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\begin{document}

\title{Maternal and neonatal outcomes following trial of labor after two
previous cesareans: a retrospective cohort study.}



\author[1]{Reut Rotem}%
\author[1]{Ayala Hirsch}%
\author[1]{Hen Sela}%
\author[1]{Arnon Samueloff}%
\author[1]{Sorina Grisaru-Granovsky}%
\author[2]{Misgav Rottenstreich}%
\affil[1]{Shaare Zedek Medical Center}%
\affil[2]{ Shaare Zedek Medical Center}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: To evaluate the maternal and neonatal outcomes of parturients
attempting trial of labor (TOL) after two previous cesarean deliveries
(CD) Design: A retrospective computerized database cohort study.
Setting: A single tertiary center between 2005 and 2019. Population:
Parturients attempting TOL after two CD were compared to parturients
opting for elective third repeat CD. TOL after two CD was allowed only
for those who met all the criteria of our departments' protocol.
Methods: A univariate analysis was conducted and was followed by a
multivariate analysis. Main outcome measures: A composite of adverse
maternal and neonatal outcomes. Results: A total of 2719 eligible births
following two CD were identified, of which 485 (17.8\%) had attempted
TOL. Overall, successful vaginal delivery rate following two CDs was
86.2\%. Uterine rupture rates were higher among those attempting TOL
(0.6\% vs 0.1\% p=0.04). However, rates of hysterectomy, re-laparotomy,
blood product infusion and intensive care unit admission did not differ
significantly between the groups. Neonatal outcomes following elective
repeat CD were less favorable (specifically, neonatal intensive care
unit admission and composite adverse neonatal outcome). Nonetheless,
when controlling for potential confounders, an independent association
between composite adverse neonatal outcome and an elective repeat CD was
not demonstrated. In a subgroup analysis, diabetes mellitus and
hypertensive disorders of pregnancy were found independently associated
with failed TOLAC. Conclusion: When following a strict protocol, TOL
after two CD is a reasonable alternative and associated with favorable
maternal and neonatal outcomes%
\end{abstract}%



\sloppy


\textbf{Introduction}

Rates of cesarean deliveries (CD) have substantially increased in recent
decades to approximately 21\% of births worldwide\textsuperscript{1}with
the most common indication for CD being a previous uterine
scar\textsuperscript{2}. Repeat CD is associated with significant
morbidities including: the need for blood transfusion, bowel and bladder
injury and placenta previa with its related
complications\textsuperscript{3,4}. In 1980, the National Institute of
Child Health and Human Development Conference on Childbirth concluded
that vaginal delivery (VD) after a CD is a relevant alternative.
Successful vaginal birth after CD (VBAC) compared to elective repeat CD
is associated with fewer complications. However, a failed trail of labor
after CD (TOLAC) is associated with serious complications. Therefore,
efforts are made in order to identify the best candidates for
TOLAC\textsuperscript{5}\textbf{.}The American College of Obstetrics and
Gynecology (ACOG) committee opinion from 1994 on the issue of TOLAC
stated that TOLAC after two or more previous CDs should not be
discouraged.\textsuperscript{6}Thereafter, institutions consented and
allowed TOLAC following two previous CD\textsuperscript{7--10}.
Subsequently, the ACOG guidelines from 2019\textsuperscript{11}
maintains that it is reasonable to consider parturients with two
previous low segment transverse (LSTCS) CD as appropriate candidates for
TOLAC following a thorough individual consultation assessing their
previous and current obstetrical history and their probability of
achieving a successful VBAC.

Initiated in 2000, our medical center follows a strict protocol
regarding TOLAC in parturients who previously had 2 CD. There is a
paucity of data regarding maternal and neonatal risks associated with
TOLAC in this specific population. The purpose of this study was to
investigate the outcomes of TOLAC following two CD versus a third repeat
elective CD and to explore factors associated with successful TOLAC.

\textbf{Methods:}

In this retrospective cohort study all parturients at the Shaare Zedek
Medical Center (SZMC) with a history of two previous CD between August
2005 and November 2019, were enrolled. We included parturients between
24-42 weeks of gestations who had two prior CDs and subsequently had
vaginal vertex births and parturients who chose to have a repeat
elective CD. Excluded from the study were parturients with non-vertex
presentation, placenta previa, placenta accrete, mullerian uterine
anomalies, multifetal gestation other than twins and parturients without
at least one previous vaginal delivery. A comparison was made between
those who attempted TOLAC and those who were scheduled for an elective
repeat CD.

In general, our department's standard recommendation following previous
two CD is to undergo an elective repeat CD. However, TOLAC is discussed
with those parturients who express interest in attempting labor after
CD. TOLAC is discussed only if all the following criteria are validated.
The criteria are as follows: 1. The parturient explicitly expresses her
request for TOLAC and comprehends the potential risks, benefits, and
alternatives. 2. The parturient had a previous vaginal delivery (VD),
either before, between or after the second CD. 3. Both previous uterine
incisions were low segment transverse, there were no extensions or
severe adhesions. 4. Fetal estimated weight is \textless{}4000 grams. 5.
Vertex presentation. Additionally, the onset of labor must be
spontaneous, we do not induce or augment labor in parturient with 2
previous CD. SZMC's medical record database on all labor and deliveries
is updated in real time during labor and delivery by attending
healthcare professionals and audited periodically by trained technical
personnel to ensure validity of the data. Over 95\% of Israeli citizens'
medical care is covered by the Israeli National Health Plan hence
continuity of care is granted for long periods of time for most of the
patients. Maternal and neonatal records were reviewed and retrieved for
relevant data, information was coded and identifiable, and personal
information for each patient was protected by anonymization prior to
analysis.

Definitions: The terms used were defined as the following: \emph{Uterine
rupture -} complete uterine scar ruptures, i.e. involving the occurrence
of a full-thickness defect with direct connection between peritoneal
space and the uterine cavity. Diagnosis was made by an attending
physician during an explorative laparotomy. \emph{Re-laparotomy
--}additional abdominal operation performed during hospitalization for
delivery\textsuperscript{12} \emph{Postpartum hemorrhage} (PPH): Was
defined using one of the two following definitions: 1. Estimated blood
loss of over 500 ml in vaginal delivery (VD) and over 1000 ml in
CD\textsuperscript{13} (In SZMC pads are weighted following VD, but in
some cases when pads or weighting is not feasible blood loss is
estimated subjectively by the midwife/obstetrician); 2. the transfusion
of blood products and/or hemoglobin drop\emph{\textgreater{}} 4
gr/dL.\emph{Prolonged hospitalization} : \emph{\textgreater{}} 5 days
for vaginal deliveries and \emph{\textgreater{}} 7 days for cesarean
deliveries.

\textbf{Primary outcome} was defined as \emph{a composite adverse
maternal outcome} : one or more of the following: PPH, hemoglobin
drop\emph{\textgreater{}} 4 gr/dL, blood products transfusion, intensive
care unit (ICU) admission.\textbf{Secondary outcomes} were defined as
follows: \emph{1. Composite adverse neonatal outcome} : a composite
outcome of one or more of the following: 5-min Apgar~score
\emph{\textless{}} ~7, neonatal asphyxia, neonatal intensive care unit
(NICU) admission, and the need for mechanical ventilation.

2. \emph{Composite adverse maternal and neonatal outcome} s among the
group of parturients attempting TOLAC. We compared those who achieved
VBAC and those whose attempt at labor was aborted and necessitated in
labor CD

\emph{Statistical analysis} : An initial univariate analysis was carried
out, categorical variables were presented as a percentage and compared
using Chi square and Fisher's exact test as appropriate. Continuous
variables presentation was according to each variable distribution,
while normal distributed variables were presented as a mean and standard
deviation, those displaying non-normal distribution were presented as
median with interquartile range. A comparison was made using Student's
t-test and Mann Whitney test, accordingly. All analyses were two sided
and a p value \textless{} 0.05 was considered statistically significant.
Data analysis was conducted according to the group category to which the
parturient was initially categorized corresponding to her original
request. For instance, if a parturient originally requested an elective
CD and presented in active labor, resulting in an emergency CD, she
remained in the analysis of the planned elective CD group. However, all
parturients analyzed in the TOLAC group attempted TOL even if the result
was CD. A multivariate analysis using a binary logistic regression model
was used in order to account for the independent association between
composite adverse neonatal outcomes, infusion of blood products and
TOLAC versus elective CD after 2 CDs. Adjusted Odds Ratios (aOR) and
95\% confidence intervals (CI) were computed. A sub-group analysis
comparing in-labor CD (=failed TOLAC) versus successful VBAC was
conducted. A univariate analysis was followed by a multivariate analysis
in order to examine independent factors associated with TOLAC failure.

Data analysis was carried out using SPSS software (version 23
statistical package; IBM, Armonk, NY). The study was approved by the
local institutional ethics committee in accordance with the principles
of the Declaration of Helsinki (IRB: 001-20-SZMC).

\textbf{Results:}

During the study period, 3141 eligible births were identified, of which
422 were excluded in accordance with our exclusion criteria. According
to our study inclusion criteria, all parturients with previous 2 CD
experienced a previous vaginal delivery. Of the remaining 2719
deliveries, 485 (17.8\%) parturients attempted TOLAC and the remaining
2234 (82.2\%) had a scheduled elective repeat CD. (\textbf{Figure 1)} .
Among the 485 parturients attempting TOLAC, 418 achieved vaginal
delivery (86.2\%), with 26 (26/418, 6.2\%) assisted by operative VD. The
remaining 13.8\% experienced failed TOLAC and required in labor CD.

\textbf{Table 1} displays various demographic and obstetrical
characteristics of the study groups. Parturients who had requested an
elective repeat CD were significantly younger and of lower gravidity and
parity order. In addition, they had higher rates of conception using
advanced reproductive technology, diabetes (pre-gestational and
gestational) and hypertensive disorders of pregnancy.

\emph{Maternal outcomes:}

Selected maternal outcomes as well as the mode of delivery are presented
in \textbf{Table 2} . Our primary outcome -- composite adverse maternal
outcome rate was similar in both groups; 6.2\% of the parturients
attempting TOL vs. 4.8\%of the parturients who had elective repeat CD
(p=0.2).

However, several differences were noted: rates of uterine rupture were
lower among those who had elective repeat CD (0.1\% vs. 0.6\%, p=0.04).
Overall, there were six cases of uterine rupture (0.22\%) three in each
group. All three cases of uterine rupture among parturients who intended
to have an elective CD occurred before active labor, during the latent
phase. They all presented with abdominal pain prior to their scheduled
elective date and underwent surgery without delay. Among parturients
attempting TOL two out of three cases of uterine rupture occurred in the
latent phase. These parturients presented with fetal distress or
abdominal pain. One case was diagnosed unexpectedly post-partum during a
revision of the uterine cavity due to retained placenta. Hysterectomy
rate also did not differ between the groups. Hysterectomy was the
outcome of DIC following sepsis or pre-eclampsia. Only one of the cases
of hysterectomy was due to uterine rupture. A non-significant trend of
higher rates of re-laparotomy after CD was shown among those who had a
planned repeat CD. However, there were only three cases of
re-laparotomy, all of which were in the group of elective repeat CD. In
two of the cases an internal abdominal bleeding was detected and the
third was due to an eventration of the small intestine through the
Pfannenstiel incision.

There were no differences in the rates between the groups of
endometritis, PPH, hemoglobin drop[?]4 gr/dL and blood products, prolonged
hospitalization, and ICU admission.

\emph{Neonatal Outcomes}

Neonatal outcomes are presented in \textbf{Table 3} . Parturients who
had elective repeat CD were scheduled for surgery notably earlier than
the TOLAC group and the neonatal birth weights were significantly lower.
Consequently, rates of macrosomia neonates were significantly lower in
the elective repeat CD group. One-Minute Apgar score \emph{\textless{}}7
was considerably more prevalent among those attempting TOLAC. Rates of
NICU admission were higher among those who had elective repeat CD.
However, 5-minute Apgar scores, TTN, neonatal asphyxia and mechanical
ventilation were comparable between the two groups. Overall, rates of
the composite adverse neonatal outcome were significantly higher among
those who had planned an elective repeat CD (11.0\% vs. 6.2\%,
p\textless{}0.01).

\textbf{Table 4} displays the results of a multivariate regression model
which was conducted in order to account for independent factors
associated with composite adverse neonatal outcome. Attempting TOLAC was
not independently associated (aOR 0.48, 95\% CI 0.22-1.04) with
composite adverse neonatal outcomes while failed TOLAC was found to be
independently associated with composite adverse neonatal outcome (aOR
6.08, 95\% CI 2.19-16.90)

\textbf{Failed TOLAC:}

\textbf{Table S1} presents selected maternal and delivery
characteristics and outcomes of parturients attempting TOL following 2
CD according to the actual mode of delivery. Parturients with failed
TOLAC (67/485) were of lower gravidity and parity order with higher
rates of multifetal gestation. Rates of macrosomia did not differ
between the groups. All parturients planning TOLAC with multifetal
gestation failed (4/4). Rates of composite adverse maternal and neonatal
outcomes were significantly higher among those who had failed TOLAC
(11.9\% vs. 5.3\% and 29.9\% vs 2.4\%, respectively, p\textless{}0.01
for both). A multivariate analysis controlling for parity, diabetes,
hypertensive disorder of pregnancy and epidural usage had demonstrated
an independent association between failed TOLAC and composite adverse
maternal outcome (aOR 2.55, 95\% CI 1.05-6.22). An additional
multivariate analysis controlling for diabetes, hypertensive disorder of
pregnancy, gestational age at birth and neonatal birth weight
demonstrated an independent association between failed TOLAC and
composite adverse neonatal outcome (aOR 7.05, 95\% CI 2.60-19.05). When
assessing factors associated with failed TOLAC, diabetes and
hypertensive disorders of pregnancy were found positively associated
(aOR 3.13, 95\% CI 1.30-7.70 an aOR 8.45, 95\% CI 2.09-34.12,
respectively) while epidural was found to be negatively associated (aOR
0.42, 95\% CI 0.24-0.75); an association to parity and gravidity was not
demonstrated.

\textbf{Discussion} In this retrospective cohort study, maternal and
neonatal outcomes were compared between parturients with a history of
previous two CD attempting TOL versus those who had scheduled a third
elective CD. Seventeen percent of parturients with two previous CD met
our protocol criteria and expressed their preference for TOLAC. VBAC
rates were overall high (86\%). Parturients attempting TOL had higher
rates of uterine rupture with an overall rate of 0.6\%; otherwise
maternal outcomes were comparable. Failed TOLAC was found independently
associated with composite adverse neonatal outcome, in addition to
diabetes mellitus and hypertensive disorders of pregnancy.

Previous studies have described an array of VBAC rates following two CD,
ranging between 66-75\% \textsuperscript{10,14--16}, with a pooled rate
of 71\%\textsuperscript{17}. Our VBAC success rates (86\%) are higher
than those described in the literature. It is possible that this is
related to our department's protocol which requires previous vaginal
delivery and spontaneous onset of labor which were proven to be the best
predictors for VBAC.\textsuperscript{18}

Previous studies were inconclusive regarding maternal results associated
with TOLAC. Some studies\textsuperscript{15} indicated a two-fold
increase in the risk of composite maternal morbidity, including uterine
rupture, bladder injury, or other major operative injuries, while
others\textsuperscript{17} demonstrated comparable outcomes between the
groups. Our study demonstrated a non-significant lower rate of blood
transfusion, re-laparotomy, and hysterectomy in the TOLAC group. This
result was demonstrated in previous studies\textsuperscript{7,15,17} and
most probably reflects the increased risk inherent to multiple
CD\textsuperscript{19,20}. Previous studies
\textsuperscript{15149}demonstrated rates of uterine rupture following
two or more previous CD ranging between 0.8\%-3.7\% and concluded that
uterine rupture was significantly more common in those attempting TOLAC
in comparison to those who chose repeat elective CD. On the other hand,
one\textsuperscript{16} retrospective study did not demonstrate a
significant difference in uterine rupture. A
meta-analysis\textsuperscript{17} determined a pooled risk of 1.36\% for
a uterine rupture in TOLAC after two CD. Our data indicated an absolute
risk of 0.6\% for uterine rupture when attempting TOL which is
significantly higher when compared to an elective CD (0.6\% vs. 0.1\%,
p=0.04) but it is to our knowledge, the lowest rate described in
literature and does not differ significantly from the risk described for
TOL following one CD \textsuperscript{21}. The relatively lower rates of
uterine rupture along with the remarkable high VBAC rate might be
attributed to several factors related to our departmental protocol: 1.
In our institution, labor was not induced nor augmented, unlike previous
studies in which 65\% of parturients were induced\textsuperscript{15} 2.
In our study only parturients with prior two low segment transverse
incisions were approved for TOL, unlike previous studies that included
parturients with unknown scars and had higher rates of uterine rupture
which reached 5.4\%\textsuperscript{10,14}. 3. Previous VD is a
mandatory criteria in our institution and was proven to be not only one
of the best predictors for a VBAC\textsuperscript{22,23} but also a
protective factor for uterine rupture \textsuperscript{14,15}.

Rates of composite adverse neonatal outcomes were significantly higher
among those who had an elective repeat CD. This difference could have
been explained by the difference in gestational age and higher NICU
admission rates in the parturients having elective repeat
CD\textsuperscript{24}. However, when controlling for gestational age
and other potential confounders, an independent association to an
elective repeat CD was not demonstrated. Similar to our results, other
studies\textsuperscript{4} showed no significant differences when
comparing NICU admission and term neonatal death\textsuperscript{14,17}.
Not surprisingly, the rate of the composite adverse neonatal outcome was
significantly higher among those who had failed TOLAC. This finding
correlates with other studies that demonstrated poor 1-minute Apgar
scores that were four times more common among those with a failed
TOLAC.\textsuperscript{16}

The ability to predict successful TOLAC is of great importance as
maternal and neonatal morbidity is greater among those who fail TOLAC
and require a repeat CD in labor. Our results indicated that failed
TOLAC was associate with diabetes and hypertensive disorders, both of
which were similarly identified as risk factors for failed TOLAC in
other studies. \textsuperscript{4} In our study all parturients
attempting TOLAC with multifetal gestation (4/4) failed. Due to our
relatively small sample size and the fact that previous studies did not
demonstrate an association between multifetal gestation and failed
TOLAC, we believe that further studies are needed in order to better
examine the association between the two\textsuperscript{18}. Macrosomia
was previous described as a predictor of a failed
TOLAC\textsuperscript{26}. Nevertheless, in our study rates of
macrosomia were significantly higher among those attempting TOLAC while
rates of macrosomia did not differ between those who achieved VBAC or
failed TOLAC. Comparable to findings in a previous study
\textsuperscript{27} our results raise the question of the role of
macrosomia in failed TOLAC among those parturients who previously
delivered vaginally. Further studies are needed in order to address this
issue in groups of parturients attempting TOLAC with one previous VD.

This study holds several notable strengths: This is a large-scale
population study comprising more than a third of the births in the area
studied and 10\% of all national births; therefore, suitable for
generalization. In addition, our database is validated at real-time,
which assists in eliminating potential information bias. All costs of
antenatal care, birth, postpartum care for mother and child are
uniformly covered by the National Health Insurance for the entire study
period. Moreover, all mother-child data included were from one hospital
with no transfers to other facilities. Both factors alleviate a
potential selection bias; Lastly, the adherence to our strict department
protocol permitted us to examine the results of a designated, relatively
low-risk group of patients. Despite imposing a strict study inclusion
criterion, a fair number of parturients were found eligible and
attempted a relatively safe TOL.

Our study is not without limitations: A possible limitation may be due
to our retrospective design and its' inherent fault. We were unable to
identify and conduct a subgroup analysis of parturients who intended an
elective repeat CD and presented in labor and hence underwent urgent
surgery. Furthermore, our population has specific characteristics,
particularly the motivation for large families. This may preclude in
part the ability to generalize our study's results. However, we believe
that most of the parturients who are interested in TOLAC following two
previous CD share some characteristics in common, which may set a ground
for potential partial generalization. We also recognize that our data
collection process did not provide information regarding potential risk
factors associated with uterine rupture, such as prior uterine closure
technique, the number of previous VBAC, and an unknown number of
classical uterine scars in the elective repeat CD group. Nonetheless, we
did attempt to control for most recognized factors and excluded all
identified parturients who did not meet the ACOG criteria for
TOLAC\textsuperscript{28}.

\textbf{Conclusion} : parturients with a history of two CD attempting
TOLAC complying to a strict department protocol, have overall comparable
and favorable maternal and neonatal outcomes. Therefore, TOL is a
reasonable alternative to an elective repeated third CD. Diabetes and
hypertensive disorder are associated with failed TOLAC; obstetricians
should be aware of these findings when providing consultation.

\textbf{Acknowledgements:} We thank Pnina Mor, PhD for the critical
appraisal of the manuscript and English editing.

\textbf{Declaration of interest} : The authors declare that they have
nothing to disclose and that they have no financial or non-financial
conflict of interest.

\textbf{Disclosure of interests:} The authors report no conflict of
interest.

\textbf{Funding/Support:} This study was not funded.

\textbf{Financial Disclosures:} No financial disclosures.

\textbf{Contribution to authorship: R Rotem:} Protocol development, Data
collection and management, Data analysis, Manuscript
writing/editing.\textbf{A Hirsch:} Protocol development, Data collection
and management, Data analysis, Manuscript writing/editing. \textbf{HY
Sela:} Protocol development,Manuscript writing/editing.\textbf{A
Samueloff:} Data collection and management, Manuscript
writing/editing\textbf{S Grisaru-Granovsky} : Protocol development,
Manuscript writing/editing.\textbf{M Rottenstreich:} Protocol
development, Data collection and management, Data analysis, Manuscript
writing/editing.

\textbf{Ethical approval:} The study was approved by the local
Institutional Review Board of SZMC (IRB: 001-20-SZMC, 16.12.2109). As
the study was based on patient records, no informed consent was needed.

\textbf{Figure legend} :

\emph{Figure 1:} Flow chart of the study group.

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sections. \emph{BJOG An Int J Obstet Gynaecol} . 2010;117(1):5-19.
doi:10.1111/j.1471-0528.2009.02351.x

18. Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean
Registry: factors affecting the success of trial of labor after previous
cesarean delivery. \emph{Am J Obstet Gynecol} . 2005;193(3 Pt
2):1016-1023. doi:10.1016/j.ajog.2005.05.066

19. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated
with multiple repeat cesarean deliveries. \emph{Obs Gynecol} .
2006;107(6):1226-1232.

20. Cook JR, Jarvis S, Knight M, Dhanjal MK. Multiple repeat caesarean
section in the UK: Incidence and consequences to mother and child. A
national, prospective, cohort study. \emph{BJOG An Int J Obstet
Gynaecol} . 2013;120(1):85-91. doi:10.1111/1471-0528.12010

21. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal
outcomes associated with a trial of labor after prior cesarean
delivery.\emph{N Engl J Med} . 2004;351(25):2581-2589.
doi:10.1056/NEJMoa040405

22. Caughey AB, Shipp TD, Repke JT, Zelop C, Cohen A, Lieherman E. Trial
of labor after cesarean delivery: The effect of previous vaginal
delivery. In: \emph{American Journal of Obstetrics and Gynecology} . Vol
179. Mosby Inc.; 1998:938-941. doi:10.1016/S0002-9378(98)70192-9

23. Mercer BM, Gilbert S, Landon MB, et al. Labor Outcomes With
Increasing Number of Prior Vaginal Births After Cesarean
Delivery.\emph{Obstet Gynecol} . 2008;111(2, Part 1):285-291.
doi:10.1097/AOG.0b013e31816102b9

24. Jensen JR, White WM, Coddington CC. Maternal and neonatal
complications of elective early-term deliveries. \emph{Mayo Clin Proc} .
2013;88(11):1312-1317. doi:10.1016/j.mayocp.2013.07.009

25. Wu Y, Kataria Y, Wang Z, Ming WK, Ellervik C. Factors associated
with successful vaginal birth after a cesarean section: A systematic
review and meta-analysis. \emph{BMC Pregnancy Childbirth} .
2019;19(1):1-12. doi:10.1186/s12884-019-2517-y

26. Jastrow N, Roberge S, Gauthier RJ, et al. Effect of birth weight on
adverse obstetric outcomes in vaginal birth after cesarean
delivery.\emph{Obstet Gynecol} . 2010;115(2 PART 1):338-343.
doi:10.1097/AOG.0b013e3181c915da

27. Elkousy MA, Sammel M, Stevens E, Peipert JF, Macones G. The effect
of birth weight on vaginal birth after cesarean delivery success
rates.\emph{Am J Obstet Gynecol} . 2003;188(3):824-830.
doi:10.1067/mob.2003.186

28. ACOG. Clinical Management Guidelines for Obstetrician --
Gynecologists. \emph{Obstet Gynecol} . 2019;133(76):168-186.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 1: Demographic and current delivery characteristics of the study
groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 1: Demographic and current delivery characteristics of the study
groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 1: Demographic and current delivery characteristics of the study
groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 1: Demographic and current delivery characteristics of the study
groups\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
TOLAC following 2 CD N= 485\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Elective planned repeated CD N= 2234\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Maternal Age (Mean\selectlanguage{ngerman}±SD)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
34.44\selectlanguage{ngerman}±4.32\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
33.49\selectlanguage{ngerman}±5.11\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gravidity (Median, IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7 (6-10)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4 (3-6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Parity~(Median, IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5 (4-7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (3-5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Previous miscarriage n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
228 (47.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
987 (44.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.26\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Fertility treatments n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5 (1.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
126 (5.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Diabetes n (\%)*\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30 (6.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
264 (11.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hypertensive disorders of pregnancy n (\%)**\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9 (1.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
111 (4.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Multifetal gestation n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4 (0.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
24 (1.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.62\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
BMI (kg/m\textsuperscript{2}) (Mean\selectlanguage{ngerman}±SD)***\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
29.58\selectlanguage{ngerman}±4.76\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
31.24\selectlanguage{ngerman}±5.50\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Epidural analgesia n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
235 (48.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Intrapartum fever n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Episiotomy n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7 (1.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean delivery, SD --
standard deviation, IQR -- interquartile range, NA -- not
available\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean delivery, SD --
standard deviation, IQR -- interquartile range, NA -- not
available\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean delivery, SD --
standard deviation, IQR -- interquartile range, NA -- not
available\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean delivery, SD --
standard deviation, IQR -- interquartile range, NA -- not
available\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*(pre gestational + gestational) **Hypertensive disorders of pregnancy,
a composite of: gestational hypertension, preeclampsia and eclampsia.
*** Due to missing data N=71 in TOLAC group and N=767 in Elective CD
group\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*(pre gestational + gestational) **Hypertensive disorders of pregnancy,
a composite of: gestational hypertension, preeclampsia and eclampsia.
*** Due to missing data N=71 in TOLAC group and N=767 in Elective CD
group\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*(pre gestational + gestational) **Hypertensive disorders of pregnancy,
a composite of: gestational hypertension, preeclampsia and eclampsia.
*** Due to missing data N=71 in TOLAC group and N=767 in Elective CD
group\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*(pre gestational + gestational) **Hypertensive disorders of pregnancy,
a composite of: gestational hypertension, preeclampsia and eclampsia.
*** Due to missing data N=71 in TOLAC group and N=767 in Elective CD
group\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Table 2: Maternal and delivery outcomes of the study groups.\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Table 2: Maternal and delivery outcomes of the study groups.\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Table 2: Maternal and delivery outcomes of the study groups.\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Table 2: Maternal and delivery outcomes of the study groups.\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Table 2: Maternal and delivery outcomes of the study groups.\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
TOLAC following 2 CD N= 485\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Elective planned repeated CD N= 2234\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mode of delivery n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Spontaneous vaginal\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
392 (80.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Operative vaginal\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26 (5.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Cesarean\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
67 (13.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Shoulder dystocia n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Shoulder dystocia n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (0.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Postpartum endometritis n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Postpartum endometritis n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (0.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26 (1.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.14\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Postpartum hemorrhage n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Postpartum hemorrhage n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35 (7.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
167 (7.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.84\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hemoglobin drop\emph{\textgreater{}}4 gr/dL n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hemoglobin drop\emph{\textgreater{}}4 gr/dL n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14 (2.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
74 (3.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.63\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
IV Iron administration n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
IV Iron administration n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (0.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.16\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Blood products transfusion n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Blood products transfusion n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8 (1.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58 (2.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.22\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Uterine rupture n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Uterine rupture n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (0.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (0.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.04\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Re-laparotomy n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Re-laparotomy n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (0.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.09\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hysterectomy n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hysterectomy n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (0.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (0.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.48\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Prolonged Hospitalization n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Prolonged Hospitalization n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13 (2.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
49 (2.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.51\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ICU Admission n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
ICU Admission n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.64\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Composite adverse maternal outcome n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Composite adverse maternal outcome n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
30 (6.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
107(4.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, ICU
intensive care unit; IV- intra venous. Prolonged Hospitalization -
\textgreater{} 5 days for vaginal deliveries and \textgreater{} 7 days
for cesarean deliveries. ICU -- intensive care unit Maternal composite
outcome was defined as one or more of the following: PPH, hemoglobin
drop\textgreater{}4 gr/dL, blood products infusion, ICU admission.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, ICU
intensive care unit; IV- intra venous. Prolonged Hospitalization -
\textgreater{} 5 days for vaginal deliveries and \textgreater{} 7 days
for cesarean deliveries. ICU -- intensive care unit Maternal composite
outcome was defined as one or more of the following: PPH, hemoglobin
drop\textgreater{}4 gr/dL, blood products infusion, ICU admission.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, ICU
intensive care unit; IV- intra venous. Prolonged Hospitalization -
\textgreater{} 5 days for vaginal deliveries and \textgreater{} 7 days
for cesarean deliveries. ICU -- intensive care unit Maternal composite
outcome was defined as one or more of the following: PPH, hemoglobin
drop\textgreater{}4 gr/dL, blood products infusion, ICU admission.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, ICU
intensive care unit; IV- intra venous. Prolonged Hospitalization -
\textgreater{} 5 days for vaginal deliveries and \textgreater{} 7 days
for cesarean deliveries. ICU -- intensive care unit Maternal composite
outcome was defined as one or more of the following: PPH, hemoglobin
drop\textgreater{}4 gr/dL, blood products infusion, ICU admission.\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, ICU
intensive care unit; IV- intra venous. Prolonged Hospitalization -
\textgreater{} 5 days for vaginal deliveries and \textgreater{} 7 days
for cesarean deliveries. ICU -- intensive care unit Maternal composite
outcome was defined as one or more of the following: PPH, hemoglobin
drop\textgreater{}4 gr/dL, blood products infusion, ICU admission.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 3: Neonatal outcomes of the study groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 3: Neonatal outcomes of the study groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 3: Neonatal outcomes of the study groups\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Table 3: Neonatal outcomes of the study groups\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
TOLAC following 2 CD N= 485\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Elective planned repeated CD N= 2234\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Gestational age at delivery, week (Median, IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
40 (39-40)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
38 (38-39)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Birthweight, grams (Mean\selectlanguage{ngerman}±SD)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3361.2\selectlanguage{ngerman}±585.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3134.5\selectlanguage{ngerman}±486.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal gender, male n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
228 (47.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1139 (51.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.08\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Macrosomia (\emph{\textgreater{}}4000 grams) n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
46 (9.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
86 (3.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1-Minute Apgar score \emph{\textless{}} 7 n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30 (6.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
91 (4.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.04\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5-Minute Apgar score \emph{\textless{}} 7 n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9 (1.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
45 (2.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.82\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU admission n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
23 (4.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
191 (8.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.02\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal asphyxia n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (0.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.55\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TTN n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10 (2.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
52 (2.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.72\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Mechanical ventilation n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12 (2.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
36 (1.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.19\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Composite adverse neonatal outcome n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30 (6.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
245 (11.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, SD --
standard deviation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, SD --
standard deviation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, SD --
standard deviation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
TOLAC -- Trail of labor after cesarean, CD -- cesarean deliveries, SD --
standard deviation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU Neonatal intensive care unit, TTN transient tachypnea of the
newborn\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU Neonatal intensive care unit, TTN transient tachypnea of the
newborn\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU Neonatal intensive care unit, TTN transient tachypnea of the
newborn\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
NICU Neonatal intensive care unit, TTN transient tachypnea of the
newborn\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal composite outcome was defined as one or more of the following:
5-min Apgar \textless{} 7, asphyxia, NICU admission or the need for
mechanical ventilation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal composite outcome was defined as one or more of the following:
5-min Apgar \textless{} 7, asphyxia, NICU admission or the need for
mechanical ventilation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal composite outcome was defined as one or more of the following:
5-min Apgar \textless{} 7, asphyxia, NICU admission or the need for
mechanical ventilation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Neonatal composite outcome was defined as one or more of the following:
5-min Apgar \textless{} 7, asphyxia, NICU admission or the need for
mechanical ventilation\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Table 4: Composite adverse Neonatal outcome following 2 CD, elective CD
vs. TOLAC; results from multivariate analysis & Table 4: Composite
adverse Neonatal outcome following 2 CD, elective CD vs. TOLAC; results
from multivariate analysis & Table 4: Composite adverse Neonatal outcome
following 2 CD, elective CD vs. TOLAC; results from multivariate
analysis\tabularnewline
\midrule
\endhead
~Variables & aOR, (95\% CI) & p value\tabularnewline
In labor CD & 6.08 (2.19-16.90) & \textless{}0.01\tabularnewline
Meconium aspiration & 4.64 (1.69-12.74) & \textless{}0.01\tabularnewline
Gestational age at delivery & 0.41 (0.36-0.46) &
\textless{}0.01\tabularnewline
Macrosomia (\emph{\textgreater{}}4000 grams) & 0.67 (0.32-1.40) &
0.29\tabularnewline
TOLAC vs. Planned elective CD & 0.48 (0.22-1.04) & 0.07\tabularnewline
Hypertensive disorders of pregnancy** & 1.26 (0.72-2.21) &
0.41\tabularnewline
Diabetes* & 1.10 (0.75-1.70) & 0.55\tabularnewline
Parity & 1.03 (0.97-1.09) & 0.32\tabularnewline
CD -- cesarean delivery, TOLAC -- trail of labor after cesarean, aOR-
adjusted odds ratio, CI -- confidence interval. *(pre gestational +
gestational) **Hypertensive disorders of pregnancy, a composite of:
gestational hypertension, preeclampsia and eclampsia. & CD -- cesarean
delivery, TOLAC -- trail of labor after cesarean, aOR- adjusted odds
ratio, CI -- confidence interval. *(pre gestational + gestational)
**Hypertensive disorders of pregnancy, a composite of: gestational
hypertension, preeclampsia and eclampsia. & CD -- cesarean delivery,
TOLAC -- trail of labor after cesarean, aOR- adjusted odds ratio, CI --
confidence interval. *(pre gestational + gestational) **Hypertensive
disorders of pregnancy, a composite of: gestational hypertension,
preeclampsia and eclampsia.\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure/Figure}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

