Operative Vaginal Delivery Is a Safe Option in Women Undergoing a Trial of Labor after Cesarean

Abstract

Objective To compare outcomes of operative intervention in the second stage of labor during trial of labor after cesarean (TOLAC).

Study Design A secondary analysis of the Maternal-Fetal Medicine Units Network cesarean section registry was conducted. Analysis was by first attempted mode of delivery.

Results A total of 1,837 met inclusion criteria. Subjects in the operative vaginal groups (OVDs) were more likely to have a prior vaginal delivery (vacuum 34.2%; forceps 34.3%) than the repeat cesarean delivery (RCD) group (22.6%; p < 0.0001). Most OVD attempts were successful (forceps 90.4%; vacuum 92.6%). Neonatal morbidity was not different (12.1% forceps vs. 14.6% vacuum; 14.8% RCD). Maternal morbidity was highest among forceps deliveries (32.3 vs. 24.3% vacuum; 22.0% RCD, p = 0.0001). RCD was associated with surgical injury (2.7 vs. 0.7% forceps; 0% vacuum; p < 0.0001), endometritis (8.4 vs. 3.2% forceps, 1.2% vacuum; p < 0.0001), and wound complications (1.9 vs. 0.4% forceps; 0.3% vacuum; p = 0.006). OVD was associated with anal sphincter laceration (22.7% forceps, 15.5% vacuum; 0% RCD; p = 0.01).

Conclusion The success rate of OVD is high in TOLAC with similar outcomes to RCD. Maternal composite outcomes were highest with forceps-assisted vaginal deliveries. However, considering overall morbidity, OVD in the second stage of labor in TOLAC is a reasonable, safe option in selected cases.

Keywords

trial of labor after cesarean - operative vaginal delivery - forceps delivery - vacuum-assisted delivery - vaginal birth - cesarean delivery

• References

• 1 Hamilton BE, Martin JA, Osterman MJ. Births: preliminary data for 2015. Natl Vital Stat Rep 2016; 65 (03) 1-15
• 2 Centers for Disease Control and Prevention (CDC). Rates of cesarean delivery–United States, 1991. MMWR Morb Mortal Wkly Rep 1993; 42 (15) 285-289
• 3 Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2007. Natl Vital Stat Rep 2009; 57 (12) 1-23
• 4 Silver RM, Landon MB, Rouse DJ. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
• 5 Triebwasser JE, Colvin R, Macones GA, Cahill AG. Nonreassuring fetal status in the second stage of labor: fetal monitoring features and association with neonatal outcomes. Am J Perinatol 2016; 33 (07) 665-670
• 6 Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep 2015; 64 (01) 1-65
• 7 Bailit JL, Grobman WA, Rice MM. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Evaluation of delivery options for second-stage events. Am J Obstet Gynecol 2016; 214 (05) 638.e1-638.e10
• 8 Landon MB, Hauth JC, Leveno KJ. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351 (25) 2581-2589
• 9 Son M, Roy A, Grobman WA. Attempted operative vaginal delivery vs repeat cesarean in the second stage among women undergoing a trial of labor after cesarean delivery. Am J Obstet Gynecol 2017; 216 (04) 407.e1-407.e5