Trial of labor after cesarean versus repeat cesarean in women with small-for-gestational age neonates: a secondary analysis

Objective: The objective of this study was to determine whether trial of labor after cesarean (TOLAC) is associated with increased risk of adverse outcomes for small-for-gestational-age (SGA) neonates. Methods: This secondary analysis of a multicenter prospective observational study evaluated SGA neonates born to women with a single prior cesarean delivery. Nonanomalous, singleton pregnancies delivered at 24-41 weeks were included. The primary exposure was whether women underwent planned cesarean versus attempted TOLAC. Log-linear regression models were developed to characterize the relationship between TOLAC and neonatal outcomes. The primary outcome was a composite measure of neonatal morbidity and/or mortality, including death, respiratory complications, treated hypoglycemia, sepsis, neonatal intensive care unit (NICU) admission and hospital stay >5 days. Results: Of 1009 patients identified, 258 underwent repeat cesarean; 751 attempted TOLAC. Controlling for age, race, body mass index, smoking, maternal disease, prior vaginal birth after cesarean, corticosteroids, prematurity and nonreassuring fetal status as indication for delivery, the composite adverse outcome was similarly likely in both groups (adjusted risk ratio (RR) 0.99, 95% confidence interval (95% CI) 0.88-1.12, p = 0.93). Conclusions: SGA infants born to women who TOLAC have similar neonatal outcomes to those who deliver by planned repeat cesarean. We conclude that TOLAC is an acceptable option for women with a prior cesarean and suspected SGA neonates.