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Objective Following the release of A Randomized Trial of Induction versus Expectant Management (ARRIVE) trial, the induction of labor at 39 weeks has increased in the United States. The risk of uterine rupture and optimal timing of elective induction in those patients with a prior cesarean delivery is not well-described, and they were not included in the original trial. We aimed to determine the risk of uterine rupture in those patients undergoing elective induction of labor with prior cesarean delivery.

Study Design This was a retrospective cohort of participants with prior cesarean delivery from 1996 to 2000. Participants were included if they had two or more prior cesareans. Participants were excluded if they had a history of an unknown prior incision, a classical incision, gestational age <39 weeks, any diabetes, chronic hypertension, twin gestation, collagen or vascular disease, or HIV. Those undergoing expectant management were compared with those undergoing elective induction with no medical or obstetrical indications for delivery. Analysis was performed at three gestational age groups: 39 weeks, 40 weeks, and 41 weeks. The primary outcomes were uterine rupture, rates of successful vaginal delivery, and a composite major morbidity risk. Multivariable logistic regression was performed.

Results At 39 weeks, 618 (10.3%) elective inductions were compared with 5,365 (89.7%) undergoing expectant management; uterine rupture occurred more frequently (13 patients [2.1%] vs. 49 patients [0.9%]; adjusted odds ratio [aOR], 2.5; 95% confidence interval, 1.3–4.6) with fewer successful vaginal birth after cesarean [VBAC; 66.8 vs. 75%; aOR, 0.6; 95% confidence interval, 0.5–0.7]. The risk of uterine rupture was similar between groups at 40 weeks (5 patients [0.8%] vs. 21 patients [1.2%]; p = 0.387) and 41 weeks (7 patients [1.4%] vs. 2 patients (0.8%); p = 0.448).

Conclusion Patients undergoing elective induction of labor with a prior cesarean scar had an increased risk of uterine rupture when compared with expectant management at 39 weeks, with fewer successful VBAC.

Key Points

TOLAC elective induction at 39 weeks has an increased risk of uterine rupture.

TOLAC elective induction at 39 weeks has a less successful chance of vaginal delivery.

Awaiting spontaneous labor in this cohort does not increase the risk of uterine rupture.

Keywords elective induction - prior cesarean - trial of labor - TOLAC - vaginal birth after cesarean - VBAC - uterine rupture Note

Presented as a poster at the 43rd Annual Meeting of the Society for Maternal-Fetal Medicine, San Francisco, CA, February 10, 2023.

Availability of Data and Materials

Authors L.M.H. and A.M.S. can be requested for access to data.

Authors' Contributions

All authors of this study take full responsibility for ensuring the accuracy and completeness of the reporting, as well as the fidelity of the report to the study protocol. The study concept and design were developed by all authors, while data collection was conducted by L.M.H. and A.M.S. Analysis and interpretation of the data were performed by L.M.H. and A.M.S. A.M.S. drafted the manuscript, and all authors critically revised it for important intellectual content. authors.

Publication History

Received: 31 July 2023

Accepted: 18 April 2024

Accepted Manuscript online:
22 April 2024

Article published online:
10 May 2024

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