Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989 to 1999

OBJECTIVE: The aim of this study was to compare a trial of labor with elective repeat cesarean delivery among women with previous cesarean delivery. STUDY DESIGN: We searched MEDLINE and EMBASE databases from 1989 through 1999 with the following terms: vaginal birth after cesarean delivery, trial of labor, trial of scar, and uterine rupture. We included all controlled trials from developed countries in which the control group had been eligible for a trial of labor. Outcomes of interest were uterine rupture, hysterectomy, maternal febrile morbidity, maternal mortality, 5-minute Apgar score <7, and fetal or neonatal mortality. We computed pooled odds ratios for each outcome. RESULTS: The search strategy identified 52 controlled studies, 37 of which were excluded because many of the control subjects were not eligible for a trial of labor. Fifteen studies with a total of 47,682 women were included. Uterine rupture occurred more frequently among women undergoing a trial of labor than among those undergoing elective repeat cesarean delivery (odds ratio, 2.10; 95% confidence interval, 1.45-3.05). There was no difference in maternal mortality risk between the 2 groups {odds ratio, 1.52; 95% confidence interval, 0.36-6.38). Fetal or neonatal death (odds ratio, 1.71;95% confidence interval, 1.28-2.28) and 5-minute Apgar scores <7 (odds ratio, 2.24, 95% confidence interval, 1.29-3.88) were more frequent in the trial of labor group than in the control group. Mothers undergoing a trial of labor were less likely to have febrile morbidity (odds ratio, 0.70; 95% confidence interval, 0.64-0.77) or to require transfusion (odds ratio, 0.57; 95% confidence interval, 0.42-0.76) or hysterectomy (odds ratio, 0.39; 95% confidence interval. 0.27-0.57). CONCLUSION: A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates with respect to elective repeat cesarean delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion or hysterectomy may be reduced with a trial of labor.