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Trial of labor after cesarean delivery

INTRODUCTION

The dominant practice in the United States for many decades was to follow the dictum of Cragin, "once a cesarean, always a cesarean," which was first put forth in 1916 [1]. In 1980, however, a panel convened by the National Institutes of Health questioned the need for routine elective repeat cesarean delivery (ERCD) and opined that a trial of labor after a previous lower uterine segment transverse incision could be attempted safely in properly selected patients [2]. In 1990, the United States Public Health Service proposed that an overall cesarean delivery rate of 15 percent be achieved by the year 2000, with a vaginal birth after cesarean (VBAC) rate of 35 percent (ie, rate of vaginal births per 100 births to women with a previous cesarean delivery) [3]. Some insurers and managed care organizations even mandated that almost all women with a previous cesarean delivery attempt a trial of labor (TOL) in the subsequent pregnancy. As a result of this change in philosophy, the VBAC rate rose from about 3 percent in 1980 to 20 percent in 1990 and then to 28 percent in 1996 [4-6]. Since 1996, however, the rate has fallen, decreasing to 7.6 to 8.5 percent (depending on method of tabulation) in 2006 [6].

This issue is of particular importance, given the continuing rise in cesarean deliveries in the United States. Over 10 years (1996 to 2006), the cesarean delivery rate rose 46 percent, to 31.3 percent [6]. Over time, more women and their providers will be faced with the issues regarding mode of delivery after cesarean.

Fewer women are attempting a TOL after a cesarean (TOLAC). Possible reasons for this include medical and legal pressures, changes in patient and provider preferences, changes in obstetric practice, and publication of complications related to vaginal delivery and failed TOL. Another factor contributing to the decline may be publications by the American College of Obstetricians and Gynecologists recommending specific personnel requirements for hospitals offering TOLAC [7] and discouraging the use of prostaglandins and oxytocin for cervical ripening in these patients [8,9]. This is in spite of an overall 60 percent to 80 percent chance of successful vaginal delivery in patients electing TOLAC (see 'Success rate' below.

The selection, counseling, and management of women for TOLAC will be reviewed here. General issues pertaining to cesarean delivery are discussed separately. (See individual topic reviews on cesarean delivery).

CHOOSING THE ROUTE OF DELIVERY

Pregnant women with a prior cesarean birth must choose between ERCD and TOLAC. The ability to identify women who are likely to successfully TOLAC could potentially decrease morbidity since studies consistently show that women who fail an attempt to deliver vaginally are at highest risk of adverse outcome [10-14]. The most serious concerns related to TOLAC are increased risks of uterine rupture and perinatal death, which may occur as related or independent events (see 'Complications' below. In a seminal study of women delivering after a previous cesarean, those who failed TOLAC accounted for 49 of 77 (64 percent) patients with major complications (need for hysterectomy, uterine rupture, or operative injury) [12]. Chorioamnionitis and hemorrhage also occur significantly more often in women who fail TOLAC than in those who are successful (eg, chorioamnionitis 25.8 versus 5.5 percent, hemorrhage 35.8 versus 15.8 percent [14]).
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