Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery

Landon, Mark B. MD1; Spong, Catherine Y. MD20; Thom, Elizabeth PhD21; Hauth, John C. MD2; Bloom, Steven L. MD3; Varner, Michael W. MD4; Moawad, Atef H. MD5; Caritis, Steve N. MD6; Harper, Margaret MD, MS7; Wapner, Ronald J. MD8; Sorokin, Yoram MD9; Miodovnik, Menachem MD10; Carpenter, Marshall MD11; Peaceman, Alan M. MD12; O’Sullivan, Mary J. MD13; Sibai, Baha M. MD14; Langer, Oded MD15; Thorp, John M. MD16; Ramin, Susan M. MD17; Mercer, Brian M. MD18; Gabbe, Steven G. MD; for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network

doi: 10.1097/01.AOG.0000224694.32531.f3
Original Research

OBJECTIVE: To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries.

METHODS: We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery.

RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02–1.93).

CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women.

LEVEL OF EVIDENCE: II-2

Multiple prior cesarean deliveries are not associated with an increased rate of uterine rupture in women attempting VBAC compared with those with single prior operation.

From the Departments of Obstetrics and Gynecology at the 1Ohio State University, Columbus, Ohio; 2University of Alabama at Birmingham, Birmingham, Alabama; 3University of Texas Southwestern Medical Center, Dallas, Texas; 4University of Utah, Salt Lake City, Utah; 5University of Chicago, Chicago, Illinois; 6University of Pittsburgh, Pittsburgh, Pennsylvania; 7Wake Forest University, Winston-Salem, North Carolina; 8Thomas Jefferson University, Philadelphia, Pennsylvania; 9Wayne State University, Detroit, Michigan; 10University of Cincinnati, Cincinnati, Ohio, and Columbia University, New York, New York; 11Brown University, Providence, Rhode Island; 12Northwestern University, Chicago, Illinois; 13University of Miami, Miami, Florida; 14University of Tennessee, Memphis, Tennessee; 15University of Texas Health Science Center at San Antonio, San Antonio, Texas; 16University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 17University of Texas Health Science Center at Houston, Houston, Texas; 18Case Western Reserve University, Cleveland, Ohio; 19Vanderbilt University, Nashville, Tennessee; and 20the National Institute of Child Health and Human Development, Bethesda, Maryland; and 21the George Washington University Biostatistics Center, Washington, DC.

See related editorial on page 2.

* For members of the NICHD Maternal-fetal Medicine Units Network, see the Appendix.

Supported by grants From the National Institute of Child Health and Human Development (HD21410, HD21414, HD27860, HD27861, HD27869, HD27905, HD27915, HD27917, HD34116, HD34122, HD34136, HD34208, HD34210, HD40500, HD40485, HD40544, HD40545, HD40560, HD40512, and HD36801).

The following core committee members participated in protocol/data management and statistical analysis: Sharon Gilbert, MS; and protocol development and coordination between clinical research centers: Frances Johnson, RN, and Julia McCampbell, RN.

Corresponding author: Mark B. Landon, MD, the Ohio State University College of Medicine and Public Health, 1654 Upham Drive, Means Hall 5th Floor, Columbus, OH 43210-1228; e-mail: landon.1@osu.edu.

© 2006 The American College of Obstetricians and Gynecologists