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©2013 UpToDate ® Print Email American College of Obstetricians and Gynecologists Practice Bulletin on vaginal birth after cesarean The following recommendations are based on good and consistent scientific evidence (Level A): Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC. Epidural analgesia for labor may be used as part of TOLAC. Misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery. The following recommendations are based on limited or inconsistent scientific evidence (Level B): Women with two previous low transverse cesarean deliveries may be considered candidates for TOLAC. Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC. External cephalic version for breech presentation is not contraindicated in women with a prior low transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from external cephalic version and TOLAC. Those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (eg, those with placenta previa) are not generally candidates for planned TOLAC. Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC. TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision. The following recommendations are based primarily on consensus and expert opinion (Level C):

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC. TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision. The following recommendations are based primarily on consensus and expert opinion (Level C): A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries. Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital's resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives. After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her health care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documentation of counseling and the management plan should be included in the medical record. TOLAC: trial of labor after cesarean delivery; ERCD: elective repeat cesarean delivery. Reproduced with permission from: ACOG Practice Bulletin No. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010; 116:450. Copyright © 2010 Lippincott Williams & Wilkins.