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Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery

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

OBJECTIVE: To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS: From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.

RESULTS: Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION: Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.

LEVEL OF EVIDENCE: II

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