TOLAC (Trial Of Labour After Cesarean)

Trial Of Labor After Cesarean (TOLAC/TOL) – a planned attempt to allow labor in women who had a previous cesarean birth, regardless of the outcome of the previous cesarean.

Vaginal Birth After Cesarean (VBAC) – a successful TOLAC resulting in vaginal birth

Maternal and perinatal mortality rates following VBAC-TOL are the same when compared for elective repeat cesarean births

Candidate for TOLAC

• One or two previous prior low transverse cesarean delivery (for nonrecurrent indications)
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Available health-care facilities to handle emergency
• Informed consent of the mother

Contraindications

• Previous classical or inverted T-shaped uterine incision
• Previous two or more lower segment cesarean section
• Pelvis contracted or suspected CPD
• Presence of obstetric or medical complications in pregnancy
• Resoruces limited for emergency cesarean delivery
• Patient refusal
• History of prior uterine rupture

Principles of Management

• Antenatal counselling regarding mode of delivery
• Present to the obstetric unit early on labour
• Immediate access to cesarean section, blood transfusion services, continous fetal heart monitoring, specialist obstetricians, anesthetics and pediatricians round the clock
• Partogram for progress of labour
• Epidural analgesia
• The length of second stage should not exceed 2 hours. (Prophylactic ventouse or forceps)

Look for Signs of impending scar rupture (incidence 0.5%-1%) mentioned below

• Abdominal pain and tenderness
• Pathologic retraction ring
• Increased uterine irritability
• Hematuria
• Signs of hypovolemic shock
• Sudden appearance Fetal distress during labour (most common sign)

Exploration of scar after expulsion of placenta is done in selected cases only when there is continued and excessive vaginal bleeding or maternal hypotension inspite of well-contracted uterus

Risk factors for scar rupture

• 2 previous cesarean deliveries
• Interpregnancy interval <24 months
• Induced labor
• Augmentation of labor with high dose oxytocin
• Women having single layer uterine closure in prior cesarean delivery