What are the guidelines for a repeat cesarean section (C-section) in a woman with a previous cesarean section?

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Last updated: January 27, 2026 • View editorial policy

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Repeat Cesarean Section Guidelines

For women with one prior cesarean and no contraindications, trial of labor after cesarean (TOLAC) should be offered as the preferred option when favorable predictors are present, with scheduled repeat cesarean at 39-40 weeks reserved for those with contraindications or multiple risk factors for TOLAC failure. 1

Timing of Scheduled Repeat Cesarean

  • Schedule repeat cesarean at 39-40 weeks gestation to minimize neonatal respiratory complications while avoiding spontaneous labor 1
  • Do not perform elective repeat cesarean before 39 weeks except in specific medical situations, as this increases transient respiratory distress risk 2
  • For women with cardiac disease specifically, consider induction at 40 weeks to minimize cardiac-related risks 1

Decision Framework: TOLAC vs. Elective Repeat Cesarean

Absolute Contraindications to TOLAC (Must Have Repeat Cesarean)

  • Classic (vertical) uterine scar from any prior cesarean 1
  • History of 3 or more cesareans 2
  • Scar in the uterine body 2
  • Women who have had several cesarean deliveries may not have TOLAC as an option 1

Strong Indications Favoring TOLAC (Encourage Vaginal Birth)

  • Previous vaginal delivery (before or after the cesarean) - this is the single strongest predictor of VBAC success 3, 4
  • Favorable Bishop score at presentation 3, 2
  • Spontaneous labor onset 2
  • Approximately 74% of women attempting TOLAC achieve successful vaginal delivery 1, 3

Strong Indications Favoring Elective Repeat Cesarean

  • Estimated fetal weight >4,500g, especially without previous vaginal delivery 2
  • Supermorbid obesity (BMI >50) 2
  • Multiple previous cesareans (2 or more increases cumulative risks) 1

Situations Where TOLAC is Possible But Requires Careful Counseling

  • Two previous cesareans 2
  • Uterine malformation 2
  • Low vertical incision or unknown incision type 2
  • Previous myomectomy 2
  • Interval <6 months between last cesarean and current conception 2
  • Maternal age >35 years 2
  • Diabetes 2
  • Morbid obesity (BMI 40-50) 2
  • Prolonged pregnancy 2
  • Breech presentation 2
  • Twin pregnancy 2

Risk Profile Comparison

Maternal Risks

  • Overall maternal morbidity: 2.23% with scheduled cesarean vs. 0.9% with planned vaginal birth (not statistically significant for all comparisons) 1
  • Uterine rupture risk with TOLAC: 0.22% overall, 0.35% when labor occurs 1
  • Maternal mortality is actually lower with successful VBAC compared to repeat cesarean 1
  • Failed TOLAC carries higher maternal morbidity than successful VBAC 2

Neonatal Risks

  • Perinatal mortality is higher with TOLAC compared to scheduled repeat cesarean 1, 3, 2
  • Risk of mask ventilation, intubation for meconium, and neonatal sepsis increase with TOLAC 2
  • Transient respiratory distress increases with elective repeat cesarean, especially before 39 weeks 2

Cumulative Risks with Multiple Cesareans

After the second repeat cesarean, exponentially increasing risks include: 1

  • Wound and uterine hematoma: 4-6%
  • Red cell transfusions: 1-4%
  • Hysterectomy: 0.5-4%
  • Placenta accreta: 0.25-3%
  • Placenta previa rates: 9/1,000 (one cesarean), 17/1,000 (two cesareans), 30/1,000 (three or more cesareans) 1
  • A fourth cesarean carries 2.17% placenta accreta risk 1

Labor Induction Considerations for TOLAC

Labor should only be induced for medical indications in women with previous cesarean 2

Induction Method-Specific Uterine Rupture Risks

  • Oxytocin: 1.1% risk (95% CI 0.9-1.5%) 3, 2
  • Prostaglandin E2: 2% risk (95% CI 1.1-3.5%) 3, 2
  • Misoprostol: CONTRAINDICATED - significantly increases uterine rupture risk 3, 2
  • Mechanical methods: insufficient evidence 2
  • Higher Bishop scores at admission increase VBAC success 3
  • Oxytocin use decreases VBAC likelihood in dose-dependent manner 3, 2

Intraoperative Requirements for Scheduled Repeat Cesarean

  • Immediate neonatal resuscitation capacity must be available (mandatory) 1
  • Maintain maternal body temperature 36.5-37.5°C 1
  • Onsite availability of obstetrician and anesthetist should be discussed with patient 2

Labor Management During TOLAC

  • Epidural analgesia should be encouraged 2
  • Internal tocodynamometry does not prevent uterine rupture and is not routinely recommended 2
  • In active phase, total duration of failure to progress should not exceed 3 hours before proceeding to cesarean 2
  • Routine manual uterine examination after successful VBAC is not indicated based solely on scar presence 2

Counseling and Shared Decision-Making

  • Discuss VBAC possibility early in prenatal care 3
  • Decision about planned mode of delivery must be made by 8th month 2
  • If woman prefers repeat cesarean after adequate information and time to consider, her preference should be honored 2
  • Reevaluate labor plan when patients present in labor, considering factors affecting vaginal delivery chance 3
  • X-ray pelvimetry increases repeat cesarean rate without reducing uterine rupture and is not recommended 2
  • Ultrasound assessment of uterine rupture risk has no clinical utility for delivery mode decisions 2

Common Pitfalls to Avoid

  • Using misoprostol for cervical ripening or induction in women with previous cesarean 3
  • Failing to recognize previous vaginal delivery as the strongest VBAC success predictor 3, 4
  • Scheduling elective repeat cesarean before 39 weeks without medical indication 2
  • Failing to counsel about exponentially increasing risks with each additional cesarean 1

References

1
Guideline

Optimal Timing and Approach for Repeat Cesarean Section

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Predictors and Considerations for Vaginal Birth After Cesarean Section

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Cesarean Delivery in Multiparous Women with Previous Vaginal Deliveries

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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