The Feasibility of a Trial of Labor after Two Cesarean Deliveries: Outcomes and Prognostic Factors for Success.

This study aimed to determine whether a trial of labor after two cesarean deliveries (TOLAC2) increases the risk of adverse maternal and neonatal outcomes and identify prognostic factors for TOLAC2 success. A retrospective cohort study was conducted at a single medical center. The study group was comprised of women with a history of TOLAC2. Outcomes were compared with women undergoing trial of labor after one previous cesarean delivery (TOLAC1). The primary outcome was trial of labor after cesarean delivery (TOLAC) success. Secondary outcomes included mode of delivery, uterine rupture, and combined adverse outcome (CAO; uterine rupture, postpartum hemorrhage, 5-minute Apgar score < 7, pH < 7.1). Logistic regression was used for the multivariate analysis to identify prognostic factors for TOLAC2 success. A total of 381 women who underwent TOLAC2 were compared with 3,635 women who underwent TOLAC1. Women attempting TOLAC2 were less likely to achieve vaginal births after cesarean delivery (VBAC; 80.8 and 92.5%; odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.26-0.47; p < 0.001) and more likely to experience uterine rupture (0.8 vs. 0.2%; OR: 4.1; 95% CI: 1.1-15.9; p = 0.02) but not CAO (4.2 vs. 4.8%; OR: 0.88; 95% CI: 0.5-1.5; p = 0.3). TOLAC2 women with no previous vaginal deliveries had a lower chance of VBAC and a higher risk of uterine rupture compared with TOLAC1 women without a prior vaginal delivery (45.2 vs. 86.3%; OR: 0.13; 95% CI: 0.07-0.25; p < 0.001; 2.3 vs. 0%) and TOLAC2 women with a prior vaginal delivery (45.2 vs. 85.3%; OR: 0.14; 95% CI: 0.1-0.3; p < 0.0001; 2.4 vs. 0.6%; OR: 4.1; 95% CI: 0.4-46.3; p = 0.3). Multivariate analysis revealed that a history of vaginal delivery is an independent predictor of TOLAC2 success. Women attempting TOLAC2 are less likely to achieve VBAC and are at greater risk of uterine rupture compared with those attempting TOLAC1. Despite these risks, the overall success rates remain very high, and the absolute risk of adverse outcomes is still very low. Prior vaginal delivery seems to have a protective effect on TOLAC outcomes. These data should be used to counsel women and assist in decision-making when considering the mode of delivery in women with two previous cesarean sections. · TOLAC2 has a lower chance of success and higher rate of uterine rupture compared with TOLAC1.. · Previous vaginal delivery is an independent predictor of TOLAC2 success.. · Overall TOLAC2 outcomes are associated with high chances of success and low risk of uterine rupture..

Lopian M ，Perlman S ，Cohen R ，Rosen H ，Many A ，Kashani-Ligumsky L ... -  《-》

A Trial of Labor after Cesarean Section with a Macrosomic Neonate. Is It Safe?

This study aimed to determine whether a trial of labor after cesarean section (TOLAC) with a macrosomic neonate is associated with adverse outcomes. A retrospective cohort study was conducted in a population motivated for TOLAC. Women attempting TOLAC with a neonatal birth weight >4,000 g were compared with women attempting TOLAC with neonatal birth weights between 3,500 and 4,000 g. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery, uterine rupture, postpartum hemorrhage (PPH), shoulder dystocia, obstetric anal sphincter injury (OASI), Apgar's score <7 at 5 minutes, and umbilical artery pH <7.1. Data were analyzed using Fisher's exact test and Chi-square test. Overall, 375 women who underwent TOLAC with a neonate weighing >4,000 g comprised the study group. One thousand seven hundred and eighty-three women attempting TOLAC with a neonate weighing 3,500 to 4,000 g comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, parity, and vaginal birth after cesarean (VBAC) rate. There were no significant differences in the rates of successful TOLAC (94 vs. 92.3%, p = 0.2, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.5, 1.2), operative vaginal delivery (7.4 vs. 5.3%, p = 0.18, OR = 0.7, 95% CI: 0.4, 1.1), uterine rupture (0.4 vs. 0%, p = 0.6), PPH (3.2 vs. 2.3%, p = 0.36, OR = 1.4, 95% CI: 0.7, 2.7), OASI (0.8 vs. 0.2%, p = 0.1, OR = 3.6, 95% CI: 0.8, 1.6), Apgar's score <7 at 5 minutes (0 vs. 0.4%, p = 0.37), and umbilical artery pH <7.1 (0.5 vs. 0.7%, p = 1.0, OR = 0.73, 95% CI: 0.2, 3.2). Women with a neonate weighing >4,000 g had a significantly increased risk of shoulder dystocia (4 vs. 0.4%, p < 0.05, OR = 9.2 95% CI: 3.9, 22) CONCLUSION:  Women attempting TOLAC with a macrosomic neonate are not at increased risk for failed TOLAC, operative vaginal delivery, uterine rupture, PPH, or OASI but are at risk of shoulder dystocia. This information may aid in prenatal counseling for women considering TOLAC with a macrosomic fetus. · TOLAC with fetal macrosomia does not increase the risk of uterine rupture.. · TOLAC with fetal macrosomia is associated with high chances of VBAC.. · TOLAC with fetal macrosomia is not associated with adverse neonatal outcomes..

Lopian M ，Kashani-Ligumski L ，Cohen R ，Herzlich J ，Perlman S ... -  《-》

Trial of Labor After Cesarean in Adolescents - A Multicenter Study.

Data regarding trial of labor after cesarean delivery (TOLAC) among young women are limited. The aim of this study was to assess the TOLAC success rate and its related factors among adolescent women who had never delivered vaginally. A multicenter retrospective cohort study of all adolescent women aged ≤21 years with a history of 1 previous cesarean delivery, who delivered in 2 tertiary medical centers during 2007-2019. Women were allocated to 2 groups: 1) women who underwent TOLAC, and 2) women who had a repeat cesarean delivery with no trial of labor. Maternal and neonatal outcomes were compared between the two groups. In addition, perinatal outcomes were compared between women with successful and unsuccessful TOLAC. The study cohort included 167 women who had a previous caesarean delivery; 117 underwent TOLAC and 50 underwent a repeat cesarean delivery with no trial of labor. Neonatal birthweight (median 2937 vs 3170 g, P = .03) and gestational age at delivery (median 38 weeks vs 39, P = .009) were lower in the repeat cesarean group as compared to those undergoing TOLAC. Overall, 97 of 117 participants (83%) had a successful TOLAC. Failed TOLAC was associated low birthweight as compared to successful TOLAC (5 [25%] vs 7 [7%], odds ratio [OR] 4.3, 95% confidence interval [CI] 1.2-15.3, P = .02), and birthweight difference between current and previous deliveries was higher in the failed TOLAC group (median 315 vs 197 g, P = .04). Rates of neonatal Apgar score at 1 minute < 7 and of neonatal intensive care unit admission were higher in the TOLAC failure group (4 [20%] vs 5 [5%], OR 4.6, 95% CI 1.1-19.0, P = .03, and 4 [20%] vs 4 [4%], OR 5.8, 95% CI 1.3-25.6, P = .02), respectively). In a multivariable logistic regression analysis, only low birthweight was independently associated with TOLAC failure (adjusted OR 9.9, 95% CI 2.1-45.4, P = .003). Two cases of uterine rupture occurred in the no trial of labor group, whereas none were encountered in participants undergoing TOLAC. TOLAC in adolescent women who had never delivered vaginally is associated with a relatively high success rate.

Levin G ，Meyer R ，Mor N ，Yagel S ，David M ，Yinon Y ，Rottenstreich A ... -  《-》

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.

Landon MB ，Spong CY ，Thom E ，Hauth JC ，Bloom SL ，Varner MW ，Moawad AH ，Caritis SN ，Harper M ，Wapner RJ ，Sorokin Y ，Miodovnik M ，Carpenter M ，Peaceman AM ，O'sullivan MJ ，Sibai BM ，Langer O ，Thorp JM ，Ramin SM ，Mercer BM ，Gabbe SG ，National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network ... -  《OBSTETRICS AND GYNECOLOGY》

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

To compare outcomes with trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery on maternal request (ERCD-MR). Prospective cohort study. Danish university hospital. 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. Data were obtained from the Aarhus Birth Cohort database, which comprised prospective registration of the deliveries. Adverse neonatal outcomes, risk factors for emergency cesarean, and uterine rupture in case of TOLAC. 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). TOLAC is an acceptable individualized option for women without major risk factors.

Studsgaard A ，Skorstengaard M ，Glavind J ，Hvidman L ，Uldbjerg N ... -  《-》