The American Congress of Obstetricians and Gynecologists (ACOG) issued a practice bulletin in 2010, specifically addressing research about trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC).  The old saying, “once a cesarean always a cesarean” no longer holds true. For many women who have had one prior cesarean or even two, they can attempt a TOLAC to achieve a vaginal birth.
Research Findings:

• A woman who is able to have a VBAC has fewer complications including: avoiding major abdominal surgery which results in shorter recovery period and lower rates of hemorrhage and infection.

• For women who may desire larger families, a VBAC may avoid future problems of multiple cesareans such as bowel or bladder injury, hysterectomy, infection, transfusion and issues with the placenta, such as placenta accreta and placenta previa.

• There appears to be little difference in findings among women who have a low-transverse uterine incision and women who have low vertical incisions or unknown types of uterine incisions.

• A classical, vertical incision or a T incision have the highest probability for uterine rupture.

• The most common risk factor associated with a TOLAC is the risk of uterine rupture. The chance of a rupture for women with one prior cesarean delivery is less than one percent (0.7-0.9 percent chance). For women with two cesarean deliveries the chance of a uterine rupture is 0.9-1.8 percent.

• Augmenting labor has been shown to decrease VBAC success rates, but is not contraindicated for TOLAC patients.

• It is recommended that misoprostol (cytotec) not be used in TOLAC patients, as it has been shown to increase chances for uterine rupture.

Factors to consider:

• ACOG also states in its Practice Bulletin (2010) that “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.”

• Several factors can negatively impact the likelihood of achieving a VBAC, but should not be reasons to deny a TOLAC to a patient:

• Big baby (macrosomia)            

• A pregnancy that goes beyond 40 weeks

• Pre-eclampsia

• Maternal obesity

• Short length of time between pregnancies (You want 18 months between deliveries)

• Increased maternal age

• Labor dystocia

Counseling Patients about TOLAC

• Considering a TOLAC is an on-going process that providers and patients must engage in together. Each patient has a specific set of circumstances that need to be taken into consideration for a TOLAC. If any new problems/issues arise during the pregnancy, the decision to attempt a TOLAC should be re-evaluated to minimize risk to mother and baby, but a patient’s autonomy needs to be respected in the decision-making process.

• Providers need to counsel patients on the benefits and risks of TOLAC and allow the PATIENT to make the decision regarding TOLAC.

• ACOG clearly states that “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.”

• For additional support, refer patients to the International Cesarean Awareness Network (ICAN). There is a chapter here in the Nashville area. ​