Vaginal Birth after Cesarean after Zavanelli Maneuver: A Woman’s Right to Choose

Introduction: Vaginal birth after cesarean (VBAC) plays an essential role in lowering cesarean rates. Despite endorsement, trial of labor after cesarean (TOLAC) attempt rates remain low, in part due to fear of lawsuits. Zavanelli maneuver is a last resort procedure in the management of shoulder dystocia. We discuss a case of a woman determined to have a vaginal birth after her prior birth was complicated by shoulder dystocia requiring a Zavanelli maneuver. Her physicians were reluctant to allow her a TOLAC given her prior obstetric history. Case: A 34-year-old para 1 with prior cesarean delivery due to shoulder dystocia that required Zavanelli maneuver presents determined to pursue VBAC in her current pregnancy. She considered her delivery route options and addressed her modifiable risk factors. She consulted with multiple perinatologists who agreed that a TOLAC was reasonable, however she had to travel more than 70 miles (from Pennsylvania to New Jersey) to find an obstetrical practice and hospital willing to consider VBAC. She transferred care and the remainder of her prenatal course was uncomplicated. She went into labor at 41 weeks and had a successful VBAC without complication. In a thank you letter to her obstetrician, she described her birth experience as euphoric. Conclusion: This case illustrates how a woman’s choice of delivery route may be impacted by fear of litigation. Local providers focused on her prior delivery instead of her overall improved risk profile. Delivery route decisions should be based on a thorough evaluation of all risk factors and individualized to meet the reproductive goals of each woman. .

Prediction of Success Rates of Vaginal Birth after Cesarean Delivery According to the Previous Indication for Cesarean Delivery

Background: Trial of labor after cesarean delivery (TOLAC) has long been accepted as a safe option for women with previous cesarean delivery. Previous efforts have been exerted in trials to predict the success rates of TOLAC according to specific parameters related to previous cesarean section and before TOLAC. We aimed to investigate the different indications of previous cesarean delivery as independent predictors for successful vaginal birth. Methods: A retrospective study was conducted in Armed Forces Hospitals of the Southern Region between December 15, 2019, and July 1, 2020. The included 566 patients with previous cesarean section who were willing to undergo a trial of labor were divided into two groups according to the success of vaginal birth (VBAC). Results: The nonrecurring indications for previous cesarean delivery were higher in the successful group (fetal distress 54.7% vs 41.1%, malpresentation 26% vs 21.4%, multifetal pregnancy 3.8% vs 2.7%). Additionally, the successful VBAC group had a significantly higher percentage of previous successful VBAC (47.7% vs 21.9%) and prior vaginal deliveries (58.5% vs 44.2%) and less coincidence of medical disorders and meconium-stained liquor (18.1% vs 26.3% and 3.2% vs 8.2%, respectively) than the unsuccessful group. Conclusion: During counseling regarding trial of labor after cesarean section, indications for previous cesarean section not related to arrest of labor can predict higher success of VBAC. Moreover, previous successful vaginal delivery or VBAC improves the success rates.

Risk Factors Associated with Unsuccessful Vaginal Birth after One Cesarean (VBAC-1) in Puerto Rico

Background: Cesarean section (CS) has increased steadily over the last decade, with an estimated one-third of women delivering by cesarean section worldwide. Objective: Our study aimed to investigate the demographic and associated factors influencing vaginal birth after one cesarean (VBAC-1) success focusing on variables like pre-pregnancy BMI, diabetes, hypertension, education, and smoking. Study Design and Methods: In this retrospective study, we analyzed 285 cases (81 unsuccessful VBAC-1, 204 successful VBAC-1) from San Juan City Hospital (Puerto Rico) between January 1, 2019, and December 31, 2020. We used odds ratios and model selection comparison to assess the impact of variables on successful VBAC-1, using a significance threshold of 95% CI. Model selection assessed binomial model combinations using a generalized linear approach to identify key risk factors. Results: Unsuccessful VBAC-1 (a repeat cesarean), was associated with diabetes (OR: 0.376, p = 0.086), hypertension (OR: 0.23, p = 0.006), and university-educated women (OR: 1.372, p = 0.711). High school-educated women had an OR of 3.966 (p = 0.105), while overweight women were 0.481 times more likely to have unsuccessful VBAC-1 (p = 0.041). Significant associations were not found with obesity (OR: 0.574, p = 0.122), underweight/normal (OR: 1.01, p = 0.810), or smoking (OR: 1.227, p = 0.990). Conclusion: Results revealed women with higher education levels, hypertension, or diabetes are less likely to have a successful VBAC-1. Understanding the complex interactions affecting these outcomes is aimed at establishing guidelines for healthcare professionals to conduct systematic risk/benefit assessments. This study lays a foundation for evidence-based practices and policies, offering initial insights into VBAC-1 success factors in Puerto Rico.

Vaginal Birth after a Cesarean Section at Good Shepherd Mission Hospital at Tshikaji in Democratic Republic of the Congo (DRC)

Background: The success rate of vaginal birth after cesarean section with a single cesarean scar is greater than 50%, the lack of the information about the safety of vaginal birth after cesarean delivery pushes most of obstetricians to increase the num ber of cesarean sections following a previous cesarean section. Guidelines for Vaginal birth after cesarean (VBAC) indicate that TOLAC offers women with no contraindications and one previous transverse low-segment cesarean. The objective of the current study was to study the outcome of trial of labour after caesarean section (TOLAC), the indications for emergency repeat cesarean section and to determine the maternal and fetal prognosis in vaginal birth after caesarian section (VBAC) at Tshikaji Mission Hospital. Patients, Material and Methods: This is a retrospective study of the records of 126 women were selected to undergo the TOLAC in the department of gynecology and obstetrics at the Tshikaji Mission Hospital over the period from January 1st to December 31st, 2021. The data on demography, antenatal care, labour and delivery and outcomes were collected from the maternity unit of this hospital. The data were analyzed using SPSS version 2.0. Results: The TOLAC in 126 studied women. The course of work allowed vaginal delivery 107 parturient women, a success rate of successful VBAC of 85% after the TOLAC. The repeat emergency cesarean section was necessary for delivery in 15% of cases for failed TOLAC. There was no maternal mortality, but we recorded one fetal death or 0.8% of perinatal mortality, 2 cases of cicatricial dehiscence, the incidence of 1.6%. Maternal morbidity after delivery on cicatricial uterus was dominated by postpartum hemorrhages, with 19 cases or 15.1% of cases. Cervical dilatation of more than 3 cm at the time of admission, the parity more than 3 and were the significant factors in favor of a successful VBAC. Birth weight of more than 3500 g, fetal distress and malpresentation were associated with a lower success rate of VBAC. The TOLAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas. Conclusion: Pregnancy on a cicatricial uterus represents a high-risk pregnancy. Trial of VBAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas. There is a significantly high vaginal birth after caesarian section (VBAC) success rate among selected women undergoing trial of scar in Tshikaji Hospital. TOLAC remains the option for childbirth in low resource settings as Kasai region in DRC. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remain the cornerstone to achieving high VBAC success rate.

Labor Onset, Oxytocin Use, and Epidural Anesthesia for Vaginal Birth after Cesarean Section and Associated Effects on Maternal and Neonatal Outcomes in a Tertiary Hospital in China： A Retrospective Study

Background：In the mainland of China, the trial of labor after cesarean section is still a relatively new technique. In this study, we aimed to investigate the effects of labor onset, oxytocin use, and epidural anesthesia on maternal and neonatal outcomes for vaginal birth after cesarean section （VBAC） in a tertiary hospital in China.Methods：This was a retrospective study carried out on 212 VBAC cases between January 2015 and June 2017 in Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Relevant data were acquired on a form, including maternal age, gravidity and parity, body mass index before pregnancy, weight gain during pregnancy, type of labor onset, gestational age, the use of oxytocin and epidural anesthesia, birth mode, the duration of labor, and neonatal weight. The factors affecting maternal and neonatal outcomes for cases involving VBAC, especially with regards to postpartum hemorrhage （PPH） and fetal distress, were evaluated by univariate analysis and multivariable logistic regression.Results：Data showed that 36 women （17.0%） had postpartum hemorrhage （PPH） and 51 cases （24.1%） featured fetal distress. Normal delivery took place for 163 infants （76.9%） while 49 infants （23.1%） underwent operative vaginal deliveries with forceps. There were 178 cases （84.0%） of spontaneous labor and 34 cases （16.0%） required induction. Oxytocin was used in 54 cases （25.5%） to strengthen uterine contraction, and 65 cases （30.7%） received epidural anesthesia. The rate of normal delivery in cases involving PPH was significantly lower than those without PPH （61.1% vs. 80.1%; χ2 = 6.07, P = 0.01）. Multivariate logistic analysis showed that the intrapartum administration of oxytocin （odds ratio [OR] = 2.47; 95% confidence interval [CI] = 1.07–5.74; P = 0.04） and birth mode （OR = 0.40; 95% CI = 0.18–0.87; P = 0.02） was significantly associated with PPH in VBAC cases. Operative vaginal delivery occurred more frequently in the group with fetal distress than the group without （49.0% vs. 14.9%, χ2 = 25.36, P = 0.00）. Multivariate logistic analysis also revealed that the duration of total labor （OR = 1.01; 95% CI = 1.00–1.03; P = 0.04） and the gestational week of delivery （OR = 1.08; 95% CI = 1.05–1.11; P = 0.00） were significantly associated with fetal distress in VBAC.Conclusions：The administration of oxytocin during labor and birth was identified as a protective factor for PPH in VBAC while birth mode was identified as a risk factor. Finally, the duration of total labor and the gestational week of delivery were identified as risk factors for fetal distress in cases of VBAC. This information might help obstetricians provide appropriate interventions during labor and birth for VBAC.

Profile of Pregnant Women and Success of the Uterine Test on a Uni or Bi-Scar Uterus at the Maternity Ward of Panzi Hospital, in the Democratic Republic of the Congo

Introduction: Trial of labor after a previous cesarean section (TOLAC) is a method that requires strict monitoring to decrease the cesarean section (CS) rate and improve the maternal and neonatal prognosis. The objective is to determine the profile and outcome of patients with one and two previous CSs who performed TOLAC at Panzi General Referral Hospital. Methodology: This is a cross-sectional study with a prospective collection of data of 111 patients with one and two previous CSs at Panzi Hospital from January 2021 to August 2022. Statistical Package for the Social Sciences SPSS version 23 software was used to analyze the collected data. The percentages of categorical variables were summarized in a frequency table. The mean or median with standard deviation was used to summarize quantitative variables. Results: The overall success rate of the TOLAC was 64%, with 63.8% following one previous CS and 64.3% following two CSs. The mean age of the patients was 27.09 years, with an age range of 25 - 34 years. They were mostly pauciparous (52.2%), married (88.3%), with a high school education (60.4%). The inter-delivery interval > 18 months was noted (64.1%) and overweight in 63.9%. More than three antenatal consultations were performed (58.6%). We found a mean gestational age of 38 (34 - 41) weeks. The perinatal mortality rate was 0.9%. However, we did not record any cases of maternal mortality during the study period. Conclusion: TOLAC after one and two previous CS is implemented in the maternity Unit of Panzi Hospital for well-selected patients. In addition, the success rate is similar after TOLAC with an acceptable maternal-neonatal prognosis.