title: Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.
abstract: OBJECTIVE
  To determine whether the risk for uterine rupture is increased in women attempting vaginal birth after multiple cesarean deliveries.
  
  
  METHODS
  We conducted a prospective multicenter observational study of women with prior cesarean delivery undergoing trial of labor and elective repeat operation. Maternal and perinatal outcomes were compared among women attempting vaginal birth after multiple cesarean deliveries and those with a single prior cesarean delivery. We also compared outcomes for women with multiple prior cesarean deliveries undergoing trial of labor with those electing repeat cesarean delivery.
  
  
  RESULTS
  Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93).
  
  
  CONCLUSIONS
  A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women.
  
  
  METHODS
  II-2.
authors.affiliation: Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio, USA. landon.1@osu.edu
authors.forename: Mark B
authors.initials: MB
authors.lastname: Landon
authors.forename: Catherine Y
authors.initials: CY
authors.lastname: Spong
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Thom
authors.forename: John C
authors.initials: JC
authors.lastname: Hauth
authors.forename: Steven L
authors.initials: SL
authors.lastname: Bloom
authors.forename: Michael W
authors.initials: MW
authors.lastname: Varner
authors.forename: Atef H
authors.initials: AH
authors.lastname: Moawad
authors.forename: Steve N
authors.initials: SN
authors.lastname: Caritis
authors.forename: Margaret
authors.initials: M
authors.lastname: Harper
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Wapner
authors.forename: Yoram
authors.initials: Y
authors.lastname: Sorokin
authors.forename: Menachem
authors.initials: M
authors.lastname: Miodovnik
authors.forename: Marshall
authors.initials: M
authors.lastname: Carpenter
authors.forename: Alan M
authors.initials: AM
authors.lastname: Peaceman
authors.forename: Mary J
authors.initials: MJ
authors.lastname: O'sullivan
authors.forename: Baha M
authors.initials: BM
authors.lastname: Sibai
authors.forename: Oded
authors.initials: O
authors.lastname: Langer
authors.forename: John M
authors.initials: JM
authors.lastname: Thorp
authors.forename: Susan M
authors.initials: SM
authors.lastname: Ramin
authors.forename: Brian M
authors.initials: BM
authors.lastname: Mercer
authors.forename: Steven G
authors.initials: SG
authors.lastname: Gabbe
mesh_terms: D000328:Adult; D017604:Cesarean Section, Repeat / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015999:Multivariate Analysis; D007744:Obstetric Labor Complications / Q000601:surgery; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012042:Registries; D012306:Risk; D014219:Trial of Labor; D014597:Uterine Rupture / Q000453:epidemiology* / Q000209:etiology; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects*