Subscribe to RSS
Outcomes of Operative Vaginal Delivery during Trial of Labor after Cesarean Delivery
06 December 2016
16 December 2016
31 January 2017 (online)
Objective The objective of this study is to determine the maternal and neonatal morbidity associated with attempting operative vaginal delivery (OVD) compared with the alternative of a laboring repeat cesarean delivery (LRCD) in women attempting a trial of labor after cesarean delivery (TOLAC).
Methods This is a secondary analysis of a multicenter prospective study designed to assess perinatal outcomes of OVD in women with a prior uterine scar. The study includes women who attempted TOLAC and reached +2 station with a fully dilated cervix. Composites on neonatal and maternal morbidity were compared between women in whom OVD was attempted and those who underwent LRCD by fitting multivariate logistic regression models.
Results In total, 6,489 women attempting TOLAC reached 2+ station with a fully dilated cervix. Of these, 5,640 (86.9%) had a spontaneous vaginal delivery, 762 (11.7%) underwent attempted OVD, and 87 (1.3%) had an LRCD. Compared with attempting OVD, LRCD was associated with greater neonatal morbidity (odds ratio [OR]: 2.41; 95% confidence interval [CI]: 1.13–5.15) and less maternal morbidity (OR: 0.28; 95% CI: 0.14–0.55). Maternal morbidity of OVD is driven by perineal injury.
Conclusion In laboring women with a previous uterine scar, attempting OVD is associated with greater maternal and less neonatal morbidity than LRCD.
Findings from this manuscript were presented at the 36th Annual Pregnancy Meeting of the Society for Maternal Fetal Medicine in Atlanta, Georgia, January 2, 2016, to June 2, 2016, Abstract #379. Reprints are not available.
- 1 Hamilton BE, Martin JA, Osterman MJK, Curtin SC, Mathews TJ. Births: Final Data for 2013. National vital statistics reports. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System 2015; 64 (12) 1-64
- 2 Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ 2004; 328 (7451): 1302-1305
- 3 Kyser KL, Lu X, Santillan D. , et al. Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence?. Acad Med 2014; 89 (01) 71-76
- 4 Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol 2007; 196 (06) 526.e1-526.e5
- 5 Demissie K, Rhoads GG, Smulian JC. , et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329 (7456): 24-29
- 6 Werner EF, Janevic TM, Illuzzi J, Funai EF, Savitz DA, Lipkind HS. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011; 118 (06) 1239-1246
- 7 Doumouchtsis SK, Arulkumaran S. Head injuries after instrumental vaginal deliveries. Curr Opin Obstet Gynecol 2006; 18 (02) 129-134
- 8 Gei AF. Prevention of the first cesarean delivery: the role of operative vaginal delivery. Semin Perinatol 2012; 36 (05) 365-373
- 9 Caughey AB, Cahill AG, Guise JM, Rouse DJ. ; American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
- 10 Faranesh R, Salim R. Labor progress among women attempting a trial of labor after cesarean. Do they have their own rules?. Acta Obstet Gynecol Scand 2011; 90 (12) 1386-1392
- 11 Kessous R, Tirosh D, Weintraub AY, Benshalom-Tirosh N, Sergienko R, Sheiner E. Second stage disorders in patients following a previous cesarean section: vacuum versus repeated cesarean section. Arch Gynecol Obstet 2013; 287 (06) 1075-1079
- 12 Rietveld AL, Kok N, Kazemier BM, de Groot CJ, Teunissen PW. Trial of labor after cesarean: attempted operative vaginal delivery versus emergency repeat cesarean, a prospective national cohort study. J Perinatol 2015; 35 (04) 258–262
- 13 Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341 (23) 1709-1714
- 14 Bonanno C, Clausing M, Berkowitz R. VBAC: a medicolegal perspective. Clin Perinatol 2011; 38 (02) 217-225
- 15 Landon MB, Leindecker S, Spong CY. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005; 193 (3, Pt 2): 1016-1023
- 16 Tita AT, Lai Y, Landon MB. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Timing of elective repeat cesarean delivery at term and maternal perioperative outcomes. Obstet Gynecol 2011; 117 (2, Pt 1): 280-286
- 17 Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med 2002; 21 (16) 2409-2419
- 18 Alexander JM, Leveno KJ, Hauth JC. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Failed operative vaginal delivery. Obstet Gynecol 2009; 114 (05) 1017-1022
- 19 Alexander JM, Leveno KJ, Rouse DJ. , et al; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Comparison of maternal and infant outcomes from primary cesarean delivery during the second compared with first stage of labor. Obstet Gynecol 2007; 109 (04) 917-921
- 20 Allen VM, O'Connell CM, Baskett TF. Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour. BJOG 2005; 112 (07) 986-990
- 21 Selo-Ojeme D, Sathiyathasan S, Fayyaz M. Caesarean delivery at full cervical dilatation versus caesarean delivery in the first stage of labour: comparison of maternal and perinatal morbidity. Arch Gynecol Obstet 2008; 278 (03) 245-249
- 22 Towner DR, Ciotti MC. Operative vaginal delivery: a cause of birth injury or is it?. Clin Obstet Gynecol 2007; 50 (03) 563-581