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Dwight J Rouse - One of the best experts on this subject based on the ideXlab platform.
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elective repeat cesarean delivery compared with spontaneous Trial of Labor after a prior cesarean delivery a propensity score analysis
American Journal of Obstetrics and Gynecology, 2012Co-Authors: Sharon Gilbert, Dwight J Rouse, Michael W. Varner, Catherine Y. Spong, Mark B. Landon, Kenneth J. Leveno, Steve N. Caritis, William A. Grobman, Paul J Meis, Yoram SorokinAbstract:The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or Trial of Labor (TOL).
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Trial of Labor after one previous cesarean delivery for multifetal gestation.
Obstetrics and gynecology, 2007Co-Authors: Michael W. Varner, Dwight J Rouse, Elizabeth Thom, Catherine Y. Spong, Mark B. Landon, Kenneth J. Leveno, Atef H. Moawad, Hyagriv N. Simhan, Margaret Harper, Ronald J. WapnerAbstract:OBJECTIVE: To estimate success rates and risks with a Trial of Labor after one previous cesarean delivery for multifetal gestation compared with one previous cesarean delivery for a singleton pregnancy. METHODS: Patients from the National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network Cesarean Registry with one previous cesarean delivery and a current term singleton pregnancy were identified. Cases had one previous cesarean delivery for a multifetal pregnancy. Controls had one previous cesarean delivery for a singleton pregnancy. RESULTS: of cases, 556 of 944 (58.9%) attempted a Trial of Labor. of controls, 13,923 of 29,329 (47.5%) attempted a Trial of Labor. The Trial of Labor success rate was 85.6% among cases and 73.1% among controls (odds ratio 2.19, 95% confidence interval 1.72-2.78). Compared with Trial of Labor controls, cases had no statistically increased risk of transfusion, endometritis, intensive care unit admissions, uterine rupture, or perinatal complications. Cases in this analysis with a successful Trial of Labor were more likely to have previously had a successful vaginal birth after cesarean (37.1% compared with 14.1%, P
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The MFMU Cesarean Registry: Impact of fetal size on Trial of Labor success for patients with previous cesarean for dystocia
American journal of obstetrics and gynecology, 2006Co-Authors: Alan M. Peaceman, Dwight J Rouse, Michael W. Varner, Catherine Y. Spong, Mark B. Landon, Kenneth J. Leveno, Atef H. Moawad, Steve N. Caritis, Rebecca Gersnoviez, Margaret HarperAbstract:Objective The purpose of this study was to determine the influence of change in infant birth weight between pregnancies on the outcome of a Trial of Labor for women whose first cesarean delivery was performed for dystocia. Study design Secondary analysis of 7081 patients with 1 previous cesarean delivery and no other deliveries after 20 weeks' gestation, undergoing a Trial of Labor with a singleton gestation. Cases were classified as dystocia if the listed indication for the cesarean delivery in the first pregnancy was failed induction, cephalo-pelvic disproportion, failure to progress, or failed forceps or vacuum. Outcomes of the Trial of Labor were correlated with fetal size relative to birth weight in the initial pregnancy for those women whose initial cesarean delivery was for dystocia and those with other indications. Results For the cohort being studied (n = 7081), dystocia was the indication for the first cesarean delivery for 3182 (44.9%). Trial of Labor resulted in vaginal delivery for 54% of patients whose first cesarean delivery was performed for dystocia, compared with 67% for those with other indications ( P Conclusion For women with previous cesarean delivery for dystocia, increasing birth weight in the subsequent Trial of Labor relative to the first birth weight diminishes the chances of successful vaginal delivery.
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Trial of Labor in women with transverse vaginal septa.
Obstetrics and gynecology, 2003Co-Authors: Elizabeth N Blanton, Dwight J RouseAbstract:Transverse vaginal septa are rare anomalies that may be first diagnosed during pregnancy. Management options including elective cesarean delivery, incision before Labor, and a Trial of Labor have been proposed. Two patients with transverse vaginal septa were allowed a Trial of Labor. The septa were incised in active Labor, resulting in vaginal delivery with no related complications. Allowing a Trial of Labor despite a transverse vaginal septum is a reasonable management option in selected cases.
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Trial of Labor in women with transverse vaginal septa
Obstetrics & Gynecology, 2003Co-Authors: Elizabeth N Blanton, Dwight J RouseAbstract:Abstract Background Transverse vaginal septa are rare anomalies that may be first diagnosed during pregnancy. Management options including elective cesarean delivery, incision before Labor, and a Trial of Labor have been proposed. Cases Two patients with transverse vaginal septa were allowed a Trial of Labor. The septa were incised in active Labor, resulting in vaginal delivery with no related complications. Conclusion Allowing a Trial of Labor despite a transverse vaginal septum is a reasonable management option in selected cases.
Ellice Lieberman - One of the best experts on this subject based on the ideXlab platform.
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Neonatal outcome after Trial of Labor compared with elective repeat cesarean section.
Birth (Berkeley Calif.), 2003Co-Authors: Rita E. Fisler, Amy Cohen, Steven A. Ringer, Ellice LiebermanAbstract:: Background: Trial of Labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a Trial of Labor after cesarean. Methods: All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a Trial of Labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the Trial of Labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Results: Infants delivered after a Trial of Labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p
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Post-cesarean delivery fever and uterine rupture in a subsequent Trial of Labor
Obstetrics and gynecology, 2003Co-Authors: Thomas D. Shipp, Amy Cohen, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:OBJECTIVE: To evaluate the association of uterine rupture during a Trial of Labor after cesarean with postpartum fever after the prior cesarean delivery. METHODS: We conducted a nested, case-control study in a cohort of all women undergoing a Trial of Labor after cesarean over a 12-year period in a single tertiary care institution. The current study was limited to all women undergoing a Trial of Labor after cesarean at term with a symptomatic uterine rupture and who also had their prior cesarean at the same institution. Four controls, who all had their prior cesarean at the same institution, were matched to each case by year of delivery, number of prior cesareans, prior vaginal delivery, and induction in the index pregnancy. Medical records were reviewed for maximum postpartum temperature for the previous cesarean. Fever was defined as a temperature above 38C. Conditional logistic regression analysis was performed taking into account potential confounding factors. RESULTS: There were 21 cases of uterine rupture included in the analysis. The rate of fever following the prior cesarean was 38% (8/21) among the cases, and 15% (13/84) in the controls, P = .03. Multiple logistic regression analysis examining the association of uterine rupture and postpartum fever adjusting for confounders revealed an odds ratio of 4.0, 95% confidence interval 1.0, 15.5. CONCLUSION: Postpartum fever after cesarean delivery is associated with an increased risk of uterine rupture during a subsequent Trial of Labor.
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outcomes of Trial of Labor following previous cesarean delivery among women with fetuses weighing 4000 g
American Journal of Obstetrics and Gynecology, 2001Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To compare outcomes at term of a Trial of Labor in women with previous cesarean delivery who delivered neonates weighing >4000 g versus women with those weighing ≤4000 g. Study Design: We reviewed medical records for all women undergoing a Trial of Labor after prior cesarean delivery during a 12-year period. The current analysis was limited to women at term with one prior cesarean and no other deliveries. The rates of cesarean delivery and symptomatic uterine rupture for women with infants weighing >4000 g were compared to the rates for women with infants weighing ≤4000 g. Logistic regression was used to control for the potential confounding by use of epidural, maternal age, Labor induction, Labor augmentation, indication for previous cesarean, type of uterine hysterotomy, year of delivery, receiving public assistance, and maternal race. Adjusted odds ratios and 95% confidence intervals were calculated. Results: of 2749 women, 13% (365) had infants with birth weights >4000 g. Cesarean delivery rate associated with birth weights ≤4000 g was 29% versus 40% for those with birth weights >4000 g ( P =.001). With use of logistic regression, we found that birth weight >4000 g was associated with a 1.7-fold increase in risk of cesarean delivery (95% CI, 1.3-2.2). The rate of uterine rupture for women with infants weighing ≤4000 g was 1.0% versus a 1.6% rate for those with infants weighing >4000 g ( P =.24). Although the logistic regression analysis revealed a somewhat higher rate of uterine rupture associated with birth weights of >4000 g (adjusted OR, 1.6; 95% CI, 0.7-4.1), this difference was not statistically significant. The rate of uterine rupture was 2.4% for women with infants weighing >4250 g, but this rate did not differ significantly from the rate of uterine rupture associated with birth weights ≤4250 g ( P =.1). Conclusion: A Trial of Labor after previous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of >4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights. However, some caution may apply when considering a Trial of Labor in women with infants weighing >4250 g. In these women with infants weighing >4000 g, the likelihood of successful vaginal delivery, although lower than for neonates weighing ≤4000 g, is still 60%. (Am J Obstet Gynecol 2001;185: 903-5.)
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Oxytocin dose and the risk of uterine rupture in Trial of Labor after cesarean
Obstetrics and gynecology, 2001Co-Authors: Laura Goetzl, Amy Cohen, Thomas D. Shipp, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To examine the association between uterine rupture and oxytocin use in Trial of Labor after cesarean. Methods: A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a Trial of Labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing Trial of Labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose. Results: No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P = .05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%. Conclusion: Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.
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Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor.
American journal of obstetrics and gynecology, 2000Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a Trial of Labor after prior cesarean delivery. Study Design: The medical records of all pregnant women with a history of cesarean delivery who attempted a Trial of Labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had ≥1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. Results: of 3783 women with 1 prior scar, 1021 (27.0%) also had ≥1 prior vaginal delivery. During a subsequent Trial of Labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery ( P =.01). Logistic regression analysis controlling for duration of Labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. Conclusion: Among women with 1 prior cesarean delivery undergoing a subsequent Trial of Labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery. (Am J Obstet Gynecol 2000;183:1184-6.)
Elizabeth N Blanton - One of the best experts on this subject based on the ideXlab platform.
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Trial of Labor in women with transverse vaginal septa.
Obstetrics and gynecology, 2003Co-Authors: Elizabeth N Blanton, Dwight J RouseAbstract:Transverse vaginal septa are rare anomalies that may be first diagnosed during pregnancy. Management options including elective cesarean delivery, incision before Labor, and a Trial of Labor have been proposed. Two patients with transverse vaginal septa were allowed a Trial of Labor. The septa were incised in active Labor, resulting in vaginal delivery with no related complications. Allowing a Trial of Labor despite a transverse vaginal septum is a reasonable management option in selected cases.
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Trial of Labor in women with transverse vaginal septa
Obstetrics & Gynecology, 2003Co-Authors: Elizabeth N Blanton, Dwight J RouseAbstract:Abstract Background Transverse vaginal septa are rare anomalies that may be first diagnosed during pregnancy. Management options including elective cesarean delivery, incision before Labor, and a Trial of Labor have been proposed. Cases Two patients with transverse vaginal septa were allowed a Trial of Labor. The septa were incised in active Labor, resulting in vaginal delivery with no related complications. Conclusion Allowing a Trial of Labor despite a transverse vaginal septum is a reasonable management option in selected cases.
Carolyn M. Zelop - One of the best experts on this subject based on the ideXlab platform.
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Post-cesarean delivery fever and uterine rupture in a subsequent Trial of Labor
Obstetrics and gynecology, 2003Co-Authors: Thomas D. Shipp, Amy Cohen, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:OBJECTIVE: To evaluate the association of uterine rupture during a Trial of Labor after cesarean with postpartum fever after the prior cesarean delivery. METHODS: We conducted a nested, case-control study in a cohort of all women undergoing a Trial of Labor after cesarean over a 12-year period in a single tertiary care institution. The current study was limited to all women undergoing a Trial of Labor after cesarean at term with a symptomatic uterine rupture and who also had their prior cesarean at the same institution. Four controls, who all had their prior cesarean at the same institution, were matched to each case by year of delivery, number of prior cesareans, prior vaginal delivery, and induction in the index pregnancy. Medical records were reviewed for maximum postpartum temperature for the previous cesarean. Fever was defined as a temperature above 38C. Conditional logistic regression analysis was performed taking into account potential confounding factors. RESULTS: There were 21 cases of uterine rupture included in the analysis. The rate of fever following the prior cesarean was 38% (8/21) among the cases, and 15% (13/84) in the controls, P = .03. Multiple logistic regression analysis examining the association of uterine rupture and postpartum fever adjusting for confounders revealed an odds ratio of 4.0, 95% confidence interval 1.0, 15.5. CONCLUSION: Postpartum fever after cesarean delivery is associated with an increased risk of uterine rupture during a subsequent Trial of Labor.
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outcomes of Trial of Labor following previous cesarean delivery among women with fetuses weighing 4000 g
American Journal of Obstetrics and Gynecology, 2001Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To compare outcomes at term of a Trial of Labor in women with previous cesarean delivery who delivered neonates weighing >4000 g versus women with those weighing ≤4000 g. Study Design: We reviewed medical records for all women undergoing a Trial of Labor after prior cesarean delivery during a 12-year period. The current analysis was limited to women at term with one prior cesarean and no other deliveries. The rates of cesarean delivery and symptomatic uterine rupture for women with infants weighing >4000 g were compared to the rates for women with infants weighing ≤4000 g. Logistic regression was used to control for the potential confounding by use of epidural, maternal age, Labor induction, Labor augmentation, indication for previous cesarean, type of uterine hysterotomy, year of delivery, receiving public assistance, and maternal race. Adjusted odds ratios and 95% confidence intervals were calculated. Results: of 2749 women, 13% (365) had infants with birth weights >4000 g. Cesarean delivery rate associated with birth weights ≤4000 g was 29% versus 40% for those with birth weights >4000 g ( P =.001). With use of logistic regression, we found that birth weight >4000 g was associated with a 1.7-fold increase in risk of cesarean delivery (95% CI, 1.3-2.2). The rate of uterine rupture for women with infants weighing ≤4000 g was 1.0% versus a 1.6% rate for those with infants weighing >4000 g ( P =.24). Although the logistic regression analysis revealed a somewhat higher rate of uterine rupture associated with birth weights of >4000 g (adjusted OR, 1.6; 95% CI, 0.7-4.1), this difference was not statistically significant. The rate of uterine rupture was 2.4% for women with infants weighing >4250 g, but this rate did not differ significantly from the rate of uterine rupture associated with birth weights ≤4250 g ( P =.1). Conclusion: A Trial of Labor after previous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of >4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights. However, some caution may apply when considering a Trial of Labor in women with infants weighing >4250 g. In these women with infants weighing >4000 g, the likelihood of successful vaginal delivery, although lower than for neonates weighing ≤4000 g, is still 60%. (Am J Obstet Gynecol 2001;185: 903-5.)
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Oxytocin dose and the risk of uterine rupture in Trial of Labor after cesarean
Obstetrics and gynecology, 2001Co-Authors: Laura Goetzl, Amy Cohen, Thomas D. Shipp, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To examine the association between uterine rupture and oxytocin use in Trial of Labor after cesarean. Methods: A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a Trial of Labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing Trial of Labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose. Results: No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P = .05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%. Conclusion: Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.
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Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor.
American journal of obstetrics and gynecology, 2000Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a Trial of Labor after prior cesarean delivery. Study Design: The medical records of all pregnant women with a history of cesarean delivery who attempted a Trial of Labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had ≥1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. Results: of 3783 women with 1 prior scar, 1021 (27.0%) also had ≥1 prior vaginal delivery. During a subsequent Trial of Labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery ( P =.01). Logistic regression analysis controlling for duration of Labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. Conclusion: Among women with 1 prior cesarean delivery undergoing a subsequent Trial of Labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery. (Am J Obstet Gynecol 2000;183:1184-6.)
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rate of uterine rupture during a Trial of Labor in women with one or two prior cesarean deliveries
American Journal of Obstetrics and Gynecology, 1999Co-Authors: Aaron B. Caughey, Amy Cohen, Thomas D. Shipp, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a Trial of Labor in women who have had 1 versus 2 prior cesarean deliveries. Study Design: The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a Trial of Labor during a 12-year period (July 1984–June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses. Results: Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% ( P = .001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E 2 gel, birth weight, gestational age, type of prior hysterotomy, year of Trial of Labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13.2) Conclusions: Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery. (Am J Obstet Gynecol 1999;181:872-6.)
Amy Cohen - One of the best experts on this subject based on the ideXlab platform.
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Neonatal outcome after Trial of Labor compared with elective repeat cesarean section.
Birth (Berkeley Calif.), 2003Co-Authors: Rita E. Fisler, Amy Cohen, Steven A. Ringer, Ellice LiebermanAbstract:: Background: Trial of Labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a Trial of Labor after cesarean. Methods: All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a Trial of Labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the Trial of Labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Results: Infants delivered after a Trial of Labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p
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Post-cesarean delivery fever and uterine rupture in a subsequent Trial of Labor
Obstetrics and gynecology, 2003Co-Authors: Thomas D. Shipp, Amy Cohen, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:OBJECTIVE: To evaluate the association of uterine rupture during a Trial of Labor after cesarean with postpartum fever after the prior cesarean delivery. METHODS: We conducted a nested, case-control study in a cohort of all women undergoing a Trial of Labor after cesarean over a 12-year period in a single tertiary care institution. The current study was limited to all women undergoing a Trial of Labor after cesarean at term with a symptomatic uterine rupture and who also had their prior cesarean at the same institution. Four controls, who all had their prior cesarean at the same institution, were matched to each case by year of delivery, number of prior cesareans, prior vaginal delivery, and induction in the index pregnancy. Medical records were reviewed for maximum postpartum temperature for the previous cesarean. Fever was defined as a temperature above 38C. Conditional logistic regression analysis was performed taking into account potential confounding factors. RESULTS: There were 21 cases of uterine rupture included in the analysis. The rate of fever following the prior cesarean was 38% (8/21) among the cases, and 15% (13/84) in the controls, P = .03. Multiple logistic regression analysis examining the association of uterine rupture and postpartum fever adjusting for confounders revealed an odds ratio of 4.0, 95% confidence interval 1.0, 15.5. CONCLUSION: Postpartum fever after cesarean delivery is associated with an increased risk of uterine rupture during a subsequent Trial of Labor.
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outcomes of Trial of Labor following previous cesarean delivery among women with fetuses weighing 4000 g
American Journal of Obstetrics and Gynecology, 2001Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To compare outcomes at term of a Trial of Labor in women with previous cesarean delivery who delivered neonates weighing >4000 g versus women with those weighing ≤4000 g. Study Design: We reviewed medical records for all women undergoing a Trial of Labor after prior cesarean delivery during a 12-year period. The current analysis was limited to women at term with one prior cesarean and no other deliveries. The rates of cesarean delivery and symptomatic uterine rupture for women with infants weighing >4000 g were compared to the rates for women with infants weighing ≤4000 g. Logistic regression was used to control for the potential confounding by use of epidural, maternal age, Labor induction, Labor augmentation, indication for previous cesarean, type of uterine hysterotomy, year of delivery, receiving public assistance, and maternal race. Adjusted odds ratios and 95% confidence intervals were calculated. Results: of 2749 women, 13% (365) had infants with birth weights >4000 g. Cesarean delivery rate associated with birth weights ≤4000 g was 29% versus 40% for those with birth weights >4000 g ( P =.001). With use of logistic regression, we found that birth weight >4000 g was associated with a 1.7-fold increase in risk of cesarean delivery (95% CI, 1.3-2.2). The rate of uterine rupture for women with infants weighing ≤4000 g was 1.0% versus a 1.6% rate for those with infants weighing >4000 g ( P =.24). Although the logistic regression analysis revealed a somewhat higher rate of uterine rupture associated with birth weights of >4000 g (adjusted OR, 1.6; 95% CI, 0.7-4.1), this difference was not statistically significant. The rate of uterine rupture was 2.4% for women with infants weighing >4250 g, but this rate did not differ significantly from the rate of uterine rupture associated with birth weights ≤4250 g ( P =.1). Conclusion: A Trial of Labor after previous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of >4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights. However, some caution may apply when considering a Trial of Labor in women with infants weighing >4250 g. In these women with infants weighing >4000 g, the likelihood of successful vaginal delivery, although lower than for neonates weighing ≤4000 g, is still 60%. (Am J Obstet Gynecol 2001;185: 903-5.)
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Oxytocin dose and the risk of uterine rupture in Trial of Labor after cesarean
Obstetrics and gynecology, 2001Co-Authors: Laura Goetzl, Amy Cohen, Thomas D. Shipp, Carolyn M. Zelop, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: To examine the association between uterine rupture and oxytocin use in Trial of Labor after cesarean. Methods: A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a Trial of Labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing Trial of Labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose. Results: No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P = .05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%. Conclusion: Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.
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Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor.
American journal of obstetrics and gynecology, 2000Co-Authors: Carolyn M. Zelop, Amy Cohen, Thomas D. Shipp, John T. Repke, Ellice LiebermanAbstract:Abstract Objective: We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a Trial of Labor after prior cesarean delivery. Study Design: The medical records of all pregnant women with a history of cesarean delivery who attempted a Trial of Labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent Trial of Labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had ≥1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors. Results: of 3783 women with 1 prior scar, 1021 (27.0%) also had ≥1 prior vaginal delivery. During a subsequent Trial of Labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery ( P =.01). Logistic regression analysis controlling for duration of Labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant. Conclusion: Among women with 1 prior cesarean delivery undergoing a subsequent Trial of Labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery. (Am J Obstet Gynecol 2000;183:1184-6.)
