Birth Policy Resources

Birth Policy Resources: "Trial of Labor After Cesarean (TOLAC)
Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section
American Academy of Family Physicians

Executive Summary

The American Academy of Family Physicians Commission on Clinical Policies and Research convened a panel to systematically review the available evidence on trial of labor after cesarean delivery (TOLAC) using the Agency for Healthcare Research and Quality Evidence Report on Vaginal Birth After Cesarean (VBAC). The panel’s objective was to provide an evidence-based clinical practice guideline for pregnant women and their families, maternity care professionals, facilities, and policy-makers who care about trial of labor and maternity care for a woman with one previous cesarean. The recommendations are as follows:

Recommendation 1: Women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL). (Level A)

Recommendation 2: Patients desiring trial of labor after previous cesarean (TOLAC) should be counseled that their chance for a successful vaginal birth after cesarean (VBAC) is influenced by the following: (Level B)

Positive Factors (increased likelihood of successful VBAC)

Maternal age <40 years
Prior vaginal delivery (particularly prior successful VBAC)
Favorable cervical factors
Presence of spontaneous labor
Nonrecurrent indication that was present for prior cesarean delivery

Negative Factors (decreased likelihood of successful VBAC)

Increased number of prior cesarean deliveries
Gestational age >40 weeks
Birth weight >4,000 g
Induction or augmentation of labor

Recommendation 3: Prostaglandins should not be used for cervical ripening or induction as their use is associated with higher rates of uterine rupture and decreased rates of successful vaginal delivery. (Level B)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes. (Level C) At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Recommendation 5: Maternity care professionals need to explore all the issues that may affect a woman's decision including issues such as recovery time and safety. (Level C). No evidence based recommendation can be made regarding the best way to present the risks and benefits of trial of labor after previous cesarean delivery (TOLAC) to patients.

AAFP Policy Action March 2005 -- Printed July 2005
Copyright� 2005 American Academy of Family Physicians

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