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.

Current scored models provide reasonable predictability for VBAC, but none provides consistent ability to identify women at risk for failed trial of labor. A scoring model is needed that incorporates known antepartum factors and can be adjusted for current obstetric factors and labor patterns if induction or augmentation is needed. This would allow women and clinicians to better determine individuals most likely to require repeat cesarean delivery.

had good-quality or fair-quality evidence relating to uterine rupture. Four studies reported uterine rupture outcomes for both TOL and ERCD and included 47,202 patients, in whom 154 uterine ruptures occurred; 148 ruptures (96%) were in the TOL group. The risk of uterine rupture for all women with a prior cesarean delivery was 0.30% (CI, 0.23%-0.41%) with risks in the TOL and ERCD groups reported as 0.47% (CI, 0.28%-0.77%) and 0.026% (CI, 0.009%-0.082%), respectively. Eight cohort studies (402,059 patients) with a moderate grade of evidence compared risks for hysterectomy between TOL and ERCD groups. The risk of hysterectomy was <0.3% in women with a prior cesarean delivery; the risks between TOL and ERCD were not significantly different (0.17% and 0.28%, respectively; RR 0.65; CI, 0.40-1.06). Nine cohort studies (401,307 patients) had moderate-grade evidence on the rate of transfusion between TOL and ERCD. The overall rates of transfusion did not differ significantly, with rates of 0.9% for TOL and 1.2% for ERCD (RR, 0.81; CI, 0.57-1.15). One study found that the route of delivery influenced the need for transfusion and may be mediated by maternal comorbid conditions. Evidence for hemorrhage was low-grade because of inconsistent and imprecise methods of defining and reporting the occurrence of this complication. From 6 studies involving 47,754 women, the risk rates for hemorrhage with ERCD ranged from 0.3% to 29% and no comparison could be done because of the poor quality of the data. Twenty-two studies with 354,060 patients reported infectious complications, with no significant differences in risk between TOL and ERCD 4.6% (CI, 1.5%-13.5%) and 3.2% (CI, 1.3%-7.3%), respectively. The 4 studies reporting surgical injury and including 53,282 patients had insufficient data to evaluate, with a low grade of evidence. As reported in 8 cohort studies, hospital length of stay was 3.9 d in patients undergoing ERCD and 2.6 d after TOL.Short-term neonatal outcomes included perinatal mortality, respiratory conditions, hypoxic-ischemic encephalopathy, sepsis, trauma, Apgar scores, and neonatal intensive care unit admission. With a moderate grade of evidence, 5 studies reported on perinatal deaths among 75,899 infants. These studies reported only on populations that delivered at term and recorded perinatal mortality through the first 7 d of life. The rate was significantly increased by TOL (0.13%; CI, 0.06%-0.30%) compared with ERCD (0.05%; CI, 0.007%-0.38%). Six studies reported neonatal death (within first 28 d) and included 108,328 infants. The rate of death for TOL was 0.11% (CI, 0.06%-0.20%) compared with 0.06% (CI, 0.02-0.15%) for ERCD, a significant difference. A subanalysis of the data showed that the rates of neonatal mortality were higher in women with high-risk conditions and those with indications for a repeat CD. Respiratory conditions were reported in 6 studies involving 5599 infants. The grade of evidence was low for the 3 studies that compared bag/mask ventilation and 3 other studies that examined transient tac...

Objective The impact of hospital obstetric volume specifically on maternal outcomes remains under-studied. We examined the impact of hospital obstetric volume on maternal outcomes in low-risk women delivering non-low-birthweight infants at term. Study Design We conducted a retrospective cohort study of term, singleton, non-low-birthweight live births between 2007 – 2008 in California. Deliveries were categorized by hospital obstetric volume categories, separately for non-rural hospitals (Category 1: 50 – 1,199 deliveries per year; Category 2: 1,200 – 2,399; Category 3: 2,400 – 3,599, and Category 4: ≥3,600) and rural hospitals (Category R1: 50 – 599 births per year; Category R2: 600 – 1,699; Category R3: ≥1,700). Maternal outcomes were compared using the chi-square test and multivariable logistic regression. Results There were 736,643 births in 267 hospitals that met study criteria. After adjusting for confounders, there were higher rates of postpartum hemorrhage in the lowest-volume rural hospitals (Category R1 aOR 3.06; 95% CI 1.51 – 6.23). Rates of chorioamnionitis, endometritis, severe perineal lacerations, and wound infection did not differ between volume categories. Longer lengths of stay were observed after maternal complications (e.g., chorioamnionitis) in the lowest-volume hospitals (16.9% prolonged length of stay in Category 1 hospitals versus 10.5% in Category 4 hospitals; aOR, 1.91; 95% CI, 1.01 – 3.61 ). Conclusion After confounder adjustment, few maternal outcomes differed by hospital obstetric volume. However, elevated odds of postpartum hemorrhage in low-volume rural hospitals raises the possibility that maternal outcomes may differ by hospital volume and geography. Further research is needed on maternal outcomes in hospitals of different obstetric volumes.

Introduction Shared decision‐making is considered to be a key aspect of woman‐centered care and a strategy to improve communication, respect, and satisfaction. This scoping review identified studies that used a shared decision‐making support strategy as the primary intervention in the context of perinatal care. Methods A literature search of PubMed, CINAHL, Cochrane Library, PsycINFO, and SCOPUS databases was completed for English‐language studies conducted from January 2000 through November 2019 that examined the impact of a shared decision‐making support strategy on a perinatal decision (such as choice of mode of birth after prior cesarean birth). Studies that only examined the use of a decision aid were excluded. Nine studies met inclusion criteria and were examined for the nature of the shared decision‐making intervention as well as outcome measures such as decisional evaluation, including decisional conflict, decisional regret, and certainty. Results The 9 included studies were heterogeneous with regard to shared decision‐making interventions and measured outcomes and were performed in different countries and in a variety of perinatal situations, such as women facing the choice of mode of birth after prior cesarean birth. The impact of a shared decision‐making intervention on women's perception of shared decision‐making and on their experiences of the decision‐making process were mixed. There may be a decrease in decisional conflict and regret related to feeling informed, but no change in decisional certainty. Discussion Despite the call to increase the use of shared decision‐making in perinatal care, there are few studies that have examined the effects of a shared decision‐making support strategy. Further studies that include antepartum and intrapartum settings, which include common perinatal decisions such as induction of labor, are needed. In addition, clear guidance and strategies for successfully integrating shared decision‐making and practice recommendations would help women and health care providers navigate these complex decisions.

Objective To synthesize and critique the quantitative literature on measuring childbirth self-efficacy and the effect of childbirth self-efficacy on perinatal outcomes. Data Sources Eligible studies were identified through searching MEDLINE, CINAHL, Scopus, and Google Scholar databases. Study Selection Published research using a tool explicitly intended to measure childbirth self-efficacy and also examining outcomes within the perinatal period were included. All manuscripts were in English and published in peer-reviewed journals. Data Extraction First author, country, year of publication, reference and definition of childbirth self-efficacy, measurement of childbirth self-efficacy, sample recruitment and retention, sample characteristics, study design, interventions (with experimental and quasi-experimental studies), and perinatal outcomes were extracted and summarized. Data Synthesis Of 619 publications, 23 studies published between 1983 and 2015 met inclusion criteria and were critiqued and synthesized in this review. Conclusions There is overall consistency in how childbirth self-efficacy is defined and measured among studies, facilitating comparison and synthesis. Our findings suggest that increased childbirth self-efficacy is associated with a wide variety of improved perinatal outcomes. Moreover, there is evidence that childbirth self-efficacy is a psychosocial factor that can be modified through various efficacy-enhancing interventions. Future researchers will be able to build knowledge in this area through: (a) utilization of experimental and quasi-experimental design; (b) recruitment and retention of more diverse samples; (c) explicit reporting of definitions of terms (e.g. ‘high risk’); (d) investigation of interventions that increase childbirth self-efficacy during pregnancy; and, (e) investigation regarding how childbirth self-efficacy enhancing interventions might lead to decreased active labor pain and suffering. Exploratory research should continue to examine the potential association between higher prenatal childbirth self-efficacy and improved early parenting outcomes.

Background Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse‐midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. Methods This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age < 37 weeks, or body mass index > 40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. Results A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first‐ or second‐degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. Discussion In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first‐ or second‐degree lacerations requiring sutures.

Background: Maternal milk production requires the neuropeptide oxytocin. Individual variation in oxytocin function is a compelling target for understanding low milk production, a leading cause of breastfeeding attrition. Complicating the understanding of oxytocin pathways is that vasopressin may interact with oxytocin receptors, yet little is known about the role of vasopressin in lactation. Research aims: The aims of this study were (1) to describe maternal plasma oxytocin, vasopressin, and prolactin patterns during breastfeeding following low-risk spontaneous labor and birth in healthy first-time mothers and (2) to relate hormone patterns to maternal characteristics and breastfeeding measures. Methods: Eligible women were recruited before hospital discharge. Forty-six participants enrolled and 35 attended the study visit. Participants kept a journal of breastfeeding frequency, symptoms of lactogenesis, and infant weight. Plasma samples were obtained at breastfeeding onset on Day 4–5 postpartum, and repeated after 20 min. Hormones were measured with immunoassays. Infant weight change, milk transfer, and onset of lactogenesis were also measured. Results: Baseline oxytocin and vasopressin were inversely related to one another. Oxytocin and prolactin increased significantly across the 20-min sampling period while vasopressin decreased. Higher oxytocin was associated with higher maternal age, lower BMI, shorter active labor, physiologic labor progression, and less weight loss in the newborn. Higher vasopressin correlated with younger maternal age, higher BMI, and greater newborn weight loss. Conclusions: Oxytocin and vasopressin have contrasting relationships with maternal clinical characteristics and newborn weight gain in early breastfeeding infants. Further study is needed to understand how oxytocin and vasopressin influence lactation outcomes.