177: Maternal and neonatal morbidity with operative vaginal delivery during tolac: spontaneous vs. induced labor


      Induction of labor is a known risk factor for morbidity during trial of labor after cesarean (TOLAC) but it is unknown whether operative vaginal delivery (OVD) worsens maternal and neonatal outcomes in the setting of TOLAC and induction of labor. Our objective was to compare maternal and neonatal morbidity between women who attempted TOLAC and had OVD after spontaneous labor versus induced labor.

      Study Design

      This was a secondary analysis of the Cesarean Registry database (Landon, NEJM 2004). The inclusion criteria were women with non-anomalous singletons at 34 to 42 weeks, undergoing TOLAC and had attempted OVD after spontaneous vs. induced labor. Our main outcome was a composite of the maternal morbidity (CMM) that included any of the following: rate of postpartum transfusion, third or fourth degree laceration, uterine rupture, ICU admission, and; a composite of the neonatal morbidity (CNM) that included: Apgar score ≤ 5 at 5 minutes, mechanical ventilation, respiratory distress syndrome, seizures, clavicular and skull fractures, skin laceration, facial nerve injury, brachial plexus injury or death. Chi-square or Fisher exact test were used where appropriate. A p value < 0.05 was considered significant.


      Of 1476 women that met the inclusion criteria, 1092 (73.9%) had TOLAC and OVD after spontaneous labor and 384 (26.1%) patients had TOLAC and OVD after induced labor. Women with spontaneous labor were significantly more likely to have meconium stained fluid intrapartum (22.3% Vs 12.2%, p< 0.01), women with induced labor were significantly more likely to have epidural use (88.9% Vs 35.1%, p=0.01). The rates of attempted vacuum and forceps were similar between the groups, forceps were more commonly used than vacuum (52% Vs 44%) and very few women had a combined attempted forceps and vacuum delivery (3%). Table summarizes CMM and CNM between the two study groups. There were no statistically significant differences in the groups.


      In women undergoing TOLAC, the CMM and CNM were similar among women who had spontaneous vs induced labor and had OVD. Our findings can be used to counsel patients undergoing TOLAC and induction of labor regarding safety of OVD.
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