From the Guidelines
A trial of labor is contraindicated in women with a history of previous cesarean delivery who have indications that increase the risk of uterine rupture, such as the use of misoprostol (Cytotec) for cervical preparation or induction of labor. When considering a trial of labor, it is essential to evaluate the individual's medical history and current health status to determine the safest approach. Some key factors to consider include:
- Previous uterine incision type, as certain types like classical (vertical) uterine incision, prior transmural uterine surgery, or previous uterine rupture significantly increase the risk of uterine rupture 1
- Medical or obstetric conditions that preclude vaginal delivery, such as placenta previa or active genital herpes
- The number of previous cesarean deliveries, as more than two increase the risk of complications
- The availability of resources for emergency cesarean delivery within 30 minutes, which is crucial in case of an emergency
- The type of previous uterine scars, such as T or J incisions, which may increase the risk of uterine rupture It is crucial to note that the use of misoprostol (Cytotec) for cervical preparation or induction of labor in women with a previous cesarean delivery is contraindicated due to the increased risk of uterine rupture, as stated in the guidelines from the American Academy of Family Physicians 1. Ultimately, the decision to attempt a trial of labor should be made through shared decision-making between the patient and provider, taking into account individual factors and the potential risks and benefits.
From the Research
Contraindications to Trial of Labor
The following are contraindications to a trial of labor (TOL) after cesarean section:
- Prior classical cesarean section, as it increases the risk of uterine rupture in subsequent pregnancies 2, 3
Relative Contraindications
Some situations may be considered relative contraindications, and the decision to attempt a TOL should be made on a case-by-case basis:
- Unknown type of uterine incision, but suggestive of a classical uterine incision 3
- Previous low vertical uterine incision, although the patient should be counseled about the limited evidence on risks and benefits 3
- Multiple gestation, although it is not a contraindication, the evidence on risks and benefits is limited 4
- Diabetes mellitus, not a contraindication, but close monitoring is recommended 4
- Suspected fetal macrosomia, not a contraindication, but close monitoring is recommended 4
- Postdatism, not a contraindication, but close monitoring is recommended 4
- Previous uterine scar, although not a contraindication, close monitoring is recommended 5, 6
- Induction of labor with prostaglandin E2 (dinoprostone) or prostaglandin E1 (misoprostol), which increases the risk of uterine rupture 4, 6