1. Provided there are no
contraindications, a woman with 1 previous transverse low-segment
Caesarean section should be offered a trial of labor (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous
Caesarean section (II-2B). 2. The intention of a woman undergoing a TOL after
Caesarean section should be clearly stated, and documentation of the previous uterine
scar should be clearly marked on the prenatal record (II-2B). 3. For a safe labor after
Caesarean section, a woman should deliver in a hospital where a timely
Caesarean section is available. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric,
anesthetic, pediatric, and operating-room staff (II-2A). 4. Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely
Caesarean section (III-B). 5. In the case of a TOL after Caesarean, an approximate time frame of 30 min should be considered adequate in the set-up of an urgent
laparotomy (IIIC). 6. Continuous electronic fetal monitoring of women attempting a TOL after
Caesarean section is recommended (II-2A). 7. Suspected
uterine rupture requires urgent attention and expedited
laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A). 8.
Oxytocin augmentation is not contraindicated in women undergoing a TOL after
Caesarean section (II-2A). 9. Medical
induction of labor with
oxytocin may be associated with an increased risk of
uterine rupture and should be used carefully after appropriate counseling (II-2B). 10. Medical
induction of labor with
prostaglandin E2 (
dinoprostone) is associated with an increased risk of
uterine rupture and should not be used except in rare circumstances and after appropriate counseling (II-2B). 11.
Prostaglandin E1 (
misoprostol) is associated with a high risk of
uterine rupture and should not be used as part of a TOL after
Caesarean section (II-2A). 12. A foley
catheter may be safely used to ripen the cervix in a woman planning a TOL after
Caesarean section (II-2A). 13. The available data suggest that a trial of labor in women with more than 1 previous
Caesarean section is likely to be successful but is associated with a higher risk of
uterine rupture (II-2B). 14. Multiple gestation is not a
contraindication to TOL after
Caesarean section (II-2B). 15.
Diabetes mellitus is not a
contraindication to TOL after
Caesarean section (II-2B). 16. Suspected
fetal macrosomia is not a
contraindication to TOL after
Caesarean section (II-2B). 17. Women delivering within 18-24 months of a
Caesarean section should be counseled about an increased risk of
uterine rupture in labor (II-2B). 18. Postdatism is not a
contraindication to a TOL after
Caesarean section (II-2B). 19. Every effort should be made to obtain the previous
Caesarean section operative report to determine the type of uterine incision used. In situations where the
scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, a TOL after
Caesarean section can be offered (II-2B).
VALIDATION: These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.