Recommendations for intrapartum management of TOLAC

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1. Spontaneous labor and advanced cervical dilation were associated with successful vaginal birth after Cesarean. 

2. Continuous fetal monitoring is recommended to allow for timely treatment of labor abnormalities, including uterine rupture. 

Study Rundown: This study synthesized findings from over 50 articles to provide a summary of recommendations for intrapartum management of patients undergoing a trial of labor after Cesarean (TOLAC). TOLAC may be desirable for certain patients, as repeat Cesarean deliveries can increase risk for abnormal placentation and pelvic adhesions. Existing literature focuses on the risks and benefits of vaginal birth after cesarean (VBAC) such that no previous guidelines exist for intrapartum management.  The present work identifies practices useful in safely managing TOLAC patients.

Identification of evidence included in this literature review was not systematic, which may impact the validity of the discussed guidelines. Future studies might include a meta-analysis to provide more detail on the degree to which each of these practices enhances the likelihood for a successful TOLAC or reduces maternal and infant morbidity and mortality. Additionally, this study is limited by the non-randomized, retrospective designs of the studies summarized, which is a largely unavoidable limitation of ethical research in laboring pregnant women.

Click to read the study in the British Journal of Obstetrics & Gynaecology

Relevant Reading: UpToDate: Choosing the route of delivery after cesarean birth

In-Depth [literature review]: This study reviewed evidence from over 59 articles to identify recommendations for intrapartum management of trial of labor after Cesarean (TOLAC), formerly known as vaginal birth after Cesarean (VBAC). Analgesia, induction, augmentation, monitoring of labor, surveillance for uterine rupture and delivery were assessed.

Spontaneous labor and advanced cervical dilation were associated with successful vaginal delivery, while induction and augmentation of labor were associated with increased risk of both Cesarean delivery and uterine rupture. Continuous fetal heart rate monitoring was recommended to allow for timely treatment and improved maternal-fetal outcomes. The management of the second stage of labor and delivery were similar for patients with and without previous Cesarean, with the exception of examination of the low transverse incision in the instance of post-partum hemorrhage following VBAC.

By Denise Pong, MPH and Leah Hawkins, MD, MPH

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