Background: The optimal timing of delivery after a prior cesarean is debated. Induction of labor may reduce the risk of repeat cesarean delivery, but its safety remains unclear.
Objective: To assess the risks of cesarean delivery and maternal-neonatal morbidity associated with induction of labor versus expectant management from 38 weeks gestation onward in primiparous women with one prior cesarean delivery.
Study design: This secondary analysis of the randomized LUS Trial included primiparous women eligible for a trial of labor after cesarean from 38 weeks and 0 days. Cesarean delivery rates and maternal-fetal morbidity were compared according to the intended management strategy: induction of labor or expectant management. Comparisons were made between women who underwent induction of labor at a specific gestational week and those who remained pregnant at the end of that week (expectant management group). Maternal and neonatal morbidities were assessed using composite criteria. Multivariable logistic regression models were adjusted for maternal characteristics (body mass index, diabetes, hypertensive disorders, suspected macrosomia) and hospital status.
Results: Among the 2,948 LUS Trial participants, 2,267 primiparous women at ≥ 38 weeks of gestation with a prior cesarean delivery were eligible and 1,778 (78.4%) underwent a trial of labor after cesarean. Among them, 372 (20.9%) had an induction of labor and 1,406 (79.1%) had a spontaneous labor. The cesarean delivery rate was 44.2% (1,002/2,267) in the overall population. Cesarean delivery rates were similar in the induction of labor and expectant management groups week-by-week before 40 weeks 0 days. Induction of labor between 40 weeks 0 days and 40 weeks 6 days was associated with a significant lower cesarean delivery risk compared to expectant management beyond 41 weeks 0 days (adjusted OR 0.66, 95% CI 0.30 -0.87). Induction of labor at 39, 40, or 41 weeks was not associated with an increased composite maternal or neonatal morbidity.
Conclusion: In women with one prior cesarean delivery, induction of labor at 40 weeks compared with expectant management beyond 41 weeks reduces the cesarean delivery risk without increasing adverse maternal or neonatal outcomes.
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