• Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B. Trial of labor after cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. Leawood (KS): American Academy of Family Physicians (AAFP); 2005 Mar. 18 p. [38 references]

This is the current release of the guideline.

This guideline updates a previous version: Trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. Am Fam Physician 1995 Nov 1;52(6):1763-5.

The grades of recommendations (A, B, and C) are defined at the end of the "Major Recommendations" field.

Recommendation 1: Women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL). (Level A)

Recommendation 2: Patients desiring trial of labor after previous cesarean (TOLAC) should be counseled that their chance for a successful vaginal birth after cesarean (VBAC) is influenced by the following: (Level B)

Positive Factors (increased likelihood of successful VBAC)

• Maternal age <40 years
• Prior vaginal delivery (particularly prior successful VBAC)
• Favorable cervical factors
• Presence of spontaneous labor
• Nonrecurrent indication that was present for prior cesarean delivery

Negative Factors (decreased likelihood of successful VBAC)

• Increased number of prior cesarean deliveries
• Gestational age >40 weeks
• Birth weight >4,000 g
• Induction or augmentation of labor

Recommendation 3: Prostaglandins should not be used for cervical ripening or induction as their use is associated with higher rates of uterine rupture and decreased rates of successful vaginal delivery. (Level B)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes. (Level C)

At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Recommendation 5: Maternity care professionals need to explore all the issues that may affect a woman's decision including issues such as recovery time and safety. (Level C). No evidence-based recommendation can be made regarding the best way to present the risks and benefits of trial of labor after previous cesarean delivery (TOLAC) to patients.

Definitions:

Grade of Recommendations

1. Recommendation based on consistent and good-quality, patient-oriented evidence*
2. Recommendation based on inconsistent or limited-quality, patient-oriented evidence*
3. Recommendation based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening*

*Patient-oriented evidence reflects outcomes that matter to patients: morbidity, mortality, symptoms, costs, and quality of life. Disease-oriented evidence reports intermediate, physiologic, or surrogate end points that may or may not reflect outcomes of importance to patients (e.g., blood pressure, blood chemistry, physiologic function, and pathologic findings).

None provided

The policy was based primarily on a comprehensive review of published reports. The evidence base was comprised chiefly of large population-based and prospective cohort series. There were no randomized controlled trials which directly compared trial of labor (TOL) to elective repeat cesarean delivery (ERCD).

• Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA, Ireland B. Trial of labor after cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. Leawood (KS): American Academy of Family Physicians (AAFP); 2005 Mar. 18 p. [38 references]

Not applicable: The guideline was not adapted from another source.

1995 Apr (revised 2005 Mar)

American Academy of Family Physicians - Medical Specialty Society

No external funding used.

Trial of Labor After Cesarean (TOLAC) Policy Team

Team Members: Eric Wall, MD, MPH, LifeWise Health Plan of Oregon; Richard Roberts, MD, JD, Department of Family Medicine, University of Wisconsin-Madison; Mark Deutchman, MD, Department of Family Medicine, University of Colorado Health Sciences Center; William Hueston, MD, Department of Family Medicine, Medical University of South Carolina; Lesley A. Atwood, MD, Allina Medical Clinic-Hastings; and Belinda Ireland, MD, MS, Clinical Sciences Analyst, American Academy of Family Physicians

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. Am Fam Physician 1995 Nov 1;52(6):1763-5.

None available

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This NGC summary was updated by ECRI on August 29, 2005. The updated information was verified by the guideline developer on September 20, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.