Maternal and neonatal outcomes in women undergoing trial of labor after cesarean (TOLAC) compared with elective repeat cesarean section (ERCS): a cohort study.

BACKGROUND

Trial of labor after cesarean (TOLAC) is often recommended as an alternative to elective repeat cesarean section (ERCS) in women with a single prior cesarean section. This retrospective cohort study aimed to compare obstetrical outcomes between TOLAC and ERCS in a French hospital setting.

METHODS

Women with a single prior cesarean delivery, cephalic presentation, and term pregnancies (≥ 37 weeks) between 2019 and 2024 were included. Women were analyzed according to their initially intended mode of delivery (TOLAC or ERCS), irrespective of the final delivery route, to reflect a real-world, decision-based clinical approach. Primary outcomes were uterine rupture, severe postpartum hemorrhage (PPH), and neonatal intensive care unit (NICU) admission. Statistical methods included chi-square tests, Student's t-tests, and Firth's penalized logistic regression for rare events.

RESULTS

In total, 2,424 women were included, with 2,146 undergoing TOLAC and 278 undergoing ERCS. Severe PPH occurred less frequently in the TOLAC group (5.6%) than in the ERCS group (10.4%, p = 0.002), with adjusted analysis confirming a significant reduction in risk (adjusted OR: 0.45, 95% CI: 0.31-0.69, p < 0.001). NICU admissions were also lower in the TOLAC group (6.5% vs. 13.3%, p < 0.001; adjusted OR: 0.45, 95% CI: 0.31-0.69, p < 0.001). Uterine rupture rates were low and showed no significant difference in unadjusted analysis (1.7% TOLAC vs. 1.1% ERCS, p = 0.622), though adjusted models indicated an increased risk with TOLAC (adjusted OR: 2.08, 95% CI: 1.24-3.58, p = 0.005).

CONCLUSION

The findings suggest that obstetrical practice concerning TOLAC, in a French tertiary care maternity unit, is associated with lower rates of severe PPH and NICU admission compared to ERCS, with a slightly increased risk of uterine rupture. These results support offering TOLAC as a safe and beneficial option for eligible women.