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

摘要

Objective To compare outcomes with trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery on maternal request (ERCD-MR). Design Prospective cohort study. Setting Danish university hospital. Population Women 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. Methods Data were obtained from the Aarhus Birth Cohort database, which comprised prospective registration of the deliveries. Main outcome measures Adverse neonatal outcomes, risk factors for emergency cesarean, and uterine rupture in case of TOLAC. Results TOLAC 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 12 months. 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 ≥35 years (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 4000-4499 g (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). Conclusion TOLAC is an acceptable individualized option for women without major risk factors.