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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.”


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

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


  • Previous transmural or large myomectomy

  • Classic uterine scar

  • History of uterine rupture


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