PUROC, LIZA M.

BSN-II
JOURNAL READING: OB WARD

Factors associated with successful vaginal birth after a

cesarean section:
A systematic review and meta-analysis

Background

Cesarean delivery rates have increased dramatically worldwide. In the United States, cesarean section (CS) rates increased
from 5% of all deliveries in 1970 to a high of 31.9% in 2016.Although efforts were made to reduce the number of CS, it
failed to achieve the 15% rate recommended by the World Health Organization (WHO).

Repeat CS is the most significant factor contributing to overall increased CS rates. The primary indication of repeat CS is
a prior CS. The trial of labor after cesarean (TOLAC) is an attempt to reduce CS rates. Several national medical
associations have provided practice guidelines for vaginal birth after cesarean section (VBAC), but these differ across
countries [6]. Generally speaking, VBAC is relatively safe when compared with repeat CS. However, TOLAC rates have
dropped significantly worldwide in recent years.

For women with a prior cesarean delivery, a trial of labor will often represent her last opportunity to experience a normal
birth. However, a failed VBAC increases the risk of maternal and perinatal complications more than an elective repeat CS.
A potential solution to the concerns related to VBAC would be a more accurate selection of patients opting for TOLAC.
Early communication to discuss women’s prospects for VBAC success and their attitudes towards future births might be
valuable. The probability of successful vaginal birth is one of the most crucial factors in the decision-making process
during the prenatal counseling of these women.

Two previous meta-analyses were published in 1990 (Rosen et al.) and in 2010 (Eden et al.). Rosen et al. focused on the
indicators in the previous cesarean for VBAC success. Eden et al. focused on studies about predictors of VBAC, which
were conducted in developed countries. They found that cephalopelvic disproportion (CPD) in the previous cesarean,
previous breech, previous vaginal delivery, more than one previous cesarean, Hispanic ethnicity, advanced age, birth
weight heavier than 4 kg, and use of either augmentation or induction affected the likelihood of VBAC. However, no
previous meta-analysis has focused on the influences of obesity, diabetes, hypertensive disorders complicating pregnancy
(HDCP), gestational weeks, and interdelivery interval on the chance of VBAC, which were conflicting.

Therefore, we aimed to perform a systematic review and meta-analysis of all published reports until 2018 of vaginal birth
after one previous cesarean and maternal or fetal factor from the historical and current pregnancies, and to quantify the
magnitude of each factor and the quality of the supporting data.

Methods

The study was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE)
recommendation. We have reported our findings following the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) reporting guidelines. We submitted the protocol to Prospero before initiation of the analyses.

Literature search
A search for the following sources was performed from database inception until March 16, 2018: Medline, Embase, and
Cumulative Index to Nursing and Allied Health Literature. We used Medical Subject Headings, keywords and word
variants for the trial of labor, vaginal birth and cesarean in the search strategy, with the help of an experienced librarian.
Bibliographies of selected review articles were reviewed for additional relevant studies. Only studies about human data
published in or translated into English were included. The Countway Library of Medicine at Harvard Medical School
assisted with crafting and implementing the literature search,

Exposure
Exposure was defined as maternal or fetal factors for VBAC. Factors related to previous pregnancies included: previous
vaginal birth (VB) before CS, previous VBAC, and indications for the previous CS. Factors from the current pregnancy
included: age (year), body mass index (BMI, kg/m2), obesity (BMI ≥ 30 kg/m2), smoke, race (White, Asian, Black,
Latina), diabetes (pre-existing, gestational diabetes mellitus), hypertensive disorders complicating pregnancy (HDCP),
interdelivery interval (between the last two pregnancies), gestational weeks, Bishop score at admission before delivery,
labor induction, epidural anesthesia during labor, and macrosomia (birth weight ≥ 4 kg).

Outcome
TOLAC was defined as an attempt at vaginal delivery after a previous cesarean section. A successful VBAC is defined as
spontaneous or instrumental (assisted by vacuum or forceps) delivery to a woman undergoing TOLAC. A failed VBAC is
defined as failure to achieve a VBAC and the delivery ending by emergency cesarean section. In the study, all of the
pregnant women had experienced TOLAC, and were grouped as successful VBAC or failed VBAC.

Inclusion criteria
The target population of the study included women of child-bearing ages, with a single gestation and, one previous
cesarean delivery, and that were candidates for attempted vaginal birth.

The following criteria were required for eligibility: 1) mean and SD of the continuous factors and N in women with
successful VBAC and failed VBAC, or 2) unadjusted and/ or adjusted odds ratio (OR) and 95% confidence interval (CI)
for the binary factors in women with successful VBAC and failed VBAC, or 3) raw N for the 2*2 tables to calculate the
OR and 95% CI for the binary factors in women with successful VBAC and failed VBAC.

Exclusion criteria
We excluded women with more than one previous cesarean delivery; known previous classical uterine incision or T-
incision, prior uterine rupture, or extensive transfundal uterine surgery, multiple gestations, and those in whom vaginal
delivery is otherwise contraindicated (e.g., those with placenta previa).

Data extraction
Two authors (YW and YK) examined studies on the basis of inclusion and exclusion. Studies were initially reviewed on
titles and abstracts, and those deemed relevant were reviewed in full text. Disparities in selection were resolved through
discussion and ultimately by the third reviewer (CE). In cases of study duplication, the more recent studies were selected
for inclusion. Data were extracted by two authors (YW and YK) to verify the accuracy.

Assessment of risk of bias

The quality of each study was evaluated and scored independently by two authors (YW and CE) using the nine-star
Newcastle-Ottawa Scale (NOS). Studies were evaluated based on selection, comparability, exposure, and outcome, and
scored by a maximum of nine points. Scores above five indicate moderate to high study quality. The NOS for cohort and
case-control studies was retrieved from: http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf.

Data synthesis
From each study, we extracted or estimated the odds ratio (OR) for each factor and outcome of interest, with the 95%
confidence intervals (CI). We also extracted mean and SD for continuous variables of each factor. We used the statistical
program Stata 14.0 and the commands “metan” to calculate random effects summary estimates. For continuous variables
we used standardized mean differences (SMD) with 95% CI. For binary variables, we used ORs and 95% CIs. Statistical
heterogeneity was assessed graphically with forest plots and statistically using Cochran’s Q-statistic and the I2 value.
Publication bias was measured by Egger’s test and by visually assessing funnel plots. YW and CE were responsible for
the data synthesis.

Results
The study selection process is shown in Additional file 1. A total of 94 studies were included in our analysis. Twenty-
eight were prospective cohort studies, and 66 were retrospective observational studies. No randomized trials were
identified. The number of women in the included studies ranged from 28 to 75,086. Details of the selected studies and the
data extracted from each study were shown in Additional file 19: Table S2. The Newcastle–Ottawa Scale revealed a score
of 7–8 in case-control studies and 6–9 in cohort studies. In total, 239,006 women who attempted a TOLAC were included;
the successful rate of VBAC was 68.4%. Compare to the other continents, women in African region achieved the lowest
successful rate (54.1%) of VBAC (P < 0.05).

Factors not associated with likelihood of VBAC were the following: smoke (OR, 1.11; 95% CI, 0.97–1.27), interdelivery
interval (OR, 1.24; 95% CI, 0.99–1.55; adjusted OR, 0.99; 95% CI, 0.83–1.19) (Additional file 15: Figure S15B and
S15C), gestational weeks (OR, 0.84; 95% CI, 0.63–1.12; adjusted OR, 0.95; 95% CI, 0.85–1.06) (Additional file 16:
Figure S16B and S16C), epidural anesthesia (OR, 0.71; 95% CI, 0.33–1.54) (Additional file 17: Figure S17), and the
indications for previous CS (fetal distress (OR, 1.01; 95% CI, 0.87–1.17) (Additional file 9: Figure S9C), HDCP (OR,
0.71; 95% CI, 0.29–1.75) (Additional file 9: Figure S9A), and suspected fetal macrosomia (OR, 0.56; 95% CI, 0.30--1.04)
(Additional file 9: Figure S9A).

We also performed the analysis by subgroup for age, BMI, diabetes, and HDCP. Advanced age (age ≥ 35 years-old) is
associated with VBAC failure (OR, 0.97; 95% CI, 0.85–1.11; adjusted OR, 0.75; 95% CI, 0.65–0.86). Pre-pregnancy
BMI, BMI at first prenatal visit or BMI at admission before delivery of women with successful VBAC were lower than
those of women with failed VBAC (Additional file 3: Figure S3). Obesity (BMI ≥ 30 kg/m2) was a risk factor for failed
VBAC (OR, 0.50; 95% CI, 0.39–0.64). Both pre-existing diabetes (OR, 0.42; 95% CI, 0.33–0.55) and gestational diabetes
mellitus (GDM) (OR, 0.53; 95% CI, 0.43–0.66) were identified as risk factors for failed VBAC. The trends were similar
in chronic/pregnancy-induced hypertension (OR, 0.62; 95% CI, 0.46–0.83) and preeclampsia/eclampsia (OR, 0.50; 95%
CI, 0.36–0.69).

Heterogeneity and publication Bias and sensitivity analysis

Almost all point estimates were in the same direction, and I2 heterogeneity < 50% was detected in the following meta-
analysis: OR and adjusted OR of advanced age, SMD of BMI (pre-pregnancy or at admission before delivery), OR of pre-
existing diabetes, adjusted OR of HDCP, adjusted OR of macrosomia, OR and adjusted OR of previous VBAC, adjusted
OR of Black race, adjusted OR of Asian race, adjusted OR of Latina race, OR of Bishop score, adjusted OR of gestational
weeks, and OR of indications for previous CS (such as CPD, failed induction, and suspected fetal macrosomia). The rest
of the meta-analyses had either point estimates in both directions or I2 heterogeneity > 50%. If I2 heterogeneity > 50%
and P-value < 0.05, the meta-analysis was stratified by study size, location and study design. After stratifying by
subgroup, most I2 heterogeneities became lower (Additional file 21: Table S4). Except for the SMD of age and OR of
BMI, there was no evidence of publication bias in the meta-analysis.

DISCUSSION

Main findings
Based on the meta-analyses, the following factors were associated with a successful VBAC: previous VB before CS,
previous VBAC, White race, higher bishop score, and fetal malpresentation as the indication for previous CS. The
following factors were associated with an unsuccessful VBAC: advanced age, obesity, diabetes, HDCP, non-white race,
macrosomia, labor induction, and CPD, dystocia or FTP, failed induction as the indications for previous CS. The
following factors are not statistically associated with VBAC success: smoke, interdelivery interval, gestational weeks,
epidural anesthesia during labor, and the indications for previous CS (fetal distress, HDCP, and suspected fetal
macrosomia).

Understanding the influences of factors on VBAC could provide sufficient evidence to assess chances for achieving a
successful vaginal delivery among women with prior CS. It also could help the clinician provide evidence-based
counseling about VBAC, which has important implications on avoiding repeated CS. The evidence quality was considered
moderate on the Newcastle-Ottawa Scale.

Strengths and limitations

This meta-analysis is the most recent that comprehensively, critically, and quantitatively assesses the association between
maternal or fetal factors and the chances for achieving a successful VBAC, including factors both from the historical and
current pregnancies. It is also the first large study to specifically evaluate the association between obesity, diabetes,
HDCP, gestational weeks, interdelivery interval and VBAC success. However, this study has limitations. First, there
might be pertinent studies that were not identified owing to inherent limitations in database literature searches. Second,
the quality of evidence is limited by data largely derived from retrospective observational analyses, with heterogeneous
data reporting and study design. Third, after subgroup analyzed by study size, location, and study design, I2 heterogeneity
was still high in some meta-analysis, which might result from the change of the guidelines on VBAC or guidelines
varying in different countries. Forth, there was publication bias in the meta-analyses of the SMD of age and the OR of
BMI, which might be because positive results are more likely to be published compared to null studies and almost these
studies showed the similar trends of the factors related to VBAC. Five, some studies did not present adjusted OR;
however, the pooled unadjusted OR was similar to the adjusted OR.

Interpretation

Historic maternal and fetal factors

Having experienced a vaginal birth (VB), either before CS or after CS, tripled the success rates of VBAC. Moreover, the
previous VBAC was a stronger predictor of success than previous VB before CS. These findings can further confirm that
the history of past vaginal deliveries is of the utmost importance. Previous VB also related to the lower rate of uterine
rupture [18].

Indications for previous CS have important implications for the chance for VBAC. CPD, dystocia or failure to progress,
failed induction, and suspected fetal macrosomia were risk factors for failed VBAC. Although the above conditions might
not be present in the next pregnancy, the indications for previous CS could help us to identify the VBAC candidates.

Current maternal and fetal factors

Increased age decreases the likelihood of VBAC. Women with advanced age were more likely to fail to VBAC, which
was also supported by Eden et al. Age ≥ 40 years-old was also a risk for uterine rupture when women undertook TOLAC.
So, younger women, especially that < 35-years-old, are more likely to have a successful and safe VBAC.

Maternal obesity carries the risk for many obstetric complications including macrosomia and increased risk of CS. Both
obesity and macrosomia have negative impacts on VBAC success. When comparing cases where obesity occurred at pre-
pregnancy or at admission before delivery, the trends are similar. Faucett et al. found that women with obesity were more
likely to undergo emergency cesarean for an arrest disorder before achieving active labor despite having more clinical
interventions to achieve a vaginal birth. A better understanding of the mechanisms by which maternal obesity affects the
progression of labor, might help to increase the rates of successful VBAC among this population. Maternal obesity was
also associated with a high risk of uterine dehiscence or rupture at term gestation among women with previous CS [110].
Therefore, appropriate weight and weight gain during pregnancy are vital for maternal health.

Gestational and pregestational diabetes are risk factors for VBAC failure. Diabetic women could be at high risk of CS
secondary to failed induction, labor arrest, and fetal distress. Furthermore, pregnant women with diabetes are more likely
to have increased BMI and weight gain, both of which have a negative influence on VBAC success. Prevent and control
diabetes could help to increase the likelihood of VBAC.

HDCP has a negative impact on the VBAC success. HDCP could cause maternal vasospasm, which results in placental
damage and relative insufficiency, leading to intrauterine fetal growth restriction (IUGR). These changes in vascular
physiology could predispose women to a VBAC failure due to nonreassuring fetal status. Fortunately, it was found that
HDCP did not increase the risk of uterine rupture.

Our results show that interdelivery interval is not associated with a VBAC success. The interdelivery interval shorter than
24 months doesn’t relate to VBAC failure. However, there is only one study reporting the association between the
interdelivery interval shorter than 18 months and the likelihood of VBAC, so we couldn’t conduct a meta-analysis to make
sure whether the interval shorter than 18 months is a risk for failed VBAC.

Compared to spontaneous labor, induction of labor is more likely to decrease the likelihood of VBAC. However, an
unfavorable cervix also decreases the chance of VBAC success. Whether to perform induction of labor and when to do it
are the questions we meet in clinical practice. Our results showed that the gestational week at delivery is not associated to
the VBAC success, whether the cut-off point was 37 gestational weeks, 40 gestational weeks or 41 gestational weeks. One
recent study revealed that induction of labor at 39 gestational weeks could increase the chance of VBAC compared to
expectant management, but also of uterine rupture. Thus, we should consider both benefits and harms to perform
induction of labor for appropriate VBAC candidates. Gestational week might not serve as an argument for or against
VBAC.

Smoke and epidural anesthesia are not associated with the chance of VBAC in our study. However, smoke could increase
susceptibility for nonreassuring fetal heart rate, especially in the second stage of labor, leading to higher rate of
instrumental delivery. Pain relief during labor makes women more likely to choose TOLAC. However, epidural
anesthesia could also relieve the pain caused by uterine rupture, which clinicians should be highly aware of.

During the prenatal counseling of women with one previous cesarean section, the probability of successful vaginal birth is
one of the most crucial factors. The history of previous delivery (previous VB before CS, previous VBAC and the
indications for previous CS), the characteristics of the pregnant women (age and race), the complications (obesity,
diabetes and HDCP), the size of the fetus, the bishop score of the cervix, and the necessity of labor induction should be
highly considered, which were associated to the success of VBAC. The clinicians should be also aware that uterine
rupture could complicate with TOLAC. TOLAC under continuous monitoring by a skilled clinician and at facilities with
24-h surgery services should be guaranteed to increase the safety of the delivery.

Conclusions

Our results find that age, obesity, diabetes, HDCP, Bishop Score, labor induction, birth weight, previous vaginal birth, and
the indications for the previous CS should be considered as the factors related to the success of VBAC. This meta-analysis
provides the most comprehensive review of previously reported maternal and fetal factors for the chance of VBAC. We
believe that the results are important for women who are pregnant or are planning to become pregnant after a previous CS.

Availability of data and materials

All data analyzed during this study are included in this published article and its supplementary information files.

Abbreviations

BMI:
Body mass index
CI:
Confidence interval
CPD:
Cephalopelvic disproportion
CS:
Cesarean section
HDCP:
Hypertensive disorders complicating pregnancy
OR:
Odds ratio
SMD:
Standardized mean differences
TOLAC:
Trial of labor after cesarean
VB:
Vaginal birth
VBAC:
Vaginal birth after cesarean section
WHO: World Health Organization

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LEARNING INSIGHTS:

What I really know is that when you gave birth through CS then the next time you will give birth is should also be CS
again. “Once a C-section, always a C-section.” This is what doctors used to tell women who had a cesarean section. But
it’s not true for everyone. It changed when I read this article.
Vaginal birth after cesarean section (VBAC) often is an option. In fact, studies have shown a 60 to 80 percent success rate
for women who attempt VBAC.
The American Congress of Obstetricians and Gynecologists recommended VBAC as a safe and appropriate choice for
most women who have had a prior C-section. However, not all doctors or hospitals are equipped to handle a VBAC, and
some simply choose not to do them.
I think VBAC is wonderful option for many women. But it’s a personal decision that should be made after carefully
weighing the risks and benefits and your plans to have more children.
Regarding the VBAC (Vaginal birth after cesarean section), we had encounter a patient who’s case is VBAC, and we tried
to ask the patient if it is safe and she answers “yes, since there is no complications found and the doctor suggested so I try
since they guarantee me of assurance and safety of the baby and me”.

According to research, the evidence suggests that most patients who have had a low-transverse uterine incision from a
previous cesarean delivery and who have no contra-indications for vaginal birth are candidates for a trial of labor.
Criteria for selecting candidates for VBAC include the following:
(1) One previous low-transverse cesarean delivery;
(2) Clinically adequate pelvis;
(3) No other uterine scars or previous rupture;
(4) A physician immediately available throughout active labor who is capable of monitoring labor and performing
an emergency cesarean delivery; and (5) the availability of anesthesia and personnel for emergency cesarean
delivery.
(5) If you’ve had a previous vaginal delivery: This includes if you’ve already had a successful VBAC.
(6) Age: A 2007 study found that women younger than 35 were more successful and had fewer complications
during a VBAC.
(7) Incision: A low-transverse (horizontal) uterine incision is the optimal incision for VBAC.
(8) Reason for first C-section: Your chance of VBAC success increases if you’re C-section was for what we call a
non-repetitive indication. This means the C-section was performed for the baby’s health, not because of the actual
labor process. Examples include a breech baby or abnormal fetal heart rate tracing.

The report also discusses other specific obstetric circumstances where a trial of labor may be offered. According to the
report, for women who have had two previous low-transverse cesarean deliveries, only those with a previous vaginal
delivery should be considered candidates for a spontaneous trial of labor. They state that 60 to 90 percent of women
attempting a trial of labor who give birth to infants with macrosomia are successful, and the rate of uterine rupture appears
to be increased only in women who have not had a previous vaginal delivery. Awaiting spontaneous labor beyond 40
weeks of gestation decreases the likelihood of successful VBAC but does not increase the risk of uterine rupture.
According to one case series and four retrospective studies, women who have had a previous low-vertical uterine incision
were just as likely to have successful VBAC as women who have had a previous low-transverse uterine incision. Two
trials showed no significant difference between rates of successful VBAC and uterine rupture between women with twin
or singleton gestations.

WHEN DO WE NOT RECOMMEND VBAC?

There are few instances in which they would say no to a VBAC. Other times they may tell you that your chances aren’t
great, but we can try. In those cases, we’ll have a conversation about the risks and at what point during labor we would go
for a C-section.

Incision: Most physicians — will not attempt a VBAC if your previous C-section resulted in a vertical incision (known as
a “classical” incision) or a T-shaped incision. These put you at higher risk for uterine rupture.
Labor dystocia: This refers to an abnormally slow or difficult labor. If your previous C-section was because of this, it
doesn’t exclude you from trying VBAC, but we’ll talk about how long we want to attempt vaginal labor.
Multiple C-sections: Your chance of a successful VBAC goes down with multiple C-sections. Not every physician will
feel comfortable working with you to try VBAC after a second C-section. Nearly no physician will try it after three or
four C-sections.
Health complications: An emergency C-section can be especially dangerous if you have a condition such as lung disease
or a heart defect. In these cases, we will even more carefully weigh the risks and benefits of VBAC.
Having a large baby: We still can’t pinpoint fetal weight in the third trimester, but if we suspect your baby is over 10
pounds, we may suggest rethinking a VBAC.
Going past your due date: If you go beyond 40 weeks of pregnancy, the odds of induction and having a large baby
increase. Many doctors are reluctant to induce labor in a patient with any type of prior uterine surgery because of concerns
for an increased risk of uterine rupture.

HOW CAN YOU INCREASE YOUR CHANCES FOR A SUCCESSFUL VBAC?

Many factors that contribute to a successful VBAC are out of your hands, but there are things you can do to increase your
chances:

Talk with your doctor about VBAC early in the pregnancy: Ask if your doctor and hospital will support you in a
VBAC attempt. The availability of anesthesiologists plays an important role in the safety of trying to have a VBAC. You
don’t want to find out a week before your due date that they aren’t comfortable handling VBACs.
Manage your weight: A2013 study showed that overweight women who lost at least 1 body mass index unit increased
their chance for a successful VBAC by 12 percent (compared to overweight women who maintained their weight). Talk
with your doctor about how to lose weight before you become pregnant, manage your diet, and become active or stay
active during pregnancy.

Let Mother Nature run her course: Your chance for a successful VBAC increases if you go into labor on your own.
The risk of uterine rupture slightly rises if you are induced. The average risk of uterine rupture is 0.7 percent. That goes up
to 0.9 to 1 percent if you are induced with Pitocin and 1.4 to 1.8 percent with prostaglandin.

WHY DON’T ALL DOCTORS AND HOSPITALS ALLOW VBACS?

 It was common practice in the 1960s and 1970s to perform a repeat C-section after a prior cesarean birth. But as
the C-section rates began to soar, doctors started to rethink how we approach these situations.

 VBACs were on the rise while I was in medical school and residency in the 1990s. Unfortunately, some ill-
advised VBAC attempts caused the number of uterine ruptures and other complications to increase – along with
the number of lawsuits. Because of this, we saw VBACs decline in the 2000s while C-section rates increased to
today’s rate of nearly 30 percent.

 Some doctors and hospitals are not equipped to handle an emergency C-section, and therefore don’t feel
comfortable allowing a woman to attempt a VBAC. Some are hesitant to offer them because of the potential for
lawsuits. Others are just more conservative in their labor and delivery practice.

 If your doctor or hospital does not allow VBAC, and you’re passionate about trying it, ask them to refer you to
one that does. You’ll often find large, university-based hospitals or community hospitals with 24/7 labor and
delivery and anesthesia teams promote this method of delivery.

 Ultimately, we want you and your baby to be healthy. We don’t want you to be cavalier about this decision. There
has to be an honest assessment of your risks and of how labor is progressing. I tell patients that as long as they are
following the normal labor curve, we keep going. However, if things begin to mimic what happened in their
previous pregnancy, we may need to stop before an emergency C-section becomes necessary.

 If you’ve had a C-section but hope to experience a vaginal delivery with your next child, consult with your doctor
about their views on VBAC and whether you may be a good candidate to try it. And if you aren’t a good
candidate, explore how your hospital accommodates families during C-sections – you may be pleasantly surprised
how different your experience this time may be.

INDUCTION OR AUGMENTATION OF LABOR

A successful VBAC is more likely to result from spontaneous labor than labor induction or augmentation. The report
states that evidence shows that cervical ripening with prostaglandin preparations increases the likelihood of uterine
rupture. Misoprostol also has been associated with a high rate of uterine rupture in women with a previous cesarean
delivery. The report recommends not using prostaglandins for induction of labor in most women with a previous cesarean
delivery.

MIDTRIMESTER DELIVERY
The decision to attempt a trial of labor in the midtrimester in women with a previous cesarean delivery should be based on
the patient’s individual circumstances, including the number of previous cesarean deliveries, placentation, gestational age,
and the woman’s desire to preserve reproductive function.

SUMMARY OF RECOMMENDATIONS
The following recommendations are based on good and consistent scientific evidence:

• Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be
counseled about VBAC and offered a trial of labor.
• Epidural anesthesia may be used for VBAC.
The following recommendations are based on limited or inconsistent scientific evidence (SORT = B):
• Womann with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for
VBAC.
• The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery
should be discouraged.

The following recommendations are based primarily on consensus and expert opinion:
• Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to
emergencies with physicians immediately available to provide emergency care.

• After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this
procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should
be documented in the medical record.
• Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or
extensive transfundal uterine surgery.

NURSES PLAY A SIGNIFICANT ROLE IN SUPPORTING VBAC MOTHERS

In particular, maternity care nurses play a significant role in helping mothers who want to labor for a VBAC.

Women laboring for a VBAC may have some anxiety about their prior cesarean and may need additional support. They
are grateful for the encouragement, validation, and labor progress suggestions that nurses can provide. Many times
mothers have said, “My nurse was wonderful. Just when I wanted to quit and ask for another cesarean, she told me things
were going just as they should be. I couldn’t have done it without her.”

Nurses, midwives, childbirth educators, and doulas who have experience working with mothers who want a VBAC have
learned that a mother with a prior cesarean may need additional support, time, and encouragement to have a rewarding
and satisfying birth. She needs to feel self-confident and strong. Here are some valuable suggestions that they have
shared:

When meeting a mother for the first time, try to find out how she experienced her cesarean? Can you suggest how she can
do things differently this time? Ask her how she wants to labor. What is important to her? Help her to create the birth
environment she prefers so she can feel safe and supported.
 Ask her partner or family how they feel about a VBAC? What concerns do they have?
 Remind parents that 3 out of 4 women who labor for a VBAC have a safe birth.
 Some mothers may have anxious moments and flashbacks of their prior birth. Disturbing memories of fetal
distress or of laboring “for ever” and not getting anywhere. Help mothers to overcome these difficult moments
and remind them that this is a different labor for a different baby and that they are strong enough to move through
it.
 Mothers who may have experienced a prior birth as traumatic will especially need understanding,
encouragement, and the freedom to give birth as she wishes.
 Some mothers know when they have gone as far as they can and that they will probably need to adjust to the idea
of having a cesarean birth. Give a mother time, if circumstances allow it, to think about what she would like for
this cesarean birth. Does she want her doula to be at her birth? Does she want her baby skin-to-skin after birth?
Does she want her family to visit her in recovery? Does your hospital support a “gentle cesarean?” Let her know
that your team wants her to have a good experience and will do their best to welcome her baby.

Maternity care professionals who are interested in establishing “skin-to-skin after a cesarean” clinical guidelines or
developing mother-centered VBAC education guides can freely use the hospital-developed forms included in Hospital
Policies that Support VBAC, Family-Centered Cesarean, and Informed Choice, both are part of the VBAC Education
Project.

A nurse’s support, guidance, compassion, and respect for a mother’s individual birth preferences will give both, mother
and baby their best start together