Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei, Brak, Israel.
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Am J Perinatol. 2024 May;41(S 01):e2636-e2644. doi: 10.1055/a-2135-6962. Epub 2023 Jul 24.
This study aimed to determine whether a trial of labor after two cesarean deliveries (TOLAC2) increases the risk of adverse maternal and neonatal outcomes and identify prognostic factors for TOLAC2 success.
A retrospective cohort study was conducted at a single medical center. The study group was comprised of women with a history of TOLAC2. Outcomes were compared with women undergoing trial of labor after one previous cesarean delivery (TOLAC1). The primary outcome was trial of labor after cesarean delivery (TOLAC) success. Secondary outcomes included mode of delivery, uterine rupture, and combined adverse outcome (CAO; uterine rupture, postpartum hemorrhage, 5-minute Apgar score < 7, pH < 7.1). Logistic regression was used for the multivariate analysis to identify prognostic factors for TOLAC2 success.
A total of 381 women who underwent TOLAC2 were compared with 3,635 women who underwent TOLAC1. Women attempting TOLAC2 were less likely to achieve vaginal births after cesarean delivery (VBAC; 80.8 and 92.5%; odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.26-0.47; < 0.001) and more likely to experience uterine rupture (0.8 vs. 0.2%; OR: 4.1; 95% CI: 1.1-15.9; = 0.02) but not CAO (4.2 vs. 4.8%; OR: 0.88; 95% CI: 0.5-1.5; = 0.3). TOLAC2 women with no previous vaginal deliveries had a lower chance of VBAC and a higher risk of uterine rupture compared with TOLAC1 women without a prior vaginal delivery (45.2 vs. 86.3%; OR: 0.13; 95% CI: 0.07-0.25; < 0.001; 2.3 vs. 0%) and TOLAC2 women with a prior vaginal delivery (45.2 vs. 85.3%; OR: 0.14; 95% CI: 0.1-0.3; < 0.0001; 2.4 vs. 0.6%; OR: 4.1; 95% CI: 0.4-46.3; = 0.3). Multivariate analysis revealed that a history of vaginal delivery is an independent predictor of TOLAC2 success.
Women attempting TOLAC2 are less likely to achieve VBAC and are at greater risk of uterine rupture compared with those attempting TOLAC1. Despite these risks, the overall success rates remain very high, and the absolute risk of adverse outcomes is still very low. Prior vaginal delivery seems to have a protective effect on TOLAC outcomes. These data should be used to counsel women and assist in decision-making when considering the mode of delivery in women with two previous cesarean sections.
· TOLAC2 has a lower chance of success and higher rate of uterine rupture compared with TOLAC1.. · Previous vaginal delivery is an independent predictor of TOLAC2 success.. · Overall TOLAC2 outcomes are associated with high chances of success and low risk of uterine rupture..
本研究旨在确定两次剖宫产术后试产（TOLAC2）是否会增加不良母婴结局的风险，并确定 TOLAC2 成功的预后因素。
这是一项在一家医疗中心进行的回顾性队列研究。研究组由 TOLAC2 史的女性组成。将结局与经历过一次剖宫产术后试产（TOLAC1）的女性进行比较。主要结局是剖宫产术后试产（TOLAC）成功。次要结局包括分娩方式、子宫破裂和复合不良结局（CAO；子宫破裂、产后出血、5 分钟 Apgar 评分 < 7、pH < 7.1）。使用逻辑回归进行多变量分析，以确定 TOLAC2 成功的预后因素。
共比较了 381 名 TOLAC2 女性和 3635 名 TOLAC1 女性。尝试 TOLAC2 的女性剖宫产术后阴道分娩（VBAC）的可能性更低（80.8%和 92.5%；优势比[OR]：0.35；95%置信区间[CI]：0.26-0.47； < 0.001），子宫破裂的可能性更高（0.8%对 0.2%；OR：4.1；95%CI：1.1-15.9； = 0.02），但 CAO 发生率无差异（4.2%对 4.8%；OR：0.88；95%CI：0.5-1.5； = 0.3）。没有先前阴道分娩史的 TOLAC2 女性与没有先前阴道分娩史的 TOLAC1 女性相比，VBAC 的可能性更低，子宫破裂的风险更高（45.2%对 86.3%；OR：0.13；95%CI：0.07-0.25； < 0.001；2.3%对 0%），与有先前阴道分娩史的 TOLAC2 女性相比，VBAC 的可能性更低（45.2%对 85.3%；OR：0.14；95%CI：0.1-0.3； < 0.0001；2.4%对 0.6%；OR：4.1；95%CI：0.4-46.3； = 0.3）。多变量分析显示，阴道分娩史是 TOLAC2 成功的独立预测因素。
与 TOLAC1 相比，尝试 TOLAC2 的女性 VBAC 的可能性更低，子宫破裂的风险更高。尽管存在这些风险，但总体成功率仍然非常高，不良结局的绝对风险仍然非常低。先前的阴道分娩似乎对 TOLAC 结局有保护作用。这些数据应在考虑具有两次剖宫产史的女性分娩方式时用于为女性提供咨询并协助决策。
· TOLAC2 与 TOLAC1 相比，成功的可能性更低，子宫破裂的风险更高。· 先前的阴道分娩是 TOLAC2 成功的独立预测因素。· TOLAC2 的总体结局与高成功率和低子宫破裂风险相关。
