Trial Of Labor After Cesarean Section Research Articles

Predictors of successful trial of labor after cesarean section (TOLAC) in women with one prior transverse cesarean section at Tertiary Hospitals in northwest Ethiopia: a multicenter study

BackgroundTrials of labor after cesarean section is the preferred strategy to decrease the cesarean delivery rate and reducing complications associated with multiple cesarean sections. The success rate of trials of labor after cesarean section and associated factors have not been well documented in Ethiopia. Hence, this study was aimed to determine the success rate and factors associated with the trial of labor after one cesarean section in five Comprehensive Specialized Hospitals located in northwest Ethiopia.MethodsAn institutional-based cross-sectional study was conducted among 437 women who came for the trial of labor from December 1, 2021, to March 30, 2022. All women who fulfilled the eligibility criteria were included to this study. Data was collected using structured and pre-tested questionnaire. Then, the data was entered into Epi Data 4.6 software and exported to SPSS version 26 for analysis. To identify the variables influencing the outcome variable, bivariable and multivariable logistic regression analyses were conducted. The model’s fitness was checked using the Hosmer-Lemeshow goodness of fit test, and an adjusted odds ratio with a 95% confidence interval was used to declare the predictors that are significantly associated with TOLAC.ResultsThe success rate of the trial of labor after one cesarean section was 56.3% (95% CI, 51.3%, 61.2%). Maternal age ≥ 35 years (AOR: 3.3, 95% CI 1.2, 9.3), the fetal station at admission ≤ zero (AOR: 5. 6, 95% CI 3.3, 9.5), vaginal delivery before cesarean section (AOR: 1.9, 95% CI 1.2, 3.2), and successful vaginal birth after cesarean delivery (AOR 2.2, 95% CI 1.2, 4.1) were found to have a significant association with the success rate of trial of labor after cesarean section.ConclusionsIn this study, the success rate of the trial of labor after a cesarean section was low as compared to the ACOG guideline and other studies in different countries. Therefore, the clinicians ought to offer counsel during antenatal and intrapartum period, encourage the women to make informed decision on the mode of delivery, and the practitioners need to follow fetal and maternal conditions strictly to minimize adverse birth outcomes.

Outcomes of Trial of Labor after a Cesarean Section in Bomet County, Kenya

Trial of labor after cesarean section (TOLAC) is recommended for women with one prior cesarean section. However, TOLAC positive outcomes depend on selecting candidates to achieve higher success rates. Most available TOLAC data to inform patient selection originates from developed countries, which limits a patient-centered TOLAC practice in low-resource settings. Thus, we used a prospective observational cross-sectional approach to assess the success rate of TOLAC and establish the maternal and fetal factors associated with successful TOLAC in 170 women with one previous scar at two referral hospitals in Bomet County, a low-resource setting in Kenya. The primary maternal and neonatal outcomes were compared between those who had a vaginal birth after a cesarean section (VBAC) and those who had an emergency repeat cesarean section (ERCS) following a failed TOLAC between October 2022 and June 2023. The TOLAC success rate was 48.2% with the most common indication for emergency repeat cesarean section being failure to progress (34.1%). Factors associated with successful TOLAC included inter-delivery interval >60 months (p-0.044), and parity 2-4 (p- <0.001). Breech presentation and non-reassuring fetal status (NRFS) as indications for previous cesarean section, were associated with a successful VBAC (p-< 0.001, 0.033). In contrast, a birth weight of >3500 g was associated with an increased risk of ERCS. Moreover, a failed TOLAC was associated with a prolonged (>4 days) hospital stay (p-0.012). Our findings suggest that with proper patient selection, TOLAC remains a viable option with better outcomes if successful. However, TOLAC candidates should be evaluated based on the contextual factors of a given setting, hence careful patient selection is recommended to improve outcomes associated with TOLAC.

Development of a multivariate predictive nomogram among women with antepartum fetal death diagnosed at ≥ 34 weeks of gestation for outcome of TOLAC.

The present study was planned to develop a nomogram that will give a priori estimate on the probability of vaginal birth from maternal features in women with antepartum fetal death diagnosed at ≥ 34week's gestation and previous one low transverse cesarean section (LTCS). This will help to reduce maternal complications and increase confidence when planning a trial of labor after cesarean section (TOLAC). A prospective observational study was planned where participants underwent induction of labor with Foley's catheter (unless already in spontaneous labor) within 24h of enrolment. Participants with absent or inadequate contractions, oxytocin infusion as an additional agent was used. Data was collected on maternal predelivery features. Outcome of participants was categorized into two classes-vaginal and cesarean delivery. Classifiers were trained with data on maternal features and the accuracy of predicting outcome class determined. The classifier with maximum accuracy was used to develop a nomogram. Three hundred and one women underwent treatment as per protocol. Two hundred and twenty women attained successful vaginal delivery and eighty-one women underwent caesarean section. Factors having a significant impact on outcome were maternal body mass index (BMI), bishop score, duration of augmentation, estimated foetal weight, interval from previous LTCS, admission to active labor interval, vaginal delivery after LTCS and gestational age. The Naïve -Bayes model gave the highest prediction accuracy (0.88). Non-linear classifiers by using selective features could predict the outcome of TOLAC among women with intra-uterine fetal death attempting vaginal birth at or beyond 34weeks gestation with high accuracy.

Delivery after a previous cesarean section reviewed.

At the start of the 20th century, cesarean section (CS) was uncommon in obstetrics. By the end of the century, CS rates had increased dramatically worldwide. Although the explanation for the increase is multifactorial, a major driver in the ongoing escalation is the increase in women who are delivered by repeat CS. This is due, in part, to the fact that there has been a sharp fall in vaginal birth after CS (VBAC) rates as fewer women are offered a trial of labor after CS (TOLAC), due principally to fears of a catastrophic intrapartum uterine rupture. This paper reviewed international VBAC policies and trends. A number of themes emerged. The risk of intrapartum rupture and its associated complications is low and may sometimes be overestimated. Individual maternity hospitals in both developed and developing countries are inadequately resourced to safely supervise a TOLAC. Efforts to mitigate the risks of TOLAC by careful patient selection and good clinical practices may be underutilized. Given the serious short-term and long-term consequences of rising CS rates for women and for maternity services generally, a review of TOLAC policies worldwide should be prioritized and consideration given to convening a Global Consensus Development Conference on Delivery after CS.

Delivery mode and fetal outcome in attempted vaginal deliveries after previous cesarean section: a nationwide register-based cohort study in Finland

Purpose Even though the risks and advantages of repeat Cesarean sections (CSs) and vaginal births after cesarean section (VBACs) are well studied, there is a scarcity of information on the effects of previous CS on maternal and fetal outcomes during subsequent deliveries. The aim of this study is to evaluate delivery mode and fetal outcomes in a trial of labor after cesarean section (TOLAC). Methods In this nationwide retrospective cohort study, data from the National Medical Birth Register (MBR) were used to evaluate the outcomes of TOLACs. TOLACs were compared to the outcomes of the trial of labor after previous successful vaginal delivery. A multivariable logistic regression model was used to assess the primary outcomes (delivery mode, neonatal intensive care unit, and perinatal/neonatal mortality). Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used for comparison. Results A total of 29 352 (77.0%) women attempted vaginal delivery in the TOLAC group. In the control group, 169 377 (97.2%) women attempted vaginal delivery. The adjusted odds for urgent CS (aOR 13.05, CI 12.59–13.65) and emergency CS (aOR 3.65, CI 3.26–4.08) were notably higher in the TOLAC group when compared to the control group. The odds for neonatal intensive care unit treatment (aOR 2.05, CI 1.98–2.14), perinatal mortality (aOR 2.15, CI 1.79–2.57), and neonatal mortality (aOR 1.75, CI 1.20–2.49) were higher in the TOLAC group. Conclusions The odds for emergency CS were higher among women who underwent TOLAC. The odds for neonatal intensive care and perinatal mortality were also higher, and further research is needed to identify those expecting women who are better suited for TOLAC to minimize the risk for a neonate. The results of this study should be acknowledged by the mother and the clinician when considering the possibility of vaginal births after cesarean section.

Grand multiparity, is it a help or a hindrance in a trial of labor after cesarean section (TOLAC)?

Objective Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture. Study design A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 – women who had a parity of 1; group 2 – parity of 2–4; group 3 – parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher’s exact test, Chi-square test, ANOVA, and paired t-test. Results Five thousand four hundred and forty-seven women comprised the study group: group 1 – 879 patients, group 2 – 2374 patients, and group 3 − 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9–6.5, p<.001) and group 3 (OR 5.17, 95% CI 4.0–6.7, p<.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8–1.4, p=.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively (p<.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% p=.02) and group 3 (1.02% vs. 0.2%, p=.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% p=.78). Conclusions Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC.

To Try or Not to Try: A Questionnaire Study among Women with Previous Lower Segment Cesarean Section.

The recent increase in the cesarean section (CS) rate worldwide has led to global concerns and vaginal birth after CS (VBAC) as an effective way to reduce the CS rate. In this study, our main aim was to know about various factors that help women make their preferred mode of delivery following a previous CS. This was a questionnaire-based study conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Jodhpur, among 200 women with previous one lower segment CS (LSCS). Elective repeat cesarean delivery (ERCD) was found to be more among uneducated women and those who had complications in their previous babies. The most common reason for opting for ERCD was fear of labor pains. Women who were counseled by senior doctors were more likely to opt for a trial of labor after cesarean section (TOLAC). Improving the education levels of mothers, counseling about advantages associated with vaginal birth, counseling by senior obstetrician, and information regarding labor analgesia can decrease CS rates.

A Trial of Labor after Cesarean Section with a Macrosomic Neonate. Is It Safe?

This study aimed to determine whether a trial of labor after cesarean section (TOLAC) with a macrosomic neonate is associated with adverse outcomes. A retrospective cohort study was conducted in a population motivated for TOLAC. Women attempting TOLAC with a neonatal birth weight >4,000 g were compared with women attempting TOLAC with neonatal birth weights between 3,500 and 4,000 g. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery, uterine rupture, postpartum hemorrhage (PPH), shoulder dystocia, obstetric anal sphincter injury (OASI), Apgar's score <7 at 5 minutes, and umbilical artery pH <7.1. Data were analyzed using Fisher's exact test and Chi-square test. Overall, 375 women who underwent TOLAC with a neonate weighing >4,000 g comprised the study group. One thousand seven hundred and eighty-three women attempting TOLAC with a neonate weighing 3,500 to 4,000 g comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, parity, and vaginal birth after cesarean (VBAC) rate. There were no significant differences in the rates of successful TOLAC (94 vs. 92.3%, p = 0.2, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.5, 1.2), operative vaginal delivery (7.4 vs. 5.3%, p = 0.18, OR = 0.7, 95% CI: 0.4, 1.1), uterine rupture (0.4 vs. 0%, p = 0.6), PPH (3.2 vs. 2.3%, p = 0.36, OR = 1.4, 95% CI: 0.7, 2.7), OASI (0.8 vs. 0.2%, p = 0.1, OR = 3.6, 95% CI: 0.8, 1.6), Apgar's score <7 at 5 minutes (0 vs. 0.4%, p = 0.37), and umbilical artery pH <7.1 (0.5 vs. 0.7%, p = 1.0, OR = 0.73, 95% CI: 0.2, 3.2). Women with a neonate weighing >4,000 g had a significantly increased risk of shoulder dystocia (4 vs. 0.4%, p < 0.05, OR = 9.2 95% CI: 3.9, 22) CONCLUSION: Women attempting TOLAC with a macrosomic neonate are not at increased risk for failed TOLAC, operative vaginal delivery, uterine rupture, PPH, or OASI but are at risk of shoulder dystocia. This information may aid in prenatal counseling for women considering TOLAC with a macrosomic fetus. · TOLAC with fetal macrosomia does not increase the risk of uterine rupture.. · TOLAC with fetal macrosomia is associated with high chances of VBAC.. · TOLAC with fetal macrosomia is not associated with adverse neonatal outcomes..

Establish and application of scoring scale for trial of labor after cesarean section

Objective: To establish a scoring scale for trial of labor after cesarean section (TOLAC), to explore the evaluation ability of this scoring scale for vaginal delivery after cesarean section (VBAC), and to improve the success rate of TOLAC. Methods: The delivery information of 661 TOLAC pregnant women admitted to Zhengzhou Central Hospital Affiliated to Zhengzhou University from 2014 to 2017 was retrospectively analyzed, and the TOLAC scoring scale was established by referring to relevant literatures. A prospective cohort study of pregnant women with TOLAC from January 2018 to December 2019 in Zhengzhou Central Hospital was conducted, including 440 pregnant women who were excluded from contraindications in trial labor. According to TOLAC scoring scale, pregnant women were divided into 3 groups, 0-6 group (94 cases), 7-9 group (234 cases) and 10-15 group (112 cases). The success rate of trial labor, failure reasons and incidence of maternal and neonatal complications were compared among the three groups. Results: (1) The overall success rate of TOLAC in 440 pregnant women was 75.0% (330/440). The success rates of 0-6, 7-9 and 10-15 groups were 53.2% (50/94), 76.9% (180/234) and 89.3% (100/112), respectively. The success rate of 10-15 group were significantly higher than those of 0-6 and 7-9 groups (all P<0.05). (2) Among the causes of trial labor failure, there were statistically significant differences between the three groups in terms of threatened uterine rupture and maternal abandonment (all P<0.05). Pairings showed that the incidences of threatened uterine rupture and maternal abandonment in 0-6 group was lower than those in 7-9 and 10-15 groups, and the differences were statistically significant (all P<0.05). (3) Maternal and neonatal complications mainly included postpartum hemorrhage and neonatal asphyxia, but there were no significant difference in the incidence of TOLAC success or failure among the three groups (all P>0.05). There was no uterine rupture in all groups. (4) The main factors affecting TOLAC score of pregnant women in the three groups included natural labor, estimated weight of the fetus at this time, Bishop score of the cervix at admission and gestational age, and the scores of the above indexes in 10-15 group were significantly higher than those in 0-6 group and 7-9 group (all P<0.05). Conclusions: TOLAC scoring scale has more accurate evaluation ability for VBAC, which could improve the success rate of TOLAC and maternal and child safety. The score of 0-6 is not recommended for vaginal trial labor, the score of 7-9 is recommended for vaginal trial labor, and the score of 10-15 is strongly recommended for vaginal trial labor.

Reducing surgical complications after cesarean section: Vaginal birth after cesarean section. Identifying the ideal candidate

Vaginal birth after cesarean section (VBAC) is worldwide accepted and encouraged. Currently, in Romania due to increased cesarean section rate especially for maternal request, a high number of patients with scarred uterus is seeking for VBAC at subsequent pregnancies. Because of specific complications of trial of labor after cesarean section (TOLAC), risks and benefits need to be individualized for each specific candidate. This study is about VBAC in Filantropia Clinical Hospital from Bucharest and how we are selecting the ideal candidate.

Risk of labor induction or augmentation on uterine rupture during trial of labor after cesarean

Following data by the Consortium on Safe Labor documenting rising cesarean rates in 2008, guidelines were updated to encourage a trial of labor after cesarean section (TOLAC). Previous data suggests that induction and augmentation of labor is associated with increased rates of uterine rupture. However, due to the rarity of this outcome, precise estimates of risk are difficult to calculate. The aim of this study was to assess the risk of TOLAC in women undergoing augmentation or induction of labor in a large nationally representative cohort.

Changes in lower uterine segment thickness during different gestational weeks in pregnant women qualified for trial of labor after cesarean section.

ObjectiveTo investigate the correlation between lower uterine segment thickness (LUST) and gestational weeks (GW) in women who attempted trial of labor after cesarean section (TOLAC) and to estimate the reference ranges of LUST.MethodsA prospective cohort study was conducted between January 2019 and December 2020 at a tertiary‐care center in Foshan, China. A total of 2588 women who attempted TOLAC were included. LUST was measured in different trimesters using transabdominal ultrasound. Histograms were used to review the mean and standard deviations (SD) of LUST at different GW.ResultsThe mean LUST of the patients were 6.90 ± 2.86, 4.36 ± 1.87, 2.83 ± 0.65, and 2.57 ± 0.51 mm in the first (12.10 ± 1.28 weeks), second (21.79 ± 3.40 weeks), middle third (34.28 ± 2.64 weeks), and late third (38.20 ± 1.00 weeks) trimesters, respectively. An inverse correlation was noted between LUST and uterine rupture in women who underwent a planned ERCD (P < 0.001), but not in women who attempted TOLAC during the late third trimester (P = 0.629).ConclusionLUST is inversely correlated with GW and decreases faster in the first and second trimesters than in the middle and late third trimesters. TOLAC should be approached with caution for pregnant women with a thin myometrium in late third trimester.

Professional ethics, VBAC and COVID-19 pandemic: A challenge to be resolved (Review).

Since the declaration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic by the World Health Organization (WHO) on March 11, 2020, the entire healthcare system is trying to adapt its capabilities to a challenge that induces a deep and continuous metamorphosis of people, strategies and policies. The right to proper health care is universal, and the patient's autonomy must be respected even in ambiguous times. In the context of increased Cesarean section (CS) rates, the women's desire to achieve vaginal birth after Cesarean section (VBAC) is becoming more articulate, and healthcare professionals need to adapt their approaches regarding the mode of delivery. But how to balance this aspect with respect to the paucity of resources during the pandemic, without infringing the fundamental rights and ethical principles is a demanding question. This article describes a clinical ethical decision-making framework for recommending trial of labor after Cesarean section (TOLAC), and individualized management of VBAC cases tailored upon the new circumstances dictated by the SARS-CoV-2 pandemic.

735 TOLAC versus repeat cesarean section amongst women with a twin gestation: a retrospective cohort study

Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals in the USA no longer offer a trial of labor after cesarean section (TOLAC). TOLAC amongst women with a singleton gestation is widely accepted but there is a paucity of data on TOLAC in twin gestations. We sought to assess maternal and neonatal outcomes amongst women with a current twin gestation and a prior cesarean section who opted to undergo TOLAC versus repeat cesarean section. This retrospective cohort study was undertaken at a community medical center from January 1st 2010 to December 31st 2019. Inclusion criteria were women with a current twin pregnancy at > 32 weeks gestation, presenting twin in vertex presentation and a history of one prior cesarean section. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, non-vertex presenting twin, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 83 patients fulfilled study criteria. 81% of women who underwent TOLAC (N=21) had a successful vaginal delivery. There was no difference in mean gestational age between the two groups (37+2 vs 36+6 weeks, P=0.24). There were no differences in neonatal intensive care unit admissions for twin A (29% vs 28.6%, P=0.96) or twin B (27.4% vs 28.6%, P=0.94) and 5 minute APGAR scores for twin A (P=0.24) or twin B (P=0.63) amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (4.8% vs 4.8%, P=1.0), bowel injury (0% vs 1.6 %, P=1.0) and immediate postpartum infection (0% vs 1.6 %, P=1.0). No hysterectomy, bladder injury, maternal or neonatal deaths occurred in either group. TOLAC following one prior cesarean section for women with a twin gestation has comparable maternal and neonatal morbidity with repeat cesarean section.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

Background The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. Objective Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy Methods From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. Results The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. Conclusion In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Safety and feasibility of trial of labor in pregnant women with cesarean scar diverticulum.

ObjectiveLiterature on trial of labor after cesarean section (TOLAC) in women with isthmoceles is scarce because of complications associated with the procedure. This study investigated TOLAC's safety and feasibility in patients with isthmoceles.MethodsThe study group comprised 34 pregnant women with isthmoceles who vaginally delivered. The control group comprised 102 pregnant women without isthmoceles who vaginally delivered during the same period. Scar diverticula were measured using color Doppler ultrasonography; between-group delivery outcomes were compared.ResultsOf the study group patients, 27/34 had isthmoceles diagnosed by ultrasound before pregnancy. Nineteen (70.37%) of these patients had mild defects and eight (29.63%) had moderate defects. The scar diverticula's mean length, depth, and width were 1.05 ± 0.62, 0.54 ± 0.28, and 1.20 ± 0.70 cm, respectively. The residual muscle layer's mean thickness was 0.27 ± 0.07 cm. The mean diverticulum depth/residual muscular thickness ratio was 2.39 ± 2.58. The duration of the first stage of labor was significantly shorter and the neonatal weight was significantly lower in the study group than control group.ConclusionSuccessful vaginal delivery is possible for women with mild and moderate isthmoceles. Further large-scale studies are needed to improve TOLAC's safety in pregnant women with isthmoceles.

Factors affecting the success rate of vaginal birth after cesarean section

Introduction: The success rate of vaginal birth after cesarean section (VBAC) varies among institutions and health care providers. It is also affected by various antepartum, intrapartum factors as well as the difference in the obstetric population. Objectives: The main aim of the study is to determine the factors that affect the success rate of vaginal birth after cesarean section. This will help us to choose the right patients for VBAC thereby decreasing the complications of an emergency cesarean section. Methods: This is a prospective, cohort study done over a period of twelve months. Based on the patient's preference a total of 211 women were divided into two groups either a trial of labor after cesarean section (TOLAC) or elective repeat cesarean section (ERCS) group. VBAC group was compared with the failed trial of labor group to determine the factors affecting the success rate. Result: The success rate of VBAC was found to be 47.9%. About 15% of failed VBAC was due to the tendency to abandon a TOLAC midway. The success rate of VBAC increased in women with previous vaginal delivery and in those who went into spontaneous labor. Epidural was found to be safe to use in the trial of the labor group. Conclusion: Women with factors that increase the likelihood for vaginal delivery following cesarean section should be motivated well and referred to a tertiary center to improve the success rate as well as to reduce the maternal and fetal morbidity

Characterizing Relationships Between Prenatal Care and TOLAC Outcomes in an Urban Population [07P

INTRODUCTION: Several studies have been published on factors predicting success rates of Trial of Labor after Cesarean section (TOLAC). Limited data exists on the relationship between prenatal care provider type and sufficiency of prenatal care. The purpose of this study is to evaluate the relationship between prenatal care provider and TOLAC outcomes. METHODS: Retrospective comparative analysis was performed on 289 charts. IRB approval was obtained. Criteria included patients delivered between 2013–16 with Singleton gestation, vertex presentation and at least 1 prior cesarean section attempting TOLAC at our institution. Exclusion criteria included multiple gestations, still birth and contraindications to vaginal delivery. ANOVA tests were used for the continuous variables and Chi-square test or Fisher's exact test were used for categorical variables. P-value &lt;.05 considered for statistical significance. RESULTS: A total of 289 charts were reviewed. 176 patients achieved Vaginal Birth After Cesarean section (VBAC). Patients who received prenatal care from Physicians had higher VBAC rates when compared to patients who received care from CNMs at our institution (P&lt;.0002). No statistically significance between TOLAC success and sufficiency of prenatal care was noted. There were no statistical differences between the two groups regarding Age, BMI, Race, Co-morbidities, IUGR, Calculated success scores. CONCLUSION: This study sheds light on relationship between providers, type of prenatal care and VBAC rates, a rarely explored area in TOLAC research. The results are from a single institution that functions as a staff model. Larger multi institutional prospective trials are necessary to prove or disprove results.

Trial of Labor After Two Cesarean Sections Versus Repeat Cesarean Section: A Retrospective Cohort Study [37P

INTRODUCTION: Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals no longer offer a trial of labor after cesarean section (TOLAC). We sought to assess maternal and neonatal outcomes amongst women with two prior cesarean sections who opted to undergo TOLAC versus repeat cesarean section. METHODS: This retrospective cohort study was undertaken at a community medical center from January 1st 2008 to December 31st 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, history of uterine rupture, placenta previa or invasive placentation, non-vertex presentation, or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. RESULTS: A total of 796 patients fulfilled study criteria. 69% of women who underwent TOLAC (N=85) had a successful vaginal delivery. There were no differences in neonatal intensive care unit admissions (5.7% vs 5.9%, P=1.0) or mean APGAR scores at one (P=.38) and five (P=.42) minutes amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (2.3% vs 2.1%, P=.71), bowel injury (0% vs 0.1%, P=1.0), bladder injury (1.1% vs 0.1%, P=.21), immediate postpartum infection (0% vs 0.8%, P=1.0) and hysterectomy (0% vs 0.1%, P=1.0). CONCLUSION: TOLAC following two cesarean sections has comparable maternal and neonatal morbidity with repeat cesarean section.

Maternal Outcomes of Trial of Labor After Cesarean Delivery Compared With Elective Repeat Cesarean Delivery [23P

INTRODUCTION: The vaginal birth after cesarean (VBAC) calculator developed by the MFMU Network helps to identify the likelihood of VBAC. It is not clear if undergoing a trial of labor after cesarean section (TOLAC) is associated with adverse maternal outcomes if the VBAC success rate is low. We compared maternal outcomes of TOLAC to those of elective repeat cesarean delivery after stratifying by the VBAC likelihood. METHODS: This was a retrospective cohort study of all women whose primary cesarean delivery and subsequent singleton delivery occurred at our academic center. Data from the second pregnancy were analyzed. The likelihood of VBAC success was categorized using the MFMU VBAC calculator, (less than 60% and 60–100%). The primary outcome was a composite of maternal complications (uterine rupture, postpartum hemorrhage). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI). RESULTS: Of 626 women, 469 (75%) and 157 (25%) had VBAC likelihood of 60–100% and less than 60%, respectively. Women with VBAC likelihood less than 60% and likelihood of 60–100% who had underwent TOLAC were compared with those who had an elective repeat cesarean. Both groups had similar rates of the primary outcomes; likelihood less than 60% (25% vs. 16.5%; adjusted OR 1.51 [95% CI 0.60–3.78]) and likelihood 60–100% (14.3% vs 13.8%; adjusted OR 1.04 [95% CI 0.60–1.79]). CONCLUSION: Women with a history of a primary cesarean delivery, who underwent TOLAC compared to those who had an elective repeat cesarean had similar odds of maternal adverse outcomes regardless of the VBAC likelihood.