Executive Summary of AAFP Clinical Practice Guideline on Trial of Labor After Cesarean
| The American Academy of Family Physicians Commission on Clinical Policies and Research convened a panel to systematically review the available evidence on trial of labor after cesarean (TOLAC) using the Agency for Healthcare Research and Quality “Evidence Report on Vaginal Birth After Cesarean (VBAC).” The panel’s objective was to provide an evidence-based clinical practice guideline for pregnant women and their families, maternity care professionals, facilities, and policy makers who care about trial of labor and maternity care for a woman with one previous cesarean. The recommendations are as follows: | |
| Recommendation 1: Women with 1 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 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) | Negative factors (decreased likelihood of successful VBAC) |
| Maternal age <40 years | Increased number of previous CDs |
| Previous vaginal delivery (particularly previous successful VBAC) | Gestational age >40 weeks |
| Favorable cervical factors | Birthweight >4,000 g |
| Presence of spontaneous labor | Induction or augmentation of labor |
| Nonrecurrent indication that was present for previous cesarean delivery (CD) | |
| 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, because 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 TOLAC to patients. | |