Overview

Background
“Once a cesarean, always a cesarean.” From 1916, when these words
were spoken to the New York Association of Obstetricians & Gynecologists,
through the ensuing 50-60 years, this statement reflected most of US
obstetricians’ management of patients with a prior cesarean delivery. By
1988, the overall cesarean delivery rate was 25%, rising from less than 5%
in the early 1970s. Only 3% of live-born infants were delivered vaginally
after the mother had undergone a prior cesarean delivery.
Although attempts at a trial of labor after a cesarean birth (TOLAC) have
become accepted practice, the rate of successful vaginal birth after
cesarean delivery (VBAC), as well as the rate of attempted VBACs, has
decreased during the past 10 years (see the image below). Whereas, 40-
50% of women attempted VBAC in 1996, as few as 20% of patients with a
prior cesarean delivery attempted a trial of labor in 2002. This number is
drifting down toward the 10% mark with fewer than 10% of women
achieving successful VBAC in 2005.

Vaginal birth after cesarean

delivery rates.
Nevertheless, despite the known risks (0.5-1% rate of uterine rupture),
TOLAC remains an attractive option for many patients and leads to a
successful outcome in a high proportion of cases. In comparison, the
alternative of elective repeat cesarean delivery is not without risks. In
addition to the inherent risks that cesarean delivery has over vaginal
delivery, patients may experience uterine rupture prior to the onset of labor.
The decision to undergo TOLAC is an individual one that should be based
on careful, thorough counseling. [1] Maternal characteristics and obstetric
history can provide a patient a rough estimate of her chance of a
successful trial of labor. This same obstetric history can be used to
estimate a patient’s risk of uterine rupture.
If possible, avoid induction of labor, because induction of labor decreases
the probability of success and increases the chance of uterine rupture in a
trial of labor after cesarean delivery. Counsel patients who elect to undergo
TOLAC to be evaluated early in labor and to manage the pregnancy in a
hospital setting in which uterine rupture can be both recognized and
managed expediently.
Certainly, counseling should address the question of whether patients are
interested in subsequent pregnancies after the current pregnancy.
Undergoing 2 prior cesarean deliveries further increases the risks of VBAC
in a subsequent pregnancy; thus, for a future pregnancy, having had a
successful VBAC offers protection after undergoing the risk in the current
pregnancy.
Go to Cesarean Delivery and Perimortem Cesarean Delivery for complete
information on these topics.
For patient education resources, see the Pregnancy and Reproduction
Center, as well as Labor Signs.
ACOG Guidelines
Several factors have contributed to the decline in VBAC. As practitioners
experience complications related to managing patients undergoing trials of
labor after cesarean delivery, they are less likely to allow new patients to
undergo a trial of labor. In addition, 1999 guidelines from the American
College of Obstetricians and Gynecologists (ACOG) stated explicitly that
patients undergoing TOLAC require the presence of an obstetrician, an
anesthesiologist, and/or a staff capable of performing an emergency
cesarean delivery throughout the patient’s active phase of labor. [2]
Whereas academic centers and larger community hospitals are able to
comply with these requirements, many smaller hospitals do not offer in-
house anesthesia or obstetric staff. Furthermore, to meet the financial
demands of managed care, many obstetricians now cover more than one
hospital simultaneously, making it difficult to comply with the 1999
guidelines.
The impact of these changes can be observed in national birth statistics.
The cesarean delivery rate peaked at 25% in 1988 but then declined to
21% overall in 1996. From 1996 to 2004, however, the cesarean delivery
rate increased to 29.2%, while the rate of VBAC declined from 28% to 9%.
On the assumption that the overall VBAC success rate is about 70%, this
correlates with a decline from 40% to 14% in the number of patients
choosing to undergo TOLAC.
What once was hailed as a key component of lowering the overall cesarean
birth rate (ie, TOLAC) is losing the support it had in the 1980s. Overall, this
has led to a rate of cesarean delivery of 31.1% in 2006, which is the
highest rate in US history and shows no signs of decreasing.
In 2010, with these developments in mind, ACOG issued new guidelines
that were somewhat less restrictive. [3, 4] The 2010 guidelines, based on
consensus and expert opinion, recommend that TOLAC should be
undertaken at facilities capable of emergency deliveries. Because of the
risks associated with TOLAC and complications such as uterine rupture
that may be unpredictable, ACOG recommends that TOLAC be undertaken
in facilities with staff immediately available to provide emergency care.
However, when resources for immediate cesarean delivery are not
available, health care providers and patients considering TOLAC should
discuss the hospital’s resources and availability of obstetric, pediatric,
anesthetic, and operating room staffs. Respect for patient autonomy
supports allowing patients to accept increased levels of risk; however,
patients should be clearly informed of such potential increase in risk and
counseled about management alternatives.
Recognizing that TOLAC was decreasing at community and more rural
hospitals, ACOG revised these recommendations in 2017 with an apparent
goal in softening the recommendation for immediate availability of surgical
teams. The language now reads "ACOG recommends that TOLAC be
attempted in facilities that can provide cesarean delivery for situations that
are immediate threats to the life of the woman and the fetus". This more
nuanced statement may result in an increase in attempted TOLAC at these
facilities. [5]
On the basis of level A evidence, the 2017 ACOG guidelines make the
following recommendations [5] :
 Most women with a prior cesarean delivery with a low transverse
incision are candidates for VBAC and should be offered TOLAC.
 Epidural anesthesia may be used as part of TOLAC.
 Misoprostol should not be used for patients who have had a prior
cesarean delivery or major uterine surgery.
On the basis of level B evidence, TOLAC may be considered for the
following patients [5] :
 Women with 2 previous low transverse cesarean deliveries
 Women with 1 previous cesarean delivery with a low transverse
incision who are otherwise appropriate candidates for twin vaginal
delivery
 Women with 1 previous cesarean delivery of unknown incision type,
unless clinical suspicion of a previous classical uterine incision is high
 Women with 1 previous cesarean delivery who are otherwise
appropriate candidates for twin vaginal delivery.
Level B evidence was also found for the following:
 Induction of labor during TOLAC is not contraindicated.
 In women with a prior low transverse uterine incision who are at low
risk for adverse maternal or neonatal outcomes from external cephalic
version and TOLAC, external cephalic version for breech presentation
is not contraindicated.
 Continuous fetal heart rate monitoring is recommended during
TOLAC
A comparison of VBAC in the United States, the United Kingdom, and
Canada showed understandable similarities but numerous unexplained
differences in recommendations. [6]
Outcomes of Interest
Two specific outcomes of interest regarding TOLAC have been well
investigated: successful VBAC and uterine rupture. Other outcomes are
certainly of interest, including neonatal outcome, hysterectomy, and
maternal mortality; however, few studies have focused on these outcomes,
and poor outcomes occur too rarely to be well represented in established
databases.
In earlier studies, most outcomes were reported after univariate analysis.
Risk factors were examined without controlling for potential confounding
variables, and results were reported as a relative risk or odds ratio. These
ratios represent the risk of the group of individuals who have the risk factor
divided by individuals without the risk factor. Over the last decade, several
large cohorts have examined predictors and outcomes related to women
with a prior cesarean delivery. These studies have ranged from Nova
Scotia to Boston to the state of Washington.
Finally, 2 large multicenter studies have been publishing multiple studies on
this issue, one out of Pennsylvania and the other out of the Maternal-Fetal
Medicine Units. These large studies over the last decade have used
multivariate statistics to examine risk factors. This means that other risk
factors and confounding factors, such as birth weight, maternal age,
obstetric history, and labor management, were controlled for in the
analysis.
In this article, factors associated with mode of delivery in the setting of a
trial of labor and factors associated with uterine rupture in this same setting
are reviewed.
Indications
The predictors of successful TOLAC are extensively described in the
existing literature (see the table below). Although no randomized trials have
been conducted, relatively large databases have been analyzed (with both
univariate and multivariate techniques) to determine risk factors for patients
undergoing TOLAC. In addition, several scoring systems have been
devised to help predict which patients are likely to be successful when
attempting VBAC. These scoring systems are quite varied and may inform
the discussion with the patient about TOLAC. However, there are no
prospective studies that demonstrate that these systems improve perinatal
outcomes. Examples of these calculators can be found on the ACOG
website.
Because no large, prospective, randomized, controlled trials have been conducted,
most of the risk factors have been determined from retrospective cohort and case-
control studies. These studies have been increasingly analyzed with multivariate
techniques to control for confounding factors. However, control for physician practice
is difficult, and physician practice can greatly impact the strength of the association
between these risk factors and a successful VBAC.
Even when demographic data, obstetric history, birth weight, gestational age,
induction of labor, and other variables are controlled for, the bias inherent in
nonrandomized and nonblinded trials cannot be eliminated.
Maternal characteristics
Several studies examine prepregnancy weight and height to examine the effect on
mode of delivery. Not surprising, women who are shorter and women who are obese
are more likely to undergo cesarean delivery. Of note, cesarean delivery has been
associated not only with increased prepregnancy weight but also with increased
gestational weight gain.
An increasing number of studies have been carried out in the setting of TOLAC, all of
which show that women in the morbidly obese range have a higher risk of failing a
trial of labor. Interpregnancy weight gain has been shown to increase the risk of
failure in a subsequent trial of labor, but unfortunately, interpregnancy weight loss
has not demonstrated an improvement in VBAC success.
Maternal age has also been examined in several studies in VBAC literature. With
confounding factors adjusted for, women older than 40 years who have had a prior
cesarean delivery have an almost 3-fold higher risk for a failed trial of labor than do
women younger than 40 years. In 1 scoring system, women younger than 40 years
were given an extra point as a predictor for successful VBAC. [7]
Maternal race or ethnicity has been examined as a predictor for VBAC in the setting
of trial of labor and has not generally been noted to be a strong predictor. However,
in the recent Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry, both
Hispanic ethnicity and African American ethnicity were associated with lower rates of
successful trial of labor. Whether this association is due to actual biologic reasons or
whether ethnicity is acting as a proxy for some other factor or factors remains to be
elucidated.
Birth weight
Birth weight greater than 4000 g is associated with an almost 4-fold higher risk of
cesarean birth among nulliparous women. Several studies have demonstrated a
difference in VBAC rates between patients with a birth weight greater than 4000 g
and those with a lower birth weight. In accordance with these findings, several
studies have demonstrated a higher failure of a trial of labor with increasing birth
weight.
Obstetric history
Obstetric history is enormously important in terms of risk factors for successful
TOLAC. Predictors of increased success include a nonrecurring indication for prior
cesarean delivery (eg, breech presentation, placenta previa) and prior vaginal
delivery. A history of cephalopelvic disproportion (CPD), failure to progress, no prior
vaginal deliveries, or a prior cesarean delivery performed in the second stage of
labor are negative predictors of success in a subsequent trial of labor.
Several studies have examined indications for prior cesarean delivery as a predictor
of outcome in subsequent TOLAC. In all studies, CPD had the lowest VBAC success
rate (60-65%). Fetal distress (eg, nonreassuring fetal testing) had the second lowest
success rate of VBAC (69-73%). Nonrecurrent indications, such as breech birth,
herpes, and placenta previa, were associated with the highest rates of success (77-
89%).
Failure to progress, CPD, or dystocia as indications for prior cesarean delivery are
also associated with a higher proportion of patients not attempting a trial of labor
after cesarean birth. In a meta-analysis of the existing literature prior to 1990, Rosen
et al demonstrated that women whose prior cesarean delivery was performed for
CPD were twice as likely to have an unsuccessful trial of labor. [7]
Patients with a prior vaginal delivery have higher rates of successful VBAC than
patients without a prior vaginal birth. Furthermore, women with a successful VBAC
have a higher success rate in a subsequent trial of labor compared with women
whose vaginal delivery was prior to cesarean delivery.
In an unadjusted comparison, patients with 1 prior vaginal delivery had an 89%
VBAC success rate compared with a 70% success rate in patients without a prior
vaginal delivery. In comparable comparisons controlling for confounding factors,
odds ratios of 0.3-0.5 for rate of cesarean delivery are found. Among patients with a
prior VBAC, the success rate is 93%, compared with 85% in patients with a vaginal
delivery prior to their cesarean birth but no prior VBAC. These findings have been
repeatedly validated by multiple studies.
Only 1 study carefully examines cervical dilation at prior cesarean delivery. In this
study, the degree of cervical dilation in the prior delivery is directly associated with
the likelihood of success in a subsequent trial of labor. For example, 67% of patients
who were dilated 5 cm or less at the time of their delivery had a successful VBAC,
compared with 73% of patients who were dilated 6-9 cm.
The success rate is much lower for patients whose labor arrested in the second
stage: only 13% of patients who were fully dilated at the time of their prior delivery
had a successful VBAC. In a similar study, patients who had their prior cesarean
delivery in the first stage of labor had a lower rate of cesarean delivery than those
who had their prior cesarean delivery in the second stage of labor. However, in this
study, 66% of patients who had a cesarean delivery for dystocia in the second stage
had a successful VBAC.
Induction of labor
Patients who undergo induction of labor are at a higher risk of cesarean delivery than
women who experience spontaneous labor. This finding has also been observed in
women with a prior cesarean delivery. Several studies have demonstrated that
women who are induced in TOLAC have a 2- to 3-fold increased risk of cesarean
delivery compared with those who present with spontaneous labor.
One study demonstrated that patients who could be induced with oxytocin had a
significantly lower cesarean delivery rate compared with those induced with a Foley
bulb.
The 2017 ACOG guidelines state that induction of labor for maternal or fetal
indications remains an option in women undergoing TOLAC. [5]
Gestational age
Increasing gestational age is associated with a decreased rate of successful VBAC.
Three potential factors are related to the association of increasing gestational age
with an increased rate of cesarean delivery: increasing birth weight, increased risk of
fetal intolerance of labor, and increased need for induction of labor. However, in a
recent study that controlled for both birth weight and induction/augmentation of labor,
gestational age of greater than 41 weeks was still associated with failed VBAC.
Cervical examination on admission
Not surprisingly, patients who present to labor and delivery with advanced cervical
examination findings have a greater success rate of vaginal birth. Several
components of the cervical examination have been investigated, including cervical
dilation and cervical effacement. Not surprisingly, the more advanced the cervical
examination finding is upon initial presentation, the higher the rate of successful
VBAC. A 1997 Flamm et al study demonstrated that patients presenting with dilation
greater than or equal to 4 cm had an 86% rate of VBAC. [8]
Interpregnancy interval
The timing between pregnancies has recently become an interesting predictor for a
number of obstetric outcomes, VBAC success among them. In 1 analysis, women
who had an interpregnancy interval of more than 18 months had an 86% chance of
VBAC success, while women whose interpregnancy interval was less than 18
months had a VBAC success rate of 79%. This difference was not statistically
significant, and it remains unclear whether the interpregnancy interval actually
affects the success rate or whether it affects only the risk of uterine rupture.
Preterm delivery
Preterm labor and delivery deserves attention as an opportunity to recounsel women
about the risks and benefits of a trial of labor after cesarean delivery. In a large study
by Quinones et al, 12,463 attempted a trial of labor, and the VBAC success rates for
the term and preterm groups were 74% and 82%, respectively. [9]Additionally, a trend
toward decreased risk of uterine rupture among preterm delivery gestations was
found. These data can certainly be used to counsel women with a prior cesarean
who are in preterm labor.
Gestational or pregestational diabetes
Only 1 study of patients undergoing a trial of labor after cesarean delivery has
examined the rate of success in patients with diabetes mellitus (DM). This study
demonstrated that patients with either gestational DM or pregestational DM had a
lower rate of successful trial of labor. These findings are not particularly surprising;
however, further studies are needed to sort out the differences between gestational
and pregestational DM and the interaction between DM and birth weight.
Contraindications
One of the most significant risks women face when considering a trial of labor is that
of uterine rupture. This potentially fatal event may have significant maternal and
neonatal sequelae.
A threshold of acceptable risk has been established between the risk reported in
women with 1 prior cesarean delivery (0.5-1%) and that seen in women with a
history of a prior classic cesarean delivery (6-12%). The latter patients, along with
women who have undergone metroplasties for uterine anomalies or myomectomies
that have entered the uterine cavity, are discouraged from attempting VBAC.
Other patients who are at increased risk for uterine rupture include those who have
had 2 or more hysterotomies, those who are treated with prostaglandin agents, and
those undergoing induction of labor (see the table below).
Nature of hysterotomy
Unquestionably, practitioners do not feel safe allowing a patient who has had a prior
classical hysterotomy (ie, a vertical incision that has extended above the insertion of
the round ligaments) to undergo TOLAC. Patients with a prior classical hysterotomy
have a higher rate of uterine rupture in subsequent pregnancies. Because these
patients can sustain a uterine rupture prior to labor, they are often delivered at 36-37
weeks’ gestation. Although available data are limited, the risk of uterine rupture in
this group of patients is estimated at 6-12%.
Retrospective cohort studies have demonstrated that the risk of uterine rupture is no
greater for patients who have had a vertical incision in the lower uterine segment
than for those who have had a transverse incision. The rate of uterine rupture from
these studies is 0.8-1.3%. When comparing patients with prior Krönig hysterotomies
to patients with low transverse incisions, no statistical difference exists in either
univariate or multivariate analyses controlling for the confounding factors of
obstetrical history, induction of labor, birth weight, and length of labor.
Most babies delivered abdominally are delivered through a transverse incision in the
lower uterine segment (Kerr hysterotomy). In several large retrospective cohort
studies, the reported rate of uterine rupture is 0.3-1% (see the table
below). [10, 11, 12,13, 14, 15] Rates of 0.5-1% (1 in 200 to 1 in 100) are commonly used to
counsel patients with no other additional risk factors.
When an operative report of a patient’s prior cesarean delivery is unavailable, the
obstetric history may be helpful in determining the type of uterine incision. For
example, a patient who underwent a cesarean delivery for a breech presentation at
28 weeks’ gestation has a much higher risk of a vertical uterine incision than the
patient at term with arrest of dilation. Because most cesarean deliveries are via low
transverse hysterotomies, the risk of uterine rupture for patients with an unknown
uterine scar is usually similar to that of patients with a prior transverse incision.
Several studies examining this issue have demonstrated that the rate of rupture for
patients with an unknown uterine incision is approximately 0.6%. A case-control
study of patients with and without uterine rupture did not find unknown hysterotomy
to be a risk factor compared with low transverse hysterotomy. [16]
According to the 2017 ACOG guidelines, TOLAC is not contraindicated for women
with previous cesarean delivery with an unknown uterine scar type unless clinical
suspicion of a previous classical uterine incision is high. [5]
Number of prior cesarean deliveries
Patients with more than 1 prior cesarean delivery are at increased risk of uterine
rupture. The unadjusted rate of uterine rupture for patients with 2 prior uterine
incisions ranges from 1.8% to 3.7%.
One analysis demonstrated that when potential confounding variables (eg, prior
vaginal delivery) are controlled for, patients who have had 2 prior cesarean deliveries
have 5 times the risk of uterine rupture compared with patients who have had only 1
prior cesarean delivery. This finding contradicted several earlier studies that did not
control for confounding factors, most importantly prior vaginal delivery.
More recently, a study that examined major complications overall found that while
there was a statistically significant increase, the adjusted odds ratio was only 1.6.
Type of uterine closure
Whereas the uterine hysterotomy had traditionally been closed in several layers, in
the 1990s physicians at many institutions began closing the Kerr hysterotomy in a
single layer. Because the lower uterine segment is quite thin, a single layer often
afforded adequate hemostasis. Several recent studies have compared women
whose hysterotomy was closed in a single layer with those whose hysterotomy was
closed in 2 layers. Adjusted odds ratios of 3 to 4 for uterine rupture have been
estimated for women who have a single-layer closure.
Prior vaginal delivery
Prior vaginal delivery appears to be protective for subsequent uterine rupture. A 2000
study by Zelop et al demonstrated that patients with a prior vaginal delivery had a
0.2% rate of rupture compared with 1.1% for patients with no prior vaginal delivery.
An adjusted odds ratio controlling for confounding factors was 6.2. [17]
No studies have compared the rate of uterine rupture in patients with a prior VBAC
with those with a vaginal delivery before their prior cesarean delivery. These findings
have been validated in subsequent studies, though the effect size has not been quite
as large.
Prior infection
A recent study demonstrated that women who had an infection at the time of the
cesarean delivery have an increased rate of uterine rupture in a subsequent trial of
labor. The assumed causal mechanism is poor healing of the hysterotomy secondary
to the infection.
Labor
While labor appears to be a risk factor for uterine rupture, many patients experience
a uterine rupture prior to the onset of labor. In a large study using birth certificate
data, one study found that the rate of uterine rupture before the onset of labor was
0.5%. Patients at greatest risk are those with prior classical hysterotomies. As a
result of this potential risk, these patients are usually scheduled for delivery at 36-37
weeks’ gestation.
When counseling this group of patients, however, mentioning that scheduling an
early repeat cesarean delivery does not eliminate the risk of uterine rupture entirely
is important.
Induction of labor
Induction of labor as a risk factor for uterine rupture has been examined over only
the past 5 years. One large study, which did not control for confounding factors,
demonstrated a uterine rupture rate of 2.3% in patients who had experienced
induced labor. In several studies controlling for confounding factors, adjusted odds
ratios were 2-4 for patients who were induced compared with those who presented in
spontaneous labor.
Despite these analyses, discerning whether induction of labor itself leads to uterine
rupture or whether another risk factor (as yet unmeasured) is associated with both
induction of labor and uterine rupture is difficult. When patients have an indication for
induction of labor, the best course of management is to discuss the increase over
their baseline risk of uterine rupture.
Use of oxytocin
In the only prospective randomized trial in women with a prior cesarean delivery,
oxytocin augmentation in early labor was compared with expectant management; 5
uterine ruptures occurred in the augmentation group (5%), and none occurred in the
expectant management group. Excessive use of oxytocin has been described as
leading to an increased risk of uterine rupture.
A 1993 study by Leung et al demonstrated an odds ratio of 2.7 for uterine rupture in
patients who used oxytocin compared with those without oxytocin augmentation.
[16]
However, this study included inductions and augmentation in both the latent and
active phases. These confounding factors may have contributed to much of the
difference because induction of labor alone has an increased risk.
In 2 subsequent studies, oxytocin augmentation was associated with uterine
rupture. [18, 10] In the first study, although the odds ratio was 2.3, it was not statistically
significant, probably because of inadequate statistical power. In the latter study, a
similar odds ratio of 2.4 existed.
Because labor and delivery units use oxytocin widely, this oxytocin–uterine rupture
relationship deserves careful consideration; the relationship directly affects
management of patients. At this point, using oxytocin for induction and augmentation
is probably advisable only when absolutely necessary.
Use of prostaglandins
Evidence regarding the use of prostaglandins for induction of labor remains scant.
However, in the few trials that have been conducted, the trend is toward an increase
in the rate of uterine rupture. In 1999, the use of prostaglandin E2 was demonstrated
to have an adjusted odds ratio of 3.2. This study controlled for induction of labor,
which appears to be an independent risk factor.
In 2001, Lydon-Rochelle et al demonstrated a 3-fold increase in the risk for uterine
rupture when comparing patients induced with prostaglandins with those induced
with oxytocin. [19] In the 2004 study by Landon et al, this effect of prostaglandin
induction versus other means was smaller—less than 2-fold (odds ratio of 3.95 with
prostaglandin, 2.48 without prostaglandin). [10]
As in studies examining the risk of uterine rupture in patients undergoing induction of
labor, patients who were treated with prostaglandins were likely to have other
confounding variables that were not controlled.
In particular, the prostaglandin misoprostol has been examined in small studies. In
1998, Wing et al reported a case series of 17 patients who were induced with
misoprostol, in which 2 uterine ruptures occurred. These findings have led to the
decreased use of prostaglandins for induction, particularly misoprostol. [20]
Use of transcervical Foley bulb
Only one small study exists of patients with a prior cesarean being induced with the
transcervical Foley bulb. In that study, the rate of uterine rupture was 1.1% with
spontaneous labor, 1.2% with induction with amniotomy, and 1.6% with use of a
transcervical Foley bulb. This rate is lower than some of the reported rates with
prostaglandins, but it is unclear whether the increase seen in patients requiring
cervical ripening is due to the need for cervical ripening or to the agents themselves.
Interpregnancy interval
Several studies have demonstrated that the shorter the amount of time between the
cesarean delivery and the subsequent delivery, the higher the rate of uterine rupture.
Commonly, thresholds of 18 and 24 months have been examined. Adjusted odds
ratios range from 2.5 to 3 for an increased rate of uterine rupture in the women with
less time between deliveries. The biologic plausibility of this effect is related to the
amount of time required for the uterine scar to heal completely.
Twin gestations
A study by Cahill et al revealed that whereas women with twin gestations are less
likely to undergo a trial of labor after prior cesarean, they appear to be at no
increased risk for uterine rupture. [21]
Other smaller studies examined the rate of uterine rupture in patients with twin
gestation undergoing a trial of labor after cesarean delivery, and none of them
demonstrated a frank rupture—though when their data were combined, 5
asymptomatic dehiscences in 151 patients were identified. [22, 23, 24]
The rate of asymptomatic uterine dehiscence in patients undergoing a trial of labor
after cesarean delivery is difficult to assess because it is not commonly investigated.
Thus, although the overall statistical power of the studies examining this issue in
twins is not overwhelming, there is certainly no evidence suggesting a higher risk of
uterine rupture in these women.
The 2017 ACOG guidelines state that TOLAC may be considered in women with one
previous cesarean delivery with a low transverse incision, who are otherwise
appropriate candidates for twin vaginal delivery. [5]
Mullerian anomalies
In 1999, a small series by Ravasia et al examined patients with müllerian anomalies
undergoing a trial of labor after cesarean delivery and reported 2 uterine ruptures
among 25 patients (8%). [25] However, both patients with uterine rupture had
undergone induction with prostaglandins; therefore, it is difficult to reach any firm
conclusions about the relative risk of uterine rupture in this group of patients. The
sample size in this study was certainly too small to consider particular types of
uterine anomalies.
Preparation
Patients with prior cesarean deliveries require special management, both
antenatally and in labor and delivery. Early in their prenatal care, catalogue
patients’ preexisting risk factors for both successful vaginal birth after
cesarean delivery (VBAC) and uterine rupture. If uncertain about the prior
hysterotomy facts, obtain the operative notes from patients’ cesarean
delivery.
When a full obstetric history has been obtained, counsel patients regarding
the risks and benefits of undergoing a trial of labor after cesarean delivery
(TOLAC), and plan the particular mode of delivery with patients. Some
providers and hospitals have particular consent forms for TOLAC that must
be signed at this point.
Technique
Overview
Once the patient presents to the labor and delivery unit and is in labor, it is
advisable to go through the risks and benefits of a trial of labor after
cesarean delivery (TOLAC) once again. Because of possible changes in
the patient’s status, these risks may have changed from the prenatal
setting.
For example, if the patient presents in active labor, it seems that both her
chances of failed vaginal birth after cesarean delivery (VBAC) and her risk
of uterine rupture decrease. In contrast, if she is presenting for induction of
labor, her chances of failed VBAC and uterine rupture both increase.
Regarding management on labor and delivery, several practices can help
minimize the maternal and neonatal risk. In accordance with the guidelines
of the American College of Obstetricians and Gynecologists (ACOG), have
an obstetrician, anesthesiologist, and operating room team immediately
available to carry out an emergency delivery.
Clinically, observe the patient closely for signs of uterine rupture.
Harbingers of uterine rupture include the following:
 Acute abdominal pain, persistent beyond contractions
 A popping sensation
 Palpation of fetal parts outside the uterus upon Leopold maneuvers
 Repetitive or prolonged fetal heart rate deceleration
 High presenting part upon vaginal examination
 Vaginal bleeding
Treat any of these findings as a possible uterine rupture until another
source for the finding has been identified. Rupture necessitates immediate
delivery.
Post-Procedure
Expected Outcomes
In counseling a patient with respect to the tradeoffs between a trial of labor
after cesarean delivery (TOLAC) and an elective repeat cesarean delivery,
several factors should be weighed. The rate of success is important: it has
been demonstrated that maternal outcomes are better with successful
TOLAC than with elective repeat cesarean delivery but are worse with a
cesarean delivery after failed TOLAC.
A 2004 study by Landon et al found that the overall measure of morbidity
was higher among women who underwent TOLAC. [10] However, among the
15,801 women who elected to have a repeat cesarean delivery, 2 maternal
deaths were reported. Among the 17,898 who underwent a trial of labor, no
maternal deaths due to TOLAC or uterine rupture were reported. This
difference was too small to be statistically significant; however, the risk of
repeat cesarean delivery to maternal morbidity and mortality should be
considered.
The other important factor to consider in the setting of TOLAC or a uterine
rupture is the neonatal outcomes. A large population-based study from
Scotland determined that among 15,515 patients who underwent TOLAC, 7
perinatal deaths occurred as a result of uterine rupture, for a rate of 4.5 per
10,000 women. In comparison, there were no perinatal deaths due to
uterine rupture among women undergoing elective repeat cesarean
delivery, and the mortality rate was 0.5 per 10,000 among women laboring
with no prior cesarean delivery.
A subsequent study demonstrated that among 15,338 patients at term
undergoing TOLAC, there were 2 neonatal deaths and 7 cases of hypoxic-
ischemic encephalopathy, for rates of 1.4 per 10,000 and 4.6 per 10,000,
respectively. [10] In this series, 114 uterine ruptures occurred among these
patients, yielding a neonatal death rate of 1.8% and a hypoxic-ischemic
encephalopathy rate of 6.2% in patients with uterine rupture.
Finally, an important individual factor that may tip the scales for many
women making the decision about whether to undergo TOLAC is whether
they wish to have future pregnancies beyond the current one. Once a
vaginal birth has been achieved, both the chances of future success and
the risks of uterine rupture are higher.
Furthermore, with each subsequent cesarean delivery, the risks of maternal
morbidity and, potentially, maternal mortality increase. Thus, for a woman
who wants more children, opting for TOLAC in the current pregnancy may
hold more long-term benefits than it would for a woman who is planning on
a tubal ligation after delivery.