American Journal of Obstetrics & Gynecology
Volume 195, Issue 4 , Pages 1119-1126, October 2006

The Maternal-Fetal Medicine Units Cesarean Registry: Safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery

  • Celeste P. Durnwald, MD

      Affiliations

    • Departments of Obstetrics and Gynecology at Ohio State University, Columbus, OH
    • ,
  • Dwight J. Rouse, MD

      Affiliations

    • University of Alabama at Birmingham, Birmingham, AL
    • ,
  • Kenneth J. Leveno, MD

      Affiliations

    • University of Texas Southwestern Medical Center, Dallas, TX
    • ,
  • Catherine Y. Spong, MD

      Affiliations

    • National Institute of Child Health and Human Development, Bethesda, MD
    • ,
  • Cora MacPherson, PhD

      Affiliations

    • The George Washington University Biostatistics Center, Washington, DC
    • ,
  • Michael W. Varner, MD

      Affiliations

    • University of Utah, Salt Lake City, UT
    • ,
  • Atef H. Moawad, MD

      Affiliations

    • University of Chicago, Chicago, IL
    • ,
  • Steve N. Caritis, MD

      Affiliations

    • University of Pittsburgh, Pittsburgh, PA
    • ,
  • Margaret Harper, MD

      Affiliations

    • Wake Forest University School of Medicine, Winston-Salem, NC
    • ,
  • Ronald J. Wapner, MD

      Affiliations

    • Thomas Jefferson University, Philadelphia, PA
    • ,
  • Yoram Sorokin, MD

      Affiliations

    • Wayne State University, Detroit, MI
    • ,
  • Menachem Miodovnik, MD

      Affiliations

    • University of Cincinnati, Cincinnati, OH
    • Columbia University, New York, NY
    • ,
  • Marshall Carpenter, MD

      Affiliations

    • Brown University, Providence, RI
    • ,
  • Alan M. Peaceman, MD

      Affiliations

    • Northwestern University, Chicago, IL
    • ,
  • Mary Jo O'Sullivan, MD

      Affiliations

    • University of Miami, Miami, FL
    • ,
  • Baha Sibai, MD

      Affiliations

    • University of Tennessee, Memphis, TN
    • ,
  • Oded Langer, MD

      Affiliations

    • University of Texas Health Science Center at San Antonio, San Antonio, TX
    • ,
  • John M. Thorp, MD

      Affiliations

    • University of North Carolina at Chapel Hill, Chapel Hill, NC
    • ,
  • Susan M. Ramin, MD

      Affiliations

    • University of Texas Health Science Center at Houston, Houston, TX
    • ,
  • Brian M. Mercer, MD

      Affiliations

    • Case Western Reserve University, Cleveland, OH
    • ,
  • Steven G. Gabbe, MD

      Affiliations

    • Columbia University, New York, NY
    • ,
  • for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network

Received 10 March 2006; received in revised form 22 May 2006; accepted 9 June 2006.

Objective

This study was undertaken to compare success rates of vaginal birth after cesarean (VBAC) delivery, and uterine rupture as well as maternal/perinatal outcomes between women with preterm and term pregnancies undergoing trial of labor (TOL), and to compare maternal and neonatal morbidities in those women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD).

Study design

Prospective 4-year observational study of women with a singleton gestation and a prior cesarean delivery at 19 academic centers. Clinical characteristics, maternal complications and VBAC delivery success for those with a preterm (240-366 weeks) TOL, preterm RCD and term TOL (≥37 weeks) were analyzed.

Results

Among 3119 preterm pregnancies with prior cesarean delivery, 2338 (75%) underwent a TOL. 15,331 women undergoing TOL at term were also analyzed as a control group. TOL success rates for preterm and term pregnancies were similar (72.8% vs 73.3%, P = .64). Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. Thromboembolic disease, coagulopathy and transfusion were more common in women undergoing a preterm TOL than those at term. Among women undergoing a preterm TOL, rates of uterine dehiscence, coagulopathy, transfusion, and endometritis were similar to those having a preterm RCD. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL.

Conclusion

The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.

Key words: Preterm pregnancy, Vaginal birth after cesarean, Trial of labor, Cesarean delivery

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 Supported by grants from the National Institute of Child Health and Human Development (HD21410, HD21414, HD27860, HD27861, HD27869, HD27905, HD27915, HD27917, HD34116, HD34122, HD34136, HD34208, HD34210, HD40500, HD40485, HD40544, HD40545, HD40560, HD40512, and HD36801).Presented at the 26th Annual Meeting of the Society for Maternal Fetal Medicine, January 30-February 4, 2006, Miami, FL.Reprints not available from the authors.

PII: S0002-9378(06)00771-X

doi:10.1016/j.ajog.2006.06.047

American Journal of Obstetrics & Gynecology
Volume 195, Issue 4 , Pages 1119-1126, October 2006

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