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

Deborah A Wing, MD, MBA
Section Editor
Vincenzo Berghella, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


Almost 25 percent of women with a previous cesarean delivery require early delivery because of medical indications [1]. 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 [2]. 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 [3].

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".)


In women undergoing induction after a previous cesarean delivery, the chance of vaginal birth appears to be similar whether they have had one versus two prior cesareans (69 versus 65 percent in one study [4]). The highest chance of success is in women with a prior vaginal delivery and favorable cervix. (See "Choosing the route of delivery after cesarean birth".)

Most studies of the outcome of labor induction in women with prior cesarean deliveries have compared those undergoing induction with those experiencing spontaneous onset of labor. The body of evidence from these studies indicates that induction results in a lower vaginal delivery rate than spontaneous labor (mean vaginal delivery rate 68 versus 80 percent [5]). Two factors significantly increase the chance of successful vaginal birth: (1) a previous history of vaginal delivery and (2) favorable cervical status (modified Bishop score ≥6). In one large study, 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 [6].

However, contemporary investigators have opined that women in spontaneous labor are not the appropriate control group for studies of the outcome of induction. In contrast to historic comparisons, they believe the clinically relevant comparison for determining the best approach for reducing the risk of repeat cesarean is to compare women undergoing induction with a similar group of women managed expectantly. In one such study of over 12,000 women with singleton gestations ≥39 weeks and one low transverse cesarean delivery, women undergoing induction of labor at 390/7 to 3/7ths weeks without an acute obstetric medical indication were more likely to deliver vaginally than those managed expectantly (73.8 versus 61.3 percent; odds ratio 1.31, 95% CI 1.03-1.67) [7]. These findings affirm the relatively high probability of vaginal delivery with induction after a previous cesarean delivery.

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Literature review current through: Nov 2017. | This topic last updated: Nov 16, 2017.
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  1. Kehl S, Weiss C, Rath W. Balloon catheters for induction of labor at term after previous cesarean section: a systematic review. Eur J Obstet Gynecol Reprod Biol 2016; 204:44.
  2. Jozwiak M, Dodd JM. Methods of term labour induction for women with a previous caesarean section. Cochrane Database Syst Rev 2013; :CD009792.
  3. Kayani SI, Alfirevic Z. Induction of labour with previous caesarean delivery: where do we stand? Curr Opin Obstet Gynecol 2006; 18:636.
  4. Miller ES, Grobman WA. Obstetric outcomes associated with induction of labor after 2 prior cesarean deliveries. Am J Obstet Gynecol 2015; 213:89.e1.
  5. 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.
  6. Grobman WA, Gilbert S, Landon MB, et al. Outcomes of induction of labor after one prior cesarean. Obstet Gynecol 2007; 109:262.
  7. Palatnik A, Grobman WA. Induction of labor versus expectant management for women with a prior cesarean delivery. Am J Obstet Gynecol 2015; 212:358.e1.
  8. Grantz KL, Gonzalez-Quintero V, Troendle J, et al. Labor patterns in women attempting vaginal birth after cesarean with normal neonatal outcomes. Am J Obstet Gynecol 2015; 213:226.e1.
  9. Sondgeroth KE, Stout MJ, Graseck AS, et al. Progress of induced labor in trial of labor after cesarean delivery. Am J Obstet Gynecol 2015; 213:420.e1.
  10. https://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf (Accessed on September 12, 2016).
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstet Gynecol 2017; 130:e217.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. Sanchez-Ramos L, Gaudier FL, Kaunitz AM. Cervical ripening and labor induction after previous cesarean delivery. Clin Obstet Gynecol 2000; 43:513.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
  26. Maggio L, Forbes J, Carey LL, et al. Association of Montevideo units with uterine rupture in women undergoing a trial of labor. J Reprod Med 2014; 59:464.
  27. Lappen JR, Hackney DN, Bailit JL. Outcomes of Term Induction in Trial of Labor After Cesarean Delivery: Analysis of a Modern Obstetric Cohort. Obstet Gynecol 2015; 126:115.