Trial of Labor (VBAC)

Definition
• Trial of labor after cesarean delivery (TOLAC) refers to a planned
attempt to deliver vaginally by a woman who has had a previous
cesarean delivery, regardless of the outcome.
• This method provides women who desire a vaginal delivery the
possibility of achieving that goal—a vaginal birth after cesarean
delivery (VBAC)
• About 60-80% of women who have had prior C-sections and no other
risk factors can successfully deliver a baby vaginally with their future
pregnancies
https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/02/vaginal-birth-after-cesarean-delivery
Advantages
• The ability to experience a vaginal birth
• No abdominal surgery
• Lower risk of infection
• Less blood loss
• Shorter recovery time
• Less health issues linked to multiple C-sections (including bowel or
bladder injury, hysterectomy, or problems with the placenta in future
pregnancies)
Who can pursue TOLAC ?
• Have one previous cesarean delivery with a low-transverse uterine scar, have no
other problems that would prevent a VBAC, and are counseled about a VBAC. Low
transverse uterine scars are low, side-to-side cuts made across the thinner part of
the uterus. This is the most common type of c-section scar and carries the least
likelihood of uterine rupture of all of the c-section scars.
• Have two previous low-transverse cesarean deliveries, have no other problems
that would prevent a VBAC, and are counseled about a VBAC.
• Have one previous cesarean delivery with an unknown uterine scar as long as it is
not suspected that that scar was a classical uterine incision.
• Are having a single baby (as opposed to twins, triplets or other multiples). Or one
previous low-transverse cesarean delivery who are otherwise good candidates for a
twin vaginal birth.
 • Pregnancy that continues past 40 weeks
Contraindication Advanced maternal age (over 35 years) Prior
uterine scarring, complications, or prior
• Maternal obesity
rupture
• placenta previa
• Prior extensive trans fundal uterine surgery
• Previous stalled labor (dystocia)
• A prior high vertical or “classical” uterine
• Previous need for induction
incision (an up-and-down cut made in the
• If the mother has had less than 24 months
upper part of the uterus) or an unknown
since her previous pregnancy
uterine incision that is suspected to be high
• Single-layer closure in prior c-section vertical.
• Genital herpes
• High vertical incisions carry the highest risk
• Gestational diabetes of uterine rupture
• Fetal distress
• A history of two or more C-sections
Maternal risk Fetal risk

• Uterine rupture • Stillbirth

• Uterine dehiscence • Neonatal death
• Hysterectomy • Hypoxic Ischemic
• Maternal death Encephalopathy (HIE)

characteristics are some of the biggest risk factors for a uterine rupture after a former C-section (8):
•Previous pregnancy involved a uterine rupture
•Previous C-section involved a fundal or high vertical hysterotomy (these are specific types of uterine
incisions)
•The mother is being induced (in the current pregnancy). ACOG recommends against the use of
Cytotec (misoprostol) for women undergoing a VBAC. Pitocin (synthetic oxytocin) may also increase the
risk of uterine rupture.
Risk Factors for Unsuccessful VBAC
• No previous vaginal birth
• High BMI > 30
• Birth weight > 4kg
• Advanced maternal age
• Short stature
• Less than 2 years from previous
caesarean section
Midwifery Care and Intervention.
Antenatal counselling should be
given prior to TOLAC -> to alert
women, give reassurance and make
informed choices.
Provide accurate information in
easy-to-understand terms and
clarify misconceptions.
Able to recognize sign symptoms of
uterine rupture and response to
them.
Take note on complete history of Assess psychological response to
previous caesarean section and events and availability of support
screen for indication and systems -> relieve anxiety and give
contraindication for VBAC. advices
Ensure the women’s husband Continuously monitoring fetal heart
signed consent for urgent LSCS -> rate using CTG monitor.
When VBAC delivery attempts fail,
a C-section is required. Medical
professionals must discuss the
potential for an emergency C-
section with the mother and obtain
informed consent.
Assess and record contraction to Inform the women all the risk and
prevent overstimulation of uterus chances of TOLAC
and may cause uterine rupture.