Vaginal birth after cesarean section in twin gestation

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins. STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences. RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.     

Shortcut of the photosynthetic electron transfer in a mutant lacking the reaction center-bound cytochrome subunit by gene disruption in a purple bacterium, Rubrivivax gelatinosus

OBJECTIVE: The purpose of our study was to determine the aetiological factors of uterine rupture during labour, and propose preventive measures. METHODS: This retrospective study was performed between February 1989 and July 1994, to analyze the cases of rupture uterus in relation to causes, age, parity, maternal and fetal mortality and morbidity. RESULTS: There were 37 cases of uterine rupture at our institutions. Obstructed labour by malpresentation and disproportion was the main cause. The presence of previous caesarean section scar, dysfunctional labour, injudicious use of uterine stimulant, were the other causes. There was no maternal death and the fetal loss was 17 (46%). CONCLUSIONS: The high incidence of uterine rupture is attributed to lack of prenatal care, labour in high risk patients outside the hospital because of declining economy, and more patients with 2 or more previously scarred uterus with many of them labouring more than 14 hours. Maternal and neonatal complications have remained very high in the developing countries.     

Monitoring intensive endurance training at moderate energetic demands using resting laboratory markers failed to recognize an early overtraining stage

Rupture of the gravid uterus remains one of the most disastrous complications of labour. Eighty cases of uterine rupture managed at Lagos University Teaching Hospital, Lagos over an eight year period were therefore reviewed to evaluate the characteristic of ruptured uterus in Lagos. The incidence of ruptured uterus was 5.01 per 1000 deliveries and unbooked patients accounted for 80%. Spontaneous rupture occurred in 73.8% while traumatic rupture was responsible for 26.3%. Diagnosis was not made in 25% of the cases until surgery. Poor antenatal care, foeto-pelvic disproportion, previous Caesarean section scar, grand-multiparity were major aetiological factors. Repair of the rupture with or without sterilization was carried out in 70% of the cases. Booking status and the type of surgical procedure did not significantly affect the maternal outcome. Ruptured uterus was responsible for 16.9% of the total maternal deaths in the period of review. The commonest cause of death in this series was hypovolaemic shock (64.3%). The overall perinatal mortality was 86.3% but the registered patients fared better. It was concluded that the incidence of ruptured uterus is still very high and probably on the increase in Lagos. Suggestions are made to improve the situation since the identified aetiological factors are largely preventable.     

Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE: Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN: A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION: A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.     

Cesarean hysterectomy im modern obstetrical practice from 1968 to 1993

A retrospective study of cesarean hysterectomies at the Department of Obstetrics and Gynecology in Novi Sad was conducted for the period 1968-1993. There were 129,127 deliveries, whereas cesarean section was performed in 10,485 (8.12%) cases. There were 55 cesarean hysterectomies (0.042%), while in 0.52% they were performed during cesarean section. Elective hysterectomy was performed in 7 (12.73%) cases because of neoplastic process and uterine myoma, while in 48 (87.27%) cases it was performed for heavy bleeding. Most often bleeding occurred due to complications of placenta previa, uteroplacental apoplexy, premature placental ablation, uterine rupture and atony. Total hysterectomy was performed in 30 (54.54%) cases and subtotal hysterectomy in 25 (45.45%) cases. Bilateral adnexectomy was performed in 3 (5.45%) cases. Urinary bladder injury occurred in 4 (7.27%) patients, wound infection in 11 (20.00%) patients, urinary infection in 3 (5.45%) and pelvic peritonitis in 1 (1.82%) patient. One maternal death (1.82%) occurred due to DIC (disseminated intravascular coagulation). Out of 57 delivered newborns 20 (35.10%) died in the perinatal period. There were 13 stillbirths (22.80%), whereas 7 newborns (12.30%) died in the early neonatal period due to prematurity and RDS (respiratory distress syndrome).     

Endoscopic assessment of the integrity of the postcesarean uterine wall before a trial of labor. Transcervical Endoscopy Registry

Endoscopic examination of the uterine scar site was performed on 52 women prior to a trial of labor after a previous cesarean section. A sterilized intraoperative fiberscope was introduced into the amniotic cavity after rupture of the fetal membranes under constant visual guidance. In 45 cases the site of the previous incision appeared unremarkable, and a scar from the previous surgery could not be identified. "Compromised" scars were detected in three patients, and scars were identified as vertical in four patients with no record of the type of uterine incision used for the previous surgery. Endoscopic data were confirmed postpartum in all cases. This approach seems beneficial in selected cases.     

Prenatal diagnosis of congenital toxoplasmosis transmitted by an immunocompetent woman infected before conception. Reims Toxoplasmosis Group

OBJECTIVE: To determine the outcome of subsequent labour in primiparous women after a caesarean section for delay in descent in the second stage of labour in cephalic presentations with or without trial of instrumental vaginal delivery. DESIGN: Retrospective follow up study. SETTING: Medical Centre Leeuwarden, The Netherlands. PARTICIPANTS: All primiparous parturients who delivered after prior caesarean section during the second stage of labour in the period 19861998. METHODS: Data concerning the outcome of the first subsequent delivery were gathered from delivery notes and patients charts. The group of women was subdivided into those with or without trial of instrumental vaginal delivery during the previous labour. RESULTS: Of 132 women, 29 (22%) underwent a planned repeat caesarean section. Of the 103 women who were allowed a trial of labour, 82 (80%) were successful in having a vaginal delivery, and 21 (20%) had a second caesarean section. Of the 74 women with a failed trial of instrumental delivery during the previous labour, 19 had a planned repeat caesarean section and 41 of the remaining 55 (75%) had a successful trial of labour. CONCLUSIONS: In women with a cephalic presentation who had an arrest of descent in the second stage of labour during their first delivery, the chances of vaginal delivery in their next pregnancy are high, even after a failed instrumented vaginal delivery, and a trial of labour can usually be pursued.     

Hypertensive disorders of pregnancy and maternal and foetal outcome: a case controlled study

A case controlled prospective study of 250 cases of hypertension complicating pregnancy (study group) and 400 normal pregnant women (control group) was carried out to determine the effect of hypertension on maternal and foetal outcome. Pregnancy induced hypertension was present in 96% cases and chronic hypertension in 4% cases. Preterm delivery (28.8% versus 3%), labour induction rate (52.8% versus 3.25%), caesarean section rate (14.8% versus 3.5%), stillbirth rate (4.8% versus 0.25%) and overall perinatal mortality rate (14.8% versus 1%) were higher in study group compared to controls. In study group (40%) babies required special nursery care compared to controls (6.75%). From these results it can be concluded that maternal hypertension is associated with adverse pregnancy outcome.     

Reduced nasal airway resistance following uvulopalatoplasty

OBJECTIVE: To determine whether a low transverse cesarean closure method in one or two layers affects subsequent pregnancy outcome. METHODS: In a prospective trial reported previously, 906 women were assigned randomly to either one- or two-layer uterine closure. One hundred sixty-four women had a subsequent pregnancy and delivery (18 weeks' gestation or longer) at our institution. Maternal and neonatal outcomes were ascertained by medical chart review and compared between the one- and two-layer closure groups. RESULTS: Of the 164 subsequent deliveries, 83 had previous closure in one layer, whereas 81 had involved a two-layer closure. The demographic characteristics of these two groups were similar. Nineteen women (12%) underwent elective repeat cesareans without labor, and the remaining 145 experienced labor. Length of labor, mode of delivery, duration of hospital stay, gestation at delivery, and the incidences of uterine scar dehiscence, chorioamnionitis, postpartum metritis, hemorrhage, transfusion, and abnormal placentation did not differ significantly between the groups. Selected neonatal outcomes, including Apgar scores, cord pH, birth weight, and perinatal death, were similar between groups as well. CONCLUSIONS: These findings suggest that the type of low transverse cesarean closure does not significantly affect the outcome of the next pregnancy.     

Parametric changes in response equilibrium during an intra-cranial self stimulation (ICSS) task: can reward value be assessed independently of absolute threshold?

A prospective randomized study was conducted to measure the serial thickness of the lower uterine segment (LUS) by transvaginal ultrasonography in a control group of 80 women having no history of uterine surgery and in a study group of 43 women having a history of previous cesarean section (C/S). In the study group, more than 2 mm of thickness of the LUS was considered as good healing and less than 2 mm of thickness as poor healing. After serial sonographic examination, the women with good healing were given trial for labor unless an obstetrical indication for C/S existed. The appearance of the LUS during surgery was compared with antenatal ultrasonographic assessment by direct inspection. Twenty two (79%) of 28 women with a well healed scar had trial labor with the result that 46% had a successful vaginal birth without any uterine rupture of dehiscence. Eight women with poor healing all had elective C/S. Seven women with a 2 mm LUS thickness were individually categorized for delivery mode. Two of those women delivered vaginally. The LUS was found to be thin to translucent in these later two groups. Two mm or less as a criterion for poor healing had the sensitivity and specificity of 86.7% and 100% respectively. The positive predictive value was 100% and the negative predictive value was 86.7%. Ultrasonographic evaluation is effective in predicting the quality of a uterine scar and in differentiating the risk group of probable uterine rupture from the non risk group.     

Estimation of perinatal mortalities in the world's countries from maternal mortalities

Perinatal mortality was estimated by the regression equation log10 Y = 0.7826log10X + 0.08, obtained by perinatal mortality (Y) and maternal mortality (X) in Japan in 1960-1990. The error rate was approximately 9% in the estimation. Unpublished Japanese perinatal mortality in 1899-1947 was estimated from maternal mortality by using the equation, and appropriate results were obtained. Perinatal mortalities of the world's countries were estimated from their maternal mortalities listed in UNICEF reports with use of the above equation. Two peaks were noted in the country number distribution at 0-19 and 120-140 of estimated perinatal mortality. The mortality was 20-99 in 43% of 111 countries analyzed and 100 or more in 25%. The results suggest that further efforts should be made for the improvement of worldwide maternal and child health.     

Perinatal mortality in breech presentation sibships

OBJECTIVE: To compare perinatal mortality in breech presentation delivered vaginally and by cesarean in individual births and in sibships. METHODS: A national, population registry-based study, 1967-1994, was conducted, with maternal record linkage of sibships, comprising the first to the third birth of a mother. The main outcome was perinatal mortality. Odds ratios of perinatal mortality were calculated and adjusted by logistic regression analysis. RESULTS: The overall relative perinatal mortality was 4.3 (95% confidence interval [CI] 4.1, 4.5) in breech compared with nonbreech presentation and 5.4 (95% CI 4.7, 6.2) in vaginal compared with cesarean delivery. The relative perinatal mortality in breech compared with nonbreech presentation was lowest in birth order one compared with birth orders two and three. In breech vaginal delivery compared with cesarean delivery, the opposite effect of birth order was found. The highest perinatal mortality was found in a current breech presentation of a sibship with no previous breech births. In birth subsequent to breech births, perinatal mortality was more or less independent of current presentation, without respect to delivery method. The increased perinatal mortality in breech presentation is explained partly by its association with other risk factors for perinatal death. CONCLUSION: Women with recurring breech presentation represent a lower risk of adverse perinatal outcome. This might be explained by a biologic mechanism or by increased quality of antenatal care. An increased mortality in subsequent nonbreech siblings after a breech presentation was surprising.     

Introduction to microscopic research of silver halides and related dispersed systems

> Objective: To establish whether uterine artery flow velocity waveforms in the second trimester are associated with adverse pregnancy outcome in women with a poor obstetric history. Methods: We reviewed the obstetric case notes of 50 women with a poor obstetric history in previous pregnancies in whom uterine artery flow velocity waveforms had been obtained at 18 weeks gestation. Results: In this population 40% had an adverse pregnancy outcome (preeclampsia, pregnancy-induced hypertension, preterm delivery, birthweight <10th percentile or perinatal death). Preeclampsia, perinatal death, and preterm delivery were all significantly associated with abnormal uterine artery waveforms at 18 weeks. Conclusions: Assessment of uterine artery flow velocity waveforms at 18 weeks gestation shows promise as a screening test in the high risk obstetric population. The technique requires formal evaluation in a prospective, double blinded study.     

The problem of Caesarean section (author's transl)

The Caesarean sections at the Universit?ts-Frauenklinik Innsbruck from January 1st, 1969 to December 31st, 1974 have been surveyed. Related to the total number of 12 579 deliveries 627 Caesarean sections have been performed. Two 3-year-intervals have been compared: 1969-1971 (group I) without and 1972-1974 (group II) with modern practices of prenatal supervision. There was a high significant increase of the section rate in group II (5,8% versus 4,1% which has been related to the increasing number of mainly fetal indications. The maternal morbidity didn't rise with the increasing section rate. A significant decrease in total infant mortality rate and mortality rate at vaginal deliveries has been found with the increasing incidence of Caesarean sections; whereas the number of depressed infants (Apgar score less than 7) was increased in group II. The reasons therefore have been discussed. The rise of the number of Caesarean sections in group II performed because of breech presentation (14,2% versus 6,2%) was correspondent with a statistically significant decrease in the mortality rate from 11,7 to 4,1%. A Caesarean section rate between 7% and 10% seems to be the limit at least in our hospital--the total infant mortality rate cannot be reduced by further increasing the section frequency: the infant mortality rate possibly could be lowered by a better and more wide spread prenatal care especially by taking more care for prematurity and by intensifying the perinatal period.     

The obstetric implications of teenage pregnancy

A retrospective review was performed on the obstetric outcome of teenage pregnancies delivered in 1 year in a tertiary centre. The results were compared with the rest of the obstetric population in the same hospital in the same year. The teenage mothers (n = 194) had increased incidence of sexually transmitted diseases (5.2 versus 1.0%, P < 0.05), and preterm labour (13.0 versus 7.0%, P < 0.01), but decreased incidence of gestational glucose intolerance (3.1 versus 11.4%, P < 0.001), when compared with the non-teenage mothers (n = 4914). There was no difference in the types of labour, while the incidence of Caesarean section was lower (4.1 versus 12.6%, P < 0.001) in the teenage mothers. Although the incidence of low birthweight was higher in the teenage mothers (13.5 versus 6.5%, P < 0.001), there was no significant difference in the mean birthweight, gestation at delivery, incidence of total preterm delivery, or perinatal mortality or morbidity. The results indicate that the major risk associated with teenage pregnancies is preterm labour, but the perinatal outcome is favourable. The good results accomplished in our centre could be attributed to the free and readily available prenatal care and the quality of support from the family or welfare agencies that are involved with the care of teenage mothers.     

Symphysiotomy or caesarean section after failed trial of assisted delivery

The perinatal and maternal outcomes of 65 symphysiotomies and 108 caesarean sections carried out after failed trial of assisted delivery at the Port Moresby General Hospital between 1988 and 1994 were retrospectively analyzed. There were no significant differences in perinatal outcomes between the treatment groups. There were no maternal deaths in either group. Mothers who had symphysiotomy had a longer postoperative stay in hospital but fewer complications requiring further surgery. There are many advantages of symphysiotomy, particularly in developing countries, following a failed trial of assisted delivery, provided the indications for it are strictly met. Obstetricians experienced in the technique are able to apply it at the optimal time, with long-term benefit to their patients, who thereby avoid the risks of pregnancy subsequent to caesarean section.     

Programmed childbirth - methods and results (author's transl)

Reported are 304 patients with whom programmed childbirths were introduced, between 1976 and 1978. A control group was made up of 100 women in labour who had been hospitalised for spontaneous onset of labour but then given slow drip oxytocin infusions for secondary uterine inertia. The parameters tested (time of labour, FHF behaviour, pH of umbilical artery, Apgar score, weight, length, and perinatal mortality) did not reveal any aggravated risk to mother and child. Programmed childbirth may be recommended as another important preventive step towards lower infantile morbidity.     

Study of the auriculo-ventricular conduction by means of the recording of bundle of His in deep hypothermal conditions

In a retrospective review of 440 pregnancies occurring in women over the age of 40, increased frequencies of both perinatal and maternal complications were noted. The perinatal mortality rate of the study group was three times greater than that of the general obstetric population. There were increased incidences of both low and high birthweight infants. Neonatal morbidity was increased. Congenital abnormalities were noted in 12 infants, including 2 infants with cytogenetic abnormalities. Hypertensive disorders complicated one-third of the pregnancies. Diabetes mellitus and abruptio placentae occurred with increased frequency. Cesarean section was required in 12.2% of the deliveries.