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ABSTRACT OBJECTIVE To descriptively analyze Brazilian parturient women who underwent previous cesarean section and point out the factors associated with Vaginal Birth After Cesarean (VBAC) in Brazil. METHODS The study used data from women with one, two, or three or more cesarean sections from the survey Nascer no Brasil (Birth in Brazil). Differences between categories were assessed through the chi-square test (χ2). Variables with significant differences (p < 0.05) were incorporated into logistic regression. FINDINGS Out of the total of 23,894 women, 20.9% had undergone a previous cesarean section. The majority (85.1%) underwent another cesarean section, with 75.5% occurring before the onset of labor. The rate of Vaginal Birth After Cesarean (VBAC) was 14.9%, with a success rate of 60.8%. Women who underwent three or more cesarean sections displayed greater social vulnerability. The chances of VBAC were higher among those who opted for a vaginal birth towards the end of gestation, had a prior vaginal birth, underwent labor induction, were admitted with over 4 centimeters of dilation, and without partner. Receiving care from the private health care system, having two or more prior cesarean sections, obstetric complications, and deciding on cesarean delivery late in gestation reduced the chances of VBAC. Age group, educational background, prenatal care adequacy, and the reason for the previous cesarean section did not result in significant differences. CONCLUSION The majority of women who underwent a previous cesarean section in Brazil are directed towards another surgery, and a higher number of cesarean sections is linked to greater social inequality. Factors associated with VBAC included choosing vaginal birth towards the end of gestation, having had a previous vaginal birth, higher cervical dilation upon admission, induction, assistance from the public health care system, absence of obstetric complications, and without a partner. Efforts to promote VBAC are necessary to reduce overall cesarean rates and their repercussions on maternal and child health.

RESUMO OBJETIVO Analisar descritivamente as parturientes brasileiras com cesariana anterior e apontar os fatores associados ao parto vaginal após cesárea (Vaginal Birht After Cesarean- VBAC) no Brasil. MÉTODOS Foram utilizados dados de mulheres com uma, duas ou três e mais cesáreas da pesquisa Nascer no Brasil. As diferenças entre categorias foram avaliadas pelo teste de qui-quadrado (χ2). As variáveis que apresentaram diferença significativa (< 0,05) foram incluídas em regressão logística. RESULTADOS Do total de 23.894 mulheres, 20,9% tinham cesárea anterior. A maior parte (85,1%) foi submetida a outra cesárea, 75,5% antes do início do trabalho de parto. A porcentagem de VBAC foi de 14,9%, uma taxa de sucesso de 60,8%. Mulheres com três cesáreas ou mais apresentaram maior vulnerabilidade social. As chances de VBAC foram maiores entre aquelas decididas pelo parto vaginal no fim da gestação, com parto vaginal anterior, indução de parto, admitidas com mais de 4 centímetros de dilatação e sem companheiro. Assistência no sistema privado, ter duas cesáreas ou mais, complicações obstétricas e decisão por cesariana no final da gestação diminuíram as chances de VBAC. Faixa etária, escolaridade, adequação do pré-natal e razão da cesárea anterior não apresentaram diferença significativa. CONCLUSÃO A maior parte das mulheres com cesárea anterior no Brasil é encaminhada para uma nova cirurgia, e o maior número de cesáreas está associado à maior iniquidade social. Os fatores associados ao VBAC foram decisão pelo parto vaginal no fim da gestação, parto vaginal anterior, maior dilatação cervical na internação, indução, atendimento no sistema público de saúde, ausência de complicações obstétricas e ausência de companheiro. São necessárias ações de estímulo ao VBAC, visando reduzir taxas globais de cesarianas e suas consequências para a saúde materno-infantil.

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Abstract Objectives: describe mothers, pregnancies and newborns' characteristics according to the type of childbirth history and to analyze repeated cesarean section (RCS) and vaginal delivery after cesarean section (VBACS), in São Paulo State in 2012. Methods: data are from the Sistema de Informações sobre Nascidos Vivos (Live Birth Information Systems). To find the RCS's group, the current type of childbirth equal to cesarean section was selected and from these all the previous cesareans. To identify the VBACS's group all live birth with current vaginal delivery were selected and from these all previous cesareans. Mothers with a history of RCS and VBACS were analyzed according to the characteristics of the pregnancy, newborn and the childbirth hospital. Results: 273,329 mothers of live birth with at least one previous child were studied. 43% of these were born of RCS and 7.4% of VBACS. Mothers who underwent RCS are older and higher educated and their newborns presented a lower incidence of low birth weight. Early term was the most frequent rating for gestational age born of RCS. Live births were of VBACS and had greater proportions of late term. The RCS was more common in hospitals not affiliated with the Sistema Único de Saúde (SUS) (Public Health System) (44.1%). Conclusion: the high RCS's rates, especially in the private sector, highlight the necessity of improvements in childbirth care model in São Paulo.

Resumo Objetivos: descrever características das mães, da gestação e do recém-nascido, segundo histórico de tipo de parto, analisando repetição de cesárea (RC) e parto vaginal após cesárea (PVAC), no Estado de São Paulo, em 2012. Métodos: os dados são provenientes do Sistema de Informações sobre Nascidos Vivos. Para encontrar o conjunto RC, selecionou-se o tipo de parto atual igual a cesárea e destes buscou-se todos com cesárea anterior. Para identificar o grupo PVAC, selecionou-se os recém-nascido com parto atual vaginal e destes buscou-se todos com cesárea anterior. Foram analisadas mães com história de RC e PVAC, segundo características da gestação, do recémnascido e hospital do parto. Resultados: estudou-se 273.329 nascidos vivos de mães com pelo menos um filho anterior. Destes, 43% nasceram por RC e 7,4% por PVAC. As mães que realizaram RC são mais velhas e mais escolarizadas, seus recém-nascidos apresentaram menor proporção de baixo peso ao nascer. Termo precoce foi a mais frequente idade gestacional dos que nasceram por RC. Os recém-nascidos por PVAC apresentaram maiores proporções de termo tardio. RC foi mais frequente nos hospitais sem vínculo com o Sistema Único de Saúde (44,1%). Conclusão: as altas taxas de RC, principalmente no setor privado, evidenciam necessidade de melhoras no modelo de atenção ao parto em São Paulo.

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OBJECTIVES: Our objectives were to analyze how pregnancy outcomes varied by cesarean birth as compared to vaginal birth across varying interpregnancy intervals (IPI) and determine if IPI modified mode of birth. METHODS: This secondary analysis used data from a prospective registry of home and hospital births in Chimaltenango, Guatemala from January 2017 through April 2020, through the Global Network for Women's and Children's Health Research. Bivariate comparisons and multivariable logistic regression were used to answer our study question, and the data was analyzed with STATA software v.15.1. RESULTS: Of 26,465 Guatemalan women enrolled in the registry, 2794 (10.6%) had a history of prior cesarean. 560 (20.1%) women delivered by vaginal birth after cesarean with the remaining 2,233 (79.9%) delivered by repeat cesarean. Repeat cesarean reduced the risk of needing a dilation and curettage compared to vaginal birth after cesarean, but this association did not vary by IPI, all p-values > p = 0.05. Repeat cesarean delivery, as compared to vaginal birth after cesarean, significantly reduced the likelihood a woman breastfeeding within one hour of birth (AOR ranged from 0.009 to 0.10), but IPI was not associated with the outcome. Regarding stillbirth, repeat cesarean birth reduced the likelihood of stillbirth as compared to vaginal birth (AOR 0.2), but again IPI was not associated with the outcome. CONCLUSION: Outcomes by mode of delivery among a Guatemalan cohort of women with a history of prior cesarean birth do not vary by IPI.

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Abstract Objective To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods. Methods Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil. Results The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates. Conclusion The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allowsmonitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

Resumo Objetivo Analisar e comparar a frequência de partos cesáreos e vaginais através da classificação de Robson em gestantes atendidas em um hospital terciário em dois períodos distintos. Métodos Estudo transversal retrospectivo de registros de nascimento, compreendendo 4.010 mulheres, realizado de janeiro de 2014 a dezembro de 2015 no único hospital público de referência regional para atendimento de gestações de alto risco, localizado no sul do Brasil. A via de parto foi avaliada e as mulheres foram classificadas de acordo com a Classificação de Robson. Resultados A taxa geral de cesariana foi de 57,5% e a principal indicação foi a existência de cicatriz uterina por cesariana prévia. Quando aplicada a Classificação de Robson, os grupos mais frequentes foram o 5 (26,3%) e o 10 (17,4%). No ano de 2015, ocorreu um aumento significativo da frequência dos grupos 1 e 3 (p < 0,001), quando comparado ao ano anterior, resultando em aumento do número de partos vaginais (p < 0,0001) e redução das taxas de cesariana. Conclusão A Classificação de Robson mostra ser uma ferramenta útil para identificar o perfil das parturientes e os grupos com maior risco de cesariana em diferentes períodos em um mesmo serviço. Desta forma, permitemonitorar de forma dinâmica as indicações e vias de parto e desenvolver ações para redução das taxas de cesariana conforme as características das gestantes atendidas.

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OBJECTIVE: To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods. METHODS: Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil. RESULTS: The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates. CONCLUSION: The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allows monitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

OBJETIVO: Analisar e comparar a frequência de partos cesáreos e vaginais através da classificação de Robson em gestantes atendidas em um hospital terciário em dois períodos distintos. MéTODOS: Estudo transversal retrospectivo de registros de nascimento, compreendendo 4.010 mulheres, realizado de janeiro de 2014 a dezembro de 2015 no único hospital público de referência regional para atendimento de gestações de alto risco, localizado no sul do Brasil. A via de parto foi avaliada e as mulheres foram classificadas de acordo com a Classificação de Robson. RESULTADOS: A taxa geral de cesariana foi de 57,5% e a principal indicação foi a existência de cicatriz uterina por cesariana prévia. Quando aplicada a Classificação de Robson, os grupos mais frequentes foram o 5 (26,3%) e o 10 (17,4%). No ano de 2015, ocorreu um aumento significativo da frequência dos grupos 1 e 3 (p < 0,001), quando comparado ao ano anterior, resultando em aumento do número de partos vaginais (p < 0,0001) e redução das taxas de cesariana. CONCLUSãO: A Classificação de Robson mostra ser uma ferramenta útil para identificar o perfil das parturientes e os grupos com maior risco de cesariana em diferentes períodos em um mesmo serviço. Desta forma, permite monitorar de forma dinâmica as indicações e vias de parto e desenvolver ações para redução das taxas de cesariana conforme as características das gestantes atendidas.

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Objetivo: estimar a prevalência de parto vaginal após cesárea em uma maternidade de alto risco e identificar as complicações maternas e neonatais. Método: trata-se de um estudo transversal, quantitativo e retrospectivo, realizado com 44 mulheres que tiveram parto normal com cesárea prévia, por meio da análise dos prontuários realizou-se a análise descritiva com frequências absolutas e simples. Resultados: a prevalência de parto vaginal após cesárea foi de 13%. Ocorreu complicação em 13,6% das mulheres, porém não houve rotura uterina e em 4,5% dos neonatos. Conclusões: os desfechos favoráveis comprovam a segurança deste procedimento para a mãe e para neonato e servem de estímulo para que os profissionais incentivem as gestantes com cesárea anterior a considerarem a via vaginal como uma possibilidade segura para o próximo parto

Objective: to estimate the prevalence of vaginal delivery after cesarean section in a high-risk maternity and to identify maternal and neonatal complications. Method: this is a cross-sectional, quantitative and retrospective study, carried out with 44 women who had a normal delivery with previous cesarean section, through the analysis of medical records, descriptive analysis was carried out with absolute and simple frequencies. Results: the prevalence of vaginal delivery after cesarean section was 13%. Complication occurred in 13.6% of women, but there was no uterine rupture and in 4.5% of neonates. Conclusions: the favorable outcomes prove the safety of this procedure for the mother and the newborn and serve as a stimulus for professionals to encourage pregnant women with a previous cesarean to consider the vaginal route as a safe possibility for the next delivery

Objetivo: estimar la prevalencia del parto vaginal después de una cesárea en una maternidad de alto riesgo e identificar complicaciones maternas y neonatales. Método: se trata de un estudio transversal, cuantitativo y retrospectivo, realizado con 44 mujeres que tuvieron un parto normal con cesárea previa, a través del análisis de registros médicos, se realizó un análisis descriptivo con frecuencias absolutas y simples. Resultados:la prevalencia del parto vaginal después de una cesárea fue del 13%. La complicación ocurrió en el 13.6% de las mujeres, pero no hubo ruptura uterina y en el 4.5% de los recién nacidos. Conclusiones: los resultados favorables demuestran la seguridad de este procedimiento para la madre y el recién nacido y sirven de estímulo para que los profesionales alienten a las mujeres embarazadas con una cesárea previa a considerar la vía vaginal como una posibilidad segura para el próximo parto

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Abstract Objective To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. Methods A descriptive epidemiological study using data from secondary birth records fromthe Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. Results The overall rate of CSwas of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. Conclusion Over half of the births in Brazil were cesarean sections. The Midwest had the highestCS rates,while theNorth had the lowest. The largestobstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

Resumo Objetivo Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. Métodos Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. Resultados Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais forammais frequentes nos grupos 1 (53,6%), 3(80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. Conclusão Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro- Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, amaior contribuição para a taxa geral de cesárea foi do grupo 5.

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OBJECTIVE: To obtain cesarean-section (CS) rates according to the Robson Group Classification in five different regions of Brazil. METHODS: A descriptive epidemiological study using data from secondary birth records from the Computer Science Department of the Brazilian Unified Health System (Datasus, in Portuguese) between January 1st, 2014, and December 31st, 2016, including all live births in Brazil. RESULTS: The overall rate of CS was of 56%. The sample was divided into 11 groups, and vaginal births were more frequent in groups 1 (53.6%), 3 (80.0%) and 4 (55.1%). The highest CS rates were found in groups 5 (85.7%), 6 (89.5%), 7 (85.2%) and 9 (97.0%). The overall CS rate per region varied from 46.2% in the North to 62.1% in the Midwest. Group 5 was the largest obstetric population in the South, Southeast and Midwest, and group 3 was the largest in the North and Northeast. Group 5 contributed the most to the overall CS rate, accounting for 30.8% of CSs. CONCLUSION: Over half of the births in Brazil were cesarean sections. The Midwest had the highest CS rates, while the North had the lowest. The largest obstetric population in the North and in the Northeast was composed of women in group 3, while in the South, Southeast and Midwest it was group 5. Among all regions, the largest contribution to the overall CS rate was from group 5.

OBJETIVO: Identificar as taxas de cesárea de acordo com a Classificação de Robson nas cinco regiões do Brasil. MéTODOS: Estudo epidemiológico descritivo utilizando dados secundários obtidos do Departamento de Informática do Sistema Único de Saúde (Datasus) entre 1° de janeiro de 2014 e 31 de dezembro de 2016, incluindo todos os nascidos vivos no Brasil. RESULTADOS: Cesáreas representaram 56% de todos os nascimentos. A amostra foi dividida em 11 grupos, e partos vaginais foram mais frequentes nos grupos 1 (53,6%), 3 (80,0%) e 4 (55,1%). As maiores taxas de cesárea foram encontradas nos grupos 5 (85,7%), 6 (89,5%), 7 (85,2%) e 9 (97,0%). A taxa geral de cesárea variou de 46,2% no Norte a 62,1% no Centro-Oeste. O grupo 5 representou a maior população obstétrica no Sul, Sudeste e Centro-Oeste, e o grupo 3, no Norte e Nordeste. O grupo 5 contribuiu mais para a taxa geral de cesárea, totalizando 30,8%. CONCLUSãO: Mais da metade dos nascimentos no Brasil ocorreu por cesárea. O Centro-Oeste apresentou a maior taxa, e o Norte, a mais baixa. A maior população obstétrica no Norte e no Nordeste foi o grupo 3, enquanto no Sul, Sudeste e Centro-Oeste foi o grupo 5. Entre todas as regiões, a maior contribuição para a taxa geral de cesárea foi do grupo 5.

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INTRODUCTION: The promotion of a positive birth experience has been a main goal of the World Health Organization's (WHO) recent work on improving maternity care. The purpose of this study was to assess the cesarean rates, the prevalence of birth practices, perinatal outcomes, and maternal satisfaction, in women involved with the respectful maternity care (RMC) support groups in Sao Paulo, Brazil. METHODS: This was a cross-sectional study of women with low-risk pregnancies who were assisted by professionals recommended by the RMC groups. An online questionnaire was administered. Variables to assess birth practices were classified as positive, negative, or unspecified according to the WHO guidelines. The Pearson chi-square tests and odds ratios (ORs) with their corresponding 95% confidence intervals (CIs) were computed to assess differences between the groups. RESULTS: Five-hundred and eighty women completed the questionnaire. The cesarean rate was 14.7%, and the operative vaginal birth rate was 9.5%. The VBAC rate was 87.1%, and there was no significant difference in risk for cesarean between women with or without a prior cesarean. Of all women, 83.1% had a midwife's assistance and 75.5% hired a doula; 81.4% gave birth in a nonlithotomic position. The practices of enema, fasting and episiotomy were all under 2%. All 5-minute Apgar scores were ≥7. Most (83.1%) women reported having a positive birth experience. CONCLUSIONS: Woman's engagement with the birth support groups and a transdisciplinary team focused on RMC are key elements to achieve positive perinatal outcomes and high women's satisfaction.

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INTRODUCTION: A strategy for reducing the number of cesarean sections is to allow vaginal delivery after cesarean section. OBJECTIVE: To validate two predictive models, Metz and Grobman, for successful vaginal delivery after a cesarean section. METHODS: Retrospective cohort study involving women with previous history of a previous segmental cesarean section, single pregnancy ≥37 weeks and cephalic presentation. The proportion of vaginal delivery in all pregnant women was determined, and it was compared with those (women) with successful delivery after cesarean section. Then, there were elaborated the models, and their predictive capacity was determined by curve-receiver-operator. RESULTS: The proportion of successful delivery in pregnant women with a previous cesarean section and indication of vaginal delivery was 85.64%. The observed proportion of birth for each decile predicted in the Grobman model was less than 15%, except for the 91-100% decile, where it was 64.09%; the area under the curve was 0.95. For the Metz model, the actual successful delivery rate was lower than predicted in scores between 4 and 14, and within expected for a score between 15 and 23; the area under the curve was 0.94. CONCLUSIONS: The vaginal delivery rate after cesarean was lower than expected according to the predictive models of Grobman and Metz. The implementation of these models in a prospective way can lead to a higher rate of successful birth.

INTRODUCCIÓN: Una estrategia de reducción del número de cesáreas es permitir el parto vaginal después de cesárea. OBJETIVO: Validar dos modelos predictivos, Metz y Grobman, para el parto vaginal exitoso después de una cesárea. MÉTODOS: Estudio de cohorte retrospectivo con mujeres con antecedente de una cesárea segmentaria previa, embarazo único ≥37 semanas y presentación cefálica . Se determinó la proporción de parto vaginal en todas las gestantes y se comparó con aquellas con parto exitoso después de cesárea, se elaboró los modelos y se determinó la capacidad predictiva de ellos mediante curva-receptor-operador. RESULTADOS: La proporción de parto exitoso en gestantes con cesárea previa e indicación de parto vaginal fue 85.64%. La proporción de parto observado para cada decil predicho en el modelo de Grobman fue inferior al 15%, excepto para el decil 91-100%, en el que fue 64.09%, el área bajo la curva fue 0.95. Para el modelo de Metz, la proporción de parto exitoso real fue menor a lo predicho en puntajes entre 4-14 y dentro de lo esperado para puntaje entre 15-23, con un área bajo la curva de 0.94. CONCLUSIONES: La tasa de parto vaginal después de cesárea fue menor a lo esperado de acuerdo a los modelos predictivos de Grobman y Metz. La implementación de estos modelos en forma prospectiva puede llevar una mayor tasa de parto exitoso.

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Abstract Introduction: A strategy for reducing the number of cesarean sections is to allow vaginal delivery after cesarean section. Objective: To validate two predictive models, Metz and Grobman, for successful vaginal delivery after a cesarean section. Methods: Retrospective cohort study involving women with previous history of a previous segmental cesarean section, single pregnancy ≥37 weeks and cephalic presentation. The proportion of vaginal delivery in all pregnant women was determined, and it was compared with those (women) with successful delivery after cesarean section. Then, there were elaborated the models, and their predictive capacity was determined by curve-receiver-operator. Results: The proportion of successful delivery in pregnant women with a previous cesarean section and indication of vaginal delivery was 85.64%. The observed proportion of birth for each decile predicted in the Grobman model was less than 15%, except for the 91-100% decile, where it was 64.09%; the area under the curve was 0.95. For the Metz model, the actual successful delivery rate was lower than predicted in scores between 4 and 14, and within expected for a score between 15 and 23; the area under the curve was 0.94. Conclusions: The vaginal delivery rate after cesarean was lower than expected according to the predictive models of Grobman and Metz. The implementation of these models in a prospective way can lead to a higher rate of successful birth.

Resumen Introducción: Una estrategia de reducción del número de cesáreas es permitir el parto vaginal después de cesárea. Objetivo: Validar dos modelos predictivos, Metz y Grobman, para el parto vaginal exitoso después de una cesárea. Métodos: Estudio de cohorte retrospectivo con mujeres con antecedente de una cesárea segmentaria previa, embarazo único ≥37 semanas y presentación cefálica . Se determinó la proporción de parto vaginal en todas las gestantes y se comparó con aquellas con parto exitoso después de cesárea, se elaboró los modelos y se determinó la capacidad predictiva de ellos mediante curva-receptor-operador. Resultados: La proporción de parto exitoso en gestantes con cesárea previa e indicación de parto vaginal fue 85.64%. La proporción de parto observado para cada decil predicho en el modelo de Grobman fue inferior al 15%, excepto para el decil 91-100%, en el que fue 64.09%, el área bajo la curva fue 0.95. Para el modelo de Metz, la proporción de parto exitoso real fue menor a lo predicho en puntajes entre 4-14 y dentro de lo esperado para puntaje entre 15-23, con un área bajo la curva de 0.94. Conclusiones: La tasa de parto vaginal después de cesárea fue menor a lo esperado de acuerdo a los modelos predictivos de Grobman y Metz. La implementación de estos modelos en forma prospectiva puede llevar una mayor tasa de parto exitoso.

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OBJECTIVE: To assess the hospital, maternal, and obstetric characteristics associated with elective repeat cesarean delivery (ERCD) among women eligible for trial of labor after cesarean (TOLAC) delivery in Brazil. METHODS: The present data were retrieved from the Birth in Brazil study, a national hospital-based cohort study conducted during 2011-2012. Data were collected from medical records and by interview. Univariate and hierarchical multiple logistic regression analyses were performed to analyze factors associated with ERCD among women with a previous cesarean delivery who were eligible for TOLAC. RESULTS: Among 2295 women considered eligible for TOLAC, 1516 (66.1%) had an ERCD; the overall cesarean delivery rate was 79.4%. In the private sector, almost all deliveries (95.3%) were performed by ERCD. In the public sector, ERCD was associated with socioeconomic (more years of schooling), obstetric (women's preference, no previous vaginal delivery, macrosomia), and hospital (mixed hospital, location in noncapital city, fewer than 1500 deliveries per year) characteristics. CONCLUSION: The ERCD rate in Brazil was high even in a low-risk group, indicating that nonclinical factors may be driving the decision for cesarean delivery. Efforts aiming to reduce cesarean deliveries in Brazil should target women with a previous cesarean delivery.

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OBJECTIVE: To compare the beginning and evolution of labor variables such as demographic characteristics, obstetric and perinatal outcomes of patients with vaginal birth after cesarean (VBAC). MATERIAL AND METHODS: Observational, retrospective and retro elective trial purposes of comparative analysis, were divided into groups by the onset of labor; spontaneously versus induction and by the labor evolution; spontaneously versus conduction. Being analyzing by Student's T and Fisher test. RESULTS: According the ACOG criteria. 136 patients with prior cesarean section were eligible to labor. The indications of previous cesarean have a trend of a non-recurring etiology, being the elective cesarean section the most common. Regarding the onset, 78% was spontaneous and 22% had an induction. Comparing the demographic characteristics it stands a greater number of deliveries, history of vaginal delivery, a higher Bishop score, fetal weight estimated lower and higher intergenesic period. As a perinatal prognosis, the study has shown be safe with a positive outcome. Conclusions:Vaginal birth after cesarean is safe, that should be offered to all women with a low transverse incision, with an intergenesic period greater than 18 months, whit a singleton pregnancy, in a cephalic presentation, with an appropriate fetal weight, and without obstetric contraindications of vaginal delivery.

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UNLABELLED: BAKCGROUND: Caesarean section is the main proceedings for ending of pregnancy in the world, and currently represents a public health problem. Some factors that benefit the likelihood of vaginal birth after a previous C-section have been described in literature, with scoring tools designed to predict success for trial of labor after a previous cesarean. There are few studies that identify predictors of success for vaginal delivery in Latin-American patients. OBJECTIVE: To identify predictive factors associated to vaginal delivery success in patients with a prior cesarean delivery. MATERIAL AND METHOD: Case-control study. We included patients with one previous cesarean delivery admitted at our hospital. The variables analyzed with a logistic regression system to predict vaginal delivery success probabilities. RESULTS: A total of 11 60 patients were included, 668 underwent C-section (considered control group), and 492 patients had a vaginal delivery (considered study group). The Factors associated to vaginal birth after cesarean delivery were maternal age (25.1±5.4 vs 24.7±5.5 years old, OR 0.967, p<0.05), fetal weight (3,253±389 vs 3,383±452 g, OR 0.99, p<0.05), previous vaginal delivery (49 vs 1 8.4%, OR 2.97, p<0.05) and spontaneous labor (90.8 vs 74.1%, OR 3.68, p<0.05, respectively). CONCLUSION: Maternal age, fetal weight, previous vaginal delivery and spontaneous labor were associated with vaginal delivery success in patients with a previous cesarean delivery.

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A cesárea vem aumentando progressivamente no Brasil e no mundo. Dentre os fatores associados a esse evento, destaca-se a cesárea prévia. Embora a maioria dos partos realizados em mulheres com história de cesárea seja cirúrgico, autores tem demonstrado altos índices de partos vaginais após cesárea - PVAC com baixa incidência de complicações. Diante do alarmante crescimento das taxas de cesárea, o presente estudo objetiva identificar a proporção e o perfil das mães com história de repetição de cesárea - RC no Estado de São Paulo, em 2012. Métodos: Os dados provenientes do Sistema de Informações Sobre Nascidos Vivos foram vinculados aos do Cadastro Nacional de Estabelecimentos de Saúde. Os resultados a respeito das características das mães com história de RC foram analisados segundo características da gestação, do recém-nascido RN e segundo tipo do hospital do parto. Os dados foram descritos na forma de medidas de proporção (frequências), com diferenças entre variáveis de interesse verificadas pelos testes de proporção e de médias (nível de significância de 5 por cento ). Resultados: Foram estudados 273.329 nascidos vivos de mães com pelo menos um filho anterior. Destes, 43 por cento nasceram por RC e 7,4 por cento por PVAC. As mães que realizaram CR são mais velhas e mais escolarizadas e os RNs nascidos desse grupo apresentaram menor proporção de baixo peso ao nascer. O início do pré-natal no primeiro trimestre e a realização de 7 ou mais consultas de pré-natal foi mais frequente no grupo CR. Termo precoce foi a classificação mais frequente para idade gestacional dos que nasceram por CR...

Cesarean section has been progressively increasing in Brazil and worldwide. Among the factors associated with this event stands out a prior cesarean delivery. Although most deliveries in women with a prior cesarean delivery is surgical, authors have demonstrated high levels of vaginal births after cesarean - VBAC with low incidence of complications. Given the alarming increase in cesarean rates, this study aims to identify the proportion and profile of mothers with repeat cesarean delivery - RCD in the State of São Paulo, in 2012. Methods: Data from Live Births Information Systems were linked to the National Health Establishments Registration. The results about the characteristics of mothers with RCD were analyzed according to characteristics of pregnancy, newborn and type of maternity hospital. Data were presented in the form of proportion measures (frequencies), with differences between variables of interest verified by the proportion and average tests (5 per cent significance level). Results: 273 329 live births of mothers with at least one previous child were studied. 43 per cent of these were born by RCD and 7.4 per cent by PVAC. Mothers who underwent RCD are older and more highly educated and newborn infants in this group had a lower incidence of low birth weight. The beginning of prenatal care in the first trimester and the realization of 7 or more prenatal visits was more frequent in the RCD group. Early term was the most frequent rating for gestational age born by RCD...

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OBJECTIVE: To examine the availability of trial of labor after cesarean delivery (TOLAC) in New Mexico from 1998 to 2012 and maternity care providers' perception of barriers to TOLAC. METHODS: Hospital maternity unit directors were surveyed regarding TOLAC availability from 1998 to 2012. Maternity care providers (obstetrician-gynecologists, certified nurse-midwives, and family medicine physicians) were surveyed in 2008 regarding resources and barriers to providing TOLAC and emergency cesarean delivery. RESULTS: Trial of labor after cesarean delivery was available in 100% of counties with maternity care units in 1998 (22/22); by 2008, availability decreased to 32% (7/22). After changes in national guidelines, availability increased slightly to 9 of 22 (41%) in 2012. Barriers to TOLAC included anesthesia availability (88%), hospital and medical malpractice policies (80%), malpractice cost (69%), and obstetric surgeon availability (59%). In hospitals without TOLAC services, 73% of maternity care providers indicated a surgeon could be present in the hospital within 20 minutes of the emergency delivery decision; only 43% indicated obstetric anesthesia personnel could be present within 20 minutes (P<.001). CONCLUSIONS: Availability of TOLAC in New Mexico has decreased dramatically. Policy changes are needed to support TOLAC access in rural and community hospitals. LEVEL OF EVIDENCE: III.

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Antecedentes: Los riesgos relativos y absolutos asociados a la prueba de trabajo de parto en cesareadas anteriores han originado un aumento en la tasa de cesáreas, a pesar de las evidencias que demuestran la seguridad y los beneficios de la prueba de trabajo de parto. Objetivos: Determinar los resultados materno-perinatales de las gestantes con antecedente de una cesárea previa, a quienes se les indicó prueba de trabajo de parto. Diseño: Estudio de cohortes, retrospectivo, analítico. Institución: Unidad de Medicina Fetal, Instituto Nacional Materno Perinatal, Lima, Perú. Participantes: Gestantes con antecedente de una cesárea previa y atendidas en el parto. Intervenciones: Se revisó 584 historias clínicas de mujeres con antecedente de una cesárea previa que dieron a luz entre enero y diciembre de 2007. Se excluyó las pacientes que no cumplían los criterios de inclusión y se obtuvo los resultados materno perinatales de las 266 gestantes restantes. Principales medidas de resultados: Resultados materno-perinatales. Resultados: De 266 gestantes con antecedente de una cesárea previa y sin contraindicación para el parto vaginal, a 188 (70,7%) se les indicó cesárea electiva repetida y a 78 (29,3%), prueba de trabajo de parto. De estas últimas, 51 (65,3%) tuvieron éxito. Los resultados maternos muestran en el grupo de cesárea electiva una rotura uterina, una histerectomía y dos casos de hemorragia posparto. En el grupo prueba de trabajo de parto, no hubo rotura uterina, histerectomía, hemorragia posparto. No hubo muertes maternas en algún grupo. En cuanto a los resultados perinatales, no hubo caso de muerte intraútero anteparto o intraparto, Ápgar menor de 7 a los 5 minutos, ni muertes neonatales, en ninguno de los dos grupos. Conclusiones: No hubo diferencia estadísticamente significativa en los resultados materno-perinatales de las gestantes con antecedente de una cesárea previa a quienes se indicó prueba de trabajo de parto.

Background: The absolute and relative risks associated with the trial of labour in women with previous cesarean section have led to an increase in the rate of caesarean sections, despite the evidence that demonstrates the safety and benefits of trial of labour. Objectives: To determine maternal and perinatal outcomes of pregnant women with prior cesarean section to whom trial of labor was indicated. Design: Cohorts, retrospective, analytical study. Setting: Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru. Participants: Pregnant women with prior cesarean section and attended at their delivery. Interventions: We reviewed clinical records of 584 women with history of previous cesarean section who delivered at Instituto Nacional Materno Perinatal between January and December 2007. We excluded patients who did not meet inclusion criteria and reviewed outcomes of the remaining 266. Main outcome measures: Maternal and perinatal outcomes. Results: From 266 pregnant women with one previous C-section and no contraindications for vaginal delivery 188 (70.7%) had indication of repeat cesarean section and 78 (29.3%) had trial of labor, successful in 51 (65.3%). In the elective cesarean group there was one uterine rupture, one hysterectomy, and two post-partum hemorrhages. In the trial of labour group there were no uterine ruptures, hysterectomies, post-partum hemorrhage. There were no maternal deaths in any group as well as any antepartum or intrapartum intrauterine death, Apgar score below 7 at 5 minutes or neonatal deaths. Conclusions: There was no statistical significant difference in perinatal and maternal outcomes in pregnant women with previous C-section who had trial of labour compared with those who had elective repeated cesarean section. The success rate of trial of labour group was 65.3%.

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