Trial of labor compared to repeat cesarean section in women with no other risk factors than a prior cesarean delivery

ObjectiveTo compare outcomes with trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery on maternal request (ERCD-MR). DesignProspective cohort study. SettingDanish university hospital. PopulationWomen with TOLAC (n=1161) and women with ERCD-MR (n=622) between 2003 and 2010. Exclusion criteria were diabetes, two prior cesarean sections, index cesarean at a different hospital, a delivery after the index cesarean, twin gestation, gestational age <37(+0)weeks and stillbirth. MethodsData were obtained from the Aarhus Birth Cohort database, which comprised prospective registration of the deliveries. Main outcome measuresAdverse neonatal outcomes, risk factors for emergency cesarean, and uterine rupture in case of TOLAC. ResultsTOLAC was associated with an increased risk of neonatal depression [odds ratio (OR) 3.6, 95% confidence interval (CI) 1.1-19.1] and neonatal intensive care unit admission (adjusted OR 1.9, 95% CI 1.3-2.8). Within the TOLAC group 67% delivered vaginally. In the TOLAC group 1.3% (n=15) of the women had a complete uterine rupture. None of these infants had sequelae after 12months. Significant risk factors for emergency cesarean were no prior vaginal delivery (adjusted OR 1.8, 95% CI 1.1-3.0), index emergency cesarean during labor (adjusted OR 3.0, 95% CI 2.3-4.1), maternal age 35years (adjusted OR 1.9, 95% CI 1.3-2.8), pre-pregnancy body mass index 30 (adjusted OR 2.1, 95% CI 1.3-3.3), and birthweight 4000-4499g (adjusted OR 1.5, 95% CI 1.1-2.1). Uterine rupture was associated with the use of epidural analgesia (OR 2.2, 95% CI 1.1-4.9) and no prior vaginal delivery (p=0.03). ConclusionTOLAC is an acceptable individualized option for women without major risk factors.