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The optimal timing for delivery in women with a previous cesarean section and no maternal or fetal complications has not been extensively studied. Obstetric societies advise a trial of labor after cesarean section (TOLAC) for all eligible cases, with guidelines available to determine eligibility. The Royal College of Obstetricians and Gynaecologists (RCOG) recommends considering termination at 41 weeks if eligible patients do not enter spontaneous labor by their expected delivery date. Spontaneous labor is considered safer and has a higher likelihood of successful vaginal birth after cesarean (VBAC) compared to induced labor.
To assess the rates of successful vaginal births, the authors conducted a pilot randomized controlled trial involving women with a prior lower segment cesarean section, comparing induction at 40 weeks with expectant management until 41 weeks. This nonblinded trial with a parallel design took place in a tertiary care teaching institution in South India. The study included women eligible for a trial of labor with a singleton fetus and without any pregnancy complications at recruitment, with a total of 1886 women screened. Sixty women were randomly assigned into two groups of thirty each at 40 weeks. The intervention group underwent induction at 40 weeks using either oxytocin or a single 24-hour application of a Foley catheter followed by oxytocin infusion and amniotomy. The expectant group underwent maternal and fetal surveillance and induction at 41 weeks with the same protocol if delivery had not occurred by that time.
Data from all sixty women were analyzed, revealing that twenty (66.67%) in the induction group and ten (33.33%) in the expectant group delivered vaginally. This difference was statistically significant (P = 0.016). One woman in the expectant group experienced scar dehiscence. The authors concluded that, in uncomplicated pregnancies with a prior cesarean section, induction of labor at 40 weeks resulted in significantly higher rates of successful vaginal deliveries compared to planned expectant management until 41 weeks.
The authors suggest that conducting a randomized controlled trial comparing induction of labor at 40 weeks with expectant management in women with previous cesarean sections is both feasible and acceptable. They recommend screening a larger population for more extensive trials with adequate power to detect any potential harm or differences in perinatal outcomes. Even with a relatively small sample size of 30 in each arm, a significantly higher VBAC rate was observed in the induction of labor group. Only 43% of those in the expectant management group underwent spontaneous labor. The authors conclude by advocating for further comprehensive trials to assess the safety, as well as maternal and perinatal outcomes, of induction at 40 weeks versus expectant management up to 41 weeks for women with a singleton fetus and a previous cesarean scar who are eligible for TOLAC.
Source: K. Rajalakshmi, Gowri Dorairajan, Swetha S. Kumar; Hindawi Journal of Pregnancy Volume 2023.
