How does uterine contractile activity affect the success of trial of labour after caesarean section, and the risk of uterine rupture? An exploratory, blinded analysis of a cohort from a randomised controlled trial

Objective: To investigate the impact of uterine contractile activity on the outcome of trial of labour after caesarean section (TOLAC). Design: Secondary, blinded analyses of a prospective TOLAC cohort. Setting: Two labour wards, one in a university tertiary hospital and the other in a central hospital. Population: A total of 194 TOLAC parturients with intrauterine tocodynamometry during labour. Methods: Analysis of intrauterine pressure, frequency of contractions and baseline tonus of uterine muscle in 30-minute periods for 4 hours before birth. Main outcome measures: Primary outcome: uterine contractile activity during TOLAC. Secondary aims: contributors associated with failed TOLAC and uterine rupture. Results: TOLAC succeeded in 74% of cases. Uterine contractile activity, expressed as intrauterine pressure, was significantly higher in successful TOLAC compared with failed TOLAC (210 versus 170 Montevideo units). The statistically significant risk factors of failed TOLAC, after multivariate regression analysis, were prolonged gestational age, reduced cervical dilatation at admission and lower mean intrauterine pressure. In cases of uterine rupture, contractile activity did not differ from that in failed TOLAC. Cervical ripening with a Foley catheter appeared to be a risk factor for uterine rupture, as well as cervical dilatation <3 cm at admission. The incidence of total uterine rupture was 2.6% (n = 5). Conclusions: Women with successful vaginal birth had higher uterine contractile activity than those experiencing failed TOLAC or uterine rupture despite similar use of oxytocin. Induction of labour with a Foley catheter turned out to be a risk factor for uterine rupture during TOLAC among parturients with no previous vaginal delivery. Tweetable abstract: During VBAC the response to oxytocin, assessed as intrauterine pressure, is greater and adequate, in contrast to failed TOLAC.