Trial of labor compared to repeat cesarean section in women with no other risk factors than a prior cesarean delivery

Abstract

Objective: To compare outcomes with trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery on maternal request (ERCD-MR).

Design: Prospective cohort study.

Setting: Danish university hospital.

Population: Women with TOLAC (n = 1161) and women with ERCD-MR (n = 622) between 2003 and 2010. Exclusion criteria were diabetes, two prior cesarean sections, index cesarean at a different hospital, a delivery after the index cesarean, twin gestation, gestational age <37(+0) weeks and stillbirth.

Methods: Data were obtained from the Aarhus Birth Cohort database, which comprised prospective registration of the deliveries.

Main outcome measures: Adverse neonatal outcomes, risk factors for emergency cesarean, and uterine rupture in case of TOLAC.

Results: TOLAC was associated with an increased risk of neonatal depression [odds ratio (OR) 3.6, 95% confidence interval (CI) 1.1-19.1] and neonatal intensive care unit admission (adjusted OR 1.9, 95% CI 1.3-2.8). Within the TOLAC group 67% delivered vaginally. In the TOLAC group 1.3% (n = 15) of the women had a complete uterine rupture. None of these infants had sequelae after 12 months. Significant risk factors for emergency cesarean were no prior vaginal delivery (adjusted OR 1.8, 95% CI 1.1-3.0), index emergency cesarean during labor (adjusted OR 3.0, 95% CI 2.3-4.1), maternal age ≥35 years (adjusted OR 1.9, 95% CI 1.3-2.8), pre-pregnancy body mass index ≥30 (adjusted OR 2.1, 95% CI 1.3-3.3), and birthweight 4000-4499 g (adjusted OR 1.5, 95% CI 1.1-2.1). Uterine rupture was associated with the use of epidural analgesia (OR 2.2, 95% CI 1.1-4.9) and no prior vaginal delivery (p = 0.03).

Conclusion: TOLAC is an acceptable individualized option for women without major risk factors.

Keywords: Trial of labor after cesarean; adverse neonatal outcome; elective repeat cesarean delivery; mode of delivery; uterine rupture.