J Jogc 2018 11 008

SOGC CLINICAL PRACTICE GUIDELINE
It is SOGC policy to review the content 5 years after publication, at which time the document may be re-affirmed or revised to reflect
emergent new evidence and changes in practice.
No. 382, July 2019 (Replaces No. 155, February 2005)
No. 382-Trial of Labour After Caesarean

This revised Clinical Practice Guideline has been prepared by the CHANGES IN PRACTICE
authors and reviewed by the Clinical Practice Obstetrics and Guideline
Management and Oversight Committees, and approved by the Board 1. Trial of labour after a previous Caesarean section (TOLAC)
is recommended in women with no contraindications to
of the Society of Obstetricians and Gynaecologists of Canada.
TOLAC and who have a high likelihood of vaginal birth
This Clinical Practice Guideline supersedes the original version after Caesarean.
(#155) that was published in February 2005. 2. Women with <18-month interdelivery interval have an
increased risk of uterine rupture with TOLAC.
Jessica Dy, MD, MPH, Ottawa, ON 3. Suspected uterine rupture requires immediate laparotomy
Sheri DeMeester, RN, London, ON in order to attempt to decrease maternal and perinatal
morbidity and mortality. Therefore no minimum time frame
Hayley Lipworth, BSc, BEd, Toronto, ON
to emergency Caesarean section can be considered
Jon Barrett, MD, Toronto, ON adequate.
Clinical Practice Obstetrics Committee: Hussam Azzam, MD,

Charlottetown, PE; Jon Barrett, MD, Toronto, ON; Melanie Basso, KEY MESSAGES
RN, Vancouver, BC; Hayley Bos, MD, Victoria, BC; Kim Campbell,
1. Trial of labour after a previous Caesarean section
RM, Vancouver, BC; Krista Cassell (co-chair), MD, Charlottetown,
PE; Sheryl Choo, MD, London, ON; Gina Colbourne, MD, St. (TOLAC) is recommended in women without
John’s, NL; Kirsten Duckitt, MD, Campbell River, BC; Ellen contraindications to labour and vaginal birth, with a
Giesbrecht (co-chair), MD, Vancouver, BC; Michael Helewa, MD, previous vaginal birth, and/or those who present in
spontaneous labour.
Winnipeg, MB; Amy Metcalfe, PhD, Calgary, AB; Barbara Parish,
MD, Halifax, NS; J. Larry Reynolds, MD, Winnipeg, MB; Yvonne 2. The relative risk of maternal death is higher for elective
Vasilie, MD, Pointe Claire, QC repeat Caesarean section (ERCS) and the relative risk of
uterine rupture is higher for TOLAC, but the absolute risks
Disclosure statements have been received from all authors. of either of these outcomes is low.
Key Words: Vaginal birth after Caesarean, trial of labour, uterine 3. The baseline risk of uterine rupture with a TOLAC is
rupture, induced labour, oxytocin, prostaglandins, misoprostol 0.47%.
4. Women planning a TOLAC should be advised that the relative
risk of perinatal mortality is higher with TOLAC compared to
ERCS, but the absolute risk is low.
J Obstet Gynaecol Can 2019;41(7):992−1011
5. Continuous fetal monitoring and access to immediate
https://doi.org/10.1016/j.jogc.2018.11.008 laparotomy are essential when planning a TOLAC.
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc. All rights reserved.
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to
facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to
their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of
all people − including transgender, gender non-binary, and intersex people − for whom the guideline may apply. We encourage health care
providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate
care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and
treatment options chosen by the patient should be respected.
992 JULY JOGC JUILLET 2019

Abstract 13. Women with 2 prior Caesarean sections appear to have similar vaginal
birth after Caesarean rates as those with 1 prior Caesarean section.
Objective: To provide evidence-based guidelines for the provision of a Women should be informed of a higher risk of uterine rupture in trial of
trial of labour after Caesarean section. labour after Caesarean with more than 1 Caesarean section (II-2B).
14. There are limited studies reporting on outcomes of women with
Outcomes: Fetal and maternal morbidity and mortality associated with more than 2 prior Caesarean sections (I).
vaginal birth after Caesarean and repeat Caesarean section. 15. It is not an absolute contraindication for women with a breech presen-
tation to undergo a trial of labour after Caesarean. However, women
Evidence: MEDLINE database was searched for articles published from
should be advised that there is insufficient information to assess risks
January 1, 1995, to October 31, 2017 using the key words “vaginal
of trial of labour after Caesarean with a breech presentation (III-B).
birth after Caesarean (Cesarean) section.” The quality of evidence is
16. Multiple pregnancy is not a contraindication to a trial of labour after
described using the Evaluation of Evidence criteria outlined in the
Caesarean (II-2B).
Report of the Canadian Task Force on the Periodic Health Exam.
17. Women delivering with <18-month interdelivery interval should be
Validation: These guidelines were approved by the Clinical Practice informed about an increased risk of uterine rupture with trial of
Obstetrics Committee and the Board of the Society of Obstetricians labour after Caesarean (II-2A).
and Gynaecologists of Canada. 18. Although there is relationship between lower uterine thickness and
risk of uterine rupture, the absolute cut-off between safe and
Recommendations: unsafe trial of labour after Caesarean does not exist. Therefore, at
this time, we cannot use ultrasonographic measurements of the
1. Provided there are no contraindications, a trial of labour after Cae- lower uterine segment to counsel women to either have or not
sarean should be offered to all women with 1 previous low-seg- have a trial of labour after Caesarean with confidence (II-2B).
ment transverse Caesarean section after appropriate discussion 19. Women with a classical Caesarean section or T incision should not
and documentation of maternal and perinatal risks and benefits. have a trial of labour after Caesarean (II-2A).
The discussion should be documented (II-2B). 20. Women with a previous Low Segment Cesarean Section in which the
2. Trial of labour after Caesarean is recommended in women without uterus was closed in a single layer and who wish to attempt trial of
contraindications to labour, with a previous vaginal birth, and/or labour after Caesarean should be aware that the risk of uterine rupture
those who present in spontaneous labour as they are good candi- may be increased (II-2A).
dates for a trial of labour after Caesarean and have a higher vagi- 21. Every effort should be made to obtain the previous Caesarean opera-
nal birth after Caesarean rate (II-2B). tive report to determine the type of uterine incision used. In situations
3. Women with factors negatively affecting their likelihood of vaginal where the scar is unknown, information concerning the circumstances
birth after Caesarean can be offered a trial of labour after Caesar- of the previous delivery is helpful in determining the likelihood of a low
ean. However, they should be informed that they have a lower transverse incision. If the likelihood of a lower transverse incision is
chance of vaginal birth after Caesarean and have an increased high, trial of labour after Caesarean can be offered (II-2B).
risk of complications and repeat Caesarean birth (II-2A). 22. Women planning a trial of labour after Caesarean should be advised
4. Women should be informed that the relative risk of maternal death that the relative risk of perinatal mortality and serious morbidity is
is higher for elective repeat Caesarean section and the risk of uter- higher with trial of labour after Caesarean compared to elective
ine rupture and composite serious maternal morbidity is higher for repeat Caesarean section, but the absolute risk is low (II-2B).
trial of labour after Caesarean, but the absolute risks of these out- 23. Women should be informed that the risk of placenta previa and pla-
comes are low (II-2B). centa accreta increases with increasing number of Caesarean sec-
5. Women with 1 prior low transverse Caesarean section should be tions (II-2A).
informed that the baseline risk of uterine rupture with a trial of 24. The process and documentation of informed consent with appropri-
labour after Caesarean is 0.47% (II-2A). ate discussion of the maternal and perinatal risks and benefits of
6. Women should be informed that most other maternal complications trial of labour after Caesarean and elective repeat Caesarean sec-
are not significantly different between elective repeat Caesarean tion should be a part of the care plan in a woman with a previous
section and trial of labour after Caesarean (II-2B). Caesarean section (III-A).
7. Induction of labour is not contraindicated in women undergoing a 25. The intention of a woman undergoing a trial of labour after Caesar-
trial of labour after Caesarean (II-2A). ean or elective repeat Caesarean section should be clearly stated,
8. Women should be informed that induction of labour is associated and documentation of the previous uterine scar should be clearly
with a lower vaginal birth after Caesarean rate and an increased marked on the prenatal record (III-A).
risk of uterine rupture and should be used carefully after appro- 26. The entire team should be made aware of the presence of a
priate counselling. The risk of uterine rupture with induction of woman undergoing a trial of labour after Caesarean labouring in
labour appears to be highest in women over 40 weeks gestation the birthing unit (III-A).
(II-2A). 27. Continuous electronic fetal monitoring of women having a trial of
9. A Foley catheter may be used to ripen the cervix in a woman plan- labour after Caesarean is necessary, as changes to the fetal heart
ning a trial of labour after Caesarean (II-2B). rate tracing are one of the key indicators of the presence of a uter-
10. Use of oxytocin for induction or augmentation is not contraindicated ine rupture (II-2A).
in women undergoing a trial of labour after Caesarean. However, 28. Suspected uterine rupture requires immediate attention and lapa-
use of oxytocin is associated with an increased risk of uterine rupture rotomy in order to attempt to decrease maternal and perinatal mor-
and should be used carefully after appropriate counselling (II-2B). bidity and mortality (III-B).
11. Medical induction of labour with prostaglandin E2 (dinoprostone) is 29. To optimize maternal and neonatal outcomes in situations of uter-
associated with an increased risk of uterine rupture and its use is ine rupture, a woman having a trial of labour after Caesarean
not recommended in trial of labour after Caesarean, after appropri- should be cared for in a hospital that has resources to perform an
ate counselling (II-2B). immediate Caesarean section (III-B).
12. Prostaglandin E1 (misoprostol) is associated with a high risk of 30. The woman and her health care provider must be aware of the
uterine rupture and should not be used in trial of labour after Cae- availability of obstetric, anaesthetic, pediatric, and operating room
sarean at term (II-2A). staff in the setting where she chooses to give birth (III-A).
JULY JOGC JUILLET 2019 993

BACKGROUND/INTRODUCTION and 3 hospitals (BORN database). Every year over 30 000

women in Canada are faced with this choice of a trial of
he proportion of babies delivered by CS continues to labour or an ERCS. The SOGC, along with other profes-
T increase in Canada. In 2015-2016, 27.9% of hospital
deliveries were Caesarean deliveries compared to 17.6% in
sional associations including the Royal College of Obstetri-
cians and Gynaecologists and the American Congress of
1995-1996.1 Canadian women age 35 and older continued Obstetricians and Gynecologists, recommend that a
to have significantly higher primary CS rates than their TOLAC be offered to eligible women with a history of
younger counterparts (23.6% vs. 17.8%).2 The primary previous Caesarean birth.7−9 Candidates for planned
indication for CS in Canada is a previous CS, accounting TOLAC are those women in whom the balance of risks
for over 30% of all Caesarean births. and chances of VBAC is acceptable to the woman and
the health care provider. The balance of risks and benefits
While the Canadian primary CS rate has remained stable at appropriate for 1 woman may seem unacceptable for
17.8%, the repeat CS rate—the proportion of women with another.9
previous CS who underwent a repeat CS—has steadily
increased. In 2015-2016, 81% of women with a previous CS Purpose and Scope
had a repeat CS.2 This steady rise in repeat CSs is accompa- Women and their health care providers will need to discuss
nied by a decline in women having a TOLAC and VBAC. In the risks and benefits of TOLAC and ERCS when plan-
Canada (except Quebec), between 2003 and 2014, the ning a birth after a previous Caesarean delivery. In certain
TOLAC rate among 197 540 women with a singleton preg- situations, a TOLAC will be contraindicated,10 and an
nancy at >37 weeks gestation and a single prior Caesarean ERCS will be advised. But in most cases, a VBAC can be
delivery was only 29.7%.3 This TOLAC rate varies quite safely achieved for both mother and infant.11−13 This doc-
widely across Canada. The TOLAC rate was 37.2% from ument reviews the evidence available surrounding TOLAC
1998-2014 in Nova Scotia4 and 52% in a single Quebec hos- and ERCS and will discuss these birth options and associ-
pital from 1995-2003,5 and within Ontario, TOLAC rates ated maternal and fetal risks. A Canadian consensus state-
ranged from 28.5% to 62.2% in 2015-2016.6 ment on VBAC was published in 1985, and Clinical
Practice Guidelines were published by the SOGC in
For women having a TOLAC, there is also wide variation 200414 and 2005.15 This document updates the 2005
in the VBAC rate, which ranges from 47.8% to 50.8% in SOGC Guidelines with articles published from January 1,
Canada between 2003 and 2014,3 65.1% in Quebec,5 and 1995, to June 31, 2018. Articles were obtained by searching
68.1% in Nova Scotia.4 In Ontario, the VBAC rate in the MEDLINE database, using the key words “vaginal
women with 1 prior CS in 2015-2017 was 69% in Level 2 birth after Caesarean (Cesarean) section.” The data are lim-
ited by 3 important factors: first, there are no randomized
trials of TOLAC versus CS ERCS; second, adverse mater-
nal or perinatal outcomes are rare, and large study popula-
ABBREVIATIONS tions are necessary to observe a significant difference in
BMI body mass index maternal and perinatal outcomes; and finally, a woman’s
CI confidence interval choice to attempt TOLAC is heavily influenced by her pre-
CS Caesarean section vious birth experience, her health care provider, and local
EFM electronic fetal monitoring resources, often leading to selection bias in published
ERCS elective repeat Caesarean reports.16,17
section
FHR fetal heart rate The level of evidence and quality of the recommendations
IOL induction of labour in this guideline have been determined using the criteria
LUS lower uterine segment described by the Canadian Task Force on the Periodic
OR odds ratio Health Examination (Table 1).18
PGE2 prostaglandin E2
RR relative risk CANDIDATES FOR TOLAC
SOGC Society of Obstetricians and
Gynaecologists of Canada A TOLAC should be considered in women who present
TOLAC trial of labour after a previous for prenatal care with a history of previous Caesarean
Caesarean section birth.16,19,20 In certain situations, a TOLAC will be contra-
vaginal birth after Caesarean vaginal birth after Caesarean indicated,8 and a repeat CS will be advised. In many

Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventative Health Care
Quality of evidence assessmenta Classification of recommendationsb
I: Evidence obtained from at least 1 properly randomized controlled A. There is good evidence to recommend the clinical preventive
trial action.
II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive action.
randomization
II-2: Evidence from well-designed cohort (prospective or retrospec- C. The existing evidence is conflicting and does not allow to make a
tive) or case-control studies, preferably from more than 1 centre or recommendation for or against use of the clinical preventive action;
research group however, other factors may influence decision making.
II-3: Evidence obtained from comparisons between times or places D. There is fair evidence to recommend against the clinical preventive
with or without the intervention. Dramatic results in uncontrolled action.
experiments (such as the results of treatment with penicillin in the
1940s) could also be included in the category.
III: Opinions of respected authorities, based on clinical experience, E. There is good evidence to recommend against the clinical preven-
descriptive studies, or reports of expert committees tive action.
I. There is insufficient evidence (in quantity or quality) to make a rec-
ommendation; however, other factors may influence decision
making.
a
The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.18
b
Recommendations included in these guidelines have been adapted from the Classification of recommendations criteria described in The Canadian Task Force on
Preventive Health Care.18
appropriately selected candidates for TOLAC, vaginal birth intrapartum variables and a combination of maternal,
can be safely achieved for both mother and infant.11−13 obstetric, and fetal factors that affect a woman’s probabili-
ties of a VBAC.
1. Prerequisites for a TOLAC
1. Factors that improve the likelihood of a VBAC (Table 2)
Previous or suspected classical CS
Previous inverted T or low vertical uterine incision Maternal and obstetric factors that are associated with a
Previous uterine rupture higher likelihood of VBAC include Caucasian race, pre-
Previous major uterine reconstruction (e.g., full-thick- vious vaginal birth, having a non-recurring indication
ness repair for myomectomy, repair of m€ullerian for the previous CS, for example, previous CS per-
anomaly, cornual resection) formed for malpresentation, spontaneous labour, and a
Woman requests ERCS rather than a TOLAC favourable cervix or high Bishop score on admission to
birthing unit.27,28 Multivariable regression analysis iden-
tified independent factors associated with higher VBAC
FACTORS THAT AFFECT THE LIKELIHOOD OF A VBAC rates: white race (OR 1.8; 95% CI 1.6−1.9), previous
vaginal delivery (OR 3.9; 95 % CI 3.6−4.3), previous
VBAC rates have been reported to range between 50% and nonrecurring indication such as malpresentation (OR
85%,10,12,21−25 with a Canadian study reporting an overall 1.9; 95% CI 1.0−3.7),29 previous gestational hyperten-
VBAC rate of 76.6%.26 There are many antenatal and sion (OR 2.3; 95% Cl 1.0−5.8),29 or no history of
Table 2. Factors that improve the likelihood of VBAC

Factors Maternal Obstetric Fetal
Antenatal Age ≤30 years Previous vaginal birth Birth weight <4000 g
BMI <30 Previous CS indication not dystocia
White
Intrapartum Spontaneous labour
Bishop score ≥6 on admission
BMI: body mass index.

Table 3. Factors that decrease the likelihood of a VBAC

Factors Maternal Obstetric Fetal
Antenatal Age ≥35 years Previous CS indication is dystocia Birth weight >4000 g
BMI >30
Intrapartum Preeclampsia Need for induction of labour requiring cervical ripening gestational age >40 weeks
Need for augmentation of labour
BMI: body mass index.
dystocia (OR 1.7; 95 % CI 1.5−1.8).27 Intrapartum fac- spontaneous, CS rate during subsequent trials of
tors that are associated with a greater likelihood of a labour at or before 40 weeks was 25% compared
VBAC include spontaneous labour (OR 1.6; 95 % CI with 33.5% after 40 weeks (P = 0.001; adjusted OR
1.5−1.8), cervical dilatation of ≥4 cm on admission, 1.5; CI 1.2−1.8). Similarly, the rate of CSs during
epidural use, gestational age <40 weeks at delivery, and subsequent trials of labour in induced labours at or
birth weight <4000 g (OR 2.0; 95% CI 1.8−2.3).27,28 before 40 weeks was 33.8% compared with 43%
Women who entered spontaneous labour without oxy- after 40 weeks (P = 0.03; adjusted OR 1.5; CI 1.1
tocin use achieved vaginal birth in 80.6% of cases com- −2.2).35
pared with 67.4% of women undergoing induction and Multiple studies have consistently reported a lower
73.9% of those requiring oxytocin augmentation VBAC rate in women with neonatal birth weights of
(P < 0.001). >4000 g. In a study examining the outcome of 365
2. Factors that decrease the likelihood of a VBAC (Table 3) women who underwent a TOLAC and who were giving
birth to neonates weighing more than 4000 g, Zelop
Conversely, factors that negatively influence the likelihood et al. demonstrated a success rate of 60%, with no
of VBAC include increasing maternal age, high maternal increase in maternal or fetal morbidity and no increase
BMI (>30 kg/m2), previous dystocia, IOL, gestational age in the risk of uterine rupture.36 These data support pre-
>40 weeks at delivery, and birth weight >4000 g. Women viously reported findings by Flamm et al. (success rate
who are of advanced maternal age (age ≥35 years) are 58%)37 and Sarno et al. (success rate 67%).38 In 2003
more likely to have a repeat Caesarean birth after a Elkousy et al. reported an examination of 9960 women
TOLAC (OR 1.14; 95% CI 1.03−1.25).30 The study by with a previous CS planning a trial of labour.39 The
Landon et al. noted that women with a pre-pregnancy study was further stratified by neonatal birth weights
BMI >30 were significantly less likely to deliver vaginally and birth history (primarily, whether they had a previous
than women with normal BMI (OR 0.55; 95% CI 0.51 vaginal delivery and whether it occurred before or after
−0.60, P < 0.001).27 In this same study, the VBAC rate in their CS).39 Their results indicate that the likelihood of
women with BMI >30 was 68.4% compared to a higher successful VBAC decreases with increasing birth weight
VBAC rate of 79.6% in normal weight women and is lowest in women who have never had a successful
(P < 0.001). When multiple factors were combined (BMI vaginal birth.36,39 A diagnosis of preeclampsia in the
>30, IOL, and lack of previous vaginal delivery), VBAC index pregnancy has also been associated with a lower
occurred in only 44.2% of cases.27 chance of VBAC.40
When the previous indication for Caesarean birth was for 3. Previous Vaginal Birth
dystocia, failure to progress, or cephalopelvic dispropor-
Previous vaginal delivery is the single most significant
tion, some studies found the rates of VBAC compara-
independent predictor resulting in a VBAC. Women
ble,31,32 while larger studies more consistently reported
with a previous vaginal birth have a high VBAC rate of
lower VBAC rates.12,22,29,33 Similarly, most studies on
86.7% compared to a VBAC rate of 60.9% in women
IOL and VBAC consistently report a lower vaginal deliv-
with no prior vaginal delivery (OR 4.2; 95% CI 3.8
ery rate with IOL (66.3%) compared to spontaneous
−4.5, P < 0.001).27 Women with previous vaginal deliv-
labour (74.1%) (OR 0.66; 95% CI 0.55−0.80).34
ery and previous VBAC have the highest rates of VBAC
Women who deliver after 40 weeks, whether sponta- (86.7% and 89.6%, respectively). With increasing num-
neous or induced labour, have a higher Caesarean bers of prior VBACs, VBAC rates for the index preg-
delivery rate after a TOLAC. When labour onset was nancy also increase: 63.3%, 87.6%, 90.9%, 90.6%, and

91.6% for those with 0, 1, 2, 3, and 4 or more prior VBAC Calculator tool: https://mfmu.bsc.gwu.edu/Pub
VBACs.41 licBSC/MFMU/VGBirthCalc/vagbirth.html)
Recommendations RISKS ASSOCIATED WITH TOLAC AND ERCS

1. Provided there are no contraindications, a trial of Eligible women with a prior Caesarean birth are faced with
labour after Caesarean (TOLAC) should be offered a choice of a TOLAC or ERCS. Candidates for planned
to all women with 1 previous low-segment transverse TOLAC are those women in whom the balance of risks
Caesarean section after appropriate discussion and and chances of VBAC are acceptable to the woman and
documentation of maternal and perinatal risks and the health care provider. It is important to remember that
benefits. The discussion should be documented (II- this balance of risks and benefits may be different from
2B). one woman to another.7
2. Trial of labour after Caesarean is recommended in
women without contraindications to labour, with a In cases where TOLAC is not contraindicated, the benefits
previous vaginal birth, and/or those who present in and risks of both birth options need to be presented to
spontaneous labour as they are good candidates for a women. Ideally, these are presented and discussed early in
trial of labour after Caesarean and have a higher the prenatal period so women have as much opportunity
vaginal birth after Caesarean rate (II-2B). to explore both birth options. Women need to understand
3. Women with factors negatively affecting their the benefits and risks surrounding each option and its
likelihood of vaginal birth after Caesarean can be implications in order to make informed decisions about
offered a trial of labour after Caesarean. However, planning a TOLAC versus an ERCS.
they should be informed that they have a lower
chance of vaginal birth after Caesarean and have an The main body of evidence presented in this section is
increased risk of complications and repeat Caesarean mainly drawn from the most recent systematic reviews28
birth (II-2A). and published national guidelines.7,8,50 Guise et al. (2010)
included the largest number of studies and pooled sample
size that reported on maternal and perinatal outcomes.28
All of the studies included in this review were observa-
Prediction Model tional cohort studies, and all reported outcomes are based
Women who have a TOLAC and achieve a vaginal birth on actual delivery route.
have the fewest complications. The situation that carries
the highest risk of adverse outcome is in a TOLAC result- A recent larger Canadian observational study reports
ing in Caesarean delivery.3,42 It is therefore important to data from 197 540 women with a singleton pregnancy
discuss the probabilities of a VBAC when choosing the at 37 to 43 weeks gestation, with 1 previous Caesarean
intended mode of delivery. delivery between 2003 and 2014.3 These results reflect
more contemporaneous obstetric practice in the Cana-
The probability of a VBAC in a woman attempting dian context.3 In discussing benefits and risks, it is
TOLAC will depend on her specific combination of past important to note that the evidence is limited for a
obstetric history, antenatal factors, and intrapartum factors. number of reasons. First, there are no randomized
A prediction model for TOLAC success has been devel- studies comparing a planned ERCS and TOLAC. Most
oped in the United States for women with 1 prior CS and a of the sources of information are observational studies.
term singleton gestation using factors that can be deter- Second, most studies report outcomes based on actual
mined during the prenatal period.43 This has been vali- route of delivery instead of intended birth plan. This
dated in a Canadian population, among others.44−48 This can lead to misclassification of patients and either over-
model allows a reasonable estimation of the probability of or underestimation of actual risks with each planned
VBAC and may be used in practice as a tool to refine coun- route of delivery. Third, outcomes are defined and
selling and shared decision making during antepartum vis- reported differently among studies.
its for women with a prior CS. Other prediction models
are also available, most with a high predictive value for pre- Finally, it is important to remember that although pooled
dicting VBAC, ranging from 88% to 95%. However, it is estimates attempt to quantify the magnitude of the risks
important to note that most of these prediction models are associated with ERCS and TOLAC, the value that women
poor at predicting unsuccessful TOLAC, with low predic- and providers place on these risks and mode of delivery
tive values ranging from 33% to 58%.49 (The link to the is quite variable. The balance of risks and benefits

appropriate for 1 woman may be unacceptable for another. perinatal databases have supported these findings.52,53
It is important to provide individualized counselling rele- Similarly, Guise et al. reported a significantly increased
vant to each woman and her circumstances. risk of maternal death with ERCS (13.4 per 100 000)
compared to TOLAC (3.8 per 100 000) (RR 0.33; 95%
A TOLAC offers women an opportunity to have a vaginal CI 0.13−0.88) in the analysis of 12 studies that reported
birth. If a woman has a TOLAC resulting in a VBAC, over- maternal mortality.28 The overall maternal mortality is
all risks are lower and risks associated with surgery and CS lower for both TOLAC and ERCS when the analysis was
are avoided. However, a TOLAC has a »25% chance limited to 4 term studies, with the same significantly
of resulting in an emergency CS and a 0.5% chance of lower maternal mortality risk with TOLAC (1.9 per
a uterine rupture and increased perinatal morbidity and 100 000 ) compared with ERCS (9.6 per 100 000)
mortality. (RR 0.27; 95% CI 0.09−0.85).
There are many potential benefits to ERCS. These include The more recent study by Young et al. reports more con-
planning, scheduling, avoiding typical risks associated with temporaneous Canadian data on ERCS and attempted
labour and vaginal birth (such as perineal tears, pelvic floor VBAC from 2003 to 2014.3 However, it did not report
injury), and avoiding an emergency CS. maternal death as a separate outcome and reported it only
Maternal Outcomes
as part of a composite maternal mortality and morbidity.
Major maternal morbidity and mortality includes uterine
rupture, hemorrhage, thromboembolism, infection, and In summary, the absolute risk of maternal death for both
maternal death. TOLAC and ERCS is low (Table 4). Using the estimates
from both the large Canadian study51 and the systematic
Maternal Death review,28 the absolute risk of maternal death associated
In 1 of the largest Canadian studies examining the rates with TOLAC is in the range of 1.6 to 3.8 per 100 000 and
of uterine rupture and maternal death in 308 755 births is 5.6 to 13.4 per 100 000 with ERCS.
in women with a previous Caesarean delivery between
1988 and 2000,51 the authors concluded that while the Uterine Rupture
rates of uterine rupture, blood transfusion, and hysterec- There are numerous studies published relating to uter-
tomy were higher in women who underwent a TOLAC, ine rupture and/or dehiscence. Guise et al. included
the rate of maternal death was lower in women who had only 8 cohort studies that were good or fair quality
a TOLAC (1.6 per 100 000) compared to an elective studies, included the population of interest, and used
Caesarean delivery (5.6 per 100 000) (adjusted OR 0.32; the pre-defined anatomic definition for uterine rup-
95% CI 0.07−1.47). Other studies utilizing large national ture.28 The risk of uterine rupture for all women with a
Table 4. Comparison of maternal risks with ERCS and TOLAC

Maternal outcomes ERCS TOLAC RR or aRR (95% CI)
28
Maternal death 13.4 per 100 000 3.8 per 100 000 RR 0.33 (0.13-0.88)
Maternal death28 5.6 per 100 000 1.6 per 100 000 Significantly higher for ERCS
aOR 0.32 (0.07−1.47)
Maternal morbidity and mortality3 5.6 per 1000 10.7 per 1000 aRR 1.96 (1.76−2.19)
Significantly higher for TOLAC
Uterine rupture28 0.26 per 1000 4.7 per 1000 RR 20.74 (9.77−44.02)
Uterine rupture3 0.50 per 1000 3.3 per 1000 aRR 6.41 (4.84−8.50)
Hemorrhage28 4.6 per 1000 6.6 per 1000 Not statistically significantly different
PPH and blood transfusion3 1.6 per 1000 4.5 per 1000 aRR 2.80 (2.33−3.37)
Hysterectomy28 2.8 per 1000 1.7 per 1000 Not statistically significantly different
PPH and hysterectomy3 0.55 per 1000 0.55 per 1000
Infection28 32 per 1000 46 per 1000 Not statistically significantly different
ERCS: elective repeat Caesarean section; TOLAC: trial of labour after a previous Caesarean section; RR: relative risk; aRR: adjusted relative risk; CI: confidence inter-
val; aOR: adjusted odds ratio; PPH: postpartum hemorrhage.

prior Caesarean delivery regardless of route of delivery In summary, the absolute risks of adverse maternal out-
is 0.3% (95% CI 0.2−0.4). The risk of uterine rupture comes in women with a single previous CS are low. How-
for women undergoing a TOLAC is significantly ele- ever, careful vigilance and monitoring of women who
vated at 4.7 per 1000 or 0.47% (95% CI 0.28−0.77) choose to have a TOLAC are essential as women who
compared with women undergoing an ERCS, 0.26 per have a TOLAC have been consistently shown to have a sig-
1000 or 0.026% (95% CI 0.009−0.082) (RR 20.74; nificantly higher risk of uterine rupture and composite
95% CI 9.77−44.02). The recent Canadian data report severe maternal morbidity and mortality compared to
a higher absolute rate of uterine rupture (including women who have an ERCS.
dehiscence) for both TOLAC (9.93 per 1000 or 0.99%)
and ERCS (1.75 per 1000 or 0.17%).3 However, when
only uterine rupture without dehiscence is reported, the Recommendations
risks are similar to those reported in the systematic 4. Women should be informed that the relative risk of
review for both TOLAC and ERCS (3.3 per 1000 vs. maternal death is higher for elective repeat Caesarean
0.50 per 1000), with the risk of uterine rupture remain- section and the risk of uterine rupture and composite
ing significantly higher for women undergoing TOLAC serious maternal morbidity is higher for trial of
(adjusted RR 6.41; 95% CI 4.84−8.30).3 When both labour after Caesarean, but the absolute risks of
studies are considered,28 noting that the systematic these outcomes are low (II-2B).
review by Guise et al. included studies from the 1990s 5. Women with 1 prior low transverse Caesarean
to early 2000,28 and the largest Canadian study by section should be informed that the baseline risk of
Young et al. reflected more current obstetric practices,3 uterine rupture with a trial of labour after Caesarean
with a large cohort of women with previous CS, a base- is 0.47% (II-2A).
line risk of uterine rupture in women attempting a 6. Women should be informed that most other
TOLAC can be estimated to be 0.47%. maternal complications are not significantly different
between elective repeat Caesarean section and trial of
There were no maternal deaths due to uterine rupture in labour after Caesarean (II-2B).
any of the 8 studies included in the large systematic review.
The risk of hysterectomy due to uterine rupture ranged
from 14% to 33%.28 Risk factors for uterine rupture
Other Maternal Outcomes There are many variables that affect the probabilities of
In most other maternal outcomes reported by Guise VBAC and uterine rupture risk. Most studies use regres-
et al.,28 there were no statistically significant differences sion analyses to provide a better estimate of the influence
noted in hemorrhage, hysterectomy, and infection rates attributable to individual variables. However, the true mag-
between planned TOLAC and ERCS. A trend towards nitude of effect of each variable remains uncertain. And
increased endometritis was seen with ERCS compared more importantly, the combined impact of multiple
with TOLAC; in contrast, chorioamnionitis was increased factors that are often simultaneously at play is even more
in TOLAC compared with ERCS. Increasing BMI was uncertain.
associated with increased fever in patients undergoing
Factors that increase the risk for uterine rupture
TOLAC.28 Young et al. reported an overall composite seri-
ous maternal morbidity and mortality and supports previ-
IOL with cervical-ripening pharmacological agents
ously observed increased risks in women undergoing
Use of oxytocin for augmentation or induction
TOLAC (adjusted RR 1.96; 95% CI 1.76−2.19) with abso-
2 or more prior CSs
lute rates of severe maternal mortality and morbidity still
quite low for both ERCS (5.65 per 1000) and TOLAC
Short interpregnancy delivery interval <18 months
Thin LUS
(10.7 per 1000).3 When maternal mortality and morbidity
Classical or low vertical uterine incision
were restricted to exclude transfusions, women who had a
TOLAC resulting in a vaginal birth appeared to have a Induction of Labour
lower risk (adjusted RR 0.57; 95% CI 0.45−0.73), while Women with a prior CS may require earlier delivery for
women who had a Caesarean birth after a TOLAC had various reasons. IOL is not contraindicated in those
more than double the risk (adjusted RR 2.58; 95% CI 2.25 women with a plan for TOLAC; however, it is important
−2.95) of restricted maternal mortality and morbidity com- for women to understand the potential implications of
pared to ERCS.3 IOL on their chances of a VBAC. More importantly, risks

of uterine rupture associated with specific induction and with oxytocin at 1.1%, followed by PGE2 at 2%, and high-
cervical ripening methods used need to be discussed. est risk with use of misoprostol at 6%.28 The pooled risk
of uterine rupture associated with a trial of labour and IOL
Studies including the review by Guise et al., comparing using any method was assessed (14 fair quality studies,
VBAC rates in women with previous CS whose labour was 12 659 women) is 1.2% (95% CI 0.9%−1.6%) The num-
induced, regardless of induction methods, versus sponta- ber needed to harm appears to be 56 for every IOL (all
neous labour consistently report lower VBAC rates.34 The methods) with TOLAC at greater than 40 weeks gestation.
pooled estimate of VBAC ranged from 63% (95% CI However, these risk estimations may be imprecise given
58%−67%)28 to 66.3%34 with any IOL method and higher the inconsistency in study design and methodology; the
rates of repeat CS (OR 1.52; 95 % CI 1.26−1.83). 34 results should be interpreted with caution.28,57
Uterine rupture risk is also consistently noted to be
increased in women with prior CS undergoing IOL com- Method: Mechanical
pared to spontaneous labour, expectant management, or The review by Guise et al. included evidence limited to 5
ERCS.28,54 Guise et al. reported an overall risk of uterine small studies of low to moderate quality with mechanical
rupture with any IOL method at term to be 1.5% and methods of IOL.28 The pooled estimate VBAC rate from 2
1.0% when any gestational age is considered.28 The risk of of these better quality studies involving 4127 women induced
uterine rupture with IOL appears to be highest (3.2%) in with a Foley catheter is 54% (95% CI 49%−59%).58,59 Two
women over 40 weeks gestation.28 Similarly, Palatnik et al. more recent reviews noted similar VBAC rates (56%−58%)
also reported a significantly higher uterine rupture risk with use of balloon catheters for cervical ripening.60,61 Many
with IOL compared to expectant management (1.4% vs. of these studies reported no cases of uterine rupture, suggest-
0.5%; adjusted OR 2.73; 95% CI 1.22−6.12).54 ing that the use of balloon catheters (without use of other
induction agents) in cases of TOLAC does not appear to be
In women induced with either artificial rupture of mem- associated with an increased risk of uterine rupture compared
branes or oxytocin with a favourable cervix, VBAC rates with spontaneous labour. However, these studies may have
appear to be similar to spontaneous labour (74%).55 Those been too small to identify uterine rupture.
that were induced and needed cervical priming with either
prostaglandins or Foley had a lower VBAC rate (57%).
Method: Oxytocin
Uterine rupture risk ranged from 0.7% to 2.7% in women
with IOL. It is probably more important to note that the Studies looking at oxytocin use are confounded by the fact
uterine rupture risk appears to be different depending on that some studies included oxytocin for induction only, while
the type of induction used. In most settings, a combination others included oxytocin for augmentation. Based on 5 stud-
of IOL methods is used and conclusions cannot be gener- ies that included oxytocin for induction only (augmentation
alized across all induction methods. excluded), the pooled estimate of VBAC is 62% (95% CI
53%−70%).62−66 When data from 6 other studies that
included only oxytocin for augmentation are used, the pooled
Methods of IOL VBAC rate is 68% (95% CI 64%−72%).62−64,67−69 From
A Cochrane review of the various methods of induction for these low quality studies, there appears to be a trend for
TOLAC included 8 randomized trials with a total of only improved VBAC rates when oxytocin is used for augmenta-
707 women,56 comparing any method of third trimester tion compared to oxytocin use for induction. The pooled
cervical ripening or labour induction with placebo/no estimate for the risk of uterine rupture is double that of the
treatment or other methods in women with prior CS baseline risk (1.1%; 95% CI 0.9%−1.5%) following induc-
requiring labour induction in a subsequent pregnancy. A tion or augmentation of labour with oxytocin.26
meta-analysis was not possible due to the heterogeneity of
studies included. It is important to note that there is cur-
rently very limited evidence from these small and under- Method: Prostaglandin E2
powered individual randomized studies. There were 19 studies included in the review by Guise
et al.28 When studies with similar design were combined, a
Use of observational studies, although limited, offers the pooled estimate of 63% (95% CI 58%−69%) of women
best available evidence at this time to inform us of the undergoing a TOLAC with IOL with PGE2 had a VBAC.
effectiveness in achieving a VBAC and potential risks of Pooled analysis of the proportion of women experiencing
different methods of IOL in women with a prior CS. Guise a uterine rupture after PGE2 induction provides a point
et al. reported the lowest rate of uterine rupture risk occurs estimate of 2.0% (95% CI 1.1%−3.5%).

Method: Misoprostol
Misoprostol has been proposed as an effective and eco- 10. Use of oxytocin for induction or augmentation is not
nomical agent for cervical ripening and induction.70 contraindicated in women undergoing a trial of labour
Although use of misoprostol results in a VBAC rate similar after Caesarean. However, use of oxytocin is associated
to that of other cervical ripening agents with a pooled esti- with an increased risk of uterine rupture and should be
mate of 61% (95% CI 27%−90%),28 it is based on very used carefully after appropriate counselling (II-2B).
small studies. It is also associated with a significantly higher 11. Medical induction of labour with prostaglandin E2
risk of uterine rupture in women with a previous CS. Sev- (dinoprostone) is associated with an increased risk
eral small series reported a risk from 0% to 11.7% of uter- of uterine rupture and its use is not recommended
ine rupture with misoprostol in women undergoing a in trial of labour after Caesarean, after appropriate
TOLAC.71−75 Blanchette et al. compared PGE2 to miso- counselling (II-2B).
prostol in women undergoing induction TOLAC and 12. Prostaglandin El (misoprostol) is associated with a
found them to be equally effective, but misoprostol was high risk of uterine rupture and should not be used
associated with a higher incidence of uterine rupture in trial of labour after Caesarean at term (II-2A).
(18.8% compared to no ruptures in the PGE2 group).76
The numbers in all these studies are small, and it is difficult
to draw meaningful conclusions. Until further randomized Women With 2 or More Prior Caesarean Sections
studies are completed, misoprostol is not recommended as
a method of induction or cervical ripening in women with In women with 2 prior CSs, the VBAC rate appears to
previous Caesarean delivery at term.76,77 be similar to those with only 1 prior CS.78−81 A sys-
tematic review included 17 studies comparing outcomes
in women undergoing TOLAC after 1 and 2 prior CS
Recommendations
and those undergoing a repeat CS for the third time.78
7. Induction of labour is not contraindicated in women Six of the studies reported on 50 685 VBAC1 and
undergoing a trial of labour after Caesarean (II-2A). 4565 VBAC2 women who appear to have similar vagi-
8. Women should be informed that induction of labour is nal birth rates (76.5% vs. 71.7%; OR 1.48 [1.23
associated with a lower vaginal birth after Caesarean −1.78]).80−85 However, the risk of uterine rupture,
rate and an increased risk of uterine rupture and blood transfusion, and hysterectomy rates are lower in
should be used carefully after appropriate counselling. women with 1 prior CS compared to women with 2
The risk of uterine rupture with induction of labour prior CS (0.72% vs. 1.59%; OR 0.42 [0.29−0.60];
appears to be highest in women over 40 weeks 1.21% vs. 1.99%; OR 0.56 [0.40−0.77]; 0.19% vs.
gestation (II-2A). 0.56%; OR 0.29 [0.13−0.61]).80−85 Neonatal outcomes
9. Foley catheter may be used to ripen the cervix in appear to be similar in both groups. When compared
a woman planning a trial of labour after Caesarean to 10 897 women having a third repeat CS, women
(II-2B). having a TOLAC after 2 prior CSs (2829 women) had
a higher risk of uterine rupture (1.09% vs.
0.11%).80,81,86−91 There did not appear to be statistical
differences in risks of blood transfusion, hysterectomy,
and neonatal outcomes.78
Table 5. VBAC and uterine rupture risk by type
of induction28 Miller et al. examined the difference in women with 1
IOL method VBAC rate (95% CI) Uterine rupture risk (4100 women) or 2 prior CS (152 women) undergoing
Any IOL method 63% (58%−67%) 1.2% (0.9%−1.6%)
IOL.79 In both groups, VBAC rates are similarly lower
(69% and 65%) compared to pooled estimates of VBAC
Mechanical method 54% (49%−59%) Limited data
rates in general.79 They reported that maternal and neo-
Oxytocin 62% (53%−70%) 1.1% (0.9%−1.5%)
natal composite outcomes in women with 2 prior CS
PGE2 63% (58%−69%) 2% (1.1%−3.5%)
undergoing IOL and TOLAC are similar to those
Misoprostol 61% (27%−90%) 6% women with 1 prior CS and to those having an ERCS.79
VBAC: vaginal birth after Caesarean; IOL: induction of labour; CI: confidence
interval; PGE2: prostaglandin E2.
It is important to note that although the total sample
The pooled estimates on VBAC rate and risk of uterine rupture listed above are
size is large (10 262 women) in this study, the case group
based on fair quality studies with small sample sizes and wide CIs and should be was limited to only 152 women with 2 prior CSs under-
used as a guide only. going a TOLAC.79

Recommendations Interdelivery Interval

13. Women with 2 prior Caesarean sections appear to
Six studies with a total of 9040 women have addressed the
have similar vaginal birth after Caesarean rates as
association between interdelivery interval, TOLAC rates,
those with 1 prior Caesarean section. Women
and uterine rupture risk.100−105 In singleton, term pregnan-
should be informed of a higher risk of uterine
cies with 1 prior Caesarean delivery, VBAC rates do not
rupture in trial of labour after Caesarean with more
appear to be related to the interdelivery interval.102 How-
than 1 Caesarean section. (II-2B)
ever, shorter interdelivery intervals are associated with
14. There are limited studies reporting on outcomes of
increased risk of uterine rupture. The best estimate ranges
women with more than 2 prior Caesarean sections.
from an absolute risk of rupture of 4.8% for an interdeliv-
ery interval of <12 months101,106 and 4.7% for an interval
of <15 months.101 A 2010 study by Bujold et al. showed
Breech that after adjustment for confounding factors, an interde-
livery interval shorter than 18 months was associated with
A large multicentre trial by Hannah et al. demonstrated a significant increase of uterine rupture (OR 3.0; 95% CI
that a planned Caesarean birth is associated with better 1.3−7.2), whereas an interdelivery interval between 18 to
perinatal and neonatal outcomes in breech presentation at 24 months was not (OR 1.1; 95% CI 0.4−3.2).100 There-
term.92 fore, an interdelivery interval shorter than 18 months
should be considered as a risk factor for uterine rupture;
However, the SOGC and other national organizations do however, the rate of uterine rupture between 18 and 24
support the option of a trial of labour in appropriately months (absolute risk 1.9%) was not significantly different
selected patients. There are no data addressing the issue of compared to the rupture rate at more than 24 months
vaginal breech births in TOLAC cases. Therefore, it would (1.3%).100
seem appropriate to consider these cases individually.
External cephalic version is not contraindicated in women Recommendation
with a previous Caesarean birth.93,94 17. Women delivering with <18-month interdelivery
interval should be informed about an increased risk
Recommendation of uterine rupture with trial of labour after
15. It is not an absolute contraindication for women Caesarean (II-2A).
with a breech presentation to undergo a trial of
labour after Caesarean. However, women should be
advised that there is insufficient information to Uterine Thickness
assess risks of trial of labour after Caesarean with a
breech presentation (III-B). Ultrasound measurements of the thickness of the LUS
have been used to predict uterine rupture. However, it is
important to recognize that there are different ways of
measuring it, namely full thickness or myometrium thick-
Multiple Pregnancy ness only. Practitioners must be cognizant of the difference
between these measurements.
Based on 9 studies that have examined a total of 1533
women undergoing TOLAC in multiple pregnancy,95−98 In 2013, Kok et al. performed a meta-analysis that included
the success rate of TOLAC in twin pregnancies appears 21 studies with a total of 2776 analyzed patients to evaluate
similar to that reported for singletons, and there is no clini- the accuracy of antenatal sonographic measurement of
cally significant increase in the uterine rupture rate. LUS thickness in the prediction of risk of uterine rupture
TOLAC is thus possible for women carrying twins. Out- during TOLAC.107 They reported that before the measure-
comes are similar to those women with a singleton preg- ment of LUS thickness can be implemented in clinical
nancy who have a TOLAC.7,57,99 practice, analytical and clinical validity and utility must be
addressed.107 This recent meta-analysis has shown that the
Recommendation methods of measuring full-thickness LUS and myometrial
16. Multiple pregnancy is not a contraindication to a only were found to be equivalent. However, each has a dif-
trial of labour after Caesarean (II-2B). ferent recommended value, specificity, and sensitivity.
There does not appear to be a clear cut-off for predicting

Table 6. Ultrasound measurement of uterine thickness as a predictor of risk of uterine rupture

Measurement Values Specificity Sensitivity
Full thickness 3.1−5.1 mm 0.63 (CI 0.3−0.7) 0.96 (CI 0.89−0.98)
Myometrium only 2.1−4.0 mm 0.64 (CI 0.26−0.90) 0.94 (CI 0.81−0.98)
CI: confidence interval.
uterine rupture. Table 6 presents the strong negative pre- 1- Versus 2-Layer Closure of Low Transverse
dictive value for the occurrence of a defect during TOLAC Caesarean Section
and can be used to guide counselling.107 In 1997 Chapman et al. published a review of 145 women
who underwent a TOLAC after being randomized to either
At this time, we cannot use ultrasonagraphic measure- 1-layer or 2-layer closure in the previous CS.112 They
ments to counsel women to either have or not have a reported no significant difference in the outcome of the next
TOLAC with confidence. The measurement of LUS thick- pregnancy.112 In a 2002 review of 2142 women who under-
ness seems promising in the prediction of uterine defect went a TOLAC, Bujold et al. noted that a 1-layer interlocking
occurrence. Clinical applicability should be assessed in pro- closure was associated with an increased risk of uterine rup-
spective observational studies using a standardized method ture when compared with a 2-layer closure (3.1 % vs. 0.5%;
of measurement.28,107 P < 0.001; OR 3.95; 95% Cl 1.35−11.49).106 In 2011,
Roberge et al. reviewed 9 studies including 5810 women and
Recommendation found that single-layer locked, continuous suturing as
opposed to a double-layer closure of the hysterotomy site
18. Although there is relationship between lower uterine
thickness and risk of uterine rupture, the absolute may increase the risk of uterine rupture in women attempting
TOLAC in a future pregnancy. The risk of uterine rupture
cut-off between safe and unsafe trial of labour after
after an unlocked single-layer closure seems to be compara-
Caesarean does not exist. Therefore, at this time, we
ble with that after a double-layer closure.113
cannot use ultrasonographic measurements of the
lower uterine segment to counsel women to either
have or not have a trial of labour after Caesarean Recommendations
with confidence (II-2B). 19. Women with a classical Caesarean section or T
incision should not have a trial of labour after
Caesarean (II-2A).
Types of Incision 20. Women with a previous low segment CS in which
the uterus was closed in a single layer and who wish
Classical
to attempt trial of labour after Caesarean should be
Women with a prior classical incision are at increased risk
aware that the risk of uterine rupture may be
of uterine dehiscence or rupture (4%−9%).17,23,108 Com-
increased (II-2A).
pared with women with prior low transverse Caesarean
21. Every effort should be made to obtain the previous
delivery, women with prior low vertical Caesarean delivery
Caesarean operative report to determine the type of
or with an unknown scar are not at a significantly increased
uterine incision used. In situations where the scar is
risk of uterine dehiscence or rupture.28
unknown, information concerning the circumstances
Unknown Scar of the previous delivery is helpful in determining the
All records available or obtainable describing the woman’s likelihood of a low transverse incision. If the
previous CS should be reviewed. If unavailable, informa- likelihood of a lower transverse incision is high, trial
tion about the circumstances of the CS will help determine of labour after Caesarean can be offered (II-2B).
the likelihood of a vertical uterine incision.109,110 Most
unknown scars will be lower transverse incisions (92%)
and therefore at low risk for uterine rupture.111 If the his- Maternal Obesity
tory suggests a reasonable likelihood of a classical incision,
it would be prudent to recommend a repeat CS, but in set- VBAC in obese patients may be lower than in women
tings where the history indicates a high likelihood of lower with normal BMI. In women with a pre-pregnancy
transverse uterine incision and the woman wishes to pro- BMI >30, OR is 0.66 (CI 0.54−0.80); in women with a
ceed after counselling, TOLAC is acceptable.111 BMI >35, OR is 0.38 (CI 0.30−0.38).114−116 In

addition, 1 study did report a 5-fold increase risk of Recommendation

uterine rupture/dehiscence (2.1% vs. 0.4%; OR 5.6; 22. Women planning a trial of labour after Caesarean
95% CI 2.7−11.7).115 Furthermore, compared to should be advised that the relative risk of perinatal
ERCS, women with high BMI who have a TOLAC mortality and serious morbidity is higher with trial
have increased maternal morbidity (OR 1.8; CI 1.3 of labour after Caesarean compared to elective
−2.5).115 In addition, decision-to-delivery time may be repeat Caesarean section, but the absolute risk is
longer in women with higher BMI and should be taken low.
into consideration when considering a TOLAC.
Other Factors
CONSIDERATIONS FOR FUTURE PREGNANCIES
Women who had a previous CS for dystocia in the sec-
ond stage of labour are at a higher risk of second stage With increasing numbers of women with Caesarean births,
uterine rupture at next delivery, especially in cases of the incidence of abnormal placentation including placenta
suspected fetal macrosomia or prolonged second previa, accreta, increta, and percreta is also increasing. It is
stage.117 Factors such as uterine extension, presence of therefore important to discuss long-term potential implica-
postpartum fever after CS,118 type of suture material, tions of repeat Caesarean births to all women, particularly
m€ullerian duct anomalies,119 and maternal age120 and those who are planning more than 2 children.
their relation to the risk of uterine rupture have been
examined in small studies, but definitive conclusions Planned lifetime parity of the mother is an important factor
cannot yet be drawn. and may influence the decision to attempt TOLAC. Given
the increased maternal risks associated 3 or more Caesar-
ean section pregnancies, mothers planning higher parity
Neonatal Outcomes
may be more motivated to consider TOLAC after the first
Neonatal mortality and morbidity are primarily related to
pregnancy, if they are appropriate candidates.
uterine rupture. Based on moderate quality studies, neona-
tal death (1.1 per 1000 vs. 0.55 per 1000) and perinatal Placenta Previa
death (1.3 per 1000 vs. 0.5 per 1000) are both significantly A 2010 review of 203 studies found that the estimated
increased with TOLAC compared to ERCS (RR 2.06; 95% absolute risk of placenta previa in women who had under-
CI 1.35−3.13; and RR 1.82; 95% CI 1.24−2.67, respec- gone 1 prior CS is 1.0% (95% CI 0.6%−1.3%), 2 prior
tively).26 Permanent neurological injury is similarly CSs is 1.7% (95% CI 01.1%−2.3%), 2 or more prior CSs
increased in TOLAC (8 per 10 000) compared to ERCS 2.6% (95% CI 1.1%−4.8%), and 3 or more prior CSs
(<1 per 10 000). It was noted that 60% of the cases of hyp- 3.0% (95% CI 2.1%−4.5%).28 Women with a prior CS had
oxic ischemic encephalopathy in cases of TOLAC were a statistically significant increased risk of placenta previa
associated with uterine rupture. The overall risk of perina- compared with women who had not undergone prior CS,
tal mortality due to uterine rupture is reported to be with ORs ranging from 1.48 to 3.95.28
6.2%.29 There were no significant differences in other
reported neonatal outcomes including neonatal sepsis, Prior CS was a significant risk factor for maternal morbid-
Apgar scores, neonatal intensive care unit admission, and ity in women with placenta previa. Women with 1 prior CS
breastfeeding. and placenta previa, compared with women who had pla-
centa previa but no prior CS, had a statistically significant
The increased neonatal risks in TOLAC, including neo- increased risk of blood transfusion (15% vs. 32.2%), hys-
natal death, assisted ventilation, and neonatal seizures terectomy (0.7% to 4% vs. 10%), and composite maternal
were also consistently reported in the recent large Cana- morbidity (15% vs. 23% to 30%). For women with 3 or
dian study.3 The overall neonatal mortality and morbid- more prior CSs and placenta previa, there is a significant
ity were reported to be 14.5% in ERCS compared to increase in the risk of hysterectomy (0.7% to 4% vs. 50%
20.8% in TOLAC, with an adjusted RR of 1.49 (95% to 67%) and composite maternal morbidity (15% vs. 83%,
CI 1.38−1.61).3 Similar to maternal morbidity, neonatal respectively).28
morbidity is significantly increased when attempted
TOLAC results in a repeat Caesarean birth. Respiratory Placenta Accreta
distress syndrome is the 1 neonatal outcome that is sig- The incidence of placenta accreta rose with increasing
nificantly reduced with TOLAC, with an adjusted RR number of prior CSs. The results were statistically signifi-
0.90 (95% CI 0.86−0.94).3 cant for women with 2 or more prior CSs (OR 8.6

−29.8).28 In the presence of a placenta previa, the risk for Women need to understand the evidence in order to make
placenta accreta is increased and increases with increasing informed decisions about planning a TOLAC versus a
number of prior Caesarean sections. For women with planned repeat CS. Delivery discussions and decisions for
more than 3 prior CSs and a placenta previa, they have a future pregnancies following CS should be considered on
50% to 67% incidence of placenta accreta.28 an individual basis as early as the postpartum period.
Informed consent today for any woman who desires a

Recommendation
TOLAC should include a documented discussion of the
23. Women should be informed that the risk of placenta risks and benefits of ERCS versus TOLAC.
previa and placenta accreta increases with increasing
number of Caesarean sections (II-2A). The selection of candidates for TOLAC depends on the
clinical situation and is re-evaluated on an ongoing basis
throughout the pregnancy.
PLANNING A TRIAL OF LABOUR AFTER
CAESAREAN SECTION The appropriate information should be addressed in dis-
cussions with women considering a TOLAC or an ERCS
to assist them in making choices appropriate to their indi-
Antenatal Considerations
vidual circumstances. There is growing evidence that the
A woman and her health care provider must decide
use of formalized decision aids can be very helpful in pro-
together whether an appropriate situation exists for consid-
viding visual explanations of risks and benefits relating to
ering TOLAC. The evaluation and discussion should
choice of TOLAC versus ERCS.122
address the issues outlined below and should be well docu-
mented in the prenatal record or chart. Documentation of There are some excellent resources available to help
the location and type of uterine incision used during the women who are thinking about a TOLAC. One example is
previous CS is ideal.10 In most cases, this information can British Columbia’s Best Birth Clinic handout called “Vagi-
be obtained by reviewing the operative record from the nal Birth After Caesarean and Planned Repeat Caesarean
previous surgery. Other information in this record, such as Birth,” which may be useful.123 A decision support tool
the indication for the CS and the opinion of the previous created by the Ottawa Health Decision Centre may be
surgeon, may be helpful in counselling as well. The fact helpful in assisting women. Both of these centres have
that the record has been reviewed and that no contraindi- established specific prenatal counselling and information
cations to a TOLAC are present should be documented sessions and are currently evaluating their impact on
clearly on the prenatal record.121 Review of the operative VBAC rates.
report from previous hysterotomy or myomectomy should
be documented in detail. If the operative record is not It may also be helpful for practitioners to understand some
available, the scar is considered “unknown.” of the rationales for women’s choices. A review that looked
at the factors that influence women to attempt TOLAC
Antepartum consultation with an obstetrician may be versus planning an elective Caesarean birth identified the
advisable, depending on the clinical situation and local following issues:
practice.
Table 7. Comparison of neonatal risks with ERCS and TOLAC

Neonatal outcomes ERCS TOLAC RR or aRR (95% CI)
28
Perinatal death 5 per 10,000 13 per 10,000 RR 1.82 (1.24−2.67)
Neonatal death28 5 per 10,000 11 per 10,000 RR 2.06 (1.35−3.13)
Permanent neurological injury <1 per 10,000 8 per 10,000
Neonatal seizures3 6 per 10,000 13.8 per 10,000 2.3 (1.65−3.19)
3
Respiratory distress syndrome 55 per 1000 48.5 per 1000 0.90 (0.86−0.94)
Bag/mask ventilation 2.5% 5.4%
TTN28 4.2% 3.6%
Neonatal mortality and morbidity3 14.5 per 1000 20.8 per 1000 1.49 (1.38−1.61)
ERCS: elective repeat Caesarean section; TOLAC: trial of labour after Caesarean section; RR: relative risk; aRR: adjusted relative risk; CI: confidence interval; TTN:
Transient Tachypnea of Newborn.

Physician influence heart rate tracing, persistent abdominal pain, and tachysys-
Recovery time and the need to return to caring for other tole frequently precede uterine rupture in patients undergo-
children ing TOLAC. These intrapartum factors may signal the
Ethnic differences early phases or initiation of the uterine scar separation.125
Safety for mother and baby124
Fetal Heart Rate Patterns and Uterine Rupture
FHR tracing abnormalities, especially complicated variable
Recommendations
or late decelerations and bradycardia (reported in 33% to
24. The process and documentation of informed 100% of uterine ruptures) are the most commonly
consent with appropriate discussion of the maternal observed signs of uterine rupture and are often present 30
and perinatal risks and benefits of trial of labour to 60 minutes before rupture.57,126
after Caesarean and elective repeat Caesarean
section should be a part of the care plan in a woman Leung et al. analyzed the FHR and uterine contraction pat-
with a previous Caesarean section (III-A). tern immediately prior to 78 cases of uterine rupture.127
25. The intention of a woman undergoing a trial of Prolonged deceleration (alone or preceeded by either repet-
labour after Caesarean or elective repeat Caesarean itive late or complicated variable decelerations) occurred in
section should be clearly stated, and documentation 71% of the cases of uterine rupture. In addition, prolonged
of the previous uterine scar should be clearly deceleration occurred in 100% of the FHR tracings in
marked on the prenatal record (III-A). which total fetal extrusion occurred.127 Likewise, Ayres
et al. reported that the most common fetal heart rate
abnormalities that occurred prior to uterine rupture were
INTRAPARTUM MANAGEMENT recurrent late decelerations and bradycardia.128 The
appearance of recurrent late decelerations may be an early
sign of impending uterine rupture.
Early Labour
The management of a TOLAC includes the following: In some cases, it appears that there may be very little warn-
Careful observation of: ing prior to the bradycardia in terms of fetal heart rate
Labour progress—lack of progress with adequate con- changes. However, a multicentre case-control study ana-
tractions for 2 to 3 hours warrants reassessment of the lyzed FHR tracings in the 2 hours preceding uterine rup-
mode of delivery ture during TOLAC and found that in the hour preceding
Fetal well-being uterine rupture, there are often significant FHR abnormali-
Maternal well-being ties. This leads us to consider the possibility of an earlier
Epidural or other analgesia may be used for usual indica- Caesarean section when faced with an atypical or abnormal
tions. FHR tracing before the onset of terminal bradycardia jeop-
EFM during active labour. The EFM tracing is the best ardizing maternal and fetal prognosis.126
marker of uterine rupture.
No need to restrict activity (telemetry can facilitate Poor outcome may occur if the facility cannot provide
mobility while allowing continuous monitoring)15 rapid intervention.
We recommend that the entire care team is made aware of From the above, it is therefore clear that while an abnormal
a TOLAC presence on the birthing unit for optimal situa- EFM tracing does not always imply uterine rupture, it
tional awareness. remains the best single marker that uterine rupture has
ocurred.7,8,129 The classic triad of abnormal FHR, abdomi-
Active Labour nal pain, and bleeding are only present in 9% of complete
Vigilance and early recognition of uterine rupture by the uterine rupture. There has only been 1 small trial that has
health care team are essential components of TOLAC. compared IA to continuous EFM in TOLAC.130 Until
intermittent auscultation in TOLAC has been proven to
Although the presence of risk factors may help identify effectively detect uterine rupture with comparative reliabil-
women at higher risk of uterine rupture, the diagnosis of ity to EFM, it is strongly recommended that careful obser-
rupture can be challenging because there is no single sign vation of FHR patterns through continuous EFM is
that reliably indicates the occurrence of rupture. Compli- performed during active labour.129,130 This is supported by
cated and uncomplicated variable decelerations in the fetal multiple national guidelines.7,8,15

Other Signs of Uterine Rupture revealed that rapid intervention (<18 minutes) between
Classically, other signs and symptoms of uterine rupture prolonged deceleration and birth did not always prevent
include severe metabolic acidosis and serious neonatal disease, but
it may have limited the incidence of neonatal death.132 One
Vaginal bleeding study found that all infants delivered within 18 minutes of
Acute onset of scar pain or tenderness (seldom masked suspected rupture had normal umbilical pH levels (>7.0)
by an epidural; this sign is neither sensitive nor specific) or 5-minute Agar scores greater than 7. There were poor
Other signs and symptoms may include long-term outcomes in 3 infants with decision-to-delivery
times greater than 30 minutes (range 31−42 minutes).131
Hematuria
Maternal tachycardia, hypotension, or hypovolemic shock The evidence cited above suggest that a TOLAC is optimal
Easier abdominal palpation of fetal parts in an institution that has in-house obstetric, anaesthesia,
Unexpected elevation of the presenting part and surgical staff to reduce the decision-to-delivery interval
Chest pain, shoulder tip pain, and/or sudden shortness in cases of suspected uterine rupture. The SOGC acknowl-
of breath edges that this may not be possible in birthing units across
A change in uterine activity (decrease or increase) is an Canada. In settings where an in-house operating room
uncommon and unreliable sign. team and immediate CS is not available, the likelihood of a
VBAC balanced against the risk of prolonging the deci-
sion-to-delivery interval in the case of uterine rupture
Recommendations needs to be carefully considered and a plan of care clearly
documented.7 Women who live in areas where local hospi-
26. The entire team should be made aware of the tals cannot provide immediate CS should be offered the
presence of a woman undergoing a trial of labour opportunity for antenatal (or pre-labour) transfer of care
after Caesarean labouring in the birthing unit and have their labour managed in a facility where this ser-
(III-A). vice is available.135
27. Continuous electronic fetal monitoring of women
having a trial of labour after Caesarean is necessary, All institutions should have a plan for managing uterine
as changes to the fetal heart rate tracing are one of rupture. Regular emergency drills or other simulation exer-
the key indicators of the presence of a uterine cises may be useful for team preparedness in these rare
rupture (II-2A). emergencies.
Recommendations
Timing to Uterine Rupture
28. Suspected uterine rupture requires immediate
A 2012 study by Holmgren et al. regarding uterine rupture attention and laparotomy in order to attempt to
and decision-to-delivery time found that neonates deliv- decrease maternal and perinatal morbidity and
ered within 18 minutes after a suspected uterine rupture mortality (III-B).
had normal umbilical pH levels or 5-minute Apgar scores 29. To optimize maternal and neonatal outcomes in
greater than 7.131 Poor long-term outcome occurred in 3 situations of uterine rupture, a woman having a trial
neonates with a decision-to-delivery time longer than 30 of labour after Caesarean should be cared for in a
minutes.131 However, even with an intervention time less hospital that has resources to perform an immediate
than 18 minutes from the onset of prolonged deceleration Caesarean section (III-B).
to delivery, 2 newborns with severe acidosis had impaired 30. The woman and her health care provider must be
motor development, as described by Bujold and Gauthier aware of the availability of obstetric, anaesthetic,
(2002).132 pediatric, and operating room staff in the setting
where she chooses to give birth (III-A).
Resources (Operating Room Team)
A TOLAC is always associated with a risk of uterine rup-
ture, however small, and a good outcome is not guaranteed CONCLUSION
under any circumstances. The widely accepted standard of
a timely emergency CS (initiated within 30 minutes) TOLAC is recommended in women who have no contra-
although reasonable, may not prevent serious neonatal indications after appropriate discussion. The efficacy and
morbidity and mortality.133,134 Bujold and Gauthier132 safety of a TOLAC in appropriately selected women in

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SOGC CLINICAL PRACTICE GUIDELINE

No. 382, July 2019 (Replaces No. 155, February 2005)

No. 382-Trial of Labour After Caesarean

Clinical Practice Obstetrics Committee: Hussam Azzam, MD,

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BACKGROUND/INTRODUCTION and 3 hospitals (BORN database). Every year over 30 000

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Table 2. Factors that improve the likelihood of VBAC

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Table 3. Factors that decrease the likelihood of a VBAC

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Recommendations RISKS ASSOCIATED WITH TOLAC AND ERCS

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Table 4. Comparison of maternal risks with ERCS and TOLAC

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Recommendations Interdelivery Interval

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Table 6. Ultrasound measurement of uterine thickness as a predictor of risk of uterine rupture

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addition, 1 study did report a 5-fold increase risk of Recommendation

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Informed consent today for any woman who desires a

Table 7. Comparison of neonatal risks with ERCS and TOLAC

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