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Objective Following the release of A Randomized Trial of Induction versus Expectant Management (ARRIVE) trial, the induction of labor at 39 weeks has increased in the United States. The risk of uterine rupture and optimal timing of elective induction in those patients with a prior cesarean delivery is not well-described, and they were not included in the original trial. We aimed to determine the risk of uterine rupture in those patients undergoing elective induction of labor with prior cesarean delivery. Study Design This was a retrospective cohort of participants with prior cesarean delivery from 1996 to 2000. Participants were included if they had two or more prior cesareans. Participants were excluded if they had a history of an unknown prior incision, a classical incision, gestational age <39 weeks, any diabetes, chronic hypertension, twin gestation, collagen or vascular disease, or HIV. Those undergoing expectant management were compared with those undergoing elective induction with no medical or obstetrical indications for delivery. Analysis was performed at three gestational age groups: 39 weeks, 40 weeks, and 41 weeks. The primary outcomes were uterine rupture, rates of successful vaginal delivery, and a composite major morbidity risk. Multivariable logistic regression was performed. Results At 39 weeks, 618 (10.3%) elective inductions were compared with 5,365 (89.7%) undergoing expectant management; uterine rupture occurred more frequently (13 patients [2.1%] vs. 49 patients [0.9%]; adjusted odds ratio [aOR], 2.5; 95% confidence interval, 1.3–4.6) with fewer successful vaginal birth after cesarean [VBAC; 66.8 vs. 75%; aOR, 0.6; 95% confidence interval, 0.5–0.7]. The risk of uterine rupture was similar between groups at 40 weeks (5 patients [0.8%] vs. 21 patients [1.2%]; p = 0.387) and 41 weeks (7 patients [1.4%] vs. 2 patients (0.8%); p = 0.448). Conclusion Patients undergoing elective induction of labor with a prior cesarean scar had an increased risk of uterine rupture when compared with expectant management at 39 weeks, with fewer successful VBAC. Key Points TOLAC elective induction at 39 weeks has an increased risk of uterine rupture. TOLAC elective induction at 39 weeks has a less successful chance of vaginal delivery. Awaiting spontaneous labor in this cohort does not increase the risk of uterine rupture. [ABSTRACT FROM AUTHOR]

Objective 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/m 2) and the presence of previous vaginal delivery (VD). Study Design 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/m 2. 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. Results Of 4,055,440 individuals, 2,627,131 had BMI <30 kg/m 2 , 1,108,278 had BMI 30 to 39.9 kg/m 2 , and 320,031 had BMI 40 to 69.9 kg/m 2. 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/m 2 (5.0 vs. 6.5%; aRR = 1.33 [1.30–1.36]), BMI 30 to 39.9 kg/m 2 (6.1 vs. 7.8%; aRR = 1.29 [1.24–1.34]), and BMI 40 to 69.9 kg/m 2 (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/m 2 (6.2 vs. 5.8%; aRR = 0.98 [0.96–1.00]), BMI 30 to 39.9 kg/m 2 (7.4 vs. 7.1%; aRR = 0.99 [0.95–1.02]), and BMI 40 to 69.9 kg/m 2 (9.4 vs. 8.7%; aRR = 0.96 [0.91–1.02]). Conclusion TOLAC among obese individuals could be offered in selected cases. Key Points 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. [ABSTRACT FROM AUTHOR]

Objective Vaginal birth after cesarean can reduce morbidity associated with multiple cesarean deliveries. Failed vaginal birth after cesarean is associated with increased maternal and neonatal morbidity. The Maternal-Fetal Medicine Units Vaginal Birth After Cesarean calculator is a validated tool to predict the likelihood of successful trial of labor after cesarean. Predicted likelihood < 60% has been associated with increased maternal and neonatal morbidity. We sought to determine if formal incorporation of calculated vaginal birth after cesarean likelihood into patient-centered counseling would reduce failed vaginal birth after cesarean. Study Design This is a quality improvement intervention at a single tertiary-care academic medical center, in which standardized patient counseling was implemented, facilitated by an electronic medical record template featuring patient-specific likelihood of vaginal birth after cesarean success. Term singleton pregnancies with history of one to two cesareans were included; those with contraindication to labor were excluded. Historical controls (January 2016–December 2018, n = 693) were compared with a postimplementation cohort (January 2019–April 2020, n = 328). Primary outcome was failed vaginal birth after cesarean. Results Fewer patients in the postintervention cohort had a history of an arrest disorder (PRE: 48%, 330/693 vs. POST: 40%, 130/326, p = 0.03); demographics were otherwise similar, including the proportion of patients with <60% likelihood of success (PRE: 39%, 267/693, vs. POST: 38%, 125/326). Following implementation, induction of labor in patients with a <60% likelihood of successful vaginal birth after cesarean decreased from 17% (45/267) to 5% (6/125, p < 0.01). The proportion of failed vaginal birth after cesarean decreased from 33% (107/329) to 22% (32/143, p = 0.04). Overall vaginal birth after cesarean rate did not change (PRE: 32%, 222/693, vs. POST: 34%, 111/326, p = 0.52). Conclusion An intervention targeting provider counseling that included a validated vaginal birth after cesarean success likelihood was associated with decreased risk of failed trial of labor after cesarean without affecting overall vaginal birth after cesarean rate. Key Points Labored cesarean increases maternal morbidity. Application of the Maternal-Fetal Medicine Units (MFMU) calculator to antenatal counseling decreased labored cesarean. Application of the MFMU calculator to antenatal counseling did not decrease overall vaginal birth after cesarean rate. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to estimate whether there is an association between the predicted probability of vaginal birth after cesarean delivery (VBAC) and the occurrence of obstetric anal sphincter injuries (OASIS). Study Design  This was a single-site retrospective cohort study of all women with a singleton vaginal birth after a previous cesarean section between January 2011 and December 2016. Women were divided into four ordinal groupings by the predicted probability of achieving vaginal birth after cesarean using the Maternal–Fetal Medicine Units Network VBAC calculator (less than 41%, 40.1–60%, 60.1–80%, and greater than 80%). The primary outcome was OASIS, defined as a 3rd or 4th degree perineal laceration. Bivariable and multivariable analyses were used to examine the association between predicted VBAC probability and OASIS. Results  In total, 1,411 women met inclusion criteria and 73 (5.2%) sustained OASIS. The median predicted probability of VBAC was lower in women with OASIS compared with those without OASIS (60% [interquartile range {IQR}: 48–70%] vs. 66% (IQR: 52–80%), p  = 0.02]. On bivariable and multivariable logistic regression, predicted probability of VBAC was associated with increased odds of OASIS (less than 41% probability: adjusted odds ratio [aOR]: 3.18, 95% confidence interval [CI]: 0.90–11.21; 41–60% probability: aOR: 3.76, 95% CI: 1.34–10.57; 61–80% probability aOR: 3.47, 95% CI: 1.25–9.69) relative to women with a predicted probability of VBAC of greater than 80%. Conclusion  Having a lower predicted probability of VBAC is associated with an increased risk of OASIS at the time of a VBAC relative to those with greater than 80% predicted probability. Incorporation of this aspect of maternal morbidity may inform risk-stratification at the time of trial of labor after cesarean, as well as the choice of performing an operative vaginal delivery. Key Points Predicted probability of VBAC is associated with OASIS. Low predicted probability of VBAC is associated with increased odds of OASIS. Forceps delivery was associated with the highest odds of OASIS. [ABSTRACT FROM AUTHOR]

Objective  We sought to assess the safety of transcervical Foley catheter (TCF) placement for cervical ripening in women undergoing induction of labor (IOL) after prior cesarean by evaluating the risk of uterine rupture. Study Design  We performed a secondary analysis of the Maternal-Fetal Medicine Unit's Cesarean Section Registry, a prospective observational cohort study. We included women with a history of ≤2 low-transverse cesarean deliveries who underwent IOL at ≥24 weeks of gestational age with a live singleton fetus without major anomalies. We excluded those who received prostaglandins or laminaria. We performed multinomial logistic regression to calculate adjusted odds ratios (aORs) for uterine rupture and dehiscence. Relevant confounders included prior vaginal delivery, pregnancy-induced hypertension, chorioamnionitis, and cervical effacement and dilation on admission. Results  A total of 2,564 women were eligible. Unadjusted analysis demonstrated no increased risk of uterine rupture with TCF (1.9 vs. 0.9%; p  = 0.10) but an increased risk of uterine dehiscence (1.9 vs. 0.6%; p  = 0.02). After adjustment, TCF was not associated with an increased risk of uterine rupture (aOR: 2.02; 95% confidence interval [CI]: 0.71–5.78) or uterine scar dehiscence (aOR: 1.32; 95% CI: 0.37–4.72). Conclusion  Foley catheter is a safe tool for mechanical dilation in women undergoing IOL after prior cesarean. [ABSTRACT FROM AUTHOR]

Objective  We sought to identify factors associated with a successful trial of labor (TOL) following two cesarean deliveries (CDs) in a contemporary North American cohort. Study Design  This is a retrospective cohort study of term, nonanomalous, singleton, vertex pregnancies attempting a vaginal birth after cesarean (VBAC) following a history of two previous CDs in the United States from 2012 to 2014. Maternal and intrapartum factors were analyzed using chi-square tests and multivariable logistic regression. Results  A total of 22,762 women met the inclusion criteria and underwent TOL. Of these, 12,192 (53.6%) had a VBAC. Using multivariate logistic regression, previous vaginal delivery and delivery at 40 to 41 weeks' gestation were associated with VBAC; maternal age, education, Medicaid insurance, non-Caucasian race/ethnicity, weight (overweight or obese), and gestational weight gain above the Institute of Medicine guidelines (adjusted odds ratio: 0.88; 95% confidence interval: 0.81–0.95) were associated with CD. Induction of labor did not affect the VBAC rate. Conclusion  For those desiring a TOL after two previous CDs, prospective studies are needed to assess interventions that limit gestational weight gain as well as the safety and optimal timing of an induction of labor. The decision to attempt a TOL should be guided by counseling regarding the risks, benefits, and chances of a successful TOL. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women. Study Design A 4-year retrospective cohort.We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator. Results Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p = 0.02) and uterine rupture (1.9 vs. 0.0%; p < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p = 0.51), maternal, or immediate neonatal complications. Conclusion Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective This study aims to evaluate the relationship between cervical length (CL) and trial of labor after cesarean (TOLAC) delivery. Study Design This retrospective cohort study evaluated second trimester CL and likelihood of successful TOLAC. Women undergoing TOLAC from January 2009 to December 2011 who underwent transvaginal ultrasound CL between 180/7 to 236/7 weeks gestation were included. The threshold for CL was assessed using a receiver operating characteristics curve, with ≥ 45 mm determined to be the optimal threshold. Women with CL < 45 mm were compared with women with CL ≥ 45 mm with respect to TOLAC. Multivariate analysis was used to assess the association of CL with TOLAC. Results A total of 45 patients met inclusion criteria, 14 (31%) with a long CL (≥45 mm) and 31 (69%) with CL < 45 mm. Groups did not differ in demographics or factors predictive of vaginal birth after cesarean (VBAC) delivery. More women with CL < 45 mm had successful VBAC (81%) than women with long CL (43%, relative risk 1.9, p = 0.03). Prior vaginal delivery and CL < 45 mm were both significant predictors of VBAC (odds ratio 1.8 and 2.0, respectively). Conclusion CL < 45 mm is associated with VBAC. [ABSTRACT FROM AUTHOR]

We assessed the rate of uterine rupture in patients undergoing labor induction for attempted vaginal birth after cesarean (VBAC). A retrospective study was performed of data from a computerized database. Deliveries from January 1, 1998, to June 30, 2001, in the Southern California Kaiser Permanente system were reviewed and various perinatal characteristics analyzed. A total of 16,218 patients had a prior low transverse cesarean section. Of these, 6832 (42.1%) had a trial of labor. Successful VBAC occurred in 86% of patients with spontaneous onset of labor and 66% of patients with labor induction (p <0.001). The uterine rupture rate was not different between patients with spontaneous or induced labor (1.0% versus 1.2%, p=0.51). Similarly, there was no significant difference between oxytocin or prostaglandin E2 induction (1.4% versus 1.0%, p=0.59). In our study, labor induction did not appear to increase the risk of uterine rupture in women attempting VBAC. [ABSTRACT FROM AUTHOR]