Vaginal Birth After Cesarean: How to Counsel Patients Using the Evidence

Vaginal birth after prior cesarean has become a part of routine obstetric care over the past three decades. Recently, however, the pendulum has swung in the other direction with a decreasing proportion of women choosing to undergo a trial of labor after prior cesarean. Since more than one-fourth of all deliveries are via cesarean, counseling patients regarding the risks and benefits of undergoing a trial of labor in a subsequent pregnancy is a skill all clinicians who care for obstetric patients should have. In particular, there is good evidence regarding risk factors that change the chance of success in a subsequent trial of labor as well as that of a uterine rupture. For example, women with a prior indication for cesarean that is nonrecurring (e.g. breech, previa, herpes), women with a prior vaginal delivery, and those who present in spontaneous labor all have an increased chance of success in a subsequent trial of labor. Women with more than one prior cesarean, who undergo induction of labor, are treated with prostaglandins, and who have prior classical cesareans are at increased risk for uterine rupture. Using this evidence to counsel women regarding their risks and chances of success in a subsequent trial of labor is paramount to ensuring that a well-informed decision has been made.