Outcome of a trial of labor after prior cesarean delivery.

Overview

In the United States over 90% of patients with a history of cesarean delivery in the prior pregnancy undergo repeat cesarean delivery in a subsequent pregnancy. The costs of the nearly universal approach to this issue are staggering and have been addressed by a recent National Institutes of Health consensus development conference. In 1979 at the Women's Hospital of Los Angeles County/University of Southern California Medical Center we initiated a policy of permitting a trial of spontaneous labor and vaginal delivery in selected patients with prior cesarean deliveries. Patients selected for a trial of labor (TOL) were those with a history of one prior uterine incision known to be low transverse. During 1980 there were 13,292 deliveries and 13,147 live births; 871 of these patients had a history of prior cesarean delivery. Of the 871 women, 308 (35%) were permitted a TOL. There were 240 vaginal deliveries, for a success rate of 78%. Twenty-two perinatal deaths occurred among the 871 patients, none directly attributable to the TOL. There were three ruptured uteri, one directly attributable to a TOL. Seven hysterectomies were performed in this group, none directly attributable to a TOL. This experience has encouraged us to expand the patient group offered a TOL after prior cesarean delivery under carefully controlled conditions.