Successful vaginal delivery after two caesarean sections. What are the chances?

Aim of study. To compare the outcome of attempted vaginal delivery after one and two cesarean sections. Material and methods. A prospective multicenter cohort study was carried out in the period from January 2013 to July 2019 in maternity hospitals No. 68 and No. 29 in Moscow. 334 patients were selected and divided into 2 groups: 1st — with one (1C, n=230) and 2nd — with two (2C, n=114) cesarean sections in patient’s history. The study included pregnant women with a cat-egorical disposition to deliver through vaginal delivery and refusal to deliver by caesarean section. Patients with a history of 2CS were provided with this opportunity only with a spontaneous onset of labor. Results. An attempt at vaginal delivery was more often excluded in the group with 2C than in the group with 1C (57.9% and 38%, respectively; χ2=11.88; p<0.001), and 62% of pregnant women with 1C and 42.51% — with 2C were given the attempt at vag-inal delivery. The frequency of intranatal CS in group 1 patients significantly exceeded that with a history of 2 CS (56.34% and 20.83%, respectively; χ2=18.14; p<0.001). Group 2 patients with intranatal cesarean section had a significantly higher body mass index (p<0.001) compared with that of group 1 patients. In patients with 1 CS who delivered with intranayal CS, a greater number of phenotypic markers of undifferentiated connective tissue dysplasia was revealed as compared with patients with 2 CS. Uterine rupture was diagnosed intraoperatively in only 4 patients with 1 CS, the minimum scar thickness according to the ultrasound scan was at least 2.3 mm, the maximum — 2.5 mm. The assessment of the condition of the newborn at the 1st and 5th minutes after delivery according to the Apgar scale in delivering women of all groups was higher than 8 points, including those operated on intranatal stage. This result in two groups of women with intranatal CS indicates timely diagnosis of a complicated course of labor (impaired contractile activity of the uterus, fetal distress, threatening rupture of the uterus), a change in delivery tactics in the interests of the mother or fetus. Conclusions. A history of two CSs does not preclude a successful vaginal delivery. In the presence of a history of 2CS, the chance of getting a refusal of an attempt to give birth through the vaginal birth canal is higher than with 1CS (odds ratio — OR 2.22; 95% confidence interval — CI 1.41—3.51), but when such an attempt is given — there is higher chance of success (OR 4.99; 95% CI 2.27—10.61). The success of labor is determined not by the number of CSs in history (one or two), but by the general clinical, ante-natal and intranatal characteristics of women. The success of an attempt at childbirth is determined by the full regeneration of the operated uterus, the ability of the woman’s body to ensure the effective start and maintenance of labor. The role of «non-obstet-ric» factors (body mass index for 2C, the number of markers of undifferentiated connective tissue dysplasia for 1C) is no less significant than the number of Cs in the anamnesis in the outcome of a subsequent attempt at vaginal delivery. Overweight in group 2 patients with intranatal CS necessitates correction in the pregravid period. © 2020 Global Research Online. All rights reserved

HISTOLOGICAL DETERMINANTS OF TRIAL OF LABOR AFTER CESAREAN DELIVERY

Objective: To identify histological determinants (uterine scar specifics) of trial of labor after cesarean section (CS). Materials and methods: This prospective study was conducted in 2013–2019 in Moscow maternity hospitals No. 68 and No. 29. The study included 272 women who wanted to have vaginal delivery but underwent CS. Of them, 182 underwent prelabor CS (vaginal delivery was either not considered or not attempted), and 90 had intrapartum CS (vaginal delivery was attempted but converted to CS). Results: Scar histology was correlated with a combination of highly diverse clinical, anamnestic, and maternal ultrasound factors. They included number of years lived, age of menarche, pre-pregnancy body mass index (BMI), number of phenotypic manifestations of undifferentiated connective tissue dysplasia, ordinal number of deliveries, interval between previous CS and present pregnancy, estimated fetal weight, amniotic fluid index, minimal scar thickness, right uterine artery resistance index before labor (Wilks' Lambda=0.006, p<0.001). In the attempted trial of labor, the predominance of fibrous tissue was associated with a lower age of menarche, higher prepregnancy BMI, and fifth-minute Apgar score. Conclusion: Myometrial reparation after CS characterizes the body as a whole. The histology of the uterine scar after CS combines prepregnancy, gestational, and intrapartum factors beyond those that were surgically determined. Myometrium histology is not an argument for post factum justifying or challenging attempted trial of labor: the prevalence of muscle tissue, muscle tissue with foci of fibrosis, or fibrous tissue is comparable. © A group of authors, 2022

Natural Childbirth after the Previous Caesarian Section is a Solved Problem

Тhe rapid increase in the frequency of сesarian section (CS) observed in recent years (up to 60% in some countries) is alarming and reduces the reproductive potential of the population. The operated uterus remains the main indication for CS (up to 40%). This is the factor which may allow reducing the frequency of the CS by subsequent delivering through the birth canal. A comparative analysis of maternal and neonatal outcomes enabled the authors to develop a two-stage delivery technology for patients with a caesarean scar, including the usage of the programmed delivery method. The presented algorithm confirmed the validity of vaginal delivery in such patients, and reduced the number of complications up to 4 times. Neonatal morbidity in children born through the birth canal in such patients was comparable to physiological birth