ACOG Issues Less Restrictive Guidelines for Vaginal Birth

After Cesarean Delivery

Trial of labor after previous cesarean delivery (TOLAC) is safe and appropriate for most women with
previous cesarean delivery, including some women with 2 previous cesarean deliveries, according to less
restrictive guidelines issued by the American College of Obstetricians and Gynecologists (ACOG). The
revised recommendations for attempting vaginal birth after cesarean delivery (VBAC) are reported in a
practice bulletin published in the August issue of Obstetrics & Gynecology.
ACOG defines the term trial of labor as a trial of labor in women who have had a previous cesarean
delivery, regardless of outcome. Also, the term vaginal birth after cesarean delivery is used to denote a
vaginal delivery after a trial of labor.
Benefits of VBAC
"I believe, by emphasizing the safety of a trial of labor after a past cesarean delivery for most women, the
guidelines will increase rates of TOLAC and thus increase rates of VBAC," Jeffrey Ecker, MD, past vice
chair of the Committee on Obstetric Practice Bulletins, ACOG, and vice chair during document
development..
"By discussing criteria for appropriate selection of candidates for TOLAC and appropriate management of
such patients, the guidelines should support increased TOLAC/VBAC rates while optimizing
maternal/neonatal outcome and minimizing complications to mothers and their babies."
The ACOG guidelines now consider most women with 2 previous low transverse cesarean incisions,
women with twin pregnancy, and women with an unknown type of uterine scar to be appropriate
candidates for TOLAC. Patient-specific decisions are recommended based on a woman's chance of a
successful VBAC, the risk for complications from TOLAC, her future reproductive plans, and her personal
preference.
If candidates for TOLAC are selected appropriately, approximately 60% to 80% will be successful at
VBAC. In addition to maternal preference, potential advantages of VBAC for the individual patient include
reduced maternal morbidity associated with avoiding major abdominal surgery, particularly a lower risk for
hemorrhage and infection and faster postpartum recovery.
VBAC may also help women avoid the possible future risks of having multiple cesarean deliveries, such
as hysterectom y, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions
(placenta previa and placenta accreta). At the population level, VBAC is also associated with a lower
overall rate of cesarean deliveries.
"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said ACOG
president Richard N. W aldman, MD, in a news release. "These VBAC guidelines emphasize the need for
thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of
patient autonom y. Moving forward, we need to work collaboratively with our patients and our colleagues,
hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC
rate."
Because failed TOLAC is associated with increased maternal and perinatal morbidity vs an elective
repeat cesarean delivery, it is important to evaluate individual risks and the likelihood of VBAC when

deciding whether TOLAC is a feasible option. The new guidelines attempt to point out the risks and
benefits of TOLAC in different clinical settings and to offer practical recommendations for management
and counseling of women who will undergo VBAC.
"It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so
that logistical plans can be made well in advance," said coauthor W illiam A. Grobman, MD, from
Northwestern University in Chicago, Illinois, in a news release.
Therefore, a performance measure proposed in the statement is the percentage of women who are
candidates for TOLAC with whom discussion of the risk and benefits of TOLAC vs an elective repeat
cesarean delivery has been recorded in the medical chart.
The most emergent and severe risk during TOLAC is uterine rupture. Although it affects only 0.5% to
0.9% of women attempting VBAC, it is an emergency situation with potentially serious injury to both the
mother and her infant. Therefore, the ACOG bulletin states that TOLAC is most safely undertaken where
staff can immediately provide an emergency cesarean delivery while acknowledging that such resources
may not be universally available.
"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines
led many hospitals to refuse allowing VBACs altogether," Dr. Grobman said. "Our primary goal is to
promote the safest environment for labor and delivery, not to restrict womens access to VBAC."
ACOG's Revised VBAC Guidelines
The practice bulletin makes the following specific recommendations based on good, consistent scientific
evidence (level A):
x

x
x

TOLAC may be appropriate for most women with 1 previous cesarean delivery via a low
transverse incision. These women should be counseled about VBAC and offered TOLAC as a
delivery option.
As part of TOLAC, epidural analgesia may be used for labor.
For women who have undergone previous cesarean delivery or major uterine surgery,
misoprostol should not be used for third-trimester cervical ripening or labor induction.

Also included in the statement are the following recommendations based on limited or inconsistent
scientific evidence (level B):
x
x
x

TOLAC may be considered in women with 2 previous low transverse cesarean deliveries.
TOLAC may be considered in women with 1 previous cesarean delivery via a low transverse
incision who are otherwise appropriate candidates for twin vaginal delivery.
In women with a previous cesarean delivery via a 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.
Planned TOLAC is generally not recommended in women at high risk for complications, such as
those with a classic or T-incision; prior uterine rupture; extensive transfundal uterine surgery; and
in other women in whom vaginal delivery is contraindicated, such as those with placenta previa.
In women undergoing TOLAC, it is permissible to induce labor, when appropriate, based on
maternal or fetal indications.

For women with previous cesarean delivery with an unknown uterine scar type, TOLAC is not
contraindicated unless there is a high clinical suspicion for a previous classic uterine incision.

Finally, the statement also provides the following recommendations that are based mainly on consensus
and expert opinion (level C):
x

W omen undergoing TOLAC should do so at facilities able to perform emergency deliveries and
with staff immediately available to provide emergency care because of unpredictable risks
associated with TOLAC.
W hen these resources are not available, women should be clearly advised regarding greater risks
for TOLAC and management alternatives, and counseling and management plans should be
documented in the medical record.

Obstet Gynecol. 2010;116:450-463.

DISCUSSION:

t was once thought that if a woman had one cesarean delivery, all other babies she had should be born
in the same way. Today, it is known that many women can undergo a trial of labor after a cesarean
delivery (called TOLAC). After a successful TOLAC, many women will be able to give birth through the
vagina (called a vaginal birth after cesarean delivery, or VBAC).
TOLAC is not the right choice for every woman, but it is a good choice for many women. It is important to
understand the risks and benefits before deciding to attempt TOLAC and VBAC.
This pamphlet explains
x
x
x
x

your choices when planning your delivery

why you may want to think about TOLAC
the risks that are involved
whether TOLAC is right for you

Your Choices
A woman who has had a previous cesarean delivery has the following choices when planning how to give
birth again:
x
x

She can have a scheduled cesarean delivery.

She can try to have a VBAC. If a woman wants to try VBAC and is considered a good candidate,
she will undergo TOLAC.

Of women who undergo TOLAC, 6080% succeed and are able to give birth vaginally. But if problems
arise during TOLAC, the baby may need to be born by emergency cesarean delivery. For example, if the
baby is not tolerating labor, or if labor does not progress, an emergency cesarean delivery may be
needed. There are more risks, such as a greater risk of infection, with having an emergency cesarean
delivery after TOLAC than having a planned cesarean delivery. The least number of risks occur with a
successful VBAC.
Reasons to Consider TOLAC

There are many reasons why a woman may want to consider TOLAC. Compared with a planned
cesarean delivery, a VBAC after successful TOLAC is associated with the following benefits:
x
x
x
x

No abdominal surgery
Shorter recovery period
Lower risk of infection
Less blood loss

For women planning to have more children, VBAC may help them avoid problems linked to multiple
cesarean deliveries. These problems include hysterectomy, bowel or bladder injury, and certain
problems with the placenta.
TOLAC Risks
Both TOLAC and repeat planned cesarean delivery have risks. Both can cause infection, injury, blood
loss, and other complications. W ith TOLAC, the risk of most concern is the possible rupture of the
cesarean scar on the uterus or the uterus itself. Although a rupture of the uterus is rare, it is very serious
and may harm both mother and baby. If a woman is considered at high risk of rupture of the uterus,
TOLAC should not be tried.

The incision made in the uterine wall for a cesarean birth may be low transverse, low vertical, or high vertical. The type of
incision made in the skin may not be the same type of incision made in the uterus.

Some types of uterine incisions are more likely to cause rupture than others. For cesarean birth, one
incision is made in the abdomen and another incision is made in the uterus. There are three types of
uterine incisions:
1. Low transverseA side-to-side cut made across the lower, thinner part of the uterus
2. Low verticalAn up-and-down cut made in the lower, thinner part of the uterus
3. High vertical (also called classical)An up-and-down cut made in the upper part of the uterus
Low transverse incisions carry the least chance of rupture. They also are the most common type of
incision used in cesarean births. The risk of uterine rupture with this type of incision is less than 1%.
W omen who have had one or two previous cesarean deliveries with low transverse incisions are
candidates for TOLAC. W omen with high vertical incisions are generally not considered to be candidates
for TOLAC because their risk of a uterine rupture in labor is increased. TOLAC can be considered if a
woman has had a low vertical incision.
It is not possible to tell what kind of incision was made in the uterus by looking at the scar on the skin.
Medical records from the previous delivery probably include this information. If medical records are not
available, a woman should understand the risks associated with all three types of incisions. It is still
possible to have a VBAC unless it is highly suspected that the incision is a high vertical incision.

Other Factors
In deciding whether to have a TOLAC, several factors should be considered in addition to the type of
incision. These factors include the desire for more children, whether a woman has certain complications,
and the hospital where the birth will take place:
x

x
x

Future deliveriesMultiple cesarean deliveries are associated with additional potential risks. If
you know that you want more children, you should think about these risks when making your
decision. Even if you currently think you do not want more children, you may change your mind
later.
Prior uterine ruptureIf you had this complication in a previous pregnanc y, TOLAC is not
advised. W omen who have had a previous uterine rupture should give birth by repeat cesarean
delivery before labor starts on its own. An early delivery also may be recommended (before 39
weeks of pregnancy).
A pregnancy problem or a medical condition that makes vaginal delivery risk yVaginal delivery
may not be recommended if there is a problem with the placenta or problems with the baby or if
you have certain medical conditions during pregnanc y.
Type of hospitalThe hospital in which a woman has a TOLAC should be prepared to deal with
emergencies that may arise. Some hospitals may not offer TOLAC because hospital staff do not
feel they can provide needed emergency care. You and your health care provider should consider
the resources available at the hospital you have chosen and whether these resources are
appropriate for TOLAC. If the hospital you have chosen does not have appropriate resources, you
often can be referred to one that does.
Chances for Successful TOLAC and VBAC
Although it is not possible to predict whether TOLAC
and VBAC will be successful, several factors have
been shown to increase or decrease the likelihood of
success:
x
x

Previous deliveriesW omen who have had

a prior vaginal delivery are more likely to
have a successful TOLAC and VBAC.
Spontaneous laborThe success rate for
VBAC is decreased if there is a need to
induce labor (use drugs or other means to
bring on labor). Certain drugs or
combinations of drugs that induce labor are
avoided in women undergoing TOLAC (eg,
misoprostol). Other means of labor induction
can be considered.
Reason for previous cesarean deliveryIf
the previous cesarean delivery was done for
a condition that is likely to recur, such as a
slowed or stopped labor, TOLAC and VBAC
are less likely to be successful than if the
previous cesarean delivery was done for a
condition that is not likely to recur, such as
abreech presentation.

Other factors that may decrease the chance of a

successful TOLAC and VBAC include:

Is TOLAC Right for You?

You should discuss delivery options with your
health care provider early in pregnanc y. This way,
you and your health care provider have the most
time to consider all of the options. Many of the
factors that go into the decision are known early in
pregnancy. Also, if the type of incision used in the
previous cesarean delivery is not known, an
attempt can be made to find this information.

x
x
x
x
x
x

Increased age of the mother

High birth weight of the baby
High body mass index of the mother
Pregnancy beyond 40 weeks of gestation
Preeclampsia
Short time between pregnancies

Before deciding whether to try VBAC, you need to know the risks and benefits of both TOLAC and
planned cesarean delivery. You also should discuss your individual chances of having a successful
TOLAC and VBAC and the risks associated with an emergency cesarean delivery. For women
considering TOLAC and VBAC, chances for success should be as high as possible (see box).
Be Prepared for Changes
Be prepared for changes to your delivery plan. If you have chosen TOLAC, things can happen during
pregnancy and labor that alter the balance of risks and benefits. For example, you may need to have your
labor induced, which can reduce the chances of a successful vaginal delivery and perhaps increase the
chance of complications during labor. In the event that circumstances change, you and your health care
provider may want to reconsider your decision.
If you have chosen a repeat cesarean delivery, in some situations, TOLAC may be advised. For example,
if you have planned a cesarean delivery but go into labor before your scheduled surgery, it may be best to
consider TOLAC if you are far along in your labor and your baby is healthy.