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Obstetrics & Gynecology 2006;108:125-133
© 2006 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Trial of Labor or Repeat Cesarean Delivery in Women With Morbid Obesity and Previous Cesarean Delivery

Judith U. Hibbard, MD1, Sharon Gilbert, MS, MBA2, Mark B. Landon, MD3, John C. Hauth, MD4, Kenneth J. Leveno, MD5, Catherine Y. Spong, MD6, Michael W. Varner, MD7, Steve N. Caritis, MD8, Margaret Harper, MD9, Ronald J. Wapner, MD10, Yoram Sorokin, MD11, Menachem Miodovnik, MD12,13, Marshall Carpenter, MD14, Alan M. Peaceman, MD15, Mary J. O'Sullivan, MD16, Baha M. Sibai, MD17, Oded Langer, MD18, John M. Thorp, MD19, Susan M. Ramin, MD20, Brian M. Mercer, MD21, Steven G. Gabbe, MD22 for the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network*

From the 1Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; 2George Washington University Biostatistics Center, Washington, DC; 3Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio; 4University of Alabama at Birmingham, Birmingham, Alabama; 5University of Texas Southwestern Medical Center, Dallas, Texas; 6National Institute of Child Health and Human Development, Bethesda, Maryland; 7Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; 8University of Pittsburgh, Pittsburgh, Pennsylvania; 9Wake Forest University, Winston-Salem, North Carolina; 10Thomas Jefferson University, Philadelphia, Pennsylvania; 11Wayne State University, Detroit, Michigan; 12University of Cincinnati, Cincinnati, Ohio; 13Columbia University, New York, New York; 14Brown University, Providence, Rhode Island; 15Northwestern University, Chicago, Illinois; 16University of Miami, Miami, Florida; 17University of Tennessee, Memphis, Tennessee; 18University of Texas Health Science Center at San Antonio, San Antonio, Texas; 19University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 20University of Texas Health Science Center at Houston, Houston, Texas; 21Case Western Reserve University, Cleveland, Ohio; and 22Vanderbilt University, Nashville, Tennessee.

OBJECTIVE: Assess effects of body mass index (BMI) on trial of labor after previous cesarean delivery and determine whether morbidly obese women have greater maternal and perinatal morbidity with trial of labor compared with elective repeat cesarean delivery.

METHODS: Secondary analysis from a prospective observational study included all term singletons undergoing trial of labor after previous cesarean delivery. Body mass index groups were as follows: normal 18.5–24.9, overweight 25.0–29.9, obese 30.0–39.9, morbidly obese 40.0 kg/m2 or greater, and were compared for failure and maternal and neonatal morbidities. The morbidly obese trial of labor and elective repeat cesarean delivery were compared for maternal and neonatal morbidities. Multivariable logistic regression analysis controlled for confounding variables.

RESULTS: There were 14,142 trial of labor participants and 14,304 elective repeat cesarean delivery participants. Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: from 15.2% in normal weight (1,344) to 39.3% in morbidly obese (1,638), with combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. Among morbidly obese women, trial of labor carried greater than five-fold risk of uterine rupture/dehiscence (2.1% versus 0.4%), almost a two-fold increase in composite maternal morbidity (7.2% versus 3.8%) and five-fold risk of neonatal injury (1.1% versus 0.2%) (fractures, brachial plexus injuries, and lacerations), but no neonatal encephalopathy. Morbidly obese women failing a trial of labor had six-fold greater composite maternal morbidity than those undergoing a successful trial of labor (14.2% versus 2.6%).

CONCLUSION: Body mass index correlates with outcomes in trial of labor after previous cesarean delivery. Morbidly obese women undergoing a trial of labor were at increased risk for failure. Increased BMI was associated with greater composite morbidity and neonatal injury compared with elective repeat cesarean delivery, but absolute morbidities were small. Increased risks should be considered before trial of labor after previous cesarean delivery.

LEVEL OF EVIDENCE: II-2




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T. Y. Euliano, M. T. Nguyen, D. Marossero, and R. K. Edwards
Monitoring Contractions in Obese Parturients: Electrohysterography Compared With Traditional Monitoring
Obstet. Gynecol., May 1, 2007; 109(5): 1136 - 1140.
[Abstract] [Full Text] [PDF]


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