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Cervical ripening and induction of labor in women with a prior cesarean delivery

Deborah A Wing, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


The risk of failed induction and the possibility of uterine rupture are major concerns of clinicians caring for women undergoing a trial of labor after a previous cesarean delivery (TOLAC). The best method, efficacy, and safety of cervical ripening and/or labor induction in this population have not been established [1]. Available evidence is inconclusive because no randomized trials have compared the outcome of induction of labor in women with prior cesareans with elective repeat cesarean delivery (ERCD); data are mostly limited to findings from retrospective studies of fair to poor quality. These data are insufficient for many reasons, including inconsistent definitions of uterine rupture and dehiscence, wide variation in induction protocols (eg, timing and dosage of prostaglandins and/or oxytocin administration), heterogeneity in patient populations, and inconsistency in primary outcome measures [2].

Cervical ripening and induction of labor in women attempting TOLAC will be reviewed here. Other issues relating to TOLAC are discussed separately. (See "Choosing the route of delivery after cesarean birth".)


At least 50 percent of inductions in women with a prior cesarean delivery are successful, with the highest chance of success in women with a prior vaginal delivery and favorable cervix.

A 2005 systematic review identified 14 fair-quality studies, and no good-quality studies, on the benefits and risks of inducing labor in patients with prior cesarean delivery [3]. Induction was more likely to result in cesarean delivery than spontaneous labor, consistent with findings from most studies of women without a scarred uterus (see "Induction of labor"). The mean vaginal delivery rates for women with a prior cesarean delivery undergoing spontaneous labor and oxytocin induction were 80 percent (range 65 to 89 percent) and 68 percent (range 56 to 82 percent), respectively. The risk of uterine rupture trended higher among women who were induced.

Subsequent to this review, a large prospective observational study including almost 12,000 women with one prior low transverse cesarean delivery compared pregnancy outcomes after induced versus spontaneous labor [4]. As expected, induction of labor was associated with a significantly higher risk of unsuccessful trial of labor after a previous cesarean delivery (TOLAC) (ie, cesarean delivery) than spontaneous labor, but two factors significantly increased the chance of success: (1) a previous history of vaginal delivery; and (2) favorable cervical status (modified Bishop score ≥6). Successful induction occurred in 91 percent of women with a prior vaginal delivery and a favorable cervix, 77 percent of women with a prior vaginal delivery but an unfavorable cervix, 69 percent of women with no prior vaginal delivery but a favorable cervix, and 45 percent of women with no prior vaginal delivery and an unfavorable cervix.


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Literature review current through: Jan 2015. | This topic last updated: Jan 22, 2015.
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  1. Jozwiak M, Dodd JM. Methods of term labour induction for women with a previous caesarean section. Cochrane Database Syst Rev 2013; 3:CD009792.
  2. Kayani SI, Alfirevic Z. Induction of labour with previous caesarean delivery: where do we stand? Curr Opin Obstet Gynecol 2006; 18:636.
  3. McDonagh MS, Osterweil P, Guise JM. The benefits and risks of inducing labour in patients with prior caesarean delivery: a systematic review. BJOG 2005; 112:1007.
  4. Grobman WA, Gilbert S, Landon MB, et al. Outcomes of induction of labor after one prior cesarean. Obstet Gynecol 2007; 109:262.
  5. 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.
  6. Harper LM, Cahill AG, Boslaugh S, et al. Association of induction of labor and uterine rupture in women attempting vaginal birth after cesarean: a survival analysis. Am J Obstet Gynecol 2012; 206:51.e1.
  7. Cahill AG, Stamilio DM, Odibo AO, et al. Does a maximum dose of oxytocin affect risk for uterine rupture in candidates for vaginal birth after cesarean delivery? Am J Obstet Gynecol 2007; 197:495.e1.
  8. Cahill AG, Waterman BM, Stamilio DM, et al. Higher maximum doses of oxytocin are associated with an unacceptably high risk for uterine rupture in patients attempting vaginal birth after cesarean delivery. Am J Obstet Gynecol 2008; 199:32.e1.
  9. American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010; 116:450.
  10. American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol 2003; 102:1445.
  11. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001; 345:3.
  12. Centers for Disease Control and Prevention (CDC). Use of hospital discharge data to monitor uterine rupture--Massachusetts, 1990-1997. MMWR Morb Mortal Wkly Rep 2000; 49:245.
  13. Macones GA, Peipert J, Nelson DB, et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol 2005; 193:1656.
  14. Schmitz T, Pourcelot AG, Moutafoff C, et al. Cervical ripening with low-dose prostaglandins in planned vaginal birth after cesarean. PLoS One 2013; 8:e80903.
  15. Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 1998; 91:828.
  16. Sanchez-Ramos L, Gaudier FL, Kaunitz AM. Cervical ripening and labor induction after previous cesarean delivery. Clin Obstet Gynecol 2000; 43:513.
  17. Sciscione AC, Nguyen L, Manley JS, et al. Uterine rupture during preinduction cervical ripening with misoprostol in a patient with a previous Caesarean delivery. Aust N Z J Obstet Gynaecol 1998; 38:96.
  18. Plaut MM, Schwartz ML, Lubarsky SL. Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section. Am J Obstet Gynecol 1999; 180:1535.
  19. Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (Replaces guideline Number 147), February 2005. Int J Gynaecol Obstet 2005; 89:319.
  20. Royal College of Obstetricians and Gynaecologists Induction of labour. Evidence Based Clinical Guideline No. 9, Clinical Effectiveness Support Unit, RCOG, London, Royal College of Obstetricians and Gynaecologists 2001.
  21. Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol 2000; 183:1176.
  22. Bujold E, Blackwell SC, Gauthier RJ. Cervical ripening with transcervical foley catheter and the risk of uterine rupture. Obstet Gynecol 2004; 103:18.
  23. Ben-Aroya Z, Hallak M, Segal D, et al. Ripening of the uterine cervix in a post-cesarean parturient: prostaglandin E2 versus Foley catheter. J Matern Fetal Neonatal Med 2002; 12:42.
  24. Jozwiak M, van de Lest HA, Burger NB, et al. Cervical ripening with Foley catheter for induction of labor after cesarean section: a cohort study. Acta Obstet Gynecol Scand 2014; 93:296.
  25. Hoffman MK, Sciscione A, Srinivasana M, et al. Uterine rupture in patients with a prior cesarean delivery: the impact of cervical ripening. Am J Perinatol 2004; 21:217.