781: Outcomes in trial of labor with two prior cesarean deliveries using a contemporary labor curve

The evidence regarding obstetric and neonatal outcomes in trial of labor after cesarean (TOLAC) was established prior to the institution of contemporary labor management. Our objective was to evaluate obstetric and neonatal outcomes in women attempting TOLAC with 2 prior cesareans compared with those with a history of 1 previous cesarean since the advent of a contemporary labor curve. This was a retrospective cohort study of women attempting vaginal birth after cesarean (VBAC) with 1 and 2 prior cesarean deliveries between January 2011-May 2018 at an academic tertiary care center. Women with viable, non-anomalous singleton gestations were included. The primary outcome was VBAC success. Secondary outcomes were composite maternal and neonatal adverse outcomes (Table 2). Univariate analysis was performed using Chi-squared, X tests and Fisher’s exact tests. Odds ratios (OR) were calculated for maternal and fetal outcomes according to number of prior cesareans. Of 1302 women attempting TOLAC who met inclusion criteria, 1156 (88.8%) women had 1 prior cesarean and 146 (11.2%) had 2 prior cesarean deliveries. Women attempting TOLAC were found to be similar with regard to race, baseline body mass index (BMI), delivery BMI, diabetes, hypertension, and tobacco use (p <0.05 for all). Women with 2 prior cesareans had more frequent history of prior cesarean for labor arrest (39 vs. 29%, p = .01) and lower birth weight in the current pregnancy (3260g vs. 3187g, p = .03). Women with 1 prior cesarean had higher rates of VBAC (75%) than those with 2 prior cesareans (66%) (OR 0.64, 95% CI 0.44-0.92, P=0.016). Women with 2 prior cesareans are more likely to experience postpartum hemorrhage (11.9% vs. 17.8%, OR = 1.6, CI 1.01-2.53, P=.04) and ICU admission (0.3% vs. 1.4%, OR= 5.3, CI 0.9-32, P=0.04) but both maternal and neonatal composites outcomes were not different between groups (Table 2). Women with 2 prior cesareans had lower VBAC success than those with 1 prior cesarean, but most women attempting TOLAC in both groups were successful. Uterine rupture and maternal composite morbidity was similar between women with 2 prior and 1 prior cesarean deliveries, but those with 2 cesareans had a higher incidence of postpartum hemorrhage and ICU admission. This data suggests that TOLAC after 2 prior cesarean deliveries in a population experiencing longer labors with a contemporary labor curve have outcomes comparable to previously published data regarding TOLAC.View Large Image Figure ViewerDownload Hi-res image Download (PPT)