1. 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

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

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

4. 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

5. 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 ;111:
Department of Gynecology, TOYOTA Memorial Hospital

6. 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 ;93(3):332-7.
4) Katharina E, et al. A 10-year population-base study of uterine rupture. Obstet Gynecol. 2002;100 :
Department of Gynecology, TOYOTA Memorial Hospital

7. 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:
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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. All TOLAC group vs ERCD group

16. 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 ( )
894 ( )

17. 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 ( )
894 ( )

18. 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 ( )
894 ( )

19. 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 ( )
894 ( )

20. 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 ( )
894 ( )

21. VBAC group vs failed TOLAC group

22. 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 ( )
23.8 ( )
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

23. 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 ( )
23.8 ( )
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

24. 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 ( )
23.8 ( )
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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

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