Trial of labor and vaginal delivery rates in women with a prior cesarean.

Objective: To evaluate evidence on trial of labor (TOL) and vaginal delivery rates in women with a prior cesarean and to understand the characteristics of women offered a trial of labor.

Data Sources: MEDLINE, DARE, and Cochrane databases were searched for articles evaluating mode of delivery for women with a prior cesarean delivery published between 1980 and September 2009.

Study Selection: Studies were included if they involved human participants, were in English, conducted in the United States or in developed countries, and if they were rated fair or good base on U.S. Preventive Services Task Force (USPSTF) criteria.

Data Extraction And Synthesis: The search yielded 3,134 abstracts: 69 full-text papers on TOL and vaginal birth after cesarean (VBAC) rates and 10 on predictors of TOL. The TOL rate in U.S. studies was 58% (95% CI [52, 65]) compared with 64% (95% CI [59, 70]) in non U.S.

Studies: The TOL rate in the U.S. was 62% (95% CI [57, 66]) for studies completed prior to 1996 and dropped to 44% (95% CI [34, 53]) in studies launched after 1996, p = .016. In U.S. studies, 74% (95% CI [72, 76]) of women who had a TOL delivered vaginally. Women who had a prior vaginal birth or delivered at a large teaching hospital were more likely to be offered a TOL.

Conclusions: Although the TOL rate has dropped since 1996, the rate of vaginal delivery after a TOL has remained constant. Efforts to increase rates of TOL will depend on patients understanding the risks and benefits of both options. Maternity providers are well positioned to provide key education and counseling when patients are not informed of their options.