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Safety of Trial of Labor After Cesarean Delivery in Grandmultiparous Women

Hochler, Hila MD; Yaffe, Haim MD; Schwed, Philippe MD; Mankuta, David MD

doi: 10.1097/AOG.0000000000000082
Contents: Original Research

OBJECTIVE: To evaluate the risk of uterine rupture and other major labor complications in a trial of labor after cesarean delivery (TOLAC) in grandmultiparous women.

METHODS: A retrospective descriptive study of 64,345 births in three hospitals between the years 1999 and 2009. The study group included 1,922 deliveries of women in their sixth or higher birth with one previous cesarean delivery.

RESULTS: The risk for uterine rupture was 0.3% (six cases) (95% confidence interval [CI] 0.11–0.68); of these, two cases ended in hysterectomy. There were another four hysterectomies not attributable to uterine rupture (a total risk of 0.3%). Neither induction nor augmentation of labor increased the risk for uterine rupture. Trial of labor after cesarean delivery in the first labor after prior cesarean delivery conferred a higher risk for hysterectomy (1% compared with 0.1%; P=.019). In the presence of shoulder dystocia (n=20), the risk of uterine rupture was 10% (two cases) compared with 0.2% when shoulder dystocia did not occur (P=.002; odds ratio 52.7, 95% CI 9–306).

CONCLUSION: Grandmultiparous women with one previous cesarean delivery can be offered TOLAC. Labor induction is not contraindicated in such women.

LEVEL OF EVIDENCE: III

Grandmultiparity does not increase the risk of uterine rupture during a trial of labor after cesarean delivery.

Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, and the Department of Obstetrics and Gynecology, Hadassah Hospital, Ein Kerem, The Hebrew University of Jerusalem, Jerusalem, Israel.

Corresponding author: Hila Hochler, MD, Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, PO Box 3235, Jerusalem 91031, Israel; e-mail: hilahochler@gmail.com.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.