Objective
To evaluate whether trial of labor (TOL) is associated with increased maternal or perinatal risk in women with a prior cesarean delivery (CD).
Study design
A prospective four-year (1999-2002) observational study at 19 academic centers of all women with singleton gestation and prior CD. All charts were reviewed by trained research nurses. Women attempting vaginal birth after cesarean (VBAC) were compared to women with elective repeat cesarean delivery (ERCD) without labor and no other indication for CD.
Results
Of 45,981 women with a prior CD, 15,800 underwent ERCD and 17,931 attempted VBAC. 12,250 women had other maternal or fetal indications for a repeat CD. The TOL rate was 39% and the VBAC success rate was 73%. Symptomatic uterine rupture occurred in 140 (0.78%) of TOL cases. Maternal complications (endometritis, transfusion) as well as the frequency of term infants with hypoxic ischemic encephalopathy (HIE) were increased in TOL versus ERCD (see table).
Conclusion
When compared to elective repeat cesarean delivery, women attempting VBAC are at increased risk for maternal morbidity (uterine rupture, endometritis, transfusion) and newborn HIE. Trial of labor remains an option as the absolute risk for these complications is small.
Tabled
1Maternal and Perinatal Outcome
| TOL N(%) | ERCD N(%) | RR (95% CI) | P | |
|---|---|---|---|---|
| Uterine rupture | 140/17929 (0.78) | 0/15793 (0.0) | — | <0.0001 |
| Hysterectomy | 41/17929 (0.23) | 47/15793 (0.30) | 0.77 (0.51-1.17) | 0.2158 |
| DVT/PE | 7/17898 (0.04) | 10/15773 (0.06) | 0.62 (0.23-1.62) | 0.3222 |
| Transfusion | 307/17930 (1.7) | 158/15794 (1.0) | 1.71 (1.41-2.07) | <0.0001 |
| Endometritis | 518/17930 (2.9) | 284/15793 (1.8) | 1.61 (1.39-1.85) | <0.0001 |
| Maternal death | 3/17929 (0.02) | 7/15793 (0.04) | 0.38 (0.10-1.46) | 0.2055 |
| Term intrapartum stillbirth | 7/15336 (0.05) | 3/15014 (0.02) | 2.28 (0.59-8.83) | 0.3439 |
| Term neonatal death | 12/15293 (0.08) | 6/14997 (0.04) | 1.96 (0.74-5.22) | 0.1697 |
| Term HIE | 14/15288 (0.09) | 1/14993 (0.01) | 13.73 (1.81-104.40) | <0.001 |
Article Info
Publication History
8
Identification
Copyright
© 2003 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
