BMJ  2005;330 (9 April), doi:10.1136/bmj.330.7495.0-f

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POEM^*

Trial of labour carries small but real increase in risk

Question What are the risks associated with trial of labour after caesarean delivery?

Synopsis This was an observational study in which women with a previous caesarean delivery and a current singleton pregnancy decided whether to pursue a trial of labour (they were not randomised). Among the 45 988 women at the 19 academic medical centres who qualified for the study, 9013 had clear indications for repeat caesarean and were excluded, as were 3276 who presented early in labour without a documented plan for trial of labour. Of the remainder, 17 898 underwent a trial of labour and 15 801 had an elective repeat caesarean delivery. Women choosing trial of labour were younger, more likely to be African-American, less likely to smoke, less likely to be married, and much more likely to have had a successful vaginal delivery (49.8% v 15.8%). A multivariate analysis adjusted for potential confounders of the two composite outcomes: adverse maternal events (endometritis, transfusion, uterine rupture, hysterectomy, death, dehiscence, thromboembolic disease, haematoma, cystotomy, bowel injury, and ureteral injury) and adverse neonatal events (intrapartum stillbirth, hypoxic-ischaemic encephalopathy, and neonatal death). Data were gathered prospectively, using standard forms and definitions. About a third of eligible women underwent a trial of labour (the current national rate is 12.7%). A number of important complications were significantly more common in the trial of labour group, most notably uterine rupture (0.7% v 0%), endometritis (2.9% v 1.8%), and uterine dehiscence (0.7% v 0.5%). There was no significant difference in maternal deaths between groups (0.02% v 0.04%). The risk of any adverse maternal event was higher in the trial of labour group (5.5% v 3.6%; number needed to treat to harm (NNTH) = 53, 95% confidence interval 43 to 68). Uterine rupture was especially common among women with augmented labour (odds ratio 2.4) or induced labour (odds ratio 2.9). Of the 114 uterine ruptures, nine resulted in neonatal death or encephalopathy. The overall risk of stillbirth, hypoxic-ischaemic encephalopathy, or neonatal death was very low, but was significantly higher in the trial of labour group (0.38% v 0.13%; NNTH = 398, 269 to 721).

Bottom line The risks of trial of labour after caesarean delivery are small but cannot be ignored. The most important is an increase in the risk of neonatal death, stillbirth, or encephalopathy (number needed to treat to harm = 398), which is higher than that seen in other research ( BMJ 2004;329: 19-25[Abstract/Free Full Text]). This article provides some additional guidance for physicians and patients making this important shared decision.

Level of evidence 2b (see www.infopoems.com/levels.html). Individual cohort study or low quality randomised controlled trial < 80% follow-up.

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Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351: 2581-9[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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