Which way is better to deliver the very heavy baby: mode of delivery, maternal and neonatal outcome.

PURPOSE: Currently there are no existing data regarding the maternal and neonatal outcomes for nulliparous women delivering neonates with birthweight above 4500 g. We aim to evaluate birth outcome among these subset of parturients. METHODS: A retrospective study of nulliparous delivering a singleton fetus weighing ≥ 4500 g in two tertiary medical centers between 2007 and 2018. Women who chose to undergo a trial of labor (TOL) were compared to those who underwent elective cesarean delivery (CD). RESULTS: Overall, 121 women were included. Seventy eight (65.4%) women elected a TOL while 43 (34.6%) had elective CD. Of women who chose TOL, 46 (59%) delivered with unassisted vaginal delivery, 28 (36%) by intrapartum CD, and 4 (5%) by assisted vaginal delivery, reaching TOL success rate of 64% (50/78). The rates of shoulder dystocia and anal sphincter injury in vaginal deliveries were 5/50 (10%) and 2/50 (4%) respectively. Successful TOL was negatively associated with the presence of gestational diabetes [5 (18%) vs. 0 (0%), OR 0.8 (95% CI 0.7-0.9), p = 0.005], and was positively associated with maternal height (median 170 cm vs. 165 cm, p = 0.002), epidural analgesia [42 (84%) vs. 16 (57%), OR 3.5 (95% CI 1.2-9.8), p = 0.009] and spontaneous onset of labor (38 (76%) vs. 10 (36%), OR 5.7 (95% CI 2.1-15.6), p = 0.001. Neonates born after TOL were more commonly complicated by meconium aspiration syndrome as compared to no TOL (9 (11%) vs. 0 (0%), OR 1.1 (95% CI 1.04-1.22, p = 0.02). Only maternal height was independently associated with successful TOL (aOR 6.9 (95% CI 1.03-46.3, p = 0.04). Maternal and neonatal adverse composite outcomes were associated with gestational hypertensive disorders (10 (50%) vs. 5 (5%). OR 19.2 (5.5-67.4), p < 0.001) and with delivery before 40 weeks (9 (57%) vs, 86 (82%), OR 3.5 (95% CI 1.2-10.6, p = 0.02), respectively. CONCLUSIONS: Trial of vaginal delivery in nulliparous with fetuses ≥ 4500 g was associated with a high failure rate, with only two thirds of parturients achieving successful vaginal delivery. Nevertheless, neonatal outcomes mostly did not differ according to the mode of delivery. Maternal height was the only factor associated with successful vaginal delivery.

Trial of Labor After Cesarean in Adolescents - A Multicenter Study.

STUDY OBJECTIVE: Data regarding trial of labor after cesarean delivery (TOLAC) among young women are limited. The aim of this study was to assess the TOLAC success rate and its related factors among adolescent women who had never delivered vaginally. DESIGN: A multicenter retrospective cohort study of all adolescent women aged ≤21 years with a history of 1 previous cesarean delivery, who delivered in 2 tertiary medical centers during 2007-2019. Women were allocated to 2 groups: 1) women who underwent TOLAC, and 2) women who had a repeat cesarean delivery with no trial of labor. Maternal and neonatal outcomes were compared between the two groups. In addition, perinatal outcomes were compared between women with successful and unsuccessful TOLAC. RESULTS: The study cohort included 167 women who had a previous caesarean delivery; 117 underwent TOLAC and 50 underwent a repeat cesarean delivery with no trial of labor. Neonatal birthweight (median 2937 vs 3170 g, P = .03) and gestational age at delivery (median 38 weeks vs 39, P = .009) were lower in the repeat cesarean group as compared to those undergoing TOLAC. Overall, 97 of 117 participants (83%) had a successful TOLAC. Failed TOLAC was associated low birthweight as compared to successful TOLAC (5 [25%] vs 7 [7%], odds ratio [OR] 4.3, 95% confidence interval [CI] 1.2-15.3, P = .02), and birthweight difference between current and previous deliveries was higher in the failed TOLAC group (median 315 vs 197 g, P = .04). Rates of neonatal Apgar score at 1 minute < 7 and of neonatal intensive care unit admission were higher in the TOLAC failure group (4 [20%] vs 5 [5%], OR 4.6, 95% CI 1.1-19.0, P = .03, and 4 [20%] vs 4 [4%], OR 5.8, 95% CI 1.3-25.6, P = .02), respectively). In a multivariable logistic regression analysis, only low birthweight was independently associated with TOLAC failure (adjusted OR 9.9, 95% CI 2.1-45.4, P = .003). Two cases of uterine rupture occurred in the no trial of labor group, whereas none were encountered in participants undergoing TOLAC. CONCLUSIONS: TOLAC in adolescent women who had never delivered vaginally is associated with a relatively high success rate.