The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.
The following recommendations are based on good and consistent scientific evidence (Level A):
- Most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (VBAC) and should be counseled about VBAC and offered a trial of labor.
- Epidural anesthesia may be used for VBAC.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.
- The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
- After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.
- Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.
Definitions
Grades of Evidence
I Evidence obtained from at least one properly designed randomized controlled trial
II-1 Evidence obtained from well-designed controlled trials without randomization
II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Levels of Recommendations
Level A - The recommendation is based on good and consistent scientific evidence.
Level B - The recommendation is based on limited or inconsistent scientific evidence.
Level C - The recommendation is based primarily on consensus and expert opinion.
