Attempted operative vaginal delivery vs repeat cesarean in the second stage among women undergoing a trial of labor after cesarean delivery

Published:January 29, 2017DOI:


      It is not well-characterized whether attempting operative vaginal delivery is a safe and effective alternative among women who undergo a trial of labor after cesarean delivery who are unable to complete second-stage labor with a spontaneous vaginal delivery.


      The purpose of this study was to compare maternal and neonatal outcomes that are associated with attempted operative vaginal delivery with those that are associated with second-stage repeat cesarean delivery without an operative vaginal delivery attempt among women who undergo a trial of labor after cesarean delivery.

      Study Design

      This is a retrospective secondary analysis of data from Cesarean Registry of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Women who underwent a trial of labor after cesarean delivery who were at least 36 weeks gestation were eligible for analysis if they had a live, singleton, nonanomalous gestation in cephalic presentation and reached second-stage labor (defined as complete cervical dilation) with a fetal station of at least +2. The data for women who had an attempted operative vaginal delivery with either forceps or vacuum were compared with those of women who underwent second stage repeat cesarean delivery without operative vaginal delivery attempt. Outcomes of maternal and neonatal complications were compared between groups with bivariable and multivariable analyses.


      Of 1230 women whose cases were eligible for analysis, 945 women (76.8%) had an attempted operative vaginal delivery. Of those who underwent attempted operative vaginal delivery, 914 women (96.7%) achieved a vaginal delivery. Women who attempted operative vaginal delivery had a lower mean body mass index (30.4±6.0 vs 31.8±5.9 kg/m2; P=.001) and gestational age (39.5±1.3 vs 39.8±1.2 weeks; P=.012) at delivery and were more likely to be of non-Hispanic black race (30.0% vs 22.1%; P=.002), to have had a previous vaginal delivery (34.9% vs 20.4%; P<.001), and to have fetal descent greater than +2 station at complete dilation (55.6% vs 16.8%; P<.001) and were less likely to have chorioamnionitis (6.8% vs 19.3%; P<.001). The frequency of endometritis was significantly lower among women who had an attempted operative vaginal delivery compared with those who had repeat cesarean delivery (2.5% vs 9.1%; P<.001). However, other serious maternal or neonatal adverse outcomes were not statistically different between the groups. These findings persisted after adjustment for potential confounders.


      In the setting of a trial of labor after cesarean delivery in the second stage with a fetal station of at least +2, attempted operative vaginal delivery resulted in a vaginal birth after cesarean delivery in most women and was not associated with increased adverse maternal and neonatal outcomes but was associated with a reduced frequency of endometritis compared with repeat cesarean delivery without operative vaginal delivery attempt.

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        • Hamilton B.E.
        • Martin J.A.
        • Osterman M.J.
        Births: preliminary data for 2015.
        Natl Vital Stat Rep. 2016; 65: 1-15
        • Landon M.B.
        • Hauth J.C.
        • Leveno K.J.
        • et al.
        Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.
        N Engl J Med. 2004; 351: 2581-2589
        • Hibbard J.U.
        • Ismail M.A.
        • Wang Y.
        • Te C.
        • Karrison T.
        • Ismail M.A.
        Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity.
        Am J Obstet Gynecol. 2001; 184: 1365-1373
        • Halscott T.L.
        • Reddy U.M.
        • Landy H.J.
        • et al.
        Maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor.
        Obstet Gynecol. 2015; 126: 1265-1272
        • Contag S.A.
        • Clifton R.G.
        • Bloom S.L.
        • et al.
        Neonatal outcomes and operative vaginal delivery versus cesarean delivery.
        Am J Perinatol. 2010; 27: 493-499
        • Bailit J.L.
        • Grobman W.A.
        • Rice M.M.
        • et al.
        Evaluation of delivery options for second-stage events.
        Am J Obstet Gynecol. 2016; 214: 638.e1-638.e10
        • Alexander J.M.
        • Leveno K.J.
        • Hauth J.C.
        • et al.
        Failed operative vaginal delivery.
        Obstet Gynecol. 2009; 114: 1017-1022
        • Murphy D.J.
        • Liebling R.E.
        • Verity L.
        • Swingler R.
        • Patel R.
        Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.
        Lancet. 2001; 358: 1203-1207
        • Committee on Practice B-O
        ACOG Practice Bulletin No. 154: Operative Vaginal Delivery.
        Obstet Gynecol. 2015; 126: e56-e65
        • Kessous R.
        • Tirosh D.
        • Weintraub A.Y.
        • Benshalom-Tirosh N.
        • Sergienko R.
        • Sheiner E.
        Second stage disorders in patients following a previous cesarean section: vacuum versus repeated cesarean section.
        Arch Gynecol Obstet. 2013; 287: 1075-1079
        • Rietveld A.L.
        • Kok N.
        • Kazemier B.M.
        • de Groot C.J.
        • Teunissen P.W.
        Trial of labor after cesarean: attempted operative vaginal delivery versus emergency repeat cesarean, a prospective national cohort study.
        J Perinatol. 2015; 35: 258-262
        • Majoko F.
        • Gardener G.
        Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births.
        Cochrane Database Syst Rev. 2012; 10: CD005545
        • Uddin S.F.
        • Simon A.E.
        Rates and success rates of trial of labor after cesarean delivery in the United States, 1990-2009.
        Matern Child Health J. 2013; 17: 1309-1314
        • Hamilton B.E.
        • Martin J.A.
        • Osterman M.J.
        • Curtin S.C.
        • Matthews T.J.
        Births: final data for 2014.
        Natl Vital Stat Rep. 2015; 64: 1-64