The safety of trial of labor after cesarean section (TOLAC) versus elective repeat cesarean section (ERCS): a systematic review and meta-analysis

Abstract

Objective

Women’s choice of birth following a cesarean delivery either includes a trial of elective repeat cesarean section (ERCS) or a trial of labor after cesarean (TOLAC). No comprehensive overview or systematic summary is currently available.

Methods

EMBASE, PubMed, and the Cochrane Library databases were searched from inception to 1 February 2020. Studies reporting the safety of TOLAC and ERCS in pregnant women with prior cesarean delivery were included. Statistical analysis was performed using RevMan 5.3 and Stata 15.0. Odds ratios (ORs) and 95% confidence intervals (CIs) were adopted as the effective measures.

Results

A total of 13 studies covering 676,532 cases were included in this meta-analysis. The results demonstrated that the rates of uterine rupture (OR = 3.35, 95%CI [1.57, 7.15], I² = 81%), neonatal asphyxia (OR = 2.32, 95%CI [1.76, 3.08], I² = 0%) and perinatal death (OR = 1.71, 95%CI [1.29, 2.25], I² = 0%) were higher in the TOLAC group compared with the ERCS group. The rates of peripartum hysterectomy (OR = 0.70, 95%CI [0.44, 1.11], I² = 62%), blood transfusion (OR = 1.24, 95%CI [0.72, 2.12], I² = 95%), and puerperal infection (OR = 1.11, 95%CI [0.77, 1.60], I² = 95%) showed no significant differences between the two groups.

Conclusion

TOLAC is associated with a higher risk of uterine rupture, neonatal asphyxia, and perinatal death compared with ERCS. Nevertheless, it should be noted that the risks of all complications were small in both groups. This information is important for healthcare providers and women choosing the delivery type.

Keywords:

• Safety
• trial of labor after cesarean section (TOLAC)
• elective repeat cesarean section (ERCS;)
• uterine rupture
• meta-analysis

Acknowledgements

None.

Ethics approval and consent to participate

Not applicable.

Author’s contributions

(I) Conception and design:

(II) Administrative support:

(III) Provision of study materials or patients:

(IV) Collection and assembly of data:

(V) Data analysis and interpretation:

(VI) Manuscript writing: All authors

(VII) Final approval of manuscript: All authors

Reporting checklist

The authors have completed the PRISMA reporting checklist.

Disclosure statement

All authors have completed the ICMJE uniform disclosure form. The authors have no conflicts of interest to declare.

Data availability statement

All data generated or analyzed during this study are included in this published article.

Additional information

Funding

None.