Vaginal Birth After Previous Cesarean Delivery

Recent data enable more-specific recommendations for managing pregnant patients who have experienced previous cesarean delivery.

 

Based on recent observational data as well as the outcomes of a 2010 NIH consensus conference on trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC), the American College of Obstetricians and Gynecologists (ACOG) has updated its 2004 recommendations. Although some recommendations remain unchanged (e.g., women with single prior low-transverse uterine incisions are candidates for TOLAC), the new guidelines identify additional categories of women for whom TOLAC can be considered safe. Particular emphasis is placed on antepartum predictors of successful VBAC, as risks to maternal and neonatal wellbeing are highest in the setting of failed TOLAC.

Highlights of the new guidelines include the following:

 

• Women with two prior cesarean deliveries that involved low-transverse uterine incisions are candidates for TOLAC.
• Women with twin pregnancies and one previous low-transverse incision are candidates for TOLAC (previous recommendations limited candidacy to women with two prior cesarean deliveries and one prior vaginal delivery).
• TOLAC generally is not contraindicated in women who have unknown uterine scar type in association with one previous cesarean delivery.
• Indicated induction of labor can be considered in women with one previous cesarean delivery; however, use of misoprostol for cervical ripening during the third trimester is discouraged. Conclusive recommendations about use of prostaglandin E2 are not yet possible because data are lacking. Nonetheless, risk for uterine rupture with second-trimester prostaglandin use is reported to be low.
• In 2004, ACOG recommended that TOLAC be attempted only in institutions with staff immediately available to perform emergency deliveries. The 2010 recommendations instead encourage open dialogue with potential TOLAC candidates about risks and benefits of undertaking TOLAC in the absence of immediately available resources for emergency delivery, noting that well-counseled women have the right to incur additional risk.

Comment: The dramatic rise in the U.S. cesarean delivery rate during the past few decades is a substantial public health concern. The new ACOG guidelines allow for evidence-based broadening of eligibility for TOLAC and call for careful consideration of individual patient and healthcare factors. By using these tools to identify patients with greater likelihood of successful VBAC, taking a more-permissive approach to TOLAC, and encouraging shared decision-making among providers and patients, we can make a safe and informed push toward lowering the cesarean delivery rate.

 

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Epidural Analgesia for Labor and Delivery

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