternal and neonatal morbidities. Statistical analysis was performed from February 2022 to July 2022.

FINDINGS

The sample included 4,898,441 women with mean (SD) maternal age years (5.4 years; range 13-50). Several specific maternal and neonatal characteristics were significantly associated with unsuccessful TOLAC, although women with TOLAC utilisation were associated with significantly lower risks of maternal unplanned hysterectomy (aOR, 0.60; 95% CI, 0.60-0.61), admission to intensive care (aOR, 0.84; 95% CI, 0.84-0.85), and neonatal seizures (aOR, 0.80; 95% CI, 0.74-0.84). In women who attempted TOLAC, advanced maternal age, higher maternal body mass index, more than 2 previous caesarean deliveries, having maternal co-morbidities and fetal malpresentation increased the likelihood of maternal and neonatal morbidities.

INTERPRETATION

When utilising TOLAC, specific maternal and neonatal characteristics in pregnant women should be considered in conjunction with the potential benefits of TOLAC in preventing maternal and neonatal morbidities.

FUNDING

This study is funded by the Clinical Medicine Plus X - Young Scholars Project, Peking University, the Fundamental Research Funds for the Central Universities (No: PKU2022LCXQ008).

Induction of labor for a suspected large-for-gestational-age/macrosomic fetus

Fetal macrosomia is defined as a birth weight of >4000 g, while the term large for gestational age (LGA) is defined as an estimated fetal weight >90th centile for gestational age. Current data indicate that a significant proportion of the babies are LGA. Pregnancies involving LGA babies are associated with increased maternal and perinatal morbidity including caesarean section, postpartum hemorrhage, shoulder dystocia, and birth trauma. To reduce these complications, labor induction has been suggested as a possible solution. However, despite some high-quality evidence in favor of labor induction for suspected macrosomia/LGA, existing guidelines do not support routine induction of labor in this population. The aim of this paper is to critically appraise the available evidence and clinical practice recommendations and highlight the importance of shared decision making and individualized care based on clear counselling regarding the lack of a sensitive diagnostic tool for estimating fetal weight in the third trimester.

Maternal and neonatal outcomes in transverse and vertical skin incision for placenta previa : Skin incision for placenta previa

BACKGROUND

Placenta previa, a serious obstetric issue, should be managed by experienced teams. The safe and appropriate mode of delivery for placenta previa is by cesarean delivery. However, no studies were found comparing either maternal or neonatal outcomes for different skin incision in women with placenta previa. The aim of this study was to compare maternal and neonatal outcomes by skin incision types (transverse compared with vertical) in a large cohort of women with placenta previa who were undergoing cesarean delivery.

METHODS

This was a retrospective cohort study carried out between January 2014 and June 2019. All pregnant women with placenta previa had confirmed by ultrasonologist before delivery and obstetrician at delivery. The primary outcome was the estimated blood loss during the surgery and within the first 24 hours postoperatively. Mean (standard deviation), median (interquartile range) or frequency (percentage) was reported to variables. Appropriate parametric and nonparametric tests were used to analyses.

RESULTS

The study included 1098 complete records, 332 (30.24%) cases in the vertical skin incision group and 766 (69.76%) cases in the transverse skin incision group. Those with vertical incision showed a higher percentage of preterm delivery, anterior placenta, abnormally invasive placenta, and history of previous cesarean delivery, and a lower percentage of first pregnancy, in vitro fertilization, and emergency cesarean delivery. After controlling for confounding factors, higher incidence of post-partum hemorrhage (OR 5.47, 95% CI 3.84-7.79), maternal intensive care unit (OR 4.30, 95% CI 2.86-6.45), transfusion (OR 5.97, 95% CI 4.15-8.58), and 5-min APGAR< 7 (OR 9.03, 95% CI 1.83-44.49), a more estimated blood loss (β 601.85, 95%CI 458.78-744.91), and a longer length of hospital stay after delivery (β 0.54, 95%CI 0.23-0.86) were found in the vertical skin incision group.

CONCLUSIONS

Our data demonstrated that transverse skin incision group showed the better perinatal outcomes in women with placenta previa. Future collaborative studies are needed to be done by centers for placenta previa to have a better understanding of the characteristics and the outcomes of the disease in the choosing skin incision.

Comparison of maternal and neonatal outcomes after forceps or spatulas-assisted delivery

OBJECTIVE

The aim of this study was to compare the perinatal outcomes associated with spatulas or forceps assisted delivery.

STUDY DESIGN

This is a bicentric retrospective cohort study including all assisted deliveries in cephalic presentation after 37 weeks of gestation, performed on singleton pregnancy with forceps and with spatulas in two tertiary centers. The main outcome was the rate of episiotomy. Secondary outcomes included obstetric anal sphincter injuries (OASIS), maternal outcomes and neonatal parameters.

RESULTS

Out of 37 002 deliveries, the overall rate of assisted delivery was 11.4 %, and 1 041 (2.8 %) assisted deliveries with forceps and 2 462 (6.7 %) spatulas deliveries were included. The rate of episiotomy was 90.3 % after forceps-assisted delivery and 70.9 % for spatulas (p < 0.001). The rate of OASIS was 7.2 % and 5.6 % respectively (p = 0.06). A slight but significant decrease in neonatal trauma after spatulas was observed.

CONCLUSION

In this retrospective cohort study, the episiotomy rate was higher with forceps assisted deliveries than with spatulas. Both instruments have low neonatal morbidity and are similar regarding OASIS.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]

OBJECTIVES

To determine the optimal management of singleton breech presentation.

MATERIALS AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C).

CONCLUSION

In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

Maternal and fetal effect of misgav ladach cesarean section in nigerian women: a randomized control study

Background:

The poor utilisation of the Misgav-Ladach (ML) caesarean section method in our environment despite its proven advantage has been attributed to several factors including its non-evaluation. A well designed and conducted trial is needed to provide evidence to convince clinician of its advantage over Pfannenstiel based methods.

Aim:

To evaluate the outcome of ML based caesarean section among Nigerian women.

Subjects and Methods:

Randomised controlled open label study of 323 women undergoing primary caesarean section in Lagos Nigeria. The women were randomised to either ML method or Pfannenstiel based (PB) caesarean section technique using computer generated random numbers.

Results:

The mean duration of surgery (P < 0.001), time to first bowel motion (P = 0.01) and ambulation (P < 0.001) were significantly shorter in the ML group compared to PB group. Postoperative anaemia (P < 0.01), analgesic needs (P = 0.02), extra suture use, estimated blood loss (P < 0.01) and post-operative complications (P = 0.001) were significantly lower in the ML group compared to PB group. Though the mean hospital stay was shorter (5.8 days) in the ML group as against 6.0 days, the difference was not significant statistically (P = 0.17). Of the fetal outcome measures compared, it was only in the fetal extraction time that there was significant difference between the two groups (P = 0.001). The mean fetal extraction time was 162 sec in ML group compared to 273 sec in the PB group.

Conclusions:

This study confirmed the already established benefit of ML techniques in Nigerian women, as it relates to the postoperative outcomes, duration of surgery, and fetal extraction time. The technique is recommended to clinicians as its superior maternal and fetal outcome and cost saving advantage makes it appropriate for use in poor resource setting.

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).