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Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC)

  • Sorina Grisaru-Granovsky , Maayan Bas-Lando EMAIL logo , Lior Drukker , Fred Haouzi , Rivka Farkash , Arnon Samueloff and Alexander Ioscovich



Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.

Materials and methods:

A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural “users” were compared to “non-users”. Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.


Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural “users” 8.7% vs. “non-users” 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural “users” were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.


Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

Corresponding author: Maayan Bas-Lando, MD, Department of Obstetrics and Gynecology, 12 Bayit Street, Shaare Zedek Medical Center, Jerusalem, 91031 Israel, Tel.: +972-2-655-5111, Fax: +972-2-666-6053

  1. Author’s statement

  2. Conflict of interest: Authors state no conflict of interest.

  3. Material and methods: Informed consent: Informed consent has been obtained from all individuals included in this study.

  4. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

  5. Significance: To date the impact of epidural analgesia in the context of TOLAC has not been assessed. Herein, based on data from a tertiary center with strict TOLAC protocols and large numbers of women who agreed to TOLAC and either did or did not receive epidural anesthesia during labor, we show for the first time that epidural analgesia during TOLAC is associated with a high VBAC rate and is safe for both the mother and her neonate.

  6. Funding: No special funding was received for performance of this study.


[1] Zeitlin J, Mohangoo A, Delnord M. European Perinatal Health Report. Health and Care of Pregnant Women and Babies in Europe in 2010 [Available from: in Google Scholar PubMed

[2] Quinlan JD, Murphy NJ. Cesarean delivery: counseling issues and complication management. Am Fam Physician. 2015;91:178–84.Search in Google Scholar

[3] Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol. 2012;120:1181–93.10.1097/AOG.0b013e3182704880Search in Google Scholar PubMed PubMed Central

[4] Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004;351:2581–9.10.1056/NEJMoa040405Search in Google Scholar PubMed

[5] 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. Br J Obstet Gynecol. 2013;120:1154–5.10.1111/1471-0528.12010Search in Google Scholar PubMed

[6] Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001;345:3–8.10.1056/NEJM200107053450101Search in Google Scholar PubMed

[7] Sakala EP, Kaye S, Murray RD, Munson LJ. Epidural analgesia. Effect on the likelihood of a successful trial of labor after cesarean section. J Reprod Med. 1990;35:886–90.Search in Google Scholar

[8] Anwar S, Anwar MW, Ahmad S. Effect of epidural analgesia on labor and its outcomes. J Ayub Med Coll Abbottabad. 2015;27:146–50.Search in Google Scholar

[9] Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014;123:527–35.10.1097/AOG.0000000000000134Search in Google Scholar PubMed

[10] Barger MK, Weiss J, Nannini A, Werler M, Heeren T, Stubblefield PG. Risk factors for uterine rupture among women who attempt a vaginal birth after a previous cesarean: a case-control study. J Reprod Med. 2011;56:313–20.Search in Google Scholar

[11] Di Renzo GC. Tocophobia: a new indication for cesarean delivery? J Matern Fetal Neonatal Med. 2003;13:217.10.1080/713605859Search in Google Scholar

[12] Wing DA, Farinelli CK. Abnormal labor and induction of labor. In: Gabbe SG, Niebyl JR, Galan HL, Jauniaux ERM, Landon MB, Simpson JL, Driscoll DA, editors. Obstetrics: Normal and problem pregnancies. 6th ed. Philadelphia: Elsevier/Saunders; 2012. p. 287–311.10.1016/B978-1-4377-1935-2.00014-4Search in Google Scholar

[13] Dollberg S, Haklai Z, Mimouni FB, Gorfein I, Gordon ES. Birth weight standards in the live-born population in Israel. Isr Med Assoc J. 2005;7:311–4.Search in Google Scholar

[14] Konefal H, Jaskot B, Czeszynska MB, Pastuszka J. Remifentanil patient-controlled analgesia for labor - monitoring of newborn heart rate, blood pressure and oxygen saturation during the first 24 hours after delivery. Arch Med Sci. 2013;9:697–702.10.5114/aoms.2012.31306Search in Google Scholar PubMed PubMed Central

[15] Bujold E, Gauthier RJ. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor? Obstet Gynecol. 2001;98:652–5.10.1097/00006250-200110000-00022Search in Google Scholar

[16] E KSaG. Chapter 13- Normal labor and delivery. In: Gabbe SG NJ, Galan HL, Jauniaux ERM, Landon MB, Simpson JL, Driscoll DA, editors. Normal and problem pregnancies. 6th ed. Philadelphia: Elsevier; 2012. p. 267–86.Search in Google Scholar

[17] Rietveld AL, Kok N, Kazemier BM, de Groot CJ, Teunissen PW. Trial of labor after cesarean: attempted operative vaginal delivery versus emergency repeat cesarean, a prospective national cohort study. J Perinatol. 2015;35:258–62.10.1038/jp.2014.216Search in Google Scholar PubMed

[18] Dharan VB, Srinivas SK, Parry S, Ratcliffe SJ, Macones G. Pregestational diabetes: a risk factor for vaginal birth after cesarean section failure? Am J Perinatol. 2010;27:265–70.10.1055/s-0029-1239487Search in Google Scholar PubMed

[19] Waldenstrom U, Irestedt L. Obstetric pain relief and its association with remembrance of labor pain at two months and one year after birth. J Psychosom Obstet Gynaecol. 2006;27:147–56.10.1080/01674820500433432Search in Google Scholar PubMed

[20] Witt WP, Wisk LE, Cheng ER, Mandell K, Chatterjee D, Wakeel F. Determinants of cesarean delivery in the US: a lifecourse approach. Matern Child Health J. 2015;19:84–93.10.1007/s10995-014-1498-8Search in Google Scholar PubMed PubMed Central

[21] Dunn EA, O’Herlihy C. Comparison of maternal satisfaction following vaginal delivery after caesarean section and caesarean section after previous vaginal delivery. Eur J Obstet Gynecol Reprod Biol. 2005;121:56–60.10.1016/j.ejogrb.2004.11.010Search in Google Scholar PubMed

[22] Hung TH, Hsieh TT, Liu HP. Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: cohort study. PLoS One. 2015;10:e0120907.10.1371/journal.pone.0120907Search in Google Scholar PubMed PubMed Central

[23] Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011;12:CD000331.10.1002/14651858.CD000331.pub2Search in Google Scholar PubMed

[24] Sentilhes L, Beucher G, Deneux-Tharaux C, Deruelle P, Diemunsch P, Vayssière, C. Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol. 2013;170:25–32.10.1016/j.ejogrb.2013.05.015Search in Google Scholar PubMed

[25] Wassen MM, Zuijlen J, Roumen FJ, Smits LJ, Marcus MA, Nijhuis JG. Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review. Br J Obstet Gynecol. 2011;118:655–61.10.1097/01.aoa.0000414053.94556.45Search in Google Scholar

[26] Wang F, Shen X, Guo X, Peng Y, Gu X. Labor Analgesia Examining Group. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery a five-year randomized controlled trial. Anesthesiology. 2009;111:871–80.10.1097/ALN.0b013e3181b55e65Search in Google Scholar PubMed

[27] Sng BL, Leong WL, Zeng Y, Siddiqui FJ, Assam PN, Lim Y, et al. Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev. 2014;10:CD007238.10.1002/14651858.CD007238.pub2Search in Google Scholar PubMed

[28] Bernstein SN, Matalon-Grazi S, Rosenn BM. Trial of labor versus repeat cesarean: are patients making an informed decision? Am J Obstet Gynecol. 2012;207:204.e1–6.10.1097/OGX.0b013e31827d7bccSearch in Google Scholar

[29] Shmueli A, Tamir D. Health behavior and religiosity among Israeli Jews. Isr Med Assoc J. 2007;9:703–7.Search in Google Scholar

[30] Fagerberg MC, Maršál K, Källén K. Predicting the chance of vaginal delivery after one cesarean section: validation and elaboration of a published prediction model. Eur J Obstet Gynecol Reprod Biol. 2015;188:88–94.10.1016/j.ejogrb.2015.02.031Search in Google Scholar PubMed

[31] Costantine MM, Fox K, Byers BD, Mateus J, Ghulmiyyah LM, Blackwell S. Validation of the prediction model for success of vaginal birth after cesarean delivery. Obstet Gynecol. 2009;114:1029–33.10.1097/AOG.0b013e3181bb0ddeSearch in Google Scholar PubMed

[32] Gilbert SA, Grobman WA, Landon MB, Varner MW, Wapner RJ, Sorokin Y. Lifetime cost-effectiveness of trial of labor after cesarean in the United States. Value Health. 2013;16:953–64.10.1016/j.jval.2013.06.014Search in Google Scholar PubMed PubMed Central

[33] Grobman WA, Lai Y, Landon MB, Spong CY, Leveno K, Rouse DJ. Does information available at admission for delivery improve prediction of vaginal birth after cesarean? Am J Perinatol. 2009;26:693–701.10.1055/s-0029-1239494Search in Google Scholar PubMed PubMed Central

[34] Cahill AG, Stamilio DM, Odibo AO, Peipert JF, Ratcliffe SJ, Stevens EJ. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol. 2006;195:1143–7.10.1016/j.ajog.2006.06.045Search in Google Scholar PubMed

[35] Mercer BM, Gilbert S, Landon MB, Spong CY, Leveno KJ, Rouse DJ. Labor outcomes with increasing number of prior vaginal births after cesarean delivery. Obstet Gynecol. 2008;111:285–91.10.1097/AOG.0b013e31816102b9Search in Google Scholar PubMed

[36] Alexander J, Sharma S, McIntire D, Wiley J, Leveno K. Intensity of labor pain and cesarean delivery. Anesth Analg. 2001;92:1524–8.10.1097/00000539-200106000-00034Search in Google Scholar PubMed

[37] Panni M, Segal S. Local anesthetic requirements are greater in dystocia than in normal labor. Anesthesiology. 2003;98:957–63.10.1097/00000542-200304000-00024Search in Google Scholar PubMed

[38] Grant EN, Tao W, Craig M, McIntire D, Leveno K. Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future. Br J Obstet Gynecol. 2015;122:288–93.10.1111/1471-0528.12966Search in Google Scholar

[39] Lederman RP, Lederman E, Work BA, McCann DS. The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol. 1978;132:495–500.10.1016/0002-9378(78)90742-1Search in Google Scholar

[40] Thornton C, Carrie L, Sayers L, Anderson A, Turnbull A. A comparison of the effect of extradural and parental analgesia on maternal plasma cortisol ceoncentrations during labor and the puerperium. Br J Obstet Gynaecol. 1976;83:631–5.10.1111/j.1471-0528.1976.tb00901.xSearch in Google Scholar

[41] Shnider S, Abboud T, Artal R, Henriksen E, Stefani S, Levinson G. Maternal catecholamines decrease during labor after lumbar epidural anesthesia. Am J Obstet Gynecol. 1983;147:13–5.10.1016/0002-9378(83)90076-5Search in Google Scholar

[42] Jouppila R, Hollmen A. The effect of segmental epidural analgesia on maternal and foetal acid-base balance, lactate, serum potassium and creatine phosphokinase during labour. Acta Anaesthesiol Scand. 1976;20:259–68.10.1111/j.1399-6576.1976.tb05038.xSearch in Google Scholar PubMed

[43] Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012;3:CD009234.10.1002/14651858.CD009234Search in Google Scholar

Received: 2016-11-26
Accepted: 2017-4-19
Published Online: 2017-6-5
Published in Print: 2018-4-25

©2018 Walter de Gruyter GmbH, Berlin/Boston

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