Trial of labor after cesarean in older women who never delivered vaginally

Abstract

ObjectiveMaternal age is an established determinant of successful trial of labor after cesarean (TOLAC). While an increasing proportion of parturients are aged 40 years and older, and previously underwent a cesarean section, little data regarding TOLAC success for this age group is available. This study assessed TOLAC success, and its associated characteristics, among women >40 years who never delivered vaginally. Study designA retrospective case-control study of all women who never delivered vaginally aged ≥40 years with a history of previous cesarean delivery, who delivered at our hospital during 2006-2017. Maternal, neonatal, and delivery characteristics were compared between women with successful and unsuccessful TOLAC. ResultsOf 335 older women who never delivered vaginally with a history of one cesarean delivery, 61 (18.2 %) elected TOLAC (18.2 %); the median age was 41[40–42] years and the inter-delivery interval 34 [25–50] months. Overall, 38/61 (62.3 %) had a successful TOLAC. Women with successful TOLAC had a higher rate of a non-recurrent indication for cesarean delivery in their previous cesarean delivery (42.1 % vs. 13.0 %, P = 0.01), whereas dysfunctional labor at previous delivery was more common in the failed TOLAC group (47.8 % vs. 15.8 %, P = 0.007). Failed TOLAC was associated with the presence of gestational diabetes (13.0 % vs. 0 %, P = 0.02) and having a comorbidity (47.8 % vs. 21.0 %, P = 0.02). Induction of labor at TOLAC was more common in the failed TOLAC group (34.8 % vs. 2.6 %, P < 0.001). Birthweight was higher in the failed TOLAC group (3330 vs. 3107 g, P = 0.04), as well as the birthweight difference between deliveries (212 g vs. 82 g, P = 0.03). Neonatal and maternal outcomes were comparable between groups, except for longer length of stay (5 vs. 4 days, P = 0.04) in the failed TOLAC group. In a multivariable logistic regression analysis, only two factors were independently associated with TOLAC failure: previous cesarean delivery due to dysfunctional labor (OR [95 % CI]: 13.40 (1.29, 138.71), P = 0.03) and higher inter-delivery birthweight difference (OR [95 % CI]: 1.18 (1.11, 1.39), P = 0.02). ConclusionsTOLAC in older women who never delivered vaginally is associated with a moderate success rate. The indication for cesarean delivery at the first delivery and inter-delivery birthweight difference were identified as having strong predictive value for TOLAC outcome.