Maternal morbidity following a trial of labor after cesarean birth: A scoping review of operative vaginal birth compared with cesarean birth in the second stage of labor

BACKGROUND: Increased use of operative vaginal birth (OVB; forceps and vacuum) has been proposed as a strategy to avoid cesarean birth (CB) among individuals who elect a trial of labour after CB (TOLAC). The relative maternal safety of OVB and CB in individuals with a TOLAC is poorly understood. OBJECTIVE: To summarize the available evidence and methodologic quality of the literature on the use of OVB versus CB in the second stage of labor with a focus on maternal morbidity in individuals with a TOLAC. SEARCH STRATEGY: We searched OVID MEDLINE, EMBASE, and Web of Science after 1950 to August 8, 2023. SELECTION CRITERIA: Experimental and observational studies of individuals with a TOLAC having had OVB compared with CB in the second stage of labor. DATA COLLECTION AND ANALYSIS: Relevant characteristics (participant information, OVB and CB distribution, and comparative estimates of maternal morbidity) were abstracted. Findings were summarized narratively, with results presented in tabular form to highlight key comparisons. MAIN RESULTS: Five cohort studies conducted in the USA, Israel, or Australia were included. Higher rates of surgical injuries (9/87, 10.3% vs. 19/788, 2.4%), cystotomy (12/486, 2.5% vs. 4/743, 0.5%), and ureter injury (1/486, 0.2% vs. 1/743, 0.1%) were reported with second-stage CB compared with OVB. Rates of composite maternal morbidity were elevated with OVB, but higher rates of endometritis and wound complications were documented with second-stage CB compared with OVB. All studies were at high risk of bias. CONCLUSIONS: Optimal management of individuals requiring operative birth following a TOLAC remains unclear.