Abstract
Objectives
The consultation of women aspiring a vaginal birth after caesarean may be improved by integrating the individual evaluation of factors that predict their chance of success. Retrospective analysis of correlating factors for all trials of labor after caesarean that were conducted at the Department of Obstetrics of Charité-Universitätsmedizin Berlin, Campus Virchow Clinic from 2014 to October 2017.
Methods
Of 2,151 pregnant women with previous caesarean, 408 (19%) attempted a vaginal birth after cesarean. A total of 348 women could be included in the evaluation of factors, 60 pregnant women were excluded because they had obstetric factors (for example preterm birth, intrauterine fetal death) that required a different management.
Results
Spontaneous delivery occurred in 180 (51.7%) women and 64 (18.4%) had a vacuum extraction. 104 (29.9%) of the women had a repeated caesarean delivery. The three groups showed significant differences in body mass index, the number of prior vaginal deliveries and the child’s birth weight at cesarean section. The indication for the previous cesarean section also represents a significant influencing factor. Other factors such as maternal age, gestational age, sex, birth weight and the head circumference of the child at trial of labor after caesarean showed no significant influence.
Conclusions
The clear majority (70.1%) of trials of labor after caesarean resulted in vaginal delivery. High body mass index, no previous spontaneous delivery, and fetal distress as a cesarean indication correlated negatively with a successful vaginal birth after cesarean. These factors should be used for the consultation of pregnant women.
Introduction
Cesarean delivery (CD) is one of the most common operations worldwide, with increasing incidence [1]. A woman with a previous CD has two options in the subsequent pregnancy: either a trial of labor after a cesarean delivery (TOLAC) or an elective repeat cesarean delivery (ERCD), offering advantages and disadvantages on both sides [2], [3], [4], [5].
The German TOLAC rate is 36.0–49.8%, resulting in 59.6–72.8% in a successful vaginal birth after cesarean (VBAC) or instrumented delivery [6].
Maternal mortality for ERCD is higher than for TOLAC (0.013 vs. 0,004%). On the contrary, perinatal mortality is significantly increased for TOLAC (0.13 vs. 0.05% for ERCD) [7]. The most feared complication of TOLAC is uterine rupture, associated with very high perinatal mortality rates and both maternal and perinatal morbidity. It is characterized by a complete rupture of the myometrium and fetal membranes, having a direct communication between the peritoneum and uterine cavity [8], [9], [10], [11], [12].
Main symptoms are strong abdominal pain, maternal hemodynamic instability, vaginal bleeding, fetal bradycardia or loss of fetal station [13]. The main risk factor is a previously operated uterus. A uterine rupture occurs in only 0.003% on an unscarred uterus [14]. The rupture risk of a previously operated uterus depends on the mode of birth, on average it is 0.30% [7]. For an ERCD it is 0.03% whereas the rupture risk for TOLAC is 0.47–5.6% depending on further risk factors [7, 15]. One of the main avoidable risk factors for rupture is birth induction with prostaglandins, which is strictly contraindicated in our clinic [16, 17]. Other risk factors are a short period after the last CD (less than 12 months) [15], as well as a fetal weight over 4,000 g [18].
Unfortunately, no reliable method for predicting uterine rupture exists. In our clinic we have been using measurements of the lower uterine segment in the last trimester. At a cut-off between 0.6 and 2 mm the sensitivity and specificity was 0.76 and 0.92 [19].
In order to facilitate the women’s choice between TOLAC and ERCD and lower the incidence of CD, several models aiming to predict the individual chance for a successful TOLAC have been published. One of the first published prediction models by Grobman et al. [20] is based on information being available at the first consultation. Maternal age, body mass index (BMI), ethnicity, prior vaginal delivery, the occurrence of VBAC and a potentially recurrent indication for the CD showed to be influencing factors. Since then there have been many studies validating and adapting the Grobman nomogram for their national cohort e.g. Sweden [21], France [22], and Israel [23]. To our knowledge there is no study evaluating these international established factors for a German study cohort.
In this study we analyzed TOLAC-success rate, rate of uterine rupture and potential risk factors for a successful TOLAC for a study cohort in one of the biggest university facilities in Germany. Another aim of this study was to find out whether we could adapt the model of Grobman for our study population. Gained information should be used in the prenatal consultation of women after a previous CD.
Materials and methods
This is a retrospective cohort study of all TOLAC from January 2014 until October 2017 at the Department of Obstetrics of the Charité-Universitätsmedizin Berlin, Campus Virchow Clinic.
Data were collected from hospital charts. From the 10,520 births during this period, 2,151 were deliveries after a CD (Figure 1). Of those, 408 women had a TOLAC. Sixty births were excluded as shown in the flow-chart, following the model of Grobman et al. [20] and Fagerberg et al. [21].
Flow-chart of the study.
The study cohort for the analysis consisted of 348 women who underwent a TOLAC in the above period. In this study we analyzed the factors for a successful TOLAC in the three following groups: VBAC, instrumented and unplanned intrapartum cesarean delivery (UICD). In our cohort instrumented delivery was exclusively performed as a vacuum extraction (VE).
Following parameters have been analyzed: maternal age at the beginning of the pregnancy, BMI before pregnancy, number of previous pregnancies, number of previous births, number of vaginal deliveries before CD, number of successful VBACs, time between CD and beginning of the current pregnancy, indication of the previous CD, birth weight at the CD, pregnancy age at TOLAC, sex, birth weight at TOLAC, head circumference at TOLAC.
The statistical analysis was performed with the program IBM “SPSS Statistics 24”. The p-values were calculated with following tests: chi-squared, ANOVA and Kruskal–Wallis and a possibility <5% was considered statistically significant.
Based on the expanded Grobman nomogram by Fagerberg et al. we set up a binary-logistic regression model including the following independent variables for predicting a successful TOLAC: age, BMI, any vaginal birth prior to CD, any prior VBAC and indication for the previous CD. Age and BMI were included as continuous variables whereas any vaginal birth prior to CD and any prior VBAC were dichotomous variables (yes/no). Indication for the previous CD was categorized as follows: (1) Breech and other malpresentation; (2) Preterm birth/chorioamnionitis; (3) Multiple gestation; (4) Congenital malformations; (5) Placenta praevia; (6) Suspected intrauterine growth restriction; (7) Suspected large for gestational age; (8) Prolonged pregnancy; (9) Severe pregnancy complications/severe maternal disease; (10) Complications during labor/delivery; (11) Fetal stress; (12) Unknown indication with (1) Breech and other malpresentation serving as the reference category.
To assess which combination of independent variables was most suitable to predict a VBAC in our data another binary-logistic regression analysis was run including the variables of the Grobman/Fagerberg nomogram as well as the following additional variables: total number of pregnancies, total number of births, number of vaginal births prior to CD and number of VBACs. All independent variables were entered into the analysis using backwards variable selection with a removal criterion of p>0.10 and a maximum of 20 iterations.
Both steps were completed to compare women with VBAC to (i) VE and CD, (ii) only VE, and (iii) only CD. The goodness-of-fit of the regression models is reported by unstandardized beta coefficients B and standard errors of the unstandardized beta coefficient, p-values and odd’s ratios with a 95% confidence interval, R2s, the model χ 2-tests, the Hosmer–Lemeshow tests as well as ROC curves and AUCs.
Results
A total of 10,520 births took place at our clinic between 2014 and 2017 (Figure 1). 2,151 (20.4%) births were after one or more CDs. Of those, 63.4% were an ERCD, a UICD took place in 16.9% (365 patients) and an emergency CD in 16 cases (0.8%). 18.9% (408 women) had a TOLAC.
Totally, 348 women met the inclusion criteria. Of those, 180 (51.7%) had a successful VBAC and 64 (18.4%) had a VE. 104 women (29.9%) had an UICD, 5 of those an emergency CD.
The women in our cohort were aged from 18 to 42 years (means; VBAC: 31.2 years, VE: 32.2 years, UICD: 31.7 years) (Table 1). There are no statistically significant differences between the three groups.
Potential factors for a successful TOLAC.
| Factors | Missing | VBAC | VE | UICD | p-Value <0.05 |
|---|---|---|---|---|---|
| n, % | – | 180 (51.7) | 64 (18.4) | 104 (29.9) | – |
| Age, years (AM, SD) | – | 31.2 (5.3) | 32.2 (5.3) | 31.7 (5.3) | No |
| BMI, kg/m2 (AM, SD) | – | 24.7 (5.1) | 23.4 (4.0) | 25.4 (5.4) | Yes |
| Previous vaginal birth before CD, n, % | 3 | 39 (21.6) | 8 (12.5) | 10 (9.6) | Yes |
| Previous VBAC, n, % | 3 | 56 (31.1) | 5 (7.8) | 11 (10.6) | Yes |
| Time between CD and TOLAC (mean, IQR) | 15 | 3.0 (1.6; 5.0) | 2.2 (1.5; 3.9) | 2.7 (1.9; 4.9) | No |
| Birth weight at CD, g, AM (SD) | 97 | 3.046 (839) | 3.311 (675) | 3.378 (695) | Yes |
| Gestational age at TOLAC, weeks, AM (SD) | – | 39.9 (1.0) | 38.8 (1.0) | 39.6 (1.0) | No |
| Birth weight at TOLAC, g, AM (SD) | – | 3.510 (434) | 3.448 (477) | 3.391 (479) | No |
| Male sex of child at TOLAC, n, % | – | 92 (51.1) | 31 (48.4) | 48 (46.1) | No |
| Head circumference at TOLAC, cm, AM (SD) | – | 35.0 (1.4) | 34.7 (1.3) | 34.7 (1.5) | No |
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TOLAC, trial of labor after a cesarean delivery; VBAC, vaginal birth after cesarean; VE, vacuum extraction; UICD, unplanned intrapartum cesarean delivery; AM, arithmetic mean; SD, standard deviation; CD, cesarean delivery.
The BMI before pregnancy in the three groups ranges from 15.8 to 45 kg/m2, with an arithmetic mean of 24.7 kg/m2 in the VBAC group, 23.4 kg/m2 in the VE group and 25.4 kg/m2 for UICD (Table 1). A lower BMI correlates statistically significant (p=0.042, ANOVA test) with a successful TOLAC.
In the VBAC group 21.6% of the women had a vaginal birth before the CD and 31.1% already had a successful TOLAC (Table 1). Women in the VE and UICD group had significantly less often a previous vaginal birth. A higher amount of previous pregnancies (p<0.001, Kruskal–Wallis test), previous vaginal birth before CD (p=0.016, Kruskal–Wallis test) and VBAC (p<0.001, Kruskal–Wallis test) correlates with a successful TOLAC.
Considering the time between CD and beginning of current pregnancy there is a range of 0.3–18.5 years in the study cohort. The mean in the VBAC group is 3 years with an interquartile range (IQR) of 1.6 and 5.0 years (Table 1). The mean in the VE group is 2.2 years and for UICD 2.7 years. The differences are not statistically significant.
The indication for previous CD has been hierarchically classified into 12 categories, orienting to Fagerberg et al. [21] as shown in Table 2. Information could be obtained for 320 of 348 women. Most common indications for the previous CD were: complication during labor/delivery (in 29.4%), breech or other malpresentation (in 20%) and fetal distress (in 15%). Success in the subsequent TOLAC for these three most common indications for previous CD is shown in Table 3. CD with the indications: “Prolonged pregnancy” and “Unknown indication” were performed in non-European countries.
Indication for previous CD – classification and frequency.
| n (%) | ||
|---|---|---|
| Data | ∑ | 320 (92.0) |
| Missing | 28 (8.0) | |
| Indication for previous CD |
|
15 (4.7) |
|
20 (6.3) | |
|
64 (20.0) | |
|
10 (3.1) | |
|
9 (2.8) | |
|
13 (4.0) | |
|
13 (4.0) | |
|
4 (1.3) | |
|
26 (8.1) | |
|
94 (29.4) | |
|
48 (15.0) | |
|
4 (1.3) |
-
aPerformed in non-European countries.
Indication for previous CD for the three most common categories – success in subsequent TOLAC.
| Indication, n | VBAC, n (%) | VE, n (%) | UICD, n (%) | p-Value (χ 2-test) |
|---|---|---|---|---|
| ∑ (n=320) | 165 (51.6) | 56 (17.5) | 99 (30.9) | Referent |
| Complication during labor/delivery (n=94) | 44 (46.8) | 20 (21.3) | 30 (31.9) | 0.368 |
| Breech and other malpresentation (n=64) | 43 (67.2) | 6 (9.4) | 15 (23.4) | 0.016 |
| Fetal stress (n=48) | 18 (37.5) | 6 (12.5) | 24 (50.0) | 0.012 |
Women with previous CD because of breech or other malpresentation had statistically significant more often a VBAC than the average of this cohort (p=0.016, chi-squared test). During the TOLAC of women with previous CD because of complications during labor/delivery, a VE was performed more often, but not enough to be statistically significant. Fetal distress as indication of the previous CD was associated with a higher rate of unsuccessful TOLAC (p=0.012, chi-squared test).
We also have evidence of statistically significant (p=0.006, ANOVA test) differences among the groups regarding the birth weight at CD. The arithmetic mean in the VBAC group is 3,046 g, in the VE group 3,311 g and in the UICD group 3,378 g (Table 1). A higher birth weight at the previous CD correlates negatively with a successful TOLAC.
Regarding the gestational age during TOLAC, birth weight, sex of child and head circumference of child at TOLAC there were no statistically significant differences between the three groups.
There were 6 uterine ruptures in our cohort of 408 women with TOLAC, resulting in a uterine rupture rate of 1.47%. In three cases the rupture was diagnosed during an emergency CD: in two cases the symptoms were prolonged fetal bradycardia, in one case maternal shock symptoms. Another two ruptures were diagnosed during an UICD and in one case it was seen by ultrasonography postpartum after a VE, the patient presented with strong abdominal pain.
Head circumference, obtained postnatally on the newborn, has not been statistically significant for a prediction of a successful TOLAC in our study group (Table 1).
Binary – logistic regression analysis
VBAC vs. VE and CD (Figure 2)
VBAC vs. VE and CD.
Applying Grobman’s model to our data for predicting VBAC against VE and CD, the area under the ROC curve was 0.744 (95%-CI: 0.690–0.798). Women who were younger and those who had had any vaginal birth prior to CD or any prior VBAC were more likely to have a successful TOLAC. A lower BMI was associated slightly with VBAC though not significantly. Compared to women having breech as an indication for the last CD, women in most other indication groups had lower chances for a VBAC ((3) Multiple gestation, (6) Suspected intrauterine growth restriction, (7) Suspected large for gestational age, (8) Prolonged pregnancy, (9) Severe pregnancy complications/severe maternal disease, (10) Complications during labor/delivery, (11) Fetal stress, (12) Unknown indication) but those with (2). Preterm birth/chorioamnionitis (4). Congenital malformations or (5). Placenta praevia had higher chances for a VBAC.
Model i.b resulted in BMI being excluded from the model while none of the additional variables were included. The area under the ROC curve was 0.743 (0.689–0.797). The directions of associations correspond to those reported for model i.a.
VBAC vs. VE (Figure 3)
VBAC vs. VE.
The area under the ROC curve of the Grobman/Fagerberg model applied to our data for predicting VBAC against VE was 0.775 (95%-CI: 0.709–0.842). A younger age, any vaginal delivery prior to CD and any prior VBAC were associated with VBAC. A higher BMI was slightly associated with VBAC, though not significantly. Indication for previous CD was not significantly associated with VBAC.
Model ii.b corresponds to model ii.a.
VBAC vs. CD (Figure 4)
VBAC vs. CD.
The application of the Grobman/Fagerberg nomogram to our data regarding the third analysis VBAC vs. CD resulted in an area under the ROC curve of 0.754 (95%-CI: 0.694–0.813). A younger age, any vaginal delivery prior to CD and any prior VBAC were associated with a VBAC. The association between a lower BMI and VBAC was not significant. The indication for the previous CD was not significantly associated with VBAC.
Model iii.b included maternal age, BMI, any prior vaginal birth, total number of pregnancies, and number of VBACs with an area under the ROC curve of 0.726 (95%-CI: 0.664–0.788). Women who were younger and those who had a lower BMI had a higher chance of a VBAC. Also, any vaginal birth prior to CD, a higher number of pregnancies and a higher number of VBACs were associated with a VBAC.
Discussion
Principal findings
This retrospective study analyzed 2,151 women with previous CD and their TOLAC success rate. Potential risk factors have been analyzed for 348 women.
In our group we had more births after a previous CD than in other German hospitals (20.45 vs. 11%) [24]; whereas our TOLAC rate of 18.2% is less than in other German hospitals (36–49.8%) [6]. This might be due to the higher amount of risk pregnancies at the Charité, being a university clinic. Reddy et al. [25] described significantly smaller TOLAC rates in private and small clinics than in big, specialized hospitals. At the same time, those low-risk clinics and private services had more candidates for TOLAC than bigger hospitals. After elimination of noncandidates for TOLAC, the adjusted rate did not differ among the clinical services.
According to the literature rates, of the 348 women included in the current study, 244 (70.1%) have had a successful TOLAC, 180 of those had a VBAC and another 64 a VE. 104 women (29.9%) had an UICD, 5 of those an emergency CD. Gross et al. [6] observed TOLAC success rates between 59.6 and 72.8% in Germany in 2015, while there are rates between 38.5 and 69.8% in the United States in the period 1990–2009 [26].
A specialty of our study design consists in the separate analysis of the VE group, as a step between a VBAC and an UICD, whereas other studies regard VE and VBAC together as “successful TOLAC” [27].
The model of Grobman and Fagerberg [20, 21] could be successfully adjusted to our patient cohort. Our analyses confirm the existing model.
Results and clinical implications
Maternal age had a spastically significant influence on a successful TOLAC, as shown in our multivariate analysis and confirmed by other studies [20, 28]. Haumonte et al. [22] could not affirm these findings in their study cohort.
We noted a statistically significant difference between the BMI in the three groups, showing that a higher BMI is a negative predictor for successful TOLAC. This is in accordance with literature [20], [21], [22, 29]. BMI was not statistically significant in our multivariate analysis. This might be because of the small study population and similar data in the three groups.
Previous pregnancies and births beyond the CD have also a positive influence on the success of a TOLAC, as shown in our cohort, also confirmed by our multivariate analysis. Especially a previous VBAC had a statistically significant influence in our multivariate analysis. The differences have been statistically significant considering both deliveries before, as well as after the previous CD, which is also confirmed by Eden et al. [28], describing a 4.39-fold probability for a successful TOLAC after a previous VBAC. Other groups had similar findings [20], [21], [22], [23]. This is a fact one could easily assume, since having had a VBAC in the past implements that all possible secondary disturbing factors for a successful TOLAC can be excluded in the future.
The difference considering the time between previous CD and current pregnancy has not been significant in our study group in accordance with other studies [20, 28]. Nevertheless, one should consider the influence of time on uterine ruptures. The number of uterine ruptures in our study population has been too small to investigate the factor of time, but as Bujold et al. [15] showed, there is a two- to three-fold increase in the risk of uterine rupture at an interdelivery interval of ≤24 months, compared with an interval of >24 months of gestation.
Considering the indication for previous CD, our findings are consistent with previously published data. In the study of Grobman et al. [20] women with a potentially recurrent indication of previous CD, like arrest of dilation, were less likely to be successful during TOLAC. Fagerberg et al. [21] showed that women with breech or other malpresentation had the highest chance of success during subsequent TOLAC.
For the prenatal consultation for TOLAC, the indication for the previous CD should be taken into account. While fetal distress correlated negatively with a successful TOLAC, women with breech or other malpresentation as indication for the previous CD were more likely to have a VBAC.
We showed that a higher birth weight at the previous CD has a negative correlation with a VBAC. Haumonte et al. [22] and Mizrachi et al. [23] showed the same results in their studies, although without statistical significance. One reason for the negative correlation between high birth weight at CD and success in subsequent TOLAC could be the indication for the previous CD. While multiple gestation or malpresentation as indications for previous CD are independent of birth weight, it is a contributing factor for CD because of fetal distress or complication during labor.
As for the gestational age at TOLAC we found no statistical differences between the three groups, although there is some evidence that a gestational age of more than 41 + 0 has a negative correlation with a successful TOLAC [28]. In our study cohort sex, birth weight and head circumference of the child were not found to be statistically different between the three groups. Other studies showed that a higher birth weight, especially more than 4,000 g, reduced likelihood of VBAC [28, 29].
There was a uterine rupture in 1.47% of our TOLAC cohort. As mentioned above, this is the most feared complication of a TOLAC, often ending in the need of blood transfusion or even hysterectomy [30, 31]. According to a review of severe maternal outcomes in Canada, there was a 0.2% for maternal mortality of uterine rupture [32]. The perinatal mortality rates vary between 8.7 and 26.2% [33], [34], [35]. Once a rupture is suspected, prompt intervention is required, in order to prevent a severe neonatal acidosis and hypoxic-ischemic encephalopathy [36]. Significant increase in neonatal morbidity was shown when the interval between recognition of abnormal fetal heart rates and delivery was ≥18 min [37, 38]. Thus, there is a strong recommendation that TOLAC should only be performed in special clinics capable of performing an emergency CD [16]. Specially, home TOLAC should be strictly avoided, since there is a high association with lower Apgar scores, neonatal seizures and deaths [39].
Head circumference has been shown to be associated with a successful TOLAC, but this data have not been statistically significant in our study group; thus we have not been using it in our prediction model [40].
Examining the results in more detail, the high odd’s ratio for Placenta praevia in models ii.a and ii.b VBAC vs. VE stands out, OR=410,985,611.5 (0.000). Such a high value suggests a statistical error and therefore allows no statistically meaningful interpretation. One possible explanation is that the distribution of cases of women with placenta praevia as an indication for the last CD was not balanced in the two categories VBAC and VE. Such high values typically happen, when there is no variance within one of the groups or categories of the dependent variable. This result should be viewed with caution.
Strengths and limitations
To our knowledge this is the first German study validating international prediction factors for a successful TOLAC, with births from the recent period of 2014–2017. A limitation of our study is the retrospective study design with a short time interval of three years and nine months, as well as a relatively small study population deriving from a single institution. Thus, it is difficult to generate it for other study cohorts.
Conclusions
To conclude, international established risk factors such as BMI, previous vaginal deliveries and indication of previous CD should be used in prenatal consultation. We hope that implementing these factors in prenatal consultation will improve awareness of the individual chance of VBAC and result in fewer deliveries by UICD and emergency CD in Germany.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Not applicable.
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Ethical approval: Not applicable.
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