Vaginal Birth after Cesarean Delivery (VBAC)

Definition/Abbreviation
TOLAC : Trial of labor after cesarean delivery
ERCD : Elective repeat cesarean delivery
Uterine rupture: complete disruption of all uterine layers including serosa
Uterine dehiscence: incomplete uterine scar separation where serosa remain intact, not
usually associated with hemorrhage or adverse outcomes
ACOG: American College of Obstetricians and Gynecologists
NICHD: the United States National Institute of Child Health and Human Development
ASA: American Society of Anesthesiologists

Background
The increasing primary cesarean deliveries in recent decades lead to an increasing
number of ERCD. Until 1980 when the National Institute of Health questioned the
necessity of ERCD, and with the endorsement of ACOG, encouraged attempts to
increase the rate of TOLAC. These attempt were highly successful with TOLAC
reaching a peak of 51.8% in 1995 and a decline in total C-Section in the U.S
As the rate of TOLAC increase, the rate of uterine rupture and maternal morbidities
also increase. So in 1998, ACOG issue a statement cautioned that TOLAC should
only be attempted in appropriately equipped institutions with physicians readily
available to provide emergency care. Within 9 months, ACOG and ASA revised the
practice guidelines stating physician should immediately be available.
This one word change lead to a drop in hospitals offering TOLAC. Surveys found 30
percent of hospitals discontinued allowing TOLAC because they are unable to
comply with the immediately available requirement for surgical and anesthesia
service. Concerns about medical liability claim, catastrophic complications also
contributed to the decline of TOLAC. The rates of TOLAC drop to 15.9% in 2006
before increasing again.
Why TOLAC: desire to experience natural birth, desire for their partners
involvement in labor and birth
Why ERCD: scheduling convenience, fear of failed trial of labor, fear of emergency
cesarean delivery, avoidance labor pain
Comparison of risks between TOLAC and ERCD based on systematic review
of 41 studies
Uterine rupture
Maternal death
Perinatal death
Maternal infection

TOLAC
More (468 in 100,000)
Less (4 in 100,000)
More (133 in 100,000)
No difference

ERCD
Less (26 in 100,000)
More (13 in 100,000)
Less (50 in 100,000)
No difference

Intrapartum
chorioamnionitis
Hemorrhage and
transfusion
Perineal injury

More

Less

No difference

No difference

Yes

No

Benefits of a successful TOLAC closely follow that of vaginal delivery: Shorter

hospital stay, fewer post-partum complications, quicker return to normal activities
compared to ERCD.
Candidates for a successful VBAC

Only one prior low transverse uterine incision (success rate 60%-70%, risk of
uterine rupture 0.7%)
Had a previous successful vaginal delivery, either before or after the CSection
Present in active spontaneous labor, the higher the Bishop score, the higher
the success rate
Prior indication for C-Section is unlikely to recur
Ethnicity: Caucasian women has more chance of successful TOLAC than
African American than Hispanic than Asian women
Increasing maternal height : for every 5cm, the odd ratio increase by 33%
Pregnancy interval > 6 months
Fetal weight less than 4000g
Delivery in a university hospital with an ob-gyn residency program

Candidates with lower chance of a successful VBAC

Increasing maternal age

Less than 12 years of education
Women with BMI > 30kg/m2

Candidates with increased risk of uterine rupture

Prior low vertical uterine incision (2.0% vs 0.7%)

Multiple prior low-transverse (1.59% vs 0.7%)
Macrosomia (>4000g) and no prior history of vaginal delivery

What about

Unknown type of uterine incision?

Twin gestation?

Inappropriate candidates for TOLAC

Classical, T, J or transfundal uterine incision

Prior uterine rupture: low uterine segment: 6%. Upper uterine segment: 32%!
Prior uterine dehiscence
Placenta previa, breech presentation, etc

Lack of appropriate facility

Management of TOLAC

Ability to perform emergency cesarean delivery, personnel and equipment for

neonatal resuscitation
Intrapartum monitoring
Induction of labor: amniotomy is preferred, oxytocin is acceptable.
Prostaglandins (Misoprostol) should NOT be used
Epidural anesthesia is acceptable

Uterine exploration at delivery after uncomplicated successful TOLAC?

Educational Objective

Explain to the patient fully the risks and benefits of TOLAC

The worst complication of TOLAC is uterine rupture and perinatal death
One prior low transverse, previous vaginal delivery, spontaneous labor has
the highest success rate

References
1.

Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated
with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351:2581. UptoDate.

2.

Nair M, Soffer K, Noor N, et al. Selected maternal morbidities in women with a prior
caesarean delivery planning vaginal birth or elective repeat caesarean section: a
retrospective cohort analysis using data from the UK Obstetric Surveillance System. BMJ
Open 2015; 5:e007434. UptoDate.

3.

Sentilhes L, Vayssire C, Beucher G, et al. Delivery for women with a previous

cesarean: guidelines for clinical practice from the French College of Gynecologists and
Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2013; 170:25. UptoDate.

4.

Horey D, Kealy M, Davey MA, et al. Interventions for supporting pregnant women's
decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013;
7:CD010041.

5.

Grobman WA, Lai Y, Landon MB, et al. Development of a nomogram for prediction of
vaginal birth after cesarean delivery. Obstet Gynecol 2007; 109:806.