Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice. The Society for Academic Specialists in General Obstetrics and Gynecology, Inc.
#TOLAC VS VBAG UPDATE#
Initial Approval: January 2017 Revised July 2018 Revised/Minor Update January 2020 Revised September 2021
#TOLAC VS VBAG FULL VERSION#
Full version also available at: (21)00587-1/pdf Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Grobman WA, Sandoval G, Rice MM, Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. 205: Vaginal Birth After Cesarean Delivery. Calculators predicting the likelihood of achieving VBAC no longer include race and ethnicity in an effort to mitigate risks of health disparities.Īmerican College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. Options including TOLAC and elective repeat cesarean delivery should be discussed early during prenatal care allowing time for consideration of resources, counseling, addressing questions or changes in status. ACOG recommends TOLAC be undertaken where immediate emergency cesarean delivery can be performed. The most common sign of uterine rupture is a change in fetal heart tracing. Prostaglandin induction may be considered in the setting of fetal demise given the altered fetal risk profile.Įpidural analgesia does not mask signs or symptoms of uterine rupture or decrease the risk of successful TOLAC.
Prostaglandins should be avoided due to the increased risk of uterine rupture, although mechanical cervical ripening (e.g., transcervical foley catheter) may be offered to ripen an unfavorable cervix. While the need for induction or augmentation of labor decreases VBAC success, TOLAC may still be offered and undertaken in certain circumstances. There is insufficient data to know with certainty if TOLAC success or uterine rupture risk is altered with a prior low vertical hysterotomy, two or more low transverse hysterotomies or twin gestation. Patients with a history of uterine rupture or an obstetrical contraindication to vaginal delivery should not be offered the option for TOLAC. The risk of uterine rupture in this setting is 4-9%.
Consideration should be given to gestational age, estimated fetal weight, and inter-pregnancy interval.Ībsolute contraindications for TOLAC include a classical, “T” or “J” hysterotomy, extensive transfundal surgery or any incision that extends through the active portion of the myometrium. An unknown uterine scar performed in the setting of usual indications for a low transverse cesarean is not a contraindication to a TOLAC.
Other predictors of success include a history of vaginal delivery or VBAC, spontaneous onset of labor, and a non-recurring indication for the primary cesarean delivery. There does not appear to be an appreciable difference in risk to neonates born by VBAC and elective repeat cesarean delivery.Ĭharacteristics of an optimal TOLAC candidate include a single prior low transverse cesarean delivery, with anticipated success rate of greater than 60% and 0.5% uterine rupture risk. If TOLAC is unsuccessful requiring an intrapartum cesarean delivery, the risks of infection and blood transfusion increase. Neonatal neurologic morbidity and neonatal death are also important considerations (3-6%).
Benefits of elective repeat cesarean delivery include predictable timing, access for sterilization procedures and minimization of uterine rupture risk.Īlthough uterine rupture is a rare complication of TOLAC, approximately 25% will undergo a hysterectomy. No large, randomized trials have compared outcomes of TOLAC and elective repeat cesarean delivery.Ī successful VBAC may decrease the potential risks associated with multiple cesarean deliveries, including abnormal placentation. Successful TOLAC results in vaginal birth after cesarean (VBAC).
#TOLAC VS VBAG TRIAL#
Options following a cesarean delivery include elective repeat cesarean delivery and trial of labor after cesarean (TOLAC).
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