Clinical Considerations and Recommendations
- What are the benefits and risks associated with a trial of labor after previous cesarean delivery?
- What is the vaginal delivery rate in women attempting a trial of labor after previous cesarean delivery?
- Who are candidates for a trial of labor after previous cesarean delivery?
- How does management of labor differ for patients attempting trial of labor after cesarean delivery?
- How should future pregnancies be managed after uterine rupture?
- How should women considering a trial of labor after previous cesarean delivery be counseled?
- How should second-trimester preterm delivery or delivery after a fetal death be accomplished in women with a previous cesarean delivery?
- What resources are recommended for obstetricians or other obstetric care providers and facilities offering a trial of labor after previous cesarean delivery?
The following recommendations are based on good and consistent scientific evidence (Level A):
- Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered TOLAC.
- Misoprostol should not be used for cervical ripening or labor induction in patients at term who have had a cesarean delivery or major uterine surgery.
- Epidural analgesia for labor may be used as part of TOLAC.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Those at high risk of uterine rupture (eg, those with previous classical uterine incision or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (eg, those with placenta previa) are not generally candidates for planned TOLAC.
- Given the overall data, it is reasonable to consider women with two previous low-transverse cesarean deliveries to be candidates for TOLAC and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.
- Women with one previous cesarean delivery with an unknown uterine scar type may be candidates for TOLAC, unless there is a high clinical suspicion of a previous classical uterine incision such as cesar-ean delivery performed at an extremely preterm gestation age.
- Women with one previous cesarean delivery with a low-transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, are considered candidates for TOLAC.
- Induction of labor remains an option in women undergoing TOLAC.
- External cephalic version for breech presentation is not contraindicated in women with a prior low-transverse uterine incision who are candidates for external cephalic version and TOLAC.
- Continuous fetal heart monitoring during TOLAC is recommended.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her obstetrician or obstetric care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documenta-tion of counseling and the management plan should be included in the medical record.
- Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.
- Women attempting TOLAC should be cared for in a level 1 center (ie, one that can provide basic care) or higher.
- Because of the risks associated with TOLAC, and because uterine rupture and other complications may be unpredictable, ACOG recommends that TOLAC be attempted in facilities that can provide cesarean delivery for situations that are immediate threats to the life of the woman or fetus. When resources for emergency cesarean delivery are not available, ACOG recommends that obstetricians or other obstetric care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthesiology, and operating room staffs.
- Because of the unpredictability of complications requiring emergency medical care, home birth is contraindicated for women undergoing TOLAC.
1. Little MO, Lyerly AD, Mitchell LM, Armstrong EM, Harris LH, Kukla R, et al. Mode of delivery: toward responsible inclusion of patient preferences. Obstet Gynecol 2008;112:913–8. (Level III)
2. Menacker F, Curtin SC. Trends in cesarean birth and vaginal birth after previous cesarean, 1991–99. Natl Vital Stat Rep 2001;49:1–16. (Level III)
3. Curtin SC, Gregory KD, Korst LM, Uddin SF. Maternal morbidity for vaginal and cesarean deliveries, according to previous cesarean history: new data from the birth certificate, 2013. Natl Vital Stat Rep. 2015;64(4):1–13. (Level III)
4. Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity. Am J Obstet Gyne-col 2001;184:1365,71; discussion 1371–3. (Level II-2)
5. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. N Engl J Med 2004;351:2581–9. Level II-2)
6. Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio DM, et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol 2005;193:1656–62. (Level II-3)
Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:
Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:
Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence.
Level C—Recommendations are based primarily on consensus and expert opinion.