For a reproductive‑age woman with one prior low‑transverse cesarean delivery and no contraindications (no classical scar, no multiple prior cesareans, no placenta previa, no active genital herpes, no fetal macrosomia), should she be offered a trial of labour after cesarean (vaginal birth after cesarean) and what are the recommended management steps?

Management of Women with One Prior Low-Transverse Cesarean Delivery

For a woman with one prior low-transverse cesarean and no contraindications, trial of labor after cesarean (TOLAC) should be offered and encouraged, as it reduces maternal morbidity, decreases complications in future pregnancies, and achieves successful vaginal delivery in approximately 74% of attempts. 1, 2

Counseling and Decision-Making Framework

Early Prenatal Discussion (Before 32 Weeks)

• Discuss TOLAC versus elective repeat cesarean delivery (ERCD) early in prenatal care, ideally during the first or second trimester 2
• Finalize the delivery plan by the 8th month of pregnancy, ensuring the decision is shared between patient and physician 3
• VBAC is associated with lower maternal mortality compared to repeat cesarean delivery 1, 2
• Maternal morbidity with scheduled cesarean is 2.23% versus 0.9% with planned vaginal birth 1

Absolute Contraindications to TOLAC

• Classical (vertical) uterine scar from any prior cesarean 1, 2
• History of 3 or more cesarean deliveries 3
• Scar in the uterine body 3
• Active genital herpes, placenta previa, or other standard contraindications to vaginal delivery 4, 5, 6, 7

Factors That Strongly Favor TOLAC (Encourage These Patients)

• Previous vaginal delivery (either before or after the cesarean) is the single strongest predictor of VBAC success 2
• Spontaneous labor or favorable Bishop score at presentation 2, 3
• Preterm gestational age 3
• Estimated fetal weight <4,000g 2

Factors That Favor ERCD (Counsel Against TOLAC)

• Estimated fetal weight >4,500g, especially without previous vaginal delivery 3
• Supermorbid obesity (BMI >50) 3
• Multiple risk factors for TOLAC failure present simultaneously 3

Intrapartum Management During TOLAC

Labor Induction Considerations

• Induce labor only for medical indications, not for convenience 3
• Never use misoprostol for cervical ripening or labor induction—it carries a 13% uterine rupture risk 2, 3
• Prostaglandin E₂ carries a 2% uterine rupture risk and should be avoided 2, 3
• Oxytocin may be used cautiously with a 1.1% uterine rupture risk, using dose-dependent titration 2, 3

Monitoring and Progress Expectations

• Continuous fetal monitoring is standard during TOLAC 2
• In the active phase, if failure to progress exceeds 3 hours total duration, proceed to cesarean delivery 3
• Epidural analgesia should be encouraged and does not mask signs of uterine rupture 3
• Overall uterine rupture risk during TOLAC is approximately 0.22%, increasing to 0.35% when labor occurs 1

Facility Requirements

• Facilities offering TOLAC must have capability to perform emergency cesarean within 30 minutes of decision 2
• If uterine rupture is suspected, surgical intervention should begin within 18 minutes 2
• Immediate availability of obstetrician and anesthesiologist onsite should be confirmed 3

Risk Counseling: Maternal and Perinatal Outcomes

Maternal Outcomes

• Successful VBAC results in lower maternal mortality than repeat cesarean 1, 2
• Short-term maternal morbidity (infection, blood loss, hospital stay) is better with successful VBAC than repeat cesarean 2
• Failed TOLAC carries higher maternal morbidity than either successful VBAC or elective repeat cesarean 3

Perinatal Outcomes

• Perinatal mortality is modestly higher with TOLAC compared to scheduled repeat cesarean 1, 2
• This increased perinatal risk must be balanced against maternal benefits when counseling patients 1, 2

Future Pregnancy Considerations

Interpregnancy Interval

• Recommend waiting at least 18-24 months after cesarean delivery before conceiving again 8
• Intervals shorter than 18 months significantly increase uterine rupture risk in subsequent pregnancies 8

Cumulative Risks with Multiple Cesareans

• Each additional cesarean exponentially increases risks: placenta accreta rises from 12.9 per 10,000 after one cesarean to 41.3 per 10,000 after two 8
• Placenta previa incidence: 9 per 1,000 after one cesarean, 17 per 1,000 after two, 30 per 1,000 after three or more 1, 8
• After the second repeat cesarean, risks increase for wound hematoma (4-6%), transfusion (1-4%), hysterectomy (0.5-4%), and placenta accreta (0.25-3%) 1

Common Pitfalls to Avoid

• Do not use X-ray pelvimetry to decide mode of delivery—it increases repeat cesarean rates without reducing uterine rupture 3
• Do not perform routine manual uterine examination after successful VBAC unless clinically indicated 3
• Do not schedule ERCD before 39 weeks except for specific medical indications, as this increases neonatal respiratory complications 1, 3
• Do not fail to recognize that previous vaginal delivery is the most powerful predictor of VBAC success 2