95: Attempted operative vaginal delivery versus repeat cesarean in the second stage in women undergoing a trial of labor after cesarean

Abstract

In a cohort of women undergoing a trial of labor after cesarean (TOLAC), to compare maternal and neonatal outcomes in those attempting operative vaginal delivery (OVD) with those undergoing a second-stage repeat cesarean delivery (RCD) without OVD attempt. This is a secondary analysis of data in the NICHD MFMU cesarean registry. Women undergoing TOLAC who reached second-stage labor (defined as complete cervical dilation with fetal descent of at least +2 station) were included. Analysis was limited to singleton, nonanomalous gestations with vertex presentation who were liveborn at ≥36 weeks. Those who underwent both forceps and vacuum application were excluded. Women who attempted OVD were compared to those who underwent second stage RCD without OVD attempt. Outcomes of maternal and neonatal complications were compared between groups with bivariable and multivariable analyses. Of 1230 eligible for analysis, 945 (76.8%) had an attempted OVD. Of those who underwent attempted OVD, 914 (96.7%) achieved a vaginal delivery. Women who attempted OVD had a lower mean body mass index (30.4±6.0 vs. 31.8 ±5.9, p=0.001) and gestational age (39.5±1.3 vs. 39.7±1.2 weeks, p=0.021) at delivery; were more likely to be of non-Hispanic black race (30.0% vs. 22.1%, p=0.002), have a prior vaginal delivery (34.9% vs. 20.4%, p<0.001), and have fetal descent greater than +2 station at complete dilation (55.6% vs. 16.8%, p<0.001); and were less likely to have chorioamnionitis (6.8% vs. 19.3%, p<0.001). The frequency of endometritis was significantly lower in women who attempted OVD compared to those who had RCD, but other maternal and neonatal outcomes were similar between the groups. These findings persisted after adjusting for potential confounders (Table). In the setting of a TOLAC in which the second stage with fetal decent to at least +2 station has been reached, attempted OVD was not associated with increased adverse maternal and neonatal outcomes, but was associated with a reduced frequency of endometritis compared to RCD without OVD attempt.