TOLAC
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#TOLAC Patient with single prior LTCS, no history of classical or T incision, uterine rupture, or extensive transfundal uterine surgery. Admitted in *** (spontaneous labor / for IOL / for augmentation), desiring TOLAC. - MFMU VBAC calculator (2021, race-free) — https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator : ***% — discussed with patient - No prior classical/inverted T or J incision, no prior uterine rupture, no extensive transfundal surgery (prior op report reviewed*** / not available***) - If cervical ripening needed: Foley OK, misoprostol contraindicated; oxytocin acceptable with counseling re: increased rupture risk - Risks/benefits of TOLAC vs. elective repeat CS discussed in detail, including uterine rupture (~0.3–0.7% spontaneous labor, higher with induction/augmentation) and possibility of emergent CD/hysterectomy - FWB: *** - Options discussed in detail with patient; patient elected TOLAC. Consented for cesarean delivery (Date***).
Yellow *** markers = placeholders you fill in or delete per case.
Deep dive — rationale & evidence
Reference only — this section is not copied when you hit Copy. It explains the evidence behind the plan.
Candidacy — ACOG Practice Bulletin No. 205 (2019)
- •Most women with one prior low transverse cesarean are candidates for, and should be counseled about, TOLAC.
- •Women with two prior LTCS may also be offered TOLAC (VBAC success ~74%, comparable to one prior CD).
- •Unknown scar type is not a contraindication if a classical incision is unlikely (no increased rupture risk; aOR 0.71, 95% CI 0.37–1.37).
Absolute contraindications
- •Prior classical (vertical/fundal) or inverted T/J-shaped uterine incision (rupture risk 4–9%)
- •Prior uterine rupture
- •Extensive transfundal uterine surgery (e.g., full-thickness myomectomy entering the cavity)
- •Any independent contraindication to vaginal delivery (previa, active herpes, malpresentation)
Misoprostol is contraindicated for cervical ripening in patients with prior uterine surgery (ACOG Clinical Practice Guideline No. 9, 2025). Mechanical methods (Foley catheter) and oxytocin are acceptable.
Uterine rupture risk
| Scenario | Rupture rate |
|---|---|
| Spontaneous labor, 1 prior LTCS | 0.3–0.7% |
| Oxytocin induction / augmentation | 1.4–2.2% |
| Prostaglandin induction | 2.4–2.5% |
| Balloon catheter (Foley) | No increased risk (aOR 0.99) |
| Two prior cesarean deliveries | ~1.8% |
| Interpregnancy interval <18 months | aOR 1.55 |
MFMU VBAC calculator (revised 2021, race-free)
- •Open the calculator: MFMU VBAC prediction tool
- ◦Variables: maternal age, prepregnancy weight, height, indication for prior CD (arrest vs. other), prior vaginal delivery / VBAC, treated chronic hypertension
- ◦AUC 0.75 (95% CI 0.74–0.77); validated for two prior CDs (AUC 0.74)
- ◦A predicted success of ≥60–70% is commonly used to guide discussion, though a calculator score should not be a barrier to TOLAC consideration
- •Factors favoring success: prior vaginal delivery (OR 3.14), prior VBAC (OR 4.71), spontaneous labor onset, favorable Bishop score (OR 3.77), non-recurrent indication for prior CD
- •Factors disfavoring: labor induction (OR 0.58), macrosomia ≥4000 g (OR 0.56), recurrent arrest indication (OR 0.54), diabetes, hypertensive disorders, BMI ≥30
Intrapartum requirements
- •Continuous EFM required (not a candidate for intermittent auscultation)
- •Facility must be able to begin emergency cesarean delivery in a timely fashion
- •IV access established; type and screen available
- •Signs of rupture: prolonged fetal bradycardia (most discriminating finding), recurrent variable decelerations, fetal tachycardia, loss of variability, uterine tachysystole, cessation of contractions
- •Classic triad (FHR abnormalities + pain + bleeding) is present in <10% of complete ruptures
- •Epidural analgesia is not contraindicated
Sources
- •ACOG Practice Bulletin No. 205 (2019) — Vaginal Birth After Cesarean Delivery: candidacy criteria, contraindications, rupture rates, intrapartum management, epidural safety
- •ACOG Clinical Practice Guideline No. 9 (2025) — Labor After Cesarean: misoprostol contraindication, Foley catheter and oxytocin acceptability
- •Grobman et al. (Obstet Gynecol 2021) — Updated MFMU VBAC prediction model (race-free); AUC, variables, validation
- •Landon et al. (NEJM 2004) — MFMU Network: rupture rates by labor type (spontaneous, oxytocin, prostaglandin)
- •Macones et al. (Obstet Gynecol 2005) — Interpregnancy interval and rupture risk (aOR 1.55)
- •Cahill et al. (Obstet Gynecol 2010) — Two prior cesareans: rupture rate ~1.8%, VBAC success ~74%