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Chapter 21: Trial of Labor After Cesarean

Mohammed Idris

BACKGROUND

Cesarean delivery (CD) is the most frequently performed surgery in the United States, and the rates have increased since the early 1970s.1 Up to 30% of these are repeat CDs. The American College of Obstetricians and Gynecologists (ACOG) released a statement that “in the absence of a contraindication, a woman with one previous CD with a lower uterine segment incision should be counseled and encouraged to undergo a trial of labor.”

PREANESTHETIC EVALUATION

Trial of labor after cesarean (TOLAC) has progressively become more commonplace throughout the United States. Despite this, risks associated with TOLAC require a higher level of care and additional considerations (Table 21-1). This includes:

  • A multidisciplinary team including obstetricians, nursing, blood bank, neonatologists, and a dedicated in-house anesthesiologist

  • Large-bore IV (18-16G)

  • NPO (nothing by mouth) except clear liquids once in active labor

  • Type and screen or type and crossmatch

  • Early recognition of comorbidities

  • Early epidural placement for TOLAC—this has been shown to increase patient acceptance rate of TOLAC

  • Constant communication with obstetricians regarding the progress of labor

  • Availability of an operating room for emergency CD

  • TOLAC in twin pregnancy: successful in about 45% to 70% of parturients with uterine rupture rate at about 0.9%

TABLE 21-1Benefits of Planned Vaginal Birth After Cesarean and Planned Repeat Cesarean Delivery
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TABLE 21-1 Benefits of Planned Vaginal Birth After Cesarean and Planned Repeat Cesarean Delivery

Benefits of VBAC

Benefits of Elective Repeat CD

  • Less chance of placenta accreta spectrum in subsequent pregnancies

  • Less postoperative pain, early mobilization, shorter length of stay in hospital

  • Lower respiratory morbidity in newborn

  • Surgical risks associated with CD are not present

  • Less maternal morbidity

  • Less chance of obstetric hemorrhage, blood transfusion, emergency hysterectomy as seen with uterine rupture

  • Lower perinatal morbidity and mortality like hypoxic encephalopathy, brachial plexus injury

  • Perinatal mortality not increased even if delivered after 39 weeks

CD, cesarean delivery; VBAC, vaginal birth after cesarean.

Vaginal birth after cesarean (VBAC) risk score for successful TOLAC can easily be estimated with an online calculator (Table 21-2).2

TABLE 21-2Prediction of Successful Vaginal Birth After Cesarean
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TABLE 21-2 Prediction of Successful Vaginal Birth After Cesarean

Factors Favoring Successful VBAC

Factors Not In Favor Of Successful VBAC

  • Previous VBAC or vaginal delivery

  • One previous CD

  • Spontaneous labor

  • No prior vaginal delivery

  • More than one prior CD

  • CD for dystocia, cephalopelvic disproportion or failed induction

  • Induction/augmentation of labor

  • Maternal obesity body mass index >40 kg/m2

  • Fetal macrosomia (>4000 g)

  • Gestational age >41 weeks

  • Coexisting conditions including oligo/polyhydramnios, chorioamnionitis

  • Black or Hispanic race/ethnicity

CD, cesarean delivery; VBAC, vaginal birth after cesarean.

CONTRAINDICATIONS TO TOLAC

  • Previous transmural or large myomectomy

  • Classic uterine scar

  • History of uterine rupture

    ...

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