Abstract Introduction Chris Hani Baragwanath (CHB) hospital has 20 000 deliveries per annum, with 25% by caesarean section (CS). Therefore, vaginal birth after caesarean section (VBAC) is an important delivery option. We questioned the reasons for the low VBAC success following trial of labour (TOL). The primary objective was to determine the proportion of eligible patients attempting TOL and the VBAC success rate. Secondary objectives were to establish reasons for failed VBAC, predictive factors for VBAC, and maternal and neonatal morbidity and mortality. Methodology A retrospective descriptive study by record review, analysing demographic, obstetric and delivery outcome variables of women with one prior CS in a subsequent pregnancy. Results From the 340 patients eligible for VBAC, 287 (84.4%) attempted TOL and 53 (15.6%) had an elective repeat caesarean section (ERCS). VBAC success was 51.6% (148/287). Prelabour rupture of membranes and prolonged latent phase of labour resulted in 40% of failed VBAC. Successful VBAC was associated with a higher parity, lower birth weight and lower gestation (p<0.001). Positive predictors of successful VBAC were previous vaginal birth (p=0.004), previous VBAC (p=0.038), previous CS for malpresentation (p=0.012), birth weight <3500g (p=0.003), and gestation ≤ 39 weeks (p<0.001). Negative predictors were previous CS for cephalopelvic disproportion (p=0.003) and women with no prior vaginal deliveries (p<0.001). There was no maternal mortality. Complications however, included 2 uterine ruptures, 2 uterine dehiscences, 4 hysterectomies, and one intrapartum fetal death. Adverse maternal outcomes were increased with TOL compared to ERCS (p=0.038), and more so with failed compared to successful VBAC (p=0.002). Adverse neonatal outcomes were also increased with TOL compared to ERCS (p=0.048), however there was no difference in neonatal outcomes between failed and successful VBAC (p=0.420). Conclusion VBAC remains a viable option for patients with one prior CS in this setting, despite a lower VBAC success than developed countries. Failed VBAC due to prelabour rupture of membranes and prolonged latent phase of labour remains a problem.

For most of the 20th century, the saying “once a cesarean, always a cesarean” was a rule in the United States. Today, the National Institutes of Health (NIH) opposes the dictum and urges women to consider trial of labor after cesarean (TOLAC). However, the factors that lead to a successful outcome remain unclear, as research continues to be conducted in hopes of creating a predictive model for vaginal birth after cesarean (VBAC) success. The NIH’s request for more research in this area of obstetrics led to this retrospective cohort study of all TOLACs at Marin General Hospital (MGH) from 2000-2013. All labor trials were studied for patient demographics, details of labor, maternal and neonatal morbidities, insurance, and provider type. After confirming the quality of the data, verifying inclusion criteria and ignoring cases with missing data, a data set of 745 TOLACs with 13 explanatory variables of interest was prepared. A forward stepwise (Likelihood Ratio) binary logistic regression was run in IBM® SPSS® Statistics in order to create a model that could determine which variables were most predictive of delivery outcome in TOLAC patients. Ultimately, seven variables were predictive and were included in the model. Of the seven, the most predictive variable in determining VBAC success was provider type. The model concluded that a woman’s odds of having a successful VBAC were almost four times greater if she began her delivery with a certified nurse midwife, than if she began her deliver with a physician (odds ratio 0.27, 95% CI 0.17-0.44; < 0.01). The results from this study mimic the results of other models, and introduce labor support as a key factor in predicting VBAC success.

This study was designed to complement local audit data by examining the lived experience of women who elected to attempt a vaginal birth following a previous caesarean delivery. The study sought to determine whether or not women were able to exercise informed choice and to explore how they made decisions about the method of delivery and how they interpreted their experiences following the birth. Background.¿ The rising operative birth rate in the UK concerns both obstetricians and midwives. Although the popular press has characterized birth by caesarean section as the socialites' choice, in reality, maternal choice is only one factor in determining the method of birth. However, in considering the next delivery following a caesarean section, maternal choice may be a significant indicator. While accepted current UK practice favours vaginal birth after caesarean (VBAC) in line with the research evidence indicating reduced maternal morbidity, lower costs and satisfactory neonatal outcomes, Lavender et al. point out that partnership in choice has emerged as a key factor in the decision-making process over the past few decades. Chaung and Jenders explored the issue of choice in an earlier study and concluded that the best method of subsequent delivery, following a caesarean birth, is dependent on a woman's preference. Design and methodology.¿ Using a phenomenological approach enabled a holistic exploration of women's lived experiences of vaginal birth after the caesarean section. Results.¿ This was a qualitative study and, as such, the findings are not transferable to women in general. However, the results confirmed the importance of informed choice and raised some interesting issues meriting the further exploration. Conclusions.¿ Informed choice is the key to effective women-centred care. Women must have access to non-biased evidence-based information in order to engage in a collaborative partnership of equals with midwives and obstetricians. Relevance to clinical practice.¿ This study is relevant to clinical practice as it highlights the importance of informed choice and reminds practitioners that, for women, psycho-social implications may supersede their physical concerns about birth.

Background: An increasing proportion of Canadian women are experiencing a Caesarean section (CS) and a subsequent repeat CS. While CS can be necessary and lifesaving for mothers and their infants in some situations, it is also associated with greater morbidity risks to women and infants than vaginal birth. Clinical practice guidelines recommend the involvement of pregnant women in making decisions about mode of birth and shared decision making improves the informed consent process. This research examines the factors that influence mode of birth after a previous CS. Methods: Two cross sectional descriptive studies and a prospective pre-post cohort study with control were conducted to investigate the high use of repeat CS at the levels of health care providers, maternity care clients, and the organizational structure of a birthing unit. 1. Interviews and surveys with obstetricians, family physicians, midwives, and nurses were conducted to investigate the attitudes, values, and perceptions that guide their care practices for clients with a previous CS. The specific research question was: What are the factors that influence the practices of maternity care providers (obstetricians, family physicians, midwives, and nurses) regarding mode of birth after a previous CS? Data was analyzed using iterative deductive and inductive coding. 2. Interviews and surveys were conducted during pregnancy and after giving birth with healthy women who have had a previous CS to explore their decision making processes regarding mode of birth after a previous CS. The specific research question was: How do women eligible for a VBAC make decisions about their upcoming mode of birth? A thematic framework approach was used for data analysis. 3. Data from the Better Outcomes Registry and Network (“BORN”) Ontario was analyzed to examine the effectiveness of a hospital based strategy on overall proportions of CS and within Robson groups 1, 2a, and 5. The Caesarean section reduction (CARE) strategy includes interventions that target health care providers, pregnant women, and hospital policies. Results: 1. Maternity care providers would recommend a vaginal birth after CS (VBAC) for healthy pregnant women with a previous CS. They had different perceptions of the safety of birth to the health of women and infants and different approaches to engage in decision making during consultation. Providers believed women make their decision about mode of birth outside of the clinical consultation and often prior to their subsequent pregnancy. 2. The main themes that influenced the decisions of maternity care clients about mode of birth were mothers’ experiential reasoning regarding mode of birth and recovery, experiential knowledge from significant others, scheduling of CS regardless of the mode of birth decision, rating and prioritizing risks, fear of risks, and decisional conflict. When women discussed the factors that impacted their decisions about mode of birth six to eight weeks after they had given birth, the main themes were the recovery experience and fear related to the mode of birth. A lack of time during consultation was identified as a major barrier inhibiting shared decision making, specifically among clients of obstetricians. Other barriers included reliance on routine obstetric practices that are not evidence based. 3. Proportions of CS decreased at the intervention hospital by 3.9% (p=0.0006), from 30.3% (n=964) in 2009/10 to 26.4% (n=803) in 2012/13. During the same time frame, proportions of CS in the control group were stable with 28.1% (n=23,694) in 2009/10 and 28.2% (n=23,683) in 2012/13. Within the Robson classification system, the proportions of repeat CS among all low risk women with a previous CS decreased at the intervention hospital by 5.6% (p=0.0044) from 84.3% to 78.7%. In the control group, also fewer women had a repeat CS over the study period, but the decrease was smaller with 3.9% (p<0.0001) from 84.5% to 80.6%. Conclusion: A true shared decision making process addresses the power imbalance between providers and women through an incorporation of the clinical expertise of providers and the experiential expertise of pregnant women before reaching a decision about mode of birth. The use of routine obstetric practices that are not evidence based inhibited women to make decisions about their mode of birth. The introduction of the CARE strategy to a hospital birthing unit was associated with improvements in proportions of CS and VBAC among low risk women.

No description available.

Yes / Aims and objectives.  This study was designed to complement local audit data by examining the lived experience of women who elected to attempt a vaginal birth following a previous caesarean delivery. The study sought to determine whether or not women were able to exercise informed choice and to explore how they made decisions about the method of delivery and how they interpreted their experiences following the birth. .  The rising operative birth rate in the UK concerns both obstetricians and midwives. Although the popular press has characterized birth by caesarean section as the socialites’ choice, in reality, maternal choice is only one factor in determining the method of birth. However, in considering the next delivery following a caesarean section, maternal choice may be a significant indicator. While accepted current UK practice favours vaginal birth after caesarean (VBAC) in line with the research evidence indicating reduced maternal morbidity, lower costs and satisfactory neonatal outcomes, Lavender et al. point out that partnership in choice has emerged as a key factor in the decision-making process over the past few decades. Chaung and Jenders explored the issue of choice in an earlier study and concluded that the best method of subsequent delivery, following a caesarean birth, is dependent on a woman's preference. Design and methodology.  Using a phenomenological approach enabled a holistic exploration of women's lived experiences of vaginal birth after the caesarean section. Results.  This was a qualitative study and, as such, the findings are not transferable to women in general. However, the results confirmed the importance of informed choice and raised some interesting issues meriting the further exploration. Conclusions.  Informed choice is the key to effective women-centred care. Women must have access to non-biased evidence-based information in order to engage in a collaborative partnership of equals with midwives and obstetricians. Relevance to clinical practice.  This study is relevant to clinical practice as it highlights the importance of informed choice and reminds practitioners that, for women, psycho-social implications may supersede their physical concerns about birth.