Melanoma is increasingly common among reproductive-age women and is one of the most common cancers diagnosed during pregnancy. The literature for melanoma in pregnancy, especially among those with prior uterine scars, is limited. We present an interesting case of a 22-year-old woman who went to her dermatologist for a suspicious lesion on her thigh. The lesion was excised, and histopathology confirmed that it was a melanoma. The dermatologist recommended immediate delivery. The patient then urged her obstetrician to undergo the risks of an induction of labor (IOL) for a trial of labor after cesarean (TOLAC) because she desired a large family, and a second cesarean would make this more difficult to happen. She ultimately had a successful vaginal birth after cesarean (VBAC) and subsequent excision of the melanoma with surgical oncology in the immediate postpartum period. Therefore, the decision for IOL for TOLAC in this case was based on the patient\'s fears regarding melanoma disease progression in her 39th week. Given the short time course between delivery and excision of her melanoma, it is possible that she may have been able to wait for spontaneous labor, which would have avoided the risks associated with IOL for TOLAC. The optimal timing of surgical intervention for melanoma in pregnant patients who desire TOLAC is unknown. In pregnancies that are approaching their due date, waiting for spontaneous labor may be a reasonable approach to avoid the risks of labor induction, especially in women with prior cesarean delivery. A multidisciplinary approach involving dermatology, surgical oncology, and the obstetric team is warranted to optimize both dermatologic and obstetric outcomes.

BACKGROUND: Most German hospitals do not offer a trial of labour after two caesarean sections (TOLA2C). TOLA2C is claimed to be associated with too many complications, above all the high risk of uterine rupture. The objective of this study is to review our experience with TOLA2C, with special attention paid to the risk and probability of uterine ruptures. Secondary outcomes include comparing neonatal and maternal outcomes in the group of TOLA2C with the group of elective repeat caesarean section (ERCS) and to assess the success rate for vaginal birth after two caesarean sections (VBAC-2).
METHODS: The retrospective cohort study was conducted in a community hospital in North Rhine-Westphalia. Inclusion criteria were all pregnant women with two caesarean sections in their medical history, with a current vertex singleton pregnancy and the absence of morphological abnormalities of the foetus, who gave birth in our facility between January 2015 and June 2021. Descriptive statistics were calculated and Kolmogorov-Smirnov tests, Mann-Whitney U tests, Fishers exact tests, Chi2 -tests and t-tests for independent samples were performed.
RESULTS: A total of 91 cases were included in the TOLA2C-group. These were compared to 99 cases that, within the same time frame, had an elective repeat caesarean section (ERCS-group). There was no statistically significant difference found in the neonatal outcome between the two groups (except for the neonatal pH-value: p 0.024). The hospital stay was significantly shorter in the TOLA2C-group, while maternal complication rates were almost similar (13.2% in the TOLA2C-Group, vs. 16.2% in the ERCS-Group). The success rate for TOLA2C was 55%. No complete uterine rupture was found, but in three cases an incomplete rupture (3.3% rate for incomplete uterine ruptures) occurred, but had no influence on the neonatal outcome.
CONCLUSIONS: TOLA2C is not associated with a worse maternal or neonatal outcome compared to ERCS, and especially the risk of complete uterine ruptures seems to be low. TOLA2C should be more widely offered to suitable patients who are motivated for it.

BACKGROUND: Cesarean section (C-section) rates are increasing globally, and repeated C-sections are associated with increased maternal morbidity. Trial of labor after C-section (TOLAC) is an approach to reduce the recurrence of C-sections. However, limited research exists on the impact of cesarean scars on labor duration in TOLAC, considering the termination of labor through C-section and selection bias. This study aimed to investigate the impact of cesarean scars on labor duration in TOLAC participants, accounting for potential confounding factors and biases.
METHODS: This retrospective cohort study included 2,964 women who attempted vaginal birth at a single center in Japan from 2012 to 2021. The study categorized participants into TOLAC (n = 187) and non-TOLAC (n = 2,777) groups. Propensity scores were calculated based on 14 factors that could influence labor duration, and inverse probability of treatment weighting (IPTW) was applied. Cox proportional hazards regression analysis estimated hazard ratios (HRs) for labor duration, with and without IPTW adjustment. Sensitivity analyses used propensity score matching, bootstrapping, and interval censoring to address potential biases, including recall bias in the reported onset of labor.
RESULTS: The unadjusted HR for labor duration in the TOLAC group compared to the non-TOLAC group was 0.83 (95% CI: 0.70-0.98, P = 0.027), indicating a longer labor duration in the TOLAC group. After adjusting for confounding factors using IPTW, the HR was 0.98 (95% CI: 0.74-1.30, P = 0.91), suggesting no significant difference in labor duration between the groups. Sensitivity analyses using propensity score matching, bootstrapping, and interval censoring yielded consistent results. These findings suggested that the apparent association between TOLAC and longer labor duration was because of confounding factors rather than TOLAC itself.
CONCLUSIONS: After adjusting for confounding factors and addressing potential biases, cesarean scars had a limited impact on labor duration in TOLAC participants. Maternal and fetal characteristics may have a more substantial influence on labor duration.

OBJECTIVE: Given the call to reduce rates of non-medically indicated cesarean deliveries (CDs) by encouraging trials of labor after cesarean (TOLAC), this study looks at social characteristics of patients choosing a TOLAC versus a scheduled repeat cesarean delivery (SRCD) to determine disparities regarding delivery method choice.
METHODS: This was a retrospective cohort study of patients with a history of one CD between April 29, 2015-April 29, 2020. Patients were divided based on type of delivery chosen at admission. Chi-squared tests examined proportional differences between groups and logistic regression models examined odd ratios of choosing TOLAC versus SRCD according to socially dependent categories including race/ethnicity, health insurance, pre-pregnancy body mass index, and Social Vulnerability Index (SVI).
RESULTS: 1,983 patients were included. Multivariable logistic regression models revealed that patients with a high SVI (reference: low/medium SVI) (AOR 2.0, CI: 1.5, 2.5), self-identified as Black/ African American (AOR: 2.4, CI: 1.6, 3.6) or Hispanic/Latina (AOR: 2.0, CI: 1.4, 2.8) (reference: White), had public insurance (reference: private insurance) (AOR: 3.7, CI: 2.8, 5.0), and who had an obese BMI (reference: non-obese BMI) were more likely to opt for a TOLAC rather than SRCD.
CONCLUSIONS: These findings demonstrate differences in delivery method preferences. Specifically, more disadvantaged patients are more likely to choose TOLAC, suggesting that social and economic factors may play a role in delivery preferences. These findings have implications for improving individualized counselling and engaging in shared decision-making around mode of delivery.

UNASSIGNED: The growing prevalence of Cesarean Sections (CS), particularly repeated CS, is a major issue in contemporary midwifery. This study seeks to gain a comprehensive understanding of the experiences of pregnant women and specialists with vaginal delivery after CS, as well as the obstacles that may arise.
UNASSIGNED: From March 2020 to May 2021, 10 women, 12 midwives, and 8 obstetricians and obstetricians affiliated with Qom University of Medical Sciences were interviewed to investigate the experiences and challenges associated with Vaginal Birth After Cesarean section (VBAC). We used the content analysis method, and the sampling was purposive. Semi-structured interviews were conducted to collect data, which were then analyzed using qualitative content analysis based on conventional content analysis.
UNASSIGNED: The results show that subcategories \"individual aspects of VBAC\" and \"family-social aspects of VBAC\" formed \"positive aspects of VBAC.\" Subcategories \"self-efficacy\" and \"decision-making participation\" formed the \"empowerment for the woman.\" Subcategories \"technical team challenges\" and \"woman\'s challenges\" formed the main category of \"upcoming challenges.\"
UNASSIGNED: Positive relationships, choice-making ability, and self-confidence impact a woman\'s decision to choose VBAC. Informing women of alternative delivery options after a CS and pursuing their dreams increases the likelihood of successful VBAC.

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UNASSIGNED: A cesarean delivery (CD) can affect health of both mother and child and future pregnancies. Since the abandonment of the one-child policy in China, obstetricians tend to perform a repeat CD rather than a trial of labor after cesarean (TOLAC). This study aims to reduce CD rates by increasing vaginal births after cesarean (VBAC) rates and introducing electrohysterography (EHG) for accurate monitoring.
UNASSIGNED: In total, 82 women received counseling regarding TOLAC at the Shijiazhuang Sixth Hospital in China. Women opting for TOLAC were randomized for either external tocodynamometry (TOCO, i.e. standard care) or EHG. The primary outcome was the VBAC rate. Secondary outcomes were indications for CD, percentage of assisted vaginal deliveries, labor duration, maternal blood loss, complications and neonatal outcomes.
UNASSIGNED: After accounting for preterm delivery and dropouts, all counseled women opted for a TOLAC (100%). After randomization, 42 women were included in the TOCO-group and 37 in the EHG-group. Women did not receive pain medication and labor was not augmented with oxytocin. The VBAC rate was 71.4% in the TOCO-group, versus 78.4% in the EHG-group (p = .48). Birth was assisted with forceps in 11.9% of TOCO-group versus 2.7% of EHG-group (p = .21). One secondary CD (i.e. a shift from intended vaginal delivery to surgical delivery within the same labor) was performed because of a suspicion of uterine rupture (TOCO-group). Other indications for CD were: fetal distress, labor dystocia, fetal position, cephalopelvic disproportion. There were no significant differences in secondary study outcomes. No complications were reported.
UNASSIGNED: This study showed an average VBAC rate of 75%, without any complications, in a hospital with no previous experience with TOLAC. The VBAC rate with EHG-monitoring was higher than TOCO, although this difference was not significant. To demonstrate a significant difference, larger clinical studies are necessary.
UNASSIGNED: The Daily Board of the Medical Ethics Committee of The Maternal and Child Hospital of Shijiazhuang approved the study protocol (number 20171018, Dutch Trial Register NL8199).

BACKGROUND: The rates of labor induction and cesarean delivery is rising worldwide. With the confluence of these trends, the labor induction rate in trials of labor after cesarean can be as high as 27-32.7%. Induction of labor after one previous cesarean (IOLAC) is a high-risk procedure mainly due to the higher risk of uterine rupture. Nevertheless, the American College of Obstetricians and Gynecologists considers IOLAC as an option in motivated and informed women in the appropriate care setting. We sought to identify predictors of a composite of maternal and newborn adverse outcomes following IOLAC.
METHODS: The electronic medical records of women who delivered between January 2018 to September 2022 in a Malaysian university hospital were screened to identify cases of IOLAC. A case is classified as a composite adverse outcome if at least one of these 11 adverse outcomes of delivery blood loss ≥ 1000 ml, uterine scar complications, cord prolapse or presentation, placenta abruption, maternal fever (≥ 38 0C), chorioamnionitis, intensive care unit (ICU) admission, Apgar score < 7 at 5 min, umbilical artery cord artery blood pH < 7.1 or base excess ≤-12 mmol/l, and neonatal ICU admission was present. An unplanned cesarean delivery was not considered an adverse outcome as the practical management alternative for a clinically indicated IOLAC was a planned cesarean. Bivariate analysis of participants\' characteristics was performed to identify predictors of their association with composite adverse outcome. Characteristics with crude p < 0.10 on bivariate analysis were incorporated into a multivariable binary logistic regression analysis model.
RESULTS: Electronic medical records of 19,064 women were screened. 819 IOLAC cases and 98 cases with composite adverse outcomes were identified. Maternal height, ethnicity, previous vaginal delivery, indication of previous cesarean, indication for IOLAC, and method of IOLAC had p < 0.10 on bivariate analysis and were incorporated into a multivariable binary logistic regression analysis. After adjustment, only maternal height and IOLAC by vaginal dinoprostone compared to Foley balloon remained significant at p < 0.05. Post hoc adjusted analysis that included all unplanned cesarean as an added qualifier for composite adverse outcome showed higher body mass index, short stature (< 157 cm), not of Chinese ethnicity, no prior vaginal delivery, prior cesarean indicated by labor dystocia, and less favorable Bishop score (< 6) were independent predictors of the expanded composite adverse outcome.
CONCLUSIONS: Shorter women and IOLAC by vaginal dinoprostone compared to Foley balloon were independently predictive of composite of adverse outcome.
Shorter stature and dinoprostone labor induction are independent predictors of a composite maternal-newborn adverse outcome excluding unplanned cesarean delivery.

Few studies have examined the relationship between pelvic size and the success or failure of trial of labor after cesarean delivery (TOLAC). Here we aimed to determine whether pelvic size and morphological data obtained from radiography contribute to the first successful TOLAC. This retrospective single-center observational study enrolled pregnant women who underwent TOLAC between 2010 and 2021. The results of X-ray pelvimetry data, including obstetric conjugate (OC), transverse diameter of the pelvic inlet (TD), anteroposterior diameter of the pelvic inlet (APD), shape of the pelvic inlet, and other obstetrical clinical data, were compared between the success and failure groups. Seventy-five patients in successful group after excluding 35 patients with previous successful TOLAC, and 21 patients in failure group were eligible. The failure group had a higher rate of previous cesarean sections due to failed labor trials (p = 0.042) and heavier newborns (p = 0.014). OC, TD, and APD on X-ray pelvimetry did not differ significantly between the two groups nor did the shape of the pelvic inlet affect the success rate for TOLAC. The generalized linear model identified a history of failed trials of labor as a significant predictor of failed TOLAC (odds ratio, 0.26; 95% confidence interval 0.071-0.923; p = 0.037), whereas no pelvimetric parameters were found. Pelvic size and morphological findings have no discernible impact on the outcomes of TOLAC. The universal application of X-ray pelvimetry in all women attempting TOLAC may not have significant clinical relevance.

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