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1 Division of Maternal-Fetal Medicine, Department of Obstetrics and Address for correspondence Sarah C. Lassey, MD, Department of
Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts Obstetrics and Gynecology, Brigham and Women’s Hospital, 75
2 Division of Maternal-Fetal Medicine, Department of Obstetrics and Francis Street, Boston, MA 02115 (e-mail: slassey@partners.org).
Gynecology, Massachusetts General Hospital, Boston, Massachusetts
Am J Perinatol
Abstract Objective The objective of this study was to compare spontaneous labor outcomes in
The cesarean delivery rate has risen significantly in the ultimate decision to undergo TOLAC or a repeat cesarean
United States since the 1970s.1 Currently, nearly one-third delivery should be made by the patient in consultation with
of births occur by cesarean delivery.1 This increase in cesar- her health care provider.”5
ean delivery is associated with a concomitant decrease in the Multiple factors influence a woman’s decision to undergo
rate of trial of labor after cesarean (TOLAC), as many women TOLAC including concern for cesarean delivery during labor,
elect for a repeat cesarean delivery regardless of their a priori perceived safety, past labor experience, provider comfort,
likelihood of vaginal birth after cesarean (VBAC) based on and accessibility to care.5,6 Women with a prior cesarean
clinical characteristics.1–4 The American College of Obste- section have the option to either TOLAC or have a repeat
tricians and Gynecologists states that most women with one cesarean section. In an attempt to inform patient and pro-
prior low transverse cesarean are candidates for TOLAC and vider decision making in the setting of a prior cesarean,
should be counseled regarding this option, but that “the studies have compared TOLAC delivery with elective repeat
cesarean delivery. These studies have shown that with each primary outcome was need for cesarean delivery during
cesarean delivery, maternal morbidity and pregnancy risk labor. Secondary outcomes included both maternal and
increase.7,8 However, this type of comparison does not allow neonatal morbidities. Maternal morbidity included severe
the risks of TOLAC to be put in context in comparison to the hemorrhage (estimated blood loss [EBL] >1,500 mL), infec-
risks of labor in other populations for whom the expectation tion, higher order laceration (third or fourth degree perineal
is that labor will be undertaken. While a repeat cesarean laceration), shoulder dystocia, episiotomy, uterine rupture,
delivery versus a TOLAC is the clinical choice that women and need for additional procedures. Uterine rupture was
with a prior cesarean are facing, the comparison to other defined as a full-thickness disruption of the uterine wall with
laboring groups, and in particular nulliparous women, offers associated changes in the maternal or fetal status. The length
the opportunity to assess the excess risks of labor and vaginal of the second stage of labor and operative delivery rates were
delivery in women with a prior cesarean on a systems level. also recorded. Neonatal outcomes included admission to
Some have suggested that comparing the risks of labor in neonatal intensive care unit (NICU) or triage, birth weight,
women with a prior cesarean to the risks for nulliparous and Apgar <7 at 5 minutes. All women in the study were
women would be useful to avoid inappropriately placing TOLAC given oxytocin (Pitocin), if indicated, per hospital policy,
in a separate category of risk9 without taking into account the which was similar at the two institutions, with initial dosing
baseline risks associated with labor. There remains a lack of of oxytocin (Pitocin) of 2 mU/min with an increase of 1 to
information, however, comparing labor outcomes for women 2 mU/min every 15 minutes and a recommended maximum
with a prior cesarean delivery to nulliparas.8,10 We sought to dose of oxytocin (Pitocin) of 20 mU/min. Intrauterine pres-
address this evidence gap by comparing the outcomes of sure catheters were used at the discretion of the provider.
declined trial of labor when presenting in labor, resulting in 606 In our cohort, the predicted likelihood of VBAC from the
participants (►Supplementary Fig. 1, available in the online MFMU-VBAC calculator ranged from 22.0 to 84.7% with a
version). These were matched with the next nulliparous woman median of 61.4%. Overall, 20.6% of the women undergoing
at term presenting in spontaneous labor at the same institution. TOLAC had a predicted likelihood of less than 50%
►Table 1 compares demographic characteristics for the (►Supplementary Fig. 2, available in the online version). We
TOLACs and nulliparas. Women undergoing TOLAC were plotted the cesarean delivery rate at various thresholds of
older (31.5 vs. 29.3 years; p < 0.01), heavier (pre-pregnancy predicted likelihood of VBAC in the women undergoing TOLAC
body mass index [BMI] 26.1 vs. 24.7; p < 0.01), more likely to (►Fig. 1). As shown, at approximately a predicted likelihood of
be black (16.9 vs. 11.8%; p < 0.01) or Hispanic (17.4 vs. 60% the lower bound CI approaches the average for nulliparous
15.3%; p < 0.01), and more likely to have diabetes (4.1 vs. women and at approximately a predicted likelihood of 70% or
1.3%; p < 0.01) or hypertension (6.4 vs. 3.3%; p < 0.01). more the mean rate of cesarean delivery for women under-
There was no significant difference in gestational age at going TOLAC appears no different from nulliparous women.
the time of spontaneous labor. The group with a predicted likelihood of VBAC of 70% or more
Our primary outcome, cesarean delivery during labor, accounted for 29.7% of our sample. Comparing these women to
occurred more frequently in women undergoing TOLAC all nulliparas, there was no difference in cesarean delivery rate
(25.7 vs. 14.7%, p < 0.001). Maternal and neonatal complica- (16.7 vs. 14.7%; p ¼ 0.51) or maternal or immediate neonatal
tion rates were similar with the exception of the risk of complications (►Table 3).
severe hemorrhage (1.5 vs. 0.2%; p ¼ 0.02) and uterine rupture
(12 out of 606 women [1.9%] vs. 0 out of 606 woman [0.0%];
Abbreviations: BMI, body mass index; CI, confidence interval; TOLACs, trial of labor after cesareans.
Abbreviations: NICU, neonatal intensive care unit; TOLACs, trial of labor after cesareans.
MFMU-VBAC calculator (►Fig. 1). This higher than predicted delivery prenatally about their outcomes should they pre-
success score is likely due in part to the fact that we only sent in spontaneous labor.
included women in spontaneous labor and excluded labor Patients considering TOLAC may be reassured to know
induction, whereas the population studied to create the that if they present in spontaneous labor, their labor out-
VBAC calculator included 26% labor induction. Therefore, comes are similar to those of nulliparous women. Further, it
our results are generalizable only to this spontaneous labor may provide additional encouragement to women with a
subset. However, we similarly excluded nulliparous women likelihood of VBAC of 70% or more to know that their rate of
undergoing labor induction. Given potentially different cesarean delivery in labor is actually equivalent to nullipar-
thresholds clinicians may have to induce women undergoing ous women. Our desire was not to encourage a cut-off at 70%
TOLAC, we felt that using women in spontaneous labor was a success (whereby women with a prior cesarean delivery and
more accurate comparison and still provides meaningful a lower predicted success score are not encouraged to
information for counseling women with a prior cesarean TOLAC), as choosing a TOLAC is a reasonable option for
many with women with a less favorable predicted likelihood
based on other clinical characteristics and patient prefer-
ence. Rather, we felt that understanding the group of women
with a prior cesarean delivery who are similar to nulliparous
women in terms of obstetric outcomes in labor may provide
reassurance and encouragement to undergo TOLAC in these
women who are excellent candidates and at the lowest risk of
morbidity.
Of note, our uterine rupture rate of 1.9% in women under-
going TOLAC is higher than found in previous studies.7 The
exact reasons for this are unknown. It may be due to chance
as uterine rupture is a rare outcome or may in part be due to
the fact that there were many poor candidate TOLACs (with a
low predicted success score) in our cohort. However, even
among the 12 women undergoing TOLAC who did have a
uterine rupture, there were low rates of maternal/neonatal
morbidity.
Fig. 1 Cesarean delivery rates by vaginal birth after cesarean (VBAC) Our study is not without limitations. Clinical character-
success prediction. istics and outcomes were ascertained from the medical
Abbreviations: NICU, neonatal intensive care unit; TOLACs, trial of labor after cesareans.
a
Good candidate TOLACs are those with a predicted success of 70% or more.
9 Minkoff H, Fridman D. The immediately available physician cine Units Network (MFMU). Development of a nomogram for
standard. Semin Perinatol 2010;34(05):325–330 prediction of vaginal birth after cesarean delivery. Obstet Gynecol
10 Cunningham FG, Bangdiwala S, Brown SS, et al; National Institutes 2007;109(04):806–812
of Health Consensus Development Conference Panel. National 12 Grobman WA, Lai Y, Landon MB, et al; Eunice Kennedy Shriver
Institutes of Health Consensus Development conference state- National Institute of Child Health and Human Development
ment: vaginal birth after cesarean: new insights March 8-10, Maternal-Fetal Medicine Units Network. Can a prediction model
2010. Obstet Gynecol 2010;115(06):1279–1295 for vaginal birth after cesarean also predict the probability of
11 Grobman WA, Lai Y, Landon MB, et al; National Institute of Child morbidity related to a trial of labor? Am J Obstet Gynecol 2009;
Health and Human Development (NICHD) Maternal-Fetal Medi- 200(01):56.e1–56.e6