This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Recall the factors that decrease the probability of TOLAC success
2. Discuss the scenarios in which a TOLAC would be an option to a patient requesting a TOLAC
Estimated time to complete activity: 0.25 hours
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2018, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.Read Disclaimer & Fine Print
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: ACOG addresses the use of VBAC calculators and stresses the importance of shared decision making, highlighting the point that a VBAC calculator is just one aspect of the discussion
Currently, there is no evidence demonstrating improved patient outcomes and therefore
A VBAC calculator score should not be used as a barrier to TOLAC
…some patients and clinicians may prefer to utilize a calculator while others may prefer a more general discussion of options for mode of delivery, review of overall VBAC rates of 60–80% with TOLAC, and consideration of an individual’s obstetric risk factors along with their preferences and goals
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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