Successful Trial Of Labor After Cesarean Research Articles

Risks and Probabilities of Adverse Pregnancy Outcomes in Patients Undergoing Trial of Labor after Cesarean-A Retrospective Study.

(1) Background: Trial of labor after cesarean (TOLAC) can be associated with significant maternal and neonatal complications, and the aim of this retrospective study was to calculate the risks and probabilities of these complications in two tertiary maternity centers in Romania. (2) Methods: A total of 216 patients who attempted TOLAC were included in the study and were segregated into two groups, depending on TOLAC success. Medical records were assessed, and clinical data were used to determine the maternal and neonatal risks and complications, using multinomial logistic regression and postestimation predictions. (3) Results: Our data indicated that patients who had a failed TOLAC had significantly higher risks and probabilities of uterine rupture, either complete or incomplete; intensive care unit (ICU) admission; and emergency hysterectomy. The newborns of these mothers had significantly higher risks and probabilities of low Apgar score at birth, neonatal intensive care unit (NICU) admission, and invasive ventilation. (4) Conclusions: Failed TOLAC could lead to significant maternal and neonatal complications, and women who attempt this procedure should be monitored in a tertiary center where a multidisciplinary team and an emergency operating room are available.

Trial of Labor versus Repeat Cesarean Delivery in Individuals with Morbid Obesity after Previous Cesarean Delivery.

This study aimed to compare adverse neonatal outcomes associated with the trial of labor after cesarean (TOLAC) at term in pregnancies according to maternal prepregnancy body mass index (BMI; kg/m2) and the presence of previous vaginal delivery (VD). This was a repeated cross-sectional analysis of individuals with singleton, cephalic, and term deliveries with a history of one or two cesarean deliveries in the Linked Birth/Infant Death data from 2011 to 2020. Outcomes were examined according to the BMI category including BMI <30, 30 to 39.9, and 40 to 69.9 kg/m2. The primary outcome was a composite neonatal outcome, defined as any presence of neonatal death, neonatal intensive care unit admission, assisted ventilation, surfactant therapy, or seizures. Outcomes were compared between TOLAC and elective repeat cesarean delivery (eRCD) after stratifying by BMI category and previous VD. Log-binomial regression was performed to obtain adjusted relative risk (aRR) with 99% confidence intervals, controlling for covariates. Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m2, 1,108,278 had BMI 30 to 39.9 kg/m2, and 320,031 had BMI 40 to 69.9 kg/m2. In individuals with no previous VD, VD rates after TOLAC were 66.7, 57.2, and 48.1%, respectively. In individuals with previous VD, VD rates after TOLAC were 81.4, 74.7, and 67.3%, respectively. In individuals without previous VD, compared with those who had an eRCD, those who had TOLAC were more likely to experience composite neonatal outcomes in individuals with BMI < 30 kg/m2 (5.0 vs. 6.5%; aRR = 1.33 [1.30-1.36]), BMI 30 to 39.9 kg/m2 (6.1 vs. 7.8%; aRR = 1.29 [1.24-1.34]), and BMI 40 to 69.9 kg/m2 (8.2 vs. 9.0%; aRR = 1.15 [1.07-1.23]). In individuals with previous VD, there was no difference in the composite neonatal outcomes in BMI < 30 kg/m2 (6.2 vs. 5.8%; aRR = 0.98 [0.96-1.00]), BMI 30 to 39.9 kg/m2 (7.4 vs. 7.1%; aRR = 0.99 [0.95-1.02]), and BMI 40 to 69.9 kg/m2 (9.4 vs. 8.7%; aRR = 0.96 [0.91-1.02]). TOLAC among obese individuals could be offered in selected cases. · TOLAC among obese individuals could be offered selectively, despite their reduced likelihood of attempting or succeeding at it.. · Higher BMI individuals show decreased rates of both attempting and achieving successful TOLAC.. · Despite these trends, attempting TOLAC after a previous vaginal delivery does not heighten neonatal complications..

Exploring Vaginal Birth After Cesarean: Success Rates and Cultural Decisions in the United Arab Emirates.

This study explores the success rates and cultural influences on the decision-making process for vaginal birth after cesarean (VBAC) in the United Arab Emirates (UAE). An observational cohort study was conducted at a hospital in the UAE accredited by Joint Commission International, enrolling 263 women eligible for VBAC from March 1, 2018, to February 28, 2019. The study focused on maternal-fetal outcomes, the proportions of women opting for trial of labor after cesarean (TOLAC) versus elective repeat cesarean section (ERCS), and the impact of cultural backgrounds on these decisions. The study found significant cultural variations in VBAC acceptance and success rates. Among local Emirati/Omani women, 86% (152 out of 177) opted for TOLAC, with an 83% success rate (126 out of 152). In contrast, lower TOLAC uptake and success rates were observed among other nationalities, such as Egyptian and other Arab women. The study also noted higher VBAC success rates in women with prior vaginal deliveries and those who experienced spontaneous labor. NICU admissions and maternal readmissions were lower in the TOLAC group (1% NICU admissions and 2% maternal readmissions) compared to the ERCS group (8.2% NICU admissions). The study underscores the influence of cultural factors in VBAC decision-making and outcomes, highlighting the need for culturally tailored counseling and care. It also confirms the safety and efficacy of VBAC in appropriately selected cases, advocating for more research into counseling practices and long-term outcomes in culturally diverse populations. Impact statement: This research adds to the understanding of how cultural and ethnic backgrounds influence VBAC decisions and outcomes, offering critical insights for clinical practice, especially in multicultural societies like the UAE. It emphasizes the role of tailored counseling and suggests avenues for future research in this domain.

Prediction of vaginal birth after cesarean in China.

This study aimed to develop and validate a prediction model of vaginal birth after cesarean delivery (VBAC) in China. A nomogram for effective prediction of VBAC of singleton, cephalic and one previous low-transverse cesarean section deliveries was created by comparing the combinations of ultrasonographic and non-ultrasonographic factors from five hospitals between 2018 and 2019. A total of 1066 women were included. Of the women who underwent trial of labor after cesarean (TOLAC), 854 (80.1%) had a VBAC. Ultrasound factors included reached a higher area under the curve (AUC) combined with non-ultrasonographic factors. Of the three ultrasonographic factors analyzed, the best predictive factor for successful TOLAC was fetal abdominal circumference. A nomogram was generated with eight validated factors, including maternal age, gestational week, height, previous vaginal delivery, Bishop score, dilatation of the cervix at the time of admission, body mass index at delivery, and fetal abdominal circumference by ultrasound. The trained and validated AUC were 0.719 (95% confident interval 0.674-0.764) and 0.774 (95% confident interval 0.712-0.837), respectively. Our VBAC nomogram based on obstetric factors and fetal abdominal circumference obtained by ultrasound could be used to counsel women who are considering TOLAC.

EVALUATING THE SUCCESS RATE OF VAGINAL DELIVERY AFTER CAESAREAN SECTION

: The retrospective study was conducted in the Department of Gynecology Dr. Ruth K. M. Pfau Civil Hospital Karachi, from February 2021 to February 2022, for the evaluation of factors associated with the success of TOLAC (trial of labor after cesarean delivery) and to identify variables for predicting the success of TOLAC in subjects with prior Caesarean section (CS). A total of 315 women were included in the study. They were divided into the validation cohort (n=20, 63%) and the training cohort(n=295, 93.6%). The primary endpoint was the success rate of vaginal delivery. The results showed that of 315 participants, 264 (83.8%) women had successful TOLAC and vaginal delivery, and 51 (16.1%) had ERCS. According to multivariate analysis, BMI-estimated birth weight, gestational age &lt;41 weeks, rupture of membranes, and cervix Bishop score ≥5 was significantly associated with the success of TOLAC. Results suggest that TOLAC has a high success rate in women with a history of c-sections.

Elective induction of trial of labor after cesarean at 39 weeks: is it risk reducing?

After the ARRIVE trial, induction of labor (IOL) at 39 weeks became ubiquitous. We aim to determine whether patients with a prior cesarean should undergo risk reducing induction of labor at 39 weeks or be expectantly managed beyond 39 weeks. We created a decision analytic model to compare two management strategies in patients with a prior cesarean: 1) IOL at 39 weeks, 2) expectant management beyond 39 weeks. Patients expectantly managed beyond 39 weeks could: experience stillbirth, undergo indicated induction, or reach 40 weeks. At 40 weeks, patients could be induced or expectantly managed. We assumed all patients would be induced if they reached 41 weeks. We further assumed that all patients would attempt a trial of labor after cesarean (TOLAC) and all patients undergoing TOLAC were at risk for uterine rupture; the risk of uterine rupture was varied by IOL versus spontaneous labor and gestational age. Adverse maternal outcomes considered were maternal death, hysterectomy, operative injury (bowel or bladder injury). Neonatal outcomes considered were stillbirth, neonatal death, and hypoxic ischemic encephalopathy. Baseline risk estimates for uterine rupture, adverse events associated with uterine rupture, failed TOLAC, and successful TOLAC were obtained from the literature. One-way and multi-way sensitivity analyses were performed to address uncertainties in baseline assumptions. Within baseline assumptions, the model identified that IOL at 39 weeks resulted in fewer adverse maternal or neonatal events compared to expectant management and more vaginal deliveries (Table). The model is sensitive to the risk of uterine rupture associated with IOL at 39 weeks; if the incidence of uterine rupture exceeds 1.42% in those undergoing IOL at 39 weeks, the model favors expectant management. In Monte Carlo simulations, induction of labor was selected in 91.7% of simulations. Risk-reducing IOL at 39 weeks should not be withheld from women undergoing TOLAC and, depending on the risk of uterine rupture, may be associated with more favorable outcomes than expectant management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The association between TOLAC in obese women and adverse maternal outcomes

The American College of Obstetricians and Gynecologists encourages trial of labor after cesarean (TOLAC) as a method of reducing the cesarean delivery rate. However, evidence regarding TOLAC outcomes in obese women is lacking. Several studies demonstrated an inverse relationship between obesity and TOLAC success but have not examined maternal morbidity in this population. We hypothesized that a TOLAC among obese women with a history of cesarean delivery is associated with decreased composite maternal adverse outcome (CMAO) as compared with planned repeat low transverse cesarean section (RLTCS). In this population-based retrospective cohort study using the National Birth Certificate database from 2016-2020, we compared obese patients who attempted TOLAC at term (37+ weeks gestational age) to planned RLTCS. The primary outcome was a CMAO, defined as delivery complications including intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or maternal blood transfusion. A sensitivity analysis was performed of the CMAO excluding maternal blood transfusion. Relative risks were calculated and adjusted based on socio-demographic differences between the two groups. 794,278 patients met inclusion criteria; 126,809 underwent a TOLAC and 667,469 had a planned RLTCS. The overall composite maternal adverse outcome was significantly higher for patients undergoing TOLAC (9.0 per 1,000 live births) compared to RLTCS (5.3 per 1,000 live births; aRR 1.64, 95% CI 1.53-1.75) (Table 1). Among individual conditions within the primary composite outcome, TOLAC was associated with increased ICU admission, maternal transfusion, uterine rupture, and unplanned hysterectomy (Table 1). In the sensitivity analysis, the rate of composite maternal adverse outcome excluding maternal transfusion was significantly higher in the TOLAC (5.1 per 1,000 live births) than the RLTCS cohort (1.9 per 1,000 live births; aRR 2.58, 95% CI 2.35-2.84). In obese patients with a history of cesarean delivery, TOLAC was associated with increased maternal adverse outcomes as compared to planned RLTCS.

Vaginal Birth after Cesarean Score for the Prediction of Successful Vaginal Birth after Cesarean Section – A Prospective Observational Study

Aim: The aim of this study was to evaluate the demographic and obstetrical factors affecting the chances of vaginal birth after cesarean (VBAC) delivery and to develop a scoring system for the prediction of same. Materials and Methods: It was a prospective observational study done over a period of 1 year. A total of 100 term pregnant women with previous one lower-segment cesarean section (LSCS) fulfilling the criteria for a trial of labor were recruited for the study. As 23 patients refused to undergo trial of labor after cesarean (TOLAC) in early labor, 77 women formed the study group. Parameters assessed to predict successful TOLAC were maternal age, body mass index (BMI), history of prior vaginal delivery, interdelivery interval, indication of previous cesarean section, gestational age, type of labor, Bishop's score, and expected baby weight. Scores 0–2 were given, and the mean score obtained was correlated with the outcome of TOLAC. Results: Successful vaginal delivery occurred in 57.14% (44/77) of women. BMI ≤30 kg/m2 (P = 0.004), parity ≤ 3 (P = 0.005), Bishop's score &gt;4 (P = 0.000), spontaneous onset of labor at the time of admission (P = 0.001), and nonrecurrent indication of previous LSCS (P = 0.029) were found to be significantly associated with the VBAC. The probability of having a successful VBAC was 83.3% and 100%, with the VBAC score value of more than 18 and 20, respectively. Conclusion: The mean VBAC score of 18–20 by the current scoring system is beneficial in predicting the outcome. This can help in counseling the patient, relatives as well as health professionals to undergo labor trial to decrease the cesarean section rate in the current era.

Trends in Attempted and Successful Trial of Labor After Cesarean Delivery in the United States From 2010 to 2020.

The vaginal birth after cesarean (VBAC) delivery rate was last reported as 13.8% in 2019. However, contemporary trends in attempted and successful trial of labor after cesarean (TOLAC) delivery among individuals with prior cesarean delivery have not been evaluated. We performed a repeated cross-sectional analysis of singleton, cephalic, term deliveries in individuals with a history of one or two cesarean deliveries in the National Vital Statistics System from 2010 to 2020. Temporal trends in attempted and successful TOLAC, as well as VBAC, were characterized using joinpoint regression. Overall, 4,277,800 deliveries were included. Attempted TOLAC increased from 15.3% in 2010 to 21.7% in 2020, with an annual percent increase (relative) of 4.25% (95% CI 2.9-5.6%). Successful TOLAC increased from 69.8% to 74.7%, with an annual percent change (relative) of 0.91% (95% CI 0.7-1.2%). The VBAC rate similarly increased such that, by 2020, it was 16.2%.

Twenty-four versus 48 hours of expectant management in the setting of premature rupture of membranes at term among women with a prior cesarean delivery.

Compare two approaches of expectant management in the setting of term premature rupture of membranes (PROM) among women with prior cesarean delivery. A retrospective study conducted in a tertiary care center during 2006 to 2017, including primiparous women with singleton pregnancy and a prior low-transverse cesarean delivery who presented with term PROM and requested trial of labor after cesarean (TOLAC). Outcomes were compared between the two campuses at our center: campus A enabled expectant management up to 48 hours following PROM and campus B enabled up to 24 hours after PROM. A total of 158 women met the inclusion criteria and were divided into two groups. Maternal characteristics of the two groups were similar. In campus B, the rate of oxytocin administration was significantly higher as compared with campus A (46.6% versus 26.0%, P= 0.01). The rate of successful TOLAC was similar between the groups (84.0% versus 84.5%, P= 0.96). Rates of chorioamnionitis, uterine rupture, postpartum hemorrhage, recurrent hospitalization, and Apg scores did not differ between the groups. Expectant management up to 48 hours in women with TOLAC presenting with term PROM was associated with a lower rate of induction of labor and similar maternal and neonatal outcomes.

Trial of labor after cesarean in women with hypertensive disorders and no prior vaginal delivery.

Trial of labor among women who never delivered vaginally with hypertensive disorder is associated with nearly half the success rate of the general population. To study the trial of labor after cesarean (TOLAC) among women with hypertensive disorders and no prior vaginal delivery. A retrospective cohort study was conducted including women with no prior vaginal delivery undergoing TOLAC during 2010-2020. Women with hypertensive disorder were compared to those without. A total of 54/2,144 (2.5%) TOLACs had a hypertensive disorder: 32 (59%) had gestational hypertension, 16 (30%) had chronic hypertension and 6 (11%) had preeclampsia. Women with hypertensive disorders had higher BMI and higher proportion of diabetic disorders. TOLAC success rate was lower among hypertensive mothers: 32 (59%) vs. 1,605 (76.8%), p=0.003 odds ratio (OR), 95% confidence interval (CI) 0.44 (0.25-0.76). The rate of uterine rupture was 23/2,144 (1.1%). In a multivariable logistic regression analysis, hypertensive disorder was independently negatively associated with TOLAC success, adjusted OR (95% CI) 0.47 (0.26-0.85). Other factors negatively independently associated with TOLAC failure were maternal age, predelivery body mass index, dystocia at primary CD, gestational age at TOLAC, induction of labor and birth weight. Epidural was independently positively associated with TOLAC success, adjusted OR (95% CI) 1.54 (1.18-1.99). TOLAC in hypertensive women with no prior vaginal delivery is safe. Success rate is impaired in comparison to non-hypertensive women.

Sonographic fetal head circumference is associated with trial of labor after cesarean section success.

The purpose is to study the association of the fetal sonographic head circumference (SHC) with trial of labor after cesarean (TOLAC) success rate, among women with no prior vaginal deliveries. A retrospective case-control study including all women with no prior vaginal delivery undergoing TOLAC during 3/2011-6/2020 with a sonographic estimated fetal weight within one week from delivery. TOLAC success and failure groups were compared. Of 1232 included women, 948 (76.9%) delivered vaginally. The mean fetal SHC was smaller in the TOLAC success group (330 ± 10 vs. 333 ± 11mm, p < 0.001). In a multivariate regression analysis, predelivery BMI, hypertensive disorders, gestational age at prior CD, SHC and epidural analgesia administration were independently associated with TOLAC success. A ROC analysis of the multivariable model composed of the factors found independently associated with TOLAC success, excluding SHC, yielded an area under curve of 0.659 (95% CI 0.622-0.697) compared with 0.668 (95% CI 0.630-0.705) with SHC included. Smaller SHC is independently associated with TOLAC success among women that did not deliver vaginally before, and has additive clinical value for the prediction of TOLAC success when combined with non-sonographic factors.

Predicting Vaginal Birth After Previous Cesarean: Using Machine-learning Models and a Population-based Cohort in Sweden

(Acta Obstet Gynecol Scand. 2021;100:513–520. doi: 10.1111/aogs.14020. Epub October 31, 2020) There are risks and benefits to choosing a trial of labor after cesarean (TOLAC) or a repeat cesarean delivery (CD). When TOLAC is successful (international success rate is 40% to 80%) and the patient has a vaginal birth (VD) after cesarean (VBAC), a benefit is decreased epidemic CD rate and decreased risk for repeat CD maternal morbidity. However risks of TOLAC include unplanned repeat CD, uterine rupture, and greater likelihood of maternal and neonatal adverse outcomes. Due to these tradeoffs, it is important to make accurate predictions regarding potential TOLAC success, thus leading to improved clinical counseling, and outcomes for women. This study aims to evaluate individualized predictions using machine-learning models for TOLAC for women with no previous VD and only one previous CD. It also aims to compare machine-learning methods with established regression prediction models.

Trial of labor after cesarean in twin gestation with no prior vaginal delivery - evidence from largest cohort reported.

ObjectiveTo investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery.MethodsA retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011–2020. TOLAC success and failure groups were compared.ResultsOf 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56–11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (<7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07–96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07–0.69, P = 0.009).ConclusionTOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.

Total breech extraction of the second twin in trial of labor after cesarean

Maternal and neonatl outcomes in trial of labor after cesarean (TOLAC) deliveries of twins are similar to singleton TOLACs. We examined whether internal podalic version and total breech extraction of the second twin adversely impacts outcome. A retrospective multicenter study was conducted including data on deliveries occurring between 2005-2020. We included TOLACs only, at 320/7 gestational weeks and on, of twin gestations with a vertex presenting first twin upon labor admission. The exposed group was defined as deliveries with a non-vertex second twin at admission to labor, while the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of pre-labor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. Two hundred thirty-six twin TOLACs were included, of whom 128 presented with a non-vertex second twin, and 108 presented with a second vertex twin. There was no difference in the primary outcome of uterine rupture (1/128, 0.9% vs. 1/108, 0.8%, p=1.000) (Table 1). Successful TOLAC of both twins occurred in 76.6% of the exposed group vs. 81.5% in the comparison group, while cesarean delivery (CD) of both twins was performed in 21.9% of the exposed group vs. 17.6% of the comparison group (p=0.418, OR=1.32, CI 0.7-2.5). There were 2 cases of CD for the second twin in the exposed group and one case in the comparison group (1.6% vs. 0.9%, respectively, p=1.000) (Table 2). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, etc. (Table 1). Neonatal outcomes were also comparable between the groups. Non-cephalic second twin in TOLAC deliveries results in favorable maternal and neonatal outcomes, comparable with vertex-vertex TOLACs. Second twin non-cephalic presentation should not discourage parturients and caregivers from considering TOLAC if desired.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Trial of labor after cesarean in primiparous women with fetal macrosomia.

Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus. Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia. A retrospective cohort study conducted during 2005-2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome). Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P < 0.001), epidural anesthesia (aOR [95% CI] 2.38 (1.35, 4.20), P = 0.003) and history of cesarean delivery due to non-arrest disorder (aOR [95% CI] 2.25 (1.32, 3.85), P = 0.003) were the only independent factors associated with TOLAC success. Successful TOLAC was achieved in 82.0% (82/100) in the presence of all three favorable factors, 61.3% (65/106) in the presence of two factors and 38.6% (27/70) in the presence of one or less of these three factors (P < 0.001). Spontaneous onset of labor, epidural anesthesia and prior cesarean delivery due to non-arrest disorders were independently associated with higher vaginal birth after cesarean rate among women with fetal macrosomia, with an overall favorable success rate in the presence of these factors. These findings should be implemented in patient counseling in those contemplating a vaginal birth in this setting.

Prediction of successful trial of labor after cesarean among grand-multiparous women.

To determine the factors associated with successful trial of labor after cesarean (TOLAC) among grand-multiparous (GMP) women. A retrospective cohort study was conducted, including all GMP women (≥ 5 deliveries) undergoing TOLAC during 3/2011 and 6/2020, delivering a singleton cephalic newborn. Factors associated with successful vaginal delivery were examined by multivariable analysis. Overall, 381/413 (92.2%) GMP succeeded TOLAC. Maternal characteristics did not differ between TOLAC success and TOLAC failure groups. Previous cesarean delivery characteristics did not differ between study groups. The median number of previous vaginal births after cesarean was 2 [interquartile range 1-4]. Gestational age at TOLAC was lower in the success group (mean 371/7 ± 36/7 vs. 385/7 ± 31/7weeks, p = 0.028). A lower rate of modified Bishop score < 4 was associated with TOLAC success [149 (39.1%) vs. 22 (69%), odds ratio (OR) 95% confidence interval (CI) 0.29 (0.13-0.64), p = 0.001]. The rate of induction of labor was higher in the TOLAC failure group [120 (31.5%) vs. 17 (53%), OR 95% CI 0.40 (0.19-0.83), p = 0.013]. The rate of oxytocin administration was higher in the TOLAC failure group [94 (24.7%) vs. 15 (47%) OR (95% CI) 0.37 (0.17-0.77), p = 0.006]. The duration of rupture of membranes was negatively associated with TOLAC success. Neonatal and maternal adverse outcomes did not differ between study groups. In multivariable logistic regression analysis, only the duration of rupture of membranes and modified Bishop score < 4 were independently associated with TOLAC success [adjusted OR (95% CI) 0.98 (0.96-0.99), p = 0.027 and 0.40 (0.16-0.97), p = 0.044]. TOLAC among GMP has a very-high success rate. Shortening the duration of ruptured membranes is a modifiable factor that may be associated with increased TOLAC success rates.

Prediction of vaginal birth after cesarean for labor dystocia by sonographic estimated fetal weight.

To estimate the association of the weight difference between the index trial of labor after cesarean (TOLAC) sonographic estimated fetal weight (sEFW) and prior delivery birth weight with TOLAC success rate among women with previous labor dystocia and no prior vaginal delivery. A retrospective cohort study including all women with prior cesarean for labor dystocia and no prior vaginal delivery undergoing TOLAC during between March 2011 and June 2020 with a sEFW within 1week from delivery. Overall, 168 women were included, of those 107 (63.7%) successfully delivered vaginally. The mean sEFW and mean birth weight were lower in the TOLAC success group (P=0.010 and P=0.013, respectively). The rate of higher sEFW in the current delivery compared with the previous delivery did not differ between study groups. The rate of higher TOLAC birth weight was lower in the TOLAC success group (odds ratio 0.30; 95% confidence interval 0.15-0.58). In multivariable regression analysis, maternal age older than 30years, induction of labor, and higher birth weight were independently negatively associated with TOLAC success (adjusted odds ratio [95% confidence interval]: 0.27 [0.10-0.70], 0.27 [0.08-0.90], and 0.43 [0.19-0.94]; P=0.008, P=0.034, and P=0.035, respectively). sEFW characteristics did not predict the success or failure of TOLAC among women with prior labor dystocia and no previous vaginal delivery.

Prediction of successful preterm vaginal birth after cesarean among women who never delivered vaginally.

We aimed to determine the factors associated with a successful trial of labor after cesarean (TOLAC) in the setting of preterm delivery of women with no prior vaginal delivery. A retrospective cohort study conducted at two tertiary medical centers during 2010-2020, including all TOLACs with a single cesarean delivery and no prior vaginal delivery, delivering a singleton preterm newborn. Factors associated with successful vaginal delivery were examined by multivariable analysis. Of the 232 women with TOLAC who constituted the study cohort, 178 (76.7%) successfully delivered vaginally. Previous cesarean delivery characteristics did not differ between study groups. Maternal characteristics did not differ between TOLAC success and failure groups. The median gestational age at delivery was 35 3/7weeks (IQR 34 0/7-36 0/7). The rate of epidural analgesia administration was higher in the TOLAC success group (54.5% vs. 35%, p = 0.013). Preterm premature rupture of membranes (PPROM) rate was lower in the TOLAC success group (53.9% vs. 83%, p < 0.001). The rate of induction of labor did not differ between TOLAC success and TOLAC failure groups. There were no cases of uterine rupture. In a multivariable logistic regression analysis, PPROM was the only independent factor associated with TOLAC success [adjusted OR (95% CI) 0.29 (0.10-0.83), p = 0.030]. TOLAC in preterm deliveries among women with no prior vaginal delivery is safe, has a high success rate and PPROM is the only negatively associated predictor.

Trial of Labor After Cesarean of Small for Gestational Age Neonates Among Women with No Prior Vaginal Delivery - a Retrospective Study.

To evaluate the characteristics and outcomes of women who had never delivered vaginally and underwent a trial of labor after cesarean (TOLAC) of small for gestational age (SGA) neonates, and to identify risk factors for unplanned repeat cesarean delivery. A retrospective cohort study from two tertiary medical centers. All women undergoing a TOLAC with no prior vaginal delivery, delivering a singleton SGA neonate at term between 2005 and 2020 were included. Factors associated with successful vaginal delivery were examined by a multivariable analysis. Of the 255 women who met the inclusion criteria and underwent TOLAC, 72.2% delivered vaginally. In a multivariable analysis, maternal height [adjusted odds ratio (aOR) (95% CI): 1.10 (1.02-1.19), p = 0.012] and epidural administration [aOR (95% CI): 2.78 (1.0-7.73), p = 0.050] were positively independently associated with TOLAC success, and hypertensive disorders were negatively independently associated with TOLAC success [aOR (95% CI): 0.52 (0.004-0.74), p = 0.029]. The success rate of TOLAC among women with no prior vaginal delivery, delivering a SGA neonate is relatively high. Maternal height, hypertensive disorders, and epidural administration are independent factors associated with TOLAC success. Epidural administration is a modifiable factor and should be taken in consideration during TOLAC management.