Vaginal Birth After Cesarean Delivery
Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence.
- Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered trial of labor after cesarean delivery (TOLAC).
- Misoprostol should not be used for cervical ripening or labor induction in patients at term who have had a cesarean delivery or major uterine surgery.
- Epidural analgesia for labor may be used as part of TOLAC.
The following recommendations are based on limited or inconsistent scientific evidence.
- Those at high risk of uterine rupture (eg, those with previous classical uterine incision or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (eg, those with placenta previa) are not generally candidates for planned TOLAC.
- Given the overall data, it is reasonable to consider women with two previous low-transverse cesarean deliveries to be candidates for TOLAC and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.
- Women with one previous cesarean delivery with an unknown uterine scar type may be candidates for TOLAC, unless there is a high clinical suspicion of a previous classical uterine incision such as cesarean delivery performed at an extremely preterm gesta- tion age.
- Women with one previous cesarean delivery with a low-transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, are considered candidates for TOLAC.
- Induction of labor remains an option in women undergoing TOLAC.
- External cephalic version for breech presentation is not contraindicated in women with a prior low-transverse uterine incision who are candidates for external cephalic version and TOLAC.
- Continuous fetal heart rate monitoring during TOLAC is recommended.
The following recommendations are based primarily on consensus and expert opinion.
- After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her obstetrician or obstetric care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documenta- tion of counseling and the management plan should be included in the medical record.
- Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.
- Women attempting TOLAC should be cared for in a level I center (ie, one that can provide basic care) or higher.
- Because of the risks associated with TOLAC, and because uterine rupture and other complications may be unpredictable, ACOG recommends that TOLAC be attempted in facilities that can provide cesarean delivery for situations that are immediate threats to the life of the woman or fetus. When resources for emergency cesarean delivery are not available, ACOG recommends that obstetricians or other obstetric care providers and patients considering TOLAC discuss the hospital’s resources and avail- ability of obstetric, pediatric, anesthesiology, and operating room staffs.
- Because of the unpredictability of complications requiring emergency medical care, home birth is contraindicated for women undergoing TOLAC.
Vaginal Birth After Cesarean Delivery
February 1, 2019
External Publication Status
Country of Publication
Female, Adolescent, Adult
Health Care Settings
Hospital, Operating and recovery room
Nurse midwife, nurse, nurse practitioner, physician, physician assistant
D016064 - Vaginal Birth after Cesarean
TOLAC, Trial of labor after cesarean delivery, c-section, VBAC