Trial of labour after caesarean delivery

  • Trial of labour after cesarean (TOLAC) is a safe resort to repeat cesarean delivery in Pregnant people who have had a previous cesarean delivery or an elective cesarean. In Patients with a high likelihood of vaginal birth after cesarean (VBAC), TOLAC is recommended.
  • Three-fourths of people who attempt TOLAC will have a VBAC- Induction of labour decreases the likelihood of VBAC but is safe with mechanical cervical ripening, oxytocin and amniotomy.
  • Uterine rupture is a rare complication of TOLAC accounting for only 0.47% of cases. This risk boosts with 2 or more cesarean deliveries (1.6%), <18 months gap between deliveries (4.7%), or induction of labour (1.2%).
  • Hospital-based care is required for TOLAC- Continuous fetal heart monitoring is needed during active labour. Uterine rupture is presented with an abnormal fetal heart tracing, especially complicated variable, late or prolonged decelerations. In suspected uterine rupture cases, an emergency laparotomy and urgent delivery are needed. Therefore, onsite surgical and anesthesia teams are a must to support TOLAC.
  • Patients should be counselled regarding their eligibility for TOLAC- Early counselling regarding TOLAC and >/=18-month inter-delivery interval after cesarean will increase the acceptance of TOLAC and cause lower cesarean delivery rates.  
  • Contraindications of TOLAC- Previous or suspected inverted T or vertical uterine incision, history of uterine rupture or major uterine reconstruction, including myomectomy describes the absolute contraindications. In cases of unknown previous uterine incision orientation, TOLAC is not contraindicated unless the cesarean was for a very preterm infant, as it may be associated with a vertical incision.

SOURCE- Miazga E, Shore EM. Trial of labour after caesarean delivery. CMAJ. 2022;194(1): E13. doi:10.1503/cmaj.211686

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