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Despite the increased maternal risks associated with failed trial of labor after cesarean (TOLAC), it remains unknown whether failed TOLAC is also associated with increased morbidity and mortality in infants. The purpose of this study was to determine rates of early (EMR), late (LMR), post-neonatal (PMR) and infant (IMR) mortality in those with failed TOLAC as compared to those with successful TOLAC, specifically among women at 34-41 weeks who had induction or stimulation of labor. Secondary measures of neonatal morbidity (5-min Apgar score <4 and neonatal seizures) were also compared.
Linked birth and infant death cohort data, between 2000 and 2004, from the US were used to identify women with a prior cesarean who were between 34-41 weeks, delivered non-anomalous singletons, and underwent either labor induction or stimulation. Multivariable log-binomial regression models were fitted to estimate the risk ratio (RR) for infant morbidity and mortality in relation to TOLAC following adjustments for several confounders.
During the study period, the rate of successful TOLAC among the 164,113 women who met the inclusion criteria declined from 62% in 2000 to 52% in 2004 (P <0.001). The rates of EMR, LMR, PNMR, and IMR for the overall cohort were 0.3, 0.3, 1.6 and 2.2/1,000 live births, respectively. A failed TOLAC was significantly associated with a higher risk of neonatal and infant mortality, as well as immediate neonatal morbidity (Table).
Among women undergoing labor induction or stimulation, failed TOLAC is associated with a significantly higher rate of neonatal morbidity, as well as neonatal and infant mortality.