Trial of labor after cesarean in preterm is preferable decision for reducing neonatal breathing disorders – Propensity score matching in observational single center study

Background The percentage of cesarean section (CS) and preterm deliveries have been increasing. However, the optimal mode of delivery for pregnant women with a history of CS who experience spontaneous labor in preterm period remains unclear. This observational study aimed to evaluate the reliable delivery method for both mothers and neonates during the preterm period. Methods From 2009 to 2024, we collected data on women with a history of CS who experienced spontaneous labor between 26 and 36 weeks of gestation. Patients diagnosed with preeclampsia or fetal growth restriction were excluded. Histological examinations of the placenta and umbilical cord were performed in all cases where delivered at ≤ 35 weeks of gestation or premature rupture of membrane was present. The primary outcome of this study was the incidence of respiratory disorders in preterm neonates, stratified by delivery method. To assess the impact of delivery mode on maternal and neonatal outcomes, we conducted a propensity score matching analysis. Results Among 7,766 deliveries, a total of 122 pregnant women were included in this study. Of these, 60 underwent a trial of labor after cesarean (TOLAC), all of whom achieved successful vaginal birth, resulting in a 100% success rate. The remaining 62 underwent emergency CS due to spontaneous labor onset or premature rupture of membranes. Neonatal respiratory disorders were significantly less frequent in the TOLAC group than in the CS group (26.7% vs. 56.5%, p < 0.001). Moreover, only 20% of neonates delivered from TOLAC required incubation for mechanical ventilation, whereas over 60% of those delivered by CS at 26–32 weeks of gestation required such support, which was statistically different between the two groups (p = 0.049). No significant differences were observed between the groups in NICU admission rates or the incidence of pathological inflammatory response in the placenta or umbilical cord. Even after propensity score matching, the incidence of neonatal respiratory disorders remained significantly less frequent in the TOLAC group compared to the CS group (25.5% vs 55.3%, p = 0.006). Conclusions This long-term observational study suggests that TOLAC is a favorable and beneficial delivery option for both mothers and neonates in cases of spontaneous preterm labor.