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Labor Before a Primary Cesarean Delivery: Reduced Risk of Uterine Rupture in a Subsequent Trial of Labor for Vaginal Birth After Cesarean

Algert, Charles S. MPH1,2; Morris, Jonathan M. MBChB, PhD1,2; Simpson, Judy M. PhD3; Ford, Jane B. PhD2,3; Roberts, Christine L. MBBS, DrPH2

doi: 10.1097/AOG.0b013e31818b42e3
Original Research

OBJECTIVE: To estimate the effect of the onset of labor before a primary cesarean delivery on the risk of uterine rupture if vaginal birth after cesarean (VBAC) is attempted in the next pregnancy.

METHODS: Longitudinally linked birth records were used to follow women from a primary cesarean delivery to a trial of labor at term for their next birth. The effects of characteristics of both the trial of labor and primary cesarean deliveries on the risk of uterine rupture were examined.

RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women who were induced or augmented for their trial of labor had a greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence interval [CI] 2.23–8.07). Women whose primary cesarean delivery was planned or followed induction of labor also had an increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24–5.49), and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.

CONCLUSION: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.


Women whose primary cesarean delivery is preceded by spontaneous labor have a decreased risk of uterine rupture when subsequently attempting vaginal birth after cesarean.

From the 1Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, the 2Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, and the 3School of Public Health, University of Sydney, Sydney, Australia.

Supported by an Australian National Health and Medical Research Council (NHMRC) Project Grant (402498). Christine Roberts is supported by a NHMRC Senior Research Fellowship (457078), and Jane Ford is supported by an NHMRC capacity-building grant (262121).

The authors thank the hospital staff who collected the data and the staff of the New South Wales Department of Health who designed and maintain the HOIST data warehouse system.

Corresponding author: Charles Algert, C/-University Department of Obstetrics and Gynaecology, Level 4, Wallace Freeborn Building (26), Royal North Shore Hospital, St. Leonards 2065, Australia; e-mail:

Financial Disclosure The authors have no potential conflicts of interest to disclose.

© 2008 The American College of Obstetricians and Gynecologists