title: Safety of trial of labor after cesarean delivery in grandmultiparous women.
abstract: OBJECTIVE
  To evaluate the risk of uterine rupture and other major labor complications in a trial of labor after cesarean delivery (TOLAC) in grandmultiparous women.
  
  
  METHODS
  A retrospective descriptive study of 64,345 births in three hospitals between the years 1999 and 2009. The study group included 1,922 deliveries of women in their sixth or higher birth with one previous cesarean delivery.
  
  
  RESULTS
  The risk for uterine rupture was 0.3% (six cases) (95% confidence interval [CI] 0.11-0.68); of these, two cases ended in hysterectomy. There were another four hysterectomies not attributable to uterine rupture (a total risk of 0.3%). Neither induction nor augmentation of labor increased the risk for uterine rupture. Trial of labor after cesarean delivery in the first labor after prior cesarean delivery conferred a higher risk for hysterectomy (1% compared with 0.1%; P=.019). In the presence of shoulder dystocia (n=20), the risk of uterine rupture was 10% (two cases) compared with 0.2% when shoulder dystocia did not occur (P=.002; odds ratio 52.7, 95% CI 9-306).
  
  
  CONCLUSIONS
  Grandmultiparous women with one previous cesarean delivery can be offered TOLAC. Labor induction is not contraindicated in such women.
  
  
  METHODS
  III.
authors.affiliation: Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, and the Department of Obstetrics and Gynecology, Hadassah Hospital, Ein Kerem, The Hebrew University of Jerusalem, Jerusalem, Israel.
authors.forename: Hila
authors.initials: H
authors.lastname: Hochler
authors.forename: Haim
authors.initials: H
authors.lastname: Yaffe
authors.forename: Philippe
authors.initials: P
authors.lastname: Schwed
authors.forename: David
authors.initials: D
authors.lastname: Mankuta
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects*; D004420:Dystocia; D005260:Female; D006801:Humans; D007044:Hysterectomy; D007744:Obstetric Labor Complications; D016017:Odds Ratio; D010298:Parity; D011247:Pregnancy; D012189:Retrospective Studies; D012307:Risk Factors; D012782:Shoulder; D014219:Trial of Labor; D014597:Uterine Rupture / Q000453:epidemiology / Q000601:surgery; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects*