Trial of labor after cesarean (TOLAC) in women with premature rupture of membranes^*

Introduction: The aim of this study was to assess the success rate of a trial of labor after a previous cesarean section (TOLAC) in the settings of premature rupture of membranes (PROM) and to compare conservative management with spontaneous labor and induction of labor. Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2011 and March 2017. Women with singleton pregnancy and a previous cesarean section (CS) who presented with PROM and underwent TOLAC were included. Outcomes and rate of successful vaginal delivery after induction of labor were compared to conservative treatment and spontaneous labor. Results: Among 830 women who met the inclusion criteria, 723 (87.1%) had a spontaneous onset of labor following PROM and 107 (12.9%) had an induction of labor. The rate of successful TOLAC was similar between the groups (75.7 vs. 81.6%, respectively, p =.22). However, induction of labor was associated with an increased risk for uterine rupture (1.87 vs. 0.96%, p <.001), operative complications (6.7 vs. 2.3%, p <.001), and composite maternal postpartum complications (21.4 vs. 10.7%, respectively, p =.014) compared to conservative management with spontaneous initiation of labor. There was no difference in neonatal outcome between the groups. Conclusion: Induction of labor following PROM in women with a previous CS is associated with high successful vaginal delivery rate. However, the risk for uterine rupture and operative and maternal complications is significantly increased compared to spontaneous initiation of labor.