For providers and their patients, unfortunately, no large rndomized trials have compared outcomes of women with an intent to pursue either TOAC or ERCD. Most studies to date have compared actual routes of delivey rather than the intended route of delivery. hus, we agree with Scott (2011) regarding a "commonsense" approach. The woman-and her partner if she wishes-are encouraged to actively participate with her provider in informed consent. Counseling should include documentation of the prior uterine incision and discussion of risks, benefits, and success rates of TO AC or ERCD. This includes consideration of risks involving uture pregnancies. Ideally, counseling begins preconceptionally and continues throughout pregnancy, with lexible options extending up to delivery. For women who desire TOAC despite a factor that increases their speciic risk, additions to the consent form are recommended by the merican College of Obstetricians and Gynecologists (2017 a). Bonanno and colleagues (2011) have provided such an example. Brief synopses of professional society guidelines are shown in Table 31-4. Guidelines that tend to be more conservative are shown in Table 31-5.
TABLE 31 -5. Conservative Guidelines to Approach a Trial of Labor Following Cesarean Delivery
Early during prenatal care Develop preliminary plan Revisit at least each trimester Be willing to alter decision Have facilities availability
Review relative and absolute contraindications Reconsider risks as pregnancy progresses
Tread carefully: > 1 prior transverse CD, unknown incision, twins, macrosomia
Cautions for induction-unfavorable cervix, high station Consider AROM
Respect oxytocin-know when to quit Beware of abnormal labor progress Respect EFM pattern abnormalities
Know when to abandon a trial of labor
ACOG American College of Obstetricians and Gynecologists; AROM = artificial rupture of membranes;
American College of Obstetricians and Gynecologists (20l7a)
Society of Obstetricians and Gynaecologists of Canada (2005)
Royal College of Obstetricians and Gynaecologists (2007)
Offer to most women with one prior low-transverse incision; consider for t.IO prior low-transverse incisions
Offer to wornen with one prior transverse lowsegment cesarean delivery; withs> 1 prior CD then VBAC likely successful but increased risks
Discuss VB,\C option with women with prior low-segment cesarean delivery; decision between obstetrician and patient Safest with ability for immediate cesarean delivery; patients should be allowed to accept increased risk when not available
Should deliver in hospital in which timely cesarean delivery is available; approximate timeframe of 30 minutes
Suitable delivery suite with continuous care and monitoring; immediate cesarean delivery capability Not precluded: twins, macrosomia, prior lowvertical or unknown type of incision
Oxytocin or Foley catheter induction safe, but prostaglandins should not be used; macrosomia, diabetes, postterm pregnancy, twins are not contrai nd ications
Caution with twins and macrosomia
American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, 2017
American College of Obstetricians and Gynecologists: Guidelines for vaginal delivery ater a previous cesarean birth. Committee Opinion No. 64, October 1988
American College of Obstetricians and Gynecologists: Vaginal delivery after previous cesarean birth. Committee Opinion No. 143, October 1994 American College of Obstetricians and Gynecologists: Vaginal birth ater previous cesarean delivery. Practice Bulletin No.r2, October 1998 American College of Obstetricians and Gynecologists: Vaginal birth after previous cesarean delivery. Practice Bulletin No.r5, ] uly 1999 American College of Obstetricians and Gynecologists: External cephalic version. Practice Bulletin No. 161, February 2016