While trial of labor after cesarean delivery (TOLAC) may be considered after previous cesarean delivery, it is critical that a thorough review of risks and benefits be undertaken. Decision making should incorporate a woman’s preferences and desires. Key highlights from the most recent ACOG guidance include the following:
“…similar to a history of a prior classical cesarean, the suggested timing of delivery between 36 0/7 weeks and 37 0/7 weeks of gestation should be considered but can be individualized based on the clinical situation”
While there are risks to TOLAC, most are related to complications, such as hemorrhage, that may arise from cesarean section in the setting of an unsuccessful trial of labor. However, TOLAC is still offered to patients as an option due to the significant risks associated with multiple repeat cesarean deliveries. Risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increase with increasing number of cesarean deliveries. In the NICHD MFMU study (Obstetrics and Gynecology 2006), Placenta accreta was present in 0.24% (1st cesarean sections [CS]) 0.31% (2nd CS), 0.57% (3rd CS), 2.13% (4th CS), 2.33% (5th CS), 6.74% (6 or more CS). Hysterectomy was required in 0.65% (1st CS) 0.42% (2nd CS) (0.90% (3rd CS) 2.41% (4th CS) 3.49% (5th CS) and 8.99% (6 or more CS). In 723 women who had previa in this study, risk for placenta accreta was 3% (1st CS), 11% (2nd CS), 40% (3rd CS) 61% (4th CS), and 67% (5 or more CS).
Clinical Factors and Probability of Success
Note: The ACOG VBAC guidance document states
Although such a calculator may provide more specific information about the chance of VBAC, which can be used by health care providers and their patients to further the process of shared decision making, no prediction model for VBAC has been shown to result in improved patient outcomes
ACOG Practice Bulletin 205: Vaginal birth after previous cesarean delivery
Maternal morbidity associated with multiple repeat cesarean deliveries
MFMU Network Calculator for VBAC
SOGC Guideline 382: Trial of Labour After Caesarean
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