Hindawi

Journal of Pregnancy
Volume 2018, Article ID 6140982, 5 pages
https://doi.org/10.1155/2018/6140982

Research Article
Factors Associated with Successful Trial of Labor after Cesarean
Section: A Retrospective Cohort Study

Aram Thapsamuthdechakorn, Ratanaporn Sekararithi, and Theera Tongsong

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand

Correspondence should be addressed to Theera Tongsong; [email protected]

Received 11 September 2017; Accepted 3 May 2018; Published 3 June 2018

Academic Editor: Luca Marozio

Copyright © 2018 Aram Thapsamuthdechakorn et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Objective. To determine the effectiveness of trial of labor after cesarean section (TOLAC) and the factors associated with a successful
TOLAC. Materials and Methods. A retrospective cohort study was conducted on consecutive singleton pregnancies with a previous
single low-transverse cesarean section planned for TOLAC at a tertiary teaching hospital. The potential risk factors of a successful
TOLAC were compared with those associated with a failed TOLAC. A simple audit system used in the first two years was also taken
into account in the analysis as a potential factor for success. Results. During the study period, 2,493 women were eligible for TOLAC
and 704 of them were scheduled for TOLAC, but finally 592 underwent TOLAC. Among them, 355 (60%) had a successful vaginal
birth and 237 (40%) had a failed TOLAC. The independent factors associated with the success rate included the audit system, prior
vaginal birth, low maternal BMI, and lower birth weight or gestational age, whereas induction of labor and recurring indications
in previous pregnancy significantly increased the risk of having a failed TOLAC. Strikingly, the strongest predictor of a successful
TOLAC was the audit system with OR of 6.4 (95%CI: 3.9-10.44), followed by a history of vaginal birth in previous pregnancies (OR:
3.2; 95%CI: 1.87-5.36). Conclusion. The simple audit system had the greatest impact on the success rate of TOLAC, instead of the less
powerful obstetrical factors as reported in previous reports. The audit system is the only potential factor that could be strengthened
to improve the success rate.

1. Introduction Gynecologists (ACOG), most women with one previous

cesarean delivery and a low-transverse incision are candidates
Women undergoing cesarean section have a higher morbidity of TOLAC and should be counseled about TOLAC and
and mortality rate than those having vaginal birth, such as offered a trial of labor [1].
massive postpartum hemorrhage, need for blood transfusion, TOLAC has been practiced individually in our center
anesthesia-associated complications, surgical risks (intesti- for decades, but the formal policy of TOLAC was first
nal obstruction, wound dehiscence, wound scars, infection, implemented in the year 2000. To date, we still have that
etc.), and obstetric complications in subsequent pregnancies. policy, but its effectiveness in our real practice has never been
Recently, with the dramatic increase in the rate of cesarean evaluated. Therefore, we conducted this study to determine
deliveries worldwide, several attempts have been made to the effectiveness of trials of labor after cesarean section
reduce this rate, including trial of labor after cesarean delivery (TOLAC) and the factors associated with its success.
(TOLAC). However, TOLAC has a minimal risk of uterine
rupture with a rate of 0.2–0.8% [1], but such a risk can be
prevented by close observation and adhering to the standard 2. Materials and Methods
guideline. Overall, morbidity and mortality rates secondary
to TOLAC are less than those of repeated cesarean sections. A retrospective cohort study was conducted on consecutive
It has long been accepted that TOLAC is a safe and acceptable singleton pregnancies with a previous single low-transverse
option for women with previous cesarean section [1, 2]. cesarean section planned for TOLAC at a tertiary teaching
According to the American College of Obstetricians and hospital with ethical approval by the institutional review
2 Journal of Pregnancy

board. The database of Maternal-Fetal Medicine (MFM) unit 3. Result

was assessed to identify the consecutive records of women
with a history of previous cesarean section between January During the study period, 2,623 women with a history of
2001 and December 2015, and their medical records were previous cesarean section were eligible for TOLAC. Among
reviewed. The inclusion criteria were as follows: (1) singleton them, only 704 (28.2%) accepted TOLAC and met the
pregnancy, (2) low-transverse uterine incision, (3) no history inclusion criteria. However, 112 (4.5%) of them finally did
of other uterine incision such as myomectomy, and (4) not undergo TOLAC because of various reasons, while the
no obstetric risk or serious underlying disease unsuitable remaining 592 (23.7%) were available for analysis as presented
for vaginal delivery. Exclusion criteria were as follows: (1) in Figure 1. Of the women that participated in TOLAC, 355
pregnancy ending up in a nonviable stage or earlier than (60%) had successful TOLAC or vaginal birth after cesarean
26 weeks of gestation, (2) incomplete medical data records, section (VBAC), while 237 (40%) had failed TOLAC or
and (3) fetal macrosomia. We have been using a formal repeated cesarean section. Obviously, the rates of women
guideline for TOLAC since the year 2000, following the planning for TOLAC and VBAC dropped drastically after the
guideline recommended by ACOG [3] with some minor years of audit, from 81.8% to 51.5%, as presented in Figures
modifications (i.e., macrosomia was defined as estimated 2 and 3. The demographic and obstetric factors of the two
birth weight > 3600 g instead of 4000 g because of the groups are compared using univariate analysis in Table 1.
small size of Thai women). During the first two years of Notably, the time interval of the previous cesarean section,
using this formal guideline, TOLAC practice was audited maternal age, number of antenatal visits, and parity were
by the simple audit system, as follows: (1) one of our comparable between the two groups whereas gestational age
doctors was responsible to give a monthly orientation on and birth weight were significantly lower in the successful
the TOLAC guideline as well as a counseling guide with group. Logistic regression analysis indicated that audit system
visual aids to the team of physicians taking care of the and prior vaginal birth were strong independent factors
antenatal clinic and the labor doctors (we had a monthly associated with successful TOLAC, whereas induction of
rotation of the doctors at any point of service), throughout labor, recurring indications in previous pregnancy, high
the first two years; (2) the same doctor monthly reported the maternal BMI, and greater birth weight were significantly
outcomes of TOLAC to the audit team and then the rates associated with a higher risk of failed TOLAC, as presented
of cesarean section, TOLAC, and successful/unsuccessful in Table 2. Also it should be noted that the most common
TOLAC of each doctor were exposed to the staff members reasons for failed TOLAC were some women changing their
of the department. In summary, the main components of mind during TOLAC followed by dystocia as presented in
the simple audit were regular orientation to the care team Table 3. Fetal outcomes were comparable between the two
and disclosure of the outcome. After the first two years, groups. Note that, in this study, there was no uterine rupture
TOLAC practice was no longer audited formally, but we still in both groups.
maintained the policy of TOLAC using the same practice
guideline. In this study, the patients giving birth in the 4. Discussion
first two years were considered as the group of patients
undergoing audit system, whereas those giving birth later This study indicates that the success rate of TOLAC (approx-
during the study period were assigned as the group without imately 60%) was relatively low when compared to that of
audit system. several previous publications (60-80%) [1, 4–7]. Interestingly,
The demographic and clinical characteristics of the pre- the success rate dropped from approximately 80% at the
vious and current pregnancies were reviewed and recorded, beginning of the policy to only 50% in recent years in
including indications for prior cesarean section (dystocia or spite of the same standard practice guideline. Moreover, the
failure to progress was considered as a recurring indication), rate of women accepting TOLAC also drastically decreased
type of uterine scar, a history of prior vaginal delivery, from 54% in the year 2001 to only 21% in 2015 (Figure 2).
outcome of labor, pattern of labor/delivery (induction of The main factors responsible for the decrease were likely
labor, labor progression, etc.), complications of TOLAC, and associated with the lack of audit system, though several
causes of failed TOLAC. The main outcomes were the success factors were associated with the success rates, signifying
rate of TOLAC (vaginal delivery) and associations between that strengthening the practice guideline should be urgently
the potential risk factors and successful TOLAC. considered.
Unlike previous studies, the audit system or the strength-
ening of the practice guideline played an important role in
2.1. Statistical Analysis. The data were analyzed using SPSS both the acceptance of TOLAC and the success rate, though
version 21.0 (IBM Corp. Released 2012; IBM SPSS Statistics the other non-evaluated factors must have been involved as
for Windows, Armonk, NY: IBM Corp). The demographic well.
and obstetric characteristics of the successful and failed The rates of acceptance and success of TOLAC sharply
TOLAC groups were compared using Student’s t-test for dropped after the years of the audit system. Certainly, such
quantitative data as well as chi-square and relative risks a rapid decrease from 2003 to 2004, followed by constantly
with 95% confident interval for categorical data. Additionally, low rates with minimal change after that, could not be
logistic regression analysis was performed to identify inde- explained by scientific reasons or other factors, neither global
pendent factors of successful TOLAC. trend of increase in cesarean rate nor the change in clinical
Journal of Pregnancy 3

Pregnant women with previous cesarean section

(2623 cases)

Request repeated Requested TOLAC

cesarean section
(806 cases)
(1817 cases)

Exclude (185 cases) Exclude (102 cases)

Lost (62) Lost (48)
Pregnancy loss (123) Pregnancy loss (54)

Change to Vg Repeated section Plan for TOLAC

delivery (85) (1547) (704)

Trial of labor No trial of labor

(592) (112)

Success Repeated OB indication Change of mind OB indication

VBAC section before labor before labor in labor
(355) (237) (51) (45) (16)

Change of mind in labor (102) Macrosomia (23) Breech (8)

OB indication (135) Fetal distress (5)
Breech, APH, PIH
(CPD, fetal distress, placental Severe PIH (3)
etc. (28)
abruption etc.)

Figure 1: Pregnancy outcomes in both groups.

practice during the study period. Though other unknown low-income countries have shown a much lower success rate
factors could be responsible for the lower rate of TOLAC in of TOLAC, ranging from as low as 27.4% to 53.6% [9, 10],
recent years, our finding indicates that the audit system, even studies in some other low-income countries showed a high
the simple approach used in this study (just orientation on rate of successful TOLAC with strengthening and careful
adhering to the guideline and reporting the outcomes), is a selection (79.6-83.5%) [5, 8], which is consistent with our
factor with a very strong impact on TOLAC acceptance and finding in the year of audit. Many reasons for the low rate
its success rate. in low-income countries have been postulated, e.g., delay in
It is noteworthy that our success rate in the most recent access to health care service, unavailability of painless labor,
years was low (51.5%), when compared to a success rate of lack of constant availability of operating rooms in cases of
60%–80% reported in most high resource countries [1]. We emergency, poor educational status, great number of cases
hypothesize that the main factor of the decrease is associated with unknown previous uterine scar, and poor record keeping
with less strengthening of the practice guideline. We believe of previous cesarean delivery.
that, under strict supervision and careful selection, TOLAC No previous publication has stated that the audit system
is a very good option even in low-resource setting, as is the most predictive factor of successful TOLAC, while
demonstrated by Soni A et al. [8]. Though some studies in prior vaginal delivery as a predictive factor of success has
4 Journal of Pregnancy

Table 1: Demographic and obstetric characteristics of the women with successful TOLAC and failed TOLAC.

Characteristics Successful TOLAC Failed TOLAC P-value

Quantitative data Mean ± SD Mean ± SD Student T test
Maternal age (yr) 31.4 ± 5.6 32.1 ± 5.4 0.101
Interval from last previous cesarean 2.9 ± 1.1 3.0 ± 1.1 0.647
No. of antenatal visits 7.4 ± 3.5 8.0 ± 3.5 0.085
BMI (kg/m2 ) 23.3 ± 4.0 24.6 ± 4.7 < 0.001
Gestational age (wk) 36.2 ± 3.3 37.3 ± 2.0 < 0.001
Birth weight (g) 2714 ± 523 3062 ± 664 < 0.001
Apgar score at 1 min 8.4 ± 2.0 8.5 ± 1.6 0.370
Apgar score at 5 min 9.4 ± 1.1 9.5 ± 9.6 0.164
Categorical data n/N (%) n/N (%) Chi-square Relative risk (95% CI)
Parity (1 vs ≥2) 285/486 (58.6%) 70/106 (66.0%) 0.159 0.89 (0.76-1.04)
Induction of labor 17/47 (36.2%) 338/545 (62.0%) 0.001 0.58 (0.19-0.65)
Recurrent indications 84/166 (50.6%) 271/426 (63.6%) 0.004 0.79 (0.67-0.94)
Prior vaginal delivery 90/116 (77.6%) 265/476 (55.7%) <0.001 1.39 (1.23-1.58)
Audit system 135/165 (81.8%) 220/427 (51.5%) <0.001 1.59 (1.41-1.79)

Table 2: Multivariate logistic regression analysis for successful TOLAC.

Risk factors Odd Ratio (95% CI) P value

Audit strategy 6.40 (3.92-10.44) < 0.001
Birth weight 0.99 (0.98-0.99) < 0.001
Induction 0.41 (0.20-0.84) 0.014
Parity (1 vs ≥ 2 0.61 (0.37-1.02) 0.057
BMI (kg/m2 ) 0.93 (0.89-0.97) 0.002
Recurrent indications 0.49 (0.32-0.75) 0.001
Prior vaginal delivery 3.17 (1.87-5.36) < 0.001

200 200

150 150
Count

Count

100 100

50 50

0 0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015

2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015

Year Year
Figure 2: Proportions of the women who accepted TOLAC (yellow) Figure 3: Proportions of the women with successful TOLAC
and not accepted TOLAC (black) in each year. (yellow) and repeated cesarean section (black) in each year.

been described in literature several times. The latter was also failure rate included large fetuses, in concordance with late
observed in our study. However, prior vaginal delivery was gestational age; increased maternal BMI; induction of labor;
much less predictive when compared to the simple audit and history of recurring indications, which were mostly
system. The factors significantly associated with a higher consistent with previous reports.
Journal of Pregnancy 5

Table 3: Indications for cesarean section among women with failed TOLAC (237 cases).

Indications Number (%)

Changing their mind (no obvious obstetric indications) 102 (43.04%)
Dystocia (failure of progression) 70 (29.53%)
Failure induction 30 (12.66%)
Non-reassuring fetal heart rate 21 (8.86%)
Others (placental abruption, HELLP syndrome, etc) 12 (5.06%)

Another factor possibly responsible for the low success Acknowledgments

rate in this study is unavailability of painless labor. Several
cases could not tolerate the severe pain in advanced labor, The authors wish to acknowledge the National Research
together with the fear of uterine rupture, resulting in a higher University Project under Thailand’s Office of the Higher
rate of women changing their mind during labor. Moreover, Education Commission and Diamond Research Grant of
we also noted that a prevalence of failure to progress or Faculty of Medicine, Chiang Mai University, for financial
dystocia was relatively high in this study. This was probably support.
caused by low threshold in the diagnosis of dystocia due to
fear of uterine rupture especially in our setting of unavailable References
painless labor.
The limitations of this study include (1) the long time [1] ACOG Practice bulletin no. 115: Vaginal birth after previous
frame of the study involving several changes in clinical cesarean delivery. Obstet Gynecol 2010 Aug;116(2 Pt 1):450-63.
practice, especially the trend of higher cesarean section, [2] National Institutes of Health Consensus Development confer-
which could have affected the outcomes of TOLAC, and (2) ence statement: vaginal birth after cesarean: new insights March
8-10, 2010. Obstet Gynecol 2010 Jun;115(6):1279-95.
the retrospective nature of the study which made it difficult
[3] ACOG practice bulletin. Vaginal birth after previous cesarean
to reliably access several confounding factors. However, the
delivery. No. 5, July 1999. Clinical management guidelines for
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since it reflected a real world practice of TOLAC, not and Gynecologists. Int J Gynaecol Obstet 1999 Aug;66(2):197-
just the ideal circumstance of TOLAC in research practice. 204.
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represent actual effectiveness in real situations of implemen- and L. Hiersch, “Prediction of successful trial of labor after
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cesarean in rural India,” International Journal of Gynecology and
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[9] M. Madaan, S. Agrawal, A. Nigam, R. Aggarwal, and S. S.
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Gynaecology, vol. 31, no. 3, pp. 224–228, 2011.
Aram Thapsamuthdechakorn participated in the study [10] A. Agarwal, P. Chowdhary, V. Das, A. Srivastava, A. Pandey, and
design, data collection, and manuscript writing. Ratanaporn M. T. Sahu, “Evaluation of pregnant women with scarred uterus
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