The MFMU cesarean registry: risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery

Abstract

ObjectiveTo determine and compare success rates of trial of labor (TOL) and uterine rupture in women with single versus multiple prior cesarean deliveries (CDs).Study designProspective 4-year (1999-2002) observational study at 19 academic medical centers of singleton gestations and prior cesarean delivery. Records were reviewed by trained research nurses. Maternal and perinatal outcomes were compared between women with single versus multiple prior CDs.Results17,931 women attempted vaginal birth after cesarean (VBAC); 16,934 (94.5%) had one prior CD, whereas 995 (5.5%) had multiple prior CDs. Higher VBAC success rate was observed in women with one prior CD (73.7%) vs women with multiple prior CDs (65.7%) (P<0.0001). Uterine rupture occurred in 140 cases (0.78%). Multiple prior CDs were associated with higher uterine rupture rate 14/995 (1.4%) versus single prior CD 126/16,936 (0.74%) (P = 0.02). Induction and oxytocin augmentation increased risk of uterine rupture after controlling for single vs multiple prior CDs (P<0.0001). Maternal morbidity was increased in women with multiple prior CDs (see Table).ConclusionThe risk for uterine rupture is significantly elevated in women with multiple prior CDs undergoing TOL. Additional increased risks for these women include hysterectomy and blood transfusion.Tabled 1Multiple vs single prior cesarean deliveriesMultiple CDs N (%)Single CD N (%)RR (95% CI)PUterine rupture14/995 (1.4)126/16934 (0.74)1.89 (1.09-3.27)0.0209Endometritis31/995 (3.1)487/16395 (2.9)1.08 (0.76-1.55)0.6606Maternal death0/995 (0.00)3/16934 (0.02)—1.00Hysterectomy7/995 (0.7)34/16934 (0.20)3.50 (1.56-7.88)0.0068Transfusion32/995 (3.2)275/16935 (1.6)1.98 (1.38-2.84)0.0002Term NICU admit77/674 (11.4)1320/14619 (9.0)1.27 (1.02-1.57)0.0349Term intrapartum stillbirth1/679 (0.15)6/14657 (0.04)3.60 (0.43-29.84)0.2717Term neonatal death1/674 (0.15)11/14619 (0.08)1.97 (0.25-15.25)0.4179 Open table in a new tab ObjectiveTo determine and compare success rates of trial of labor (TOL) and uterine rupture in women with single versus multiple prior cesarean deliveries (CDs). To determine and compare success rates of trial of labor (TOL) and uterine rupture in women with single versus multiple prior cesarean deliveries (CDs). Study designProspective 4-year (1999-2002) observational study at 19 academic medical centers of singleton gestations and prior cesarean delivery. Records were reviewed by trained research nurses. Maternal and perinatal outcomes were compared between women with single versus multiple prior CDs. Prospective 4-year (1999-2002) observational study at 19 academic medical centers of singleton gestations and prior cesarean delivery. Records were reviewed by trained research nurses. Maternal and perinatal outcomes were compared between women with single versus multiple prior CDs. Results17,931 women attempted vaginal birth after cesarean (VBAC); 16,934 (94.5%) had one prior CD, whereas 995 (5.5%) had multiple prior CDs. Higher VBAC success rate was observed in women with one prior CD (73.7%) vs women with multiple prior CDs (65.7%) (P<0.0001). Uterine rupture occurred in 140 cases (0.78%). Multiple prior CDs were associated with higher uterine rupture rate 14/995 (1.4%) versus single prior CD 126/16,936 (0.74%) (P = 0.02). Induction and oxytocin augmentation increased risk of uterine rupture after controlling for single vs multiple prior CDs (P<0.0001). Maternal morbidity was increased in women with multiple prior CDs (see Table). 17,931 women attempted vaginal birth after cesarean (VBAC); 16,934 (94.5%) had one prior CD, whereas 995 (5.5%) had multiple prior CDs. Higher VBAC success rate was observed in women with one prior CD (73.7%) vs women with multiple prior CDs (65.7%) (P<0.0001). Uterine rupture occurred in 140 cases (0.78%). Multiple prior CDs were associated with higher uterine rupture rate 14/995 (1.4%) versus single prior CD 126/16,936 (0.74%) (P = 0.02). Induction and oxytocin augmentation increased risk of uterine rupture after controlling for single vs multiple prior CDs (P<0.0001). Maternal morbidity was increased in women with multiple prior CDs (see Table). ConclusionThe risk for uterine rupture is significantly elevated in women with multiple prior CDs undergoing TOL. Additional increased risks for these women include hysterectomy and blood transfusion.Tabled 1Multiple vs single prior cesarean deliveriesMultiple CDs N (%)Single CD N (%)RR (95% CI)PUterine rupture14/995 (1.4)126/16934 (0.74)1.89 (1.09-3.27)0.0209Endometritis31/995 (3.1)487/16395 (2.9)1.08 (0.76-1.55)0.6606Maternal death0/995 (0.00)3/16934 (0.02)—1.00Hysterectomy7/995 (0.7)34/16934 (0.20)3.50 (1.56-7.88)0.0068Transfusion32/995 (3.2)275/16935 (1.6)1.98 (1.38-2.84)0.0002Term NICU admit77/674 (11.4)1320/14619 (9.0)1.27 (1.02-1.57)0.0349Term intrapartum stillbirth1/679 (0.15)6/14657 (0.04)3.60 (0.43-29.84)0.2717Term neonatal death1/674 (0.15)11/14619 (0.08)1.97 (0.25-15.25)0.4179 Open table in a new tab The risk for uterine rupture is significantly elevated in women with multiple prior CDs undergoing TOL. Additional increased risks for these women include hysterectomy and blood transfusion.Tabled 1Multiple vs single prior cesarean deliveriesMultiple CDs N (%)Single CD N (%)RR (95% CI)PUterine rupture14/995 (1.4)126/16934 (0.74)1.89 (1.09-3.27)0.0209Endometritis31/995 (3.1)487/16395 (2.9)1.08 (0.76-1.55)0.6606Maternal death0/995 (0.00)3/16934 (0.02)—1.00Hysterectomy7/995 (0.7)34/16934 (0.20)3.50 (1.56-7.88)0.0068Transfusion32/995 (3.2)275/16935 (1.6)1.98 (1.38-2.84)0.0002Term NICU admit77/674 (11.4)1320/14619 (9.0)1.27 (1.02-1.57)0.0349Term intrapartum stillbirth1/679 (0.15)6/14657 (0.04)3.60 (0.43-29.84)0.2717Term neonatal death1/674 (0.15)11/14619 (0.08)1.97 (0.25-15.25)0.4179 Open table in a new tab