Trial of labor after two cesarean sections: A retrospective case–control study

Abstract

Aim The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. Methods This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. Results A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5‐min APGAR scores <7 between the two groups. Sixty‐eight percent of women who underwent TOLAC ( N = 82) had a successful vaginal delivery. The uterine rupture rate was 1.16% ( N = 1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. Conclusions There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

FIGO good practice recommendations for cesarean delivery: Prep‐for‐Labor triage to minimize risks and maximize favorable outcomes

“…Overall, a previous successful vaginal birth, or the patient entering labor spontaneously will increase VBAC success. This was recently documented even after two previous cesarean deliveries 23 …”

“…This was recently documented even after two previous cesarean deliveries. 23 Ultrasound measurement value for TOLAC is limited. The uterine thickness cut-off to allow TOLAC has not yet been defined,…”

“…| 65 an association between uterine wall thinning and rupture has been reported 23 Thus, ultrasound measurements should not be used as a reliable tool to evaluate if a woman can attempt TOLAC.…”

Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited‐resource setting

“…Tahseen and Griffiths 9 noted that in 71.1% of successful VBA2C, the rate of uterine rupture was 1.36%, with maternal morbidity similar to the repeat cesarean group. In relation to maternal morbidity, Macones et al 9 found a uterine rupture rate of 1.8%, transfusion at 0.92% while Landon et al 21 in North America found uterine rupture at 0.9% (9/975), hysterectomy rate at 0.6% and transfusion at 3.2%.…”

Vaginal Birth after Caesarean (VBAC)

“…The Royal College of Obstetricians and Gynaecologists cautiously states that VBAC can be considered in a pregnant woman at term with 2 previous uncomplicated lower segment caesarean sections after detailed informed consent by the consultant obstetrician but is contraindicated in a patient with 3 previous caesarean sections [22]. A case-controlled study that compared TOLAC and ERSC after 2 prior caesarean section found similar maternal and neonatal morbidity, however the uterine rupture rate was 1.16% compared with none in the ERSC group [60].…”