Clinical Question: What are the ris...

Clinical Question: What are the risks associated with trial of labor following cesarean delivery?

Setting: Inpatient (any location)

contemplation Design: Cohort (prospective)

Synopsis: In this observational research women with a previous cesarean delivery and a cur-rent singleton pregnancy decided whether to prosecute a trial of labor (they were not randomized). Among the 45988 women who qualified for the reflection at the 19 academic medical center 9013 had clear indications for repeated cesarean and were exclud as were 3276 women who not awayed early in labor without a documented plan for trial of labor. Of the remainder, 17898 underwent a trial of labor and 15801 had an elective repeated cesarean delivery.

Women choosing trial of labor were younger, more likely to be black, les likely to fume less likely to be married, and greatly more likely to have had a fortunate previous vaginal delivery (49.8 versus 158 percent) A multivariate analysis adjusted for potential confounder of the sum of two units composite outcomes: adverse maternal occurrences (i.e., endometritis, transfusion, uterine breach hysterectomy, death, dehiscence, thromboembolic disease, hematoma, cystotomy, bowel injury, and ureteral injury) and adverse neonatal adventures (i.e., intrapartum stillbirth, hypoxic-ischemic encephalopathy, and neonatal death). Data were gathered prospectively using standard forms and definitions. Approximately common third of the eligible women underwent a trial of labor (the instant national rate is 12.7 percent)

A number of important complications were significantly more universal in the trial of labor cluster most notably uterine rup-ture (07 versus naught percent), endometritis (2.9 versus 18 percent) and uterine dehiscence (07 versus 05 percent) The rate of maternal deaths did not differ significantly between disposes (0.02 versus 0.04 percent). The risk of any adverse maternal circumstance was higher in the trial of labor arrange (5.5 versus 3.6 percent; number exigencyed to treat to harm [NNH] = 53; 95 percent confidence interval [CI], 43 to 68) Uterine hostility was especially common in women with augmented labor (odd ratio [OR] = 24) or induced labor (OR = 29) Of the 114 uterine dissolutions nine resulted in neonatal death or encephalopathy. The overall risk of stillbirth, hypoxic-isch-emic encephalopathy, or neonatal death was excessively low, but was significantly higher in the trial of labor cluster (0.38 versus 0.13 percent; NNH = 398; 95 percent CI, 269 to 721)

Bottom Line: The risks of trial of labor after cesarean delivery are small moreover cannot be ignored. The in the greatest degree important is an increase in the risk of neonatal death, stillbirth, or encephalopathy (NNH = 398) which is higher than that occurring in other research (Guise JM et al. Systematic review of the incidence and events of uterine rupture in women with previous caesarean section. BMJ July 3 2004;329:19-25) This article provides a additional guidance for physicians and patients who must make this decision. (Level of Evidence: 2b)

contemplation Reference: Landon MB, et al. Maternal and perinatal results associated with a trial of labor after prior cesarean delivery. N Engl J M December 16 2004;351:2581-9

Used with permission from Ebell M Trial of labor carries small still real increase in risk. Accessed online January 25 2005 at: http://www.InfoPOEMs.com.

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