Loading...
Target Population: Obstetric care providers
A safe birth for both mother and newborn is often best achieved with vaginal birth. Some women may choose to attempt a trial of labor after cesarean (TOLAC) to achieve vaginal birth after cesarean (VBAC); alternatively, they may plan a repeat cesarean delivery (RCD). This ACOG practice bulletin updates guidance for providing individualized counseling about the risks and benefits of TOLAC and RCD. In the absence of randomized trials, observational data have played an essential role in developing these guidelines.
Women without contraindications to vaginal birth (e.g., placenta previa) who have had one or two prior cesarean deliveries with a low uterine incision are eligible to attempt TOLAC.
Successful prior vaginal delivery increases the chances of successful TOLAC; factors that reduce the likelihood of successful TOLAC include obesity and a prior cesarean delivery for arrest of labor.
Risks for uterine rupture and perinatal death are <1% with either TOLAC or RCD, although these adverse outcomes occur more often with TOLAC than RCD.
Successful TOLAC with an uncomplicated vaginal birth is safer than RCD due to lower risks for maternal hemorrhage, wound infection, and death; TOLAC resulting in uterine rupture (0.7% of cases) can cause serious maternal and fetal injury, resulting in a birth that is less safe than RCD.
Calculators to help assess the likelihood of successful TOLAC are available for use during prenatal care or at admission for delivery (when additional clinical information may modify the predicted success rate).
A woman's choice to attempt TOLAC or undergo RCD should be made in consultation with her clinician based on shared, individualized decision making that respects her personal values and priorities.
TOLAC should only be attempted in a birthing unit that can perform timely cesarean delivery in the event of uterine rupture; home birth is contraindicated.
The American College of Obstetricians and Gynecologists.Practice bulletin no. 184: Vaginal birth after cesarean delivery. Obstet Gynecol 2017 Nov; 130:1167. (http://dx.doi.org/10.1097/AOG.0000000000002398)
Comment
Clinicians who provide care for pregnant women are deeply committed to achieving the lowest possible rates of cesarean delivery while protecting the safety of mothers and neonates. TOLAC is a powerful clinical option for optimizing cesarean delivery rates. Although all birthing decisions should be individualized, for women with a predicted rate of successful TOLAC as low as 40%, planned RCD may be the safer option. For those with a predicted rate of successful TOLAC of ≥60%, a TOLAC may be the optimal plan; however, a predicted success rate of <60% is not a contraindication to attempting a TOLAC. Women who are likely to achieve a successful TOLAC should be encouraged to pursue this birth plan.