Vaginal Birth After Cesarean

Department of Obstetrics and Gynecology, and the Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
Obstetrics and Gynecology (Impact Factor: 5.18). 06/2010; 115(6):1267-78. DOI: 10.1097/AOG.0b013e3181df925f
Source: PubMed


To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC).
Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts.
Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses.
We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery).
Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

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    • "In the wake of these guidelines, the cesarean delivery rate in the United States rose from 21% to 32.8% between 1996 and 2010 [7] and the vaginal birth after cesarean (VBAC) rate (per 100 women with a prior cesarean) dropped from 28% to 8% [8]. In response to the rising cesarean rate, the decline in VBAC, and the intense focus on a rare outcome (0.5% for uterine rupture among TOLAC women) [9], the National Institutes of Health (NIH) convened a Consensus Development Conference Panel in March 2010 to address key questions surrounding the practice of TOLAC. A systematic literature review by a panel of experts showed that for women with one or two prior low transverse uterine incisions, both TOLAC and elective repeat cesarean delivery carry important risks and benefits, which differ for the woman and the fetus [10]. "
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    ABSTRACT: In 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals. Between November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals’ TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding. All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital. In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.
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    ABSTRACT: Uterine rupture may be defined as a disruption of the uterine muscle extending to and involving the uterine serosa or disruption of the uterine muscle with extension to the bladder or broad ligament [1]. Uterine dehiscence is defined as disruption of the uterine muscle with intact uterine serosa [1]. Uterine rupture is associated with severe maternal and perinatal morbidity and mortality, and it remains one of the most catastrophic obstetrical emergencies. It has consequences not only for the index pregnancy but also, if it is possible to conserve the uterus, for further fertility and pregnancy outcomes. In the developed world, most cases occur in women with a uterine scar [2–4]. In less and least developed countries, cephalopelvic disproportion causing obstructed labor is the major cause of uterine rupture [5–7]. The prevalence of uterine rupture is likely to increase in the developed world reflecting increasing rates of cesarean section, and it continues to contribute significantly to maternal mortality among women giving birth in the developing world.
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    ABSTRACT: A novel circuit topologies family of the current mode AC/AC converter with high frequency ac link, based on flyback converter, are proposed. These circuit topologies which can transfer one unregulated sinusoidal voltage with high THD into another regulated constant frequency sinusoidal voltage with low THD, are constituted of input cycloconverter, high frequency storage transformer and output cycloconverter. The circuit topologies family include single four-quadrant power switch mode, push-pull mode, half-bridge mode, and full-bridge mode circuit. The single four-quadrant power switch mode and push-pull mode converter are suit for low input voltage fields, but the half-bridge mode and full-bridge mode converter are suit for high input voltage fields. The operational mode, steady principle and transient voltage feedback control strategy of the kind of converter are investigated. The output characteristic curve, its relation to internal resistance, and the design criterions for the key circuit parameters are given. The current mode AC/AC converters with high frequency ac link have the advantages such as simple topology, two-stage power conversions, bi-directional power flow, high frequency electrical isolation, good line current waveform, strong load adapting ability. The correction and advance of the converters are verified by the Pspice simulation and test results
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