25th European Board & College of Obstetrics and Gynecology Obstetrician have a role to offer trial labor after cesarean section, TOLAC, as a reasonable option for patients who had a previous cesarean section Department of Obstetrics, Perinatal Medical Center, TOYOTA Memorial Hospital, Aichi, Japan Kaname Uno, Takuji Ueno, Yu Yaegashi, Makiko Kato, Shinji Monoe, Takuma Yamada, Takehiko Takeda, Sho Tano, Michinori Mayama, Mayu Ukai, Toko Harata, Yasuyuki Kishigami, Hidenori Oguchi 2017/5/20 Department of Gynecology, TOYOTA Memorial Hospital

The percentage of cesarean section in Japan. 23% The percentage of cesarean section in Japan. Department of Gynecology, TOYOTA Memorial Hospital

The percentage of cesarean section in Japan % Department of Gynecology, TOYOTA Memorial Hospital

Introduction The percentage of cesarean section (CS) has been increasing all over the world. Almost half of the reason for CS is having undertaken CS previously1). Emma L Barber, et al. Contributing Indications to the Rising Cesarean Delivery Rate. Obstet Gynecol. 2011;118:29-38. Department of Gynecology, TOYOTA Memorial Hospital

Introduction CS are more likely to have complications including bleeding, infection, embolism and continuous pain. CS is also associated with an increased risk of complications in subsequent pregnancies2). 2) Daltveit AK, et al. Cesarean delivery and subsequent pregnancies. Obstet Gynecol. 2008;111:1327-34. Department of Gynecology, TOYOTA Memorial Hospital

Introduction Trial of labor after cesarean section (TOLAC) has been conducted and the success rate is reported 60-82%3). Some reports show increased risk of uterine rupture among TOLAC group4). 3) J. Christoph rageth, et al. Delivery after previous cesarean: a risk evaluation. Obstet Gynecol. 1999;93(3):332-7. 4) Katharina E, et al. A 10-year population-base study of uterine rupture. Obstet Gynecol. 2002;100 : 749-53. Department of Gynecology, TOYOTA Memorial Hospital

Introduction The current rate of TOLAC decreases and is approximately 5%5). Most patients who are eligible for TOLAC undergo elective repetitive cesarean delivery (ERCD) without instruction of TOLAC6). 5) Gregory KD, et al. Trends and patterns of vaginal birth after cesarean availability in the United States. Semin Perinatol. 2010;34:237-43. 6) Sara N, et al. Trial of labor versus repeat cesarean: are patients making an informed decision? Am J Obstet Gynecol 2012;207:204-6. Department of Gynecology, TOYOTA Memorial Hospital

Aims of this study To reveal and reconsider the benefits and risks of TOLAC in a single perinatal medical center. Department of Gynecology, TOYOTA Memorial Hospital

Material & Methods This study was prospective cohort study from 2005 to 2016, and patients who had undertaken CS were enrolled in this study. Patients who met our criteria for TOLAC, could choose their desirable delivery way after listening the benefits and risks of both TOLAC and ERCD. Department of Gynecology, TOYOTA Memorial Hospital

Criteria for TOLAC in this study Material & Methods Criteria for TOLAC in this study Only one previous lower segment transverse CS and no complications after CS Singleton and vertex presentation No history of myomectomy Full understanding risks of TOLAC and contents of emergency CS when necessary Department of Gynecology, TOYOTA Memorial Hospital

Material & Methods This study was prospective cohort study from 2005 to 2016, and patients who had undertaken CS were enrolled in this study. Patients who met our criteria for TOLAC could choose their desirable delivery way after being explained the benefits and risks of both TOLAC and ERCD. Department of Gynecology, TOYOTA Memorial Hospital

944 women with prior CS enrolled 25 women were excluded due to abortion or intrauterine fetal demise 13 women were excluded due to severe preeclampsia and could not continue pregnancy 944 women with prior CS enrolled 257 women were excluded due to not meeting our criteria for TOLAC 687 women could choose their desirable delivery way Department of Gynecology, TOYOTA Memorial Hospital

687 women could choose their desirable delivery way 443 women chose TOLAC as their desirable delivery way 244 women chose ERCD as their desirable delivery way 64.5% Department of Gynecology, TOYOTA Memorial Hospital

Results 443 women chose TOLAC as their desirable delivery way 38 women had emergency CS (failed TOLAC) the reasons Arrest of dilation 16 Fetal distress 13 No onset of labor 7 PROM 17 Others 2 405 women had success vaginal delivery (VBAC group) Success rate was 91.6% 2 of them had uterine rupture Department of Gynecology, TOYOTA Memorial Hospital

All TOLAC group vs ERCD group

Base Excess of umbilical artery All TOLAC vs ERCD All TOLAC N=443 ERCD N=239 P-value Maternal age 32.6 ± 4.4 33.9 ± 4.7 0.02 Neonatal weight 3033 ± 489 2908 ± 420 0.01 pH of umbilical artery 7.28 ± 0.07 7.30 ± 0.05 <0.01 Base Excess of umbilical artery -4.69 ± 2.78 -0.93 ± 2.18 Weeks of gestation 39.0 (26-43) 38.0 (33-41) Apgar 1 minute 8.9 (1-10) 9.0 (4-10) Apgar 5 minutes 10.0 (6-10) 10.0 (7-10) 0.56 bleeding 480 (15-4048) 894 (216-2840)

Base Excess of umbilical artery All TOLAC vs ERCD All TOLAC N=443 ERCD N=239 P-value Maternal age 32.6 ± 4.4 33.9 ± 4.7 0.02 Weeks of gestation 39.0 (26-43) 38.0 (33-41) <0.01 Neonatal weight 3033 ± 489 2908 ± 420 0.01 pH of umbilical artery 7.28 ± 0.07 7.30 ± 0.05 Base Excess of umbilical artery -4.69 ± 2.78 -0.93 ± 2.18 Apgar 1 minute 8.9 (1-10) 9.0 (4-10) Apgar 5 minutes 10.0 (6-10) 10.0 (7-10) 0.56 Amount of bleeding 480 (15-4048) 894 (216-2840)

Base Excess of umbilical artery All TOLAC vs ERCD All TOLAC N=443 ERCD N=239 P-value Maternal age 32.6 ± 4.4 33.9 ± 4.7 0.02 Weeks of gestation 39.0 (26-43) 38.0 (33-41) <0.01 Neonatal weight 3033 ± 489 2908 ± 420 0.01 pH of umbilical artery 7.28 ± 0.07 7.30 ± 0.05 Base Excess of umbilical artery -4.69 ± 2.78 -0.93 ± 2.18 Apgar 1 minute 8.9 (1-10) 9.0 (4-10) Apgar 5 minutes 10.0 (6-10) 10.0 (7-10) 0.56 Amount of bleeding 480 (15-4048) 894 (216-2840)

Base Excess of umbilical artery All TOLAC vs ERCD All TOLAC N=443 ERCD N=239 P-value Maternal age 32.6 ± 4.4 33.9 ± 4.7 0.02 Weeks of gestation 39.0 (26-43) 38.0 (33-41) <0.01 Neonatal weight 3033 ± 489 2908 ± 420 0.01 pH of umbilical artery 7.28 ± 0.07 7.30 ± 0.05 Base Excess of umbilical artery -4.69 ± 2.78 -0.93 ± 2.18 Apgar 1 minute 8.9 (1-10) 9.0 (4-10) Apgar 5 minutes 10.0 (6-10) 10.0 (7-10) 0.56 Amount of bleeding 480 (15-4048) 894 (216-2840)

Base Excess of umbilical artery All TOLAC vs ERCD All TOLAC N=443 ERCD N=239 P-value Maternal age 32.6 ± 4.4 33.9 ± 4.7 0.02 Weeks of gestation 39.0 (26-43) 38.0 (33-41) <0.01 Neonatal weight 3033 ± 489 2908 ± 420 0.01 pH of umbilical artery 7.28 ± 0.07 7.30 ± 0.05 Base Excess of umbilical artery -4.69 ± 2.78 -0.93 ± 2.18 Apgar 1 minute 8.9 (1-10) 9.0 (4-10) Apgar 5 minutes 10.0 (6-10) 10.0 (7-10) 0.56 Amount of bleeding 480 (15-4048) 894 (216-2840)

VBAC group vs failed TOLAC group

infertility treatment VBAC vs failed TOLAC VBAC N=405 Failed TOLAC N=38 P-value Maternal age 32.7 ± 4.4 33.1 ± 4.4 0.63 BMI 20.9 (13.1-44.1) 23.8 (16.4-38.8) 0.03 Neonatal weight 3013 ± 483 3257 ± 507 0.04 Weeks of gestation 39.0 (26-42) 41.0 (37-43) <0.01 Years of previous CS 3.0 (0-16) 3.0 (0-7) 0.56 History of infertility treatment 11.3% 46/404 22.8% 8/35 0.059 vaginal delivery 24.4% 99/405 8.1% 3/37 0.024

infertility treatment VBAC vs failed TOLAC VBAC N=405 Failed TOLAC N=38 P-value Maternal age 32.7 ± 4.4 33.1 ± 4.4 0.63 BMI 20.9 (13.1-44.1) 23.8 (16.4-38.8) 0.03 Neonatal weight 3013 ± 483 3257 ± 507 0.04 Weeks of gestation 39.0 (26-42) 41.0 (37-43) <0.01 Years of previous CS 3.0 (0-16) 3.0 (0-7) 0.56 History of infertility treatment 11.3% 46/404 22.8% 8/35 0.059 vaginal delivery 24.4% 99/405 8.1% 3/37 0.024

infertility treatment VBAC vs failed TOLAC VBAC N=405 Failed TOLAC N=38 P-value Maternal age 32.7 ± 4.4 33.1 ± 4.4 0.63 BMI 20.9 (13.1-44.1) 23.8 (16.4-38.8) 0.03 Neonatal weight 3013 ± 483 3257 ± 507 0.04 Weeks of gestation 39.0 (26-42) 41.0 (37-43) <0.01 Years of previous CS 3.0 (0-16) 3.0 (0-7) 0.56 History of infertility treatment 11.3% 46/404 22.8% 8/35 0.059 vaginal delivery 24.4% 99/405 8.1% 3/37 0.024

Results No maternal and neonatal deaths occurred. Two neonates born after uterine rupture were admitted to neonatal intensive care unit. Both of them had no long term sequelae. Department of Gynecology, TOYOTA Memorial Hospital

Material & Methods To show the utility of TOLAC, we compared the success rate of vaginal delivery with patients without prior CS who met our TOLAC criteria for recent 5 years. Department of Gynecology, TOYOTA Memorial Hospital

1840 women without prior CS and meeting criteria for TOLAC 1615 women vaginal delivery 225 women Emergency CS Success rate was 87.8% Department of Gynecology, TOYOTA Memorial Hospital

Discussions If the risks and benefits of both TOLAC and ERCD are explained to patients, over half of them chose TOLAC as their desirable way of delivery. The success rate of TOLAC are as high as 90% according to the criteria. TOLAC are not inferior choice about success rate of vaginal delivery compared with women without prior CS. Department of Gynecology, TOYOTA Memorial Hospital

Limitations This study limitations were prospective study depending on patient’s choice, not randomized study. There were only 2 patients who underwent uterine rupture, which is thought too small number to know such a complication. Department of Gynecology, TOYOTA Memorial Hospital

Conclusions TOLAC is a reasonable way of delivery for patients who had undertaken CS previously. Obstetrician should offer the choice of TOLAC for suitable candidates, because over the half of them choose TOLAC as their desirable delivery and the success rate of TOLAC can be over 90%. Department of Gynecology, TOYOTA Memorial Hospital

I have no conflict of interest in relation to this presentation. Disclosure I have no conflict of interest in relation to this presentation. Department of Gynecology, TOYOTA Memorial Hospital 31

Thank you for your attention. Department of Gynecology, TOYOTA Memorial Hospital