Guidelines for Trial of Labor After Cesarean

Candidate Selection for TOLAC

The American Academy of Family Physicians recommends that previous vaginal birth is the strongest predictor of successful vaginal birth after cesarean, with approximately 74% of women who attempt TOLAC having a successful vaginal birth 1
Women who have had a previous VBAC have an even greater chance of success compared to those who have not 1
TOLAC is appropriate for most women who have had one or two cesarean deliveries with low transverse uterine incisions 1

The American Society of Anesthesiologists recommends that neuraxial techniques should be offered to patients attempting VBAC 3
Early placement of a neuraxial catheter is appropriate for women attempting VBAC, as it can be used later for labor analgesia or anesthesia if operative delivery becomes necessary 3
An intravenous infusion should be established before initiating neuraxial analgesia and maintained throughout the duration of the analgesic or anesthetic 3

Labor induction with oxytocin carries a 1.1% risk of uterine rupture (95% CI, 0.9% to 1.5%) 2
Labor induction with prostaglandin E2 carries a 2% risk of uterine rupture (95% CI, 1.1% to 3.5%) 2
Misoprostol is contraindicated due to a significantly higher risk of uterine rupture 2

The American Academy of Family Physicians states that short-term maternal outcomes are as good or better with TOLAC/VBAC compared to repeat cesarean delivery 1
Perinatal mortality is slightly higher with TOLAC compared to repeat cesarean delivery 1
Repeat cesarean delivery increases long-term risk of abnormal placentation, hysterectomy, and surgical complications compared with VBAC 1

Physicians should discuss reasons for previous cesarean delivery when counseling patients about TOLAC 1
Predictive scoring models have limited value in determining which women have a greater risk of cesarean delivery 1