Trial of labor after cesarean in primiparous women with fetal macrosomia

Naama Lessans, Stav Martonovits, Misgav Rottenstreich, Simcha Yagel, Geffen Kleinstern, Hen Y. Sela, Shay Porat, Gabriel Levin, Joshua I. Rosenbloom, Yosef Ezra, Amihai Rottenstreich*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Key message: Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus. Purpose: Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia. Methods: A retrospective cohort study conducted during 2005–2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000 g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome). Results: Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P < 0.001), epidural anesthesia (aOR [95% CI] 2.38 (1.35, 4.20), P = 0.003) and history of cesarean delivery due to non-arrest disorder (aOR [95% CI] 2.25 (1.32, 3.85), P = 0.003) were the only independent factors associated with TOLAC success. Successful TOLAC was achieved in 82.0% (82/100) in the presence of all three favorable factors, 61.3% (65/106) in the presence of two factors and 38.6% (27/70) in the presence of one or less of these three factors (P < 0.001). Conclusion: Spontaneous onset of labor, epidural anesthesia and prior cesarean delivery due to non-arrest disorders were independently associated with higher vaginal birth after cesarean rate among women with fetal macrosomia, with an overall favorable success rate in the presence of these factors. These findings should be implemented in patient counseling in those contemplating a vaginal birth in this setting.

Original languageAmerican English
Pages (from-to)389-396
Number of pages8
JournalArchives of Gynecology and Obstetrics
Issue number2
StatePublished - Aug 2022
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2021, The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.


  • Birthweight
  • Cesarean delivery
  • Macrosomia
  • Predictors
  • Trial of labor
  • Vaginal birth


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