Clinical Edge

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Assessing Vaginal Birth After Cesarean Delivery

Obstet Gynecol; ePub 2017 Nov; ACOG, et al

Most women with 1 previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered trial of labor after cesarean delivery (TOLAC), a planned attempt to deliver vaginally after a previous cesarean delivery, regardless of the outcome. This according to new clinical management guidelines from the American College of Obstetricians and Gynecologists (ACOG) which help clinicians determine who is an appropriate candidate for TOLAC after assessing the likelihood of a vaginal birth after cesarean delivery (VBAC) as well as individual risks. Among the ACOG recommendations:

Level A:

  • Most women with 1 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.

Level B:

  • Those at high risk of uterine rupture and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC.
  • Given the overall data, it is reasonable to consider women with 2 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 1 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 cesarean delivery performed at an extremely preterm gestation age.
  • Women with 1 previous cesarean delivery with a low-transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, are considered candidates for TOLAC.

Citation:

Vaginal birth after cesarean delivery. Practice Bulletin No. 184. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017:130:e217–33.