Obstetrics & Gynecology>>>>>Antepartum Care and Fetal Surveillance
Question 3#

You are counseling a 36-year-old obese, Hispanic G2P1 at 36 weeks’ gestation about route of delivery. During her first pregnancy, she was induced at 41 weeks’ gestation for mild preeclampsia, and delivered by cesarean as a result of fetal distress during her induction. The patient would like to know if she can have a trial of labor after cesarean (TOLAC) with this pregnancy.

Which of the following is the best response to this patient?

a. No, since she has never had a vaginal delivery
b. Yes, but only if she had a low transverse uterine incision
c. No, because once she has had a cesarean delivery, she must deliver all of her subsequent children by cesarean
d. Yes, but only if her skin incision was a Pfannensteil
e. Yes, but she must wait until she goes into labor spontaneously to have a repeat cesarean

Correct Answer is B


A patient with a prior low transverse incision may attempt a TOLAC. Repeat cesarean and TOLAC both have inherent risks. The main risk of TOLAC that increases maternal and neonatal morbidity is uterine rupture, the risk of which is impacted significantly by the location of the uterine incision. A low transverse incision is made transversely through the lower uterine segment, which does not actively contract during labor. The risk of uterine rupture after prior low transverse incision is less than 1%. The skin incision does not reflect the location of the uterine incision, and therefore is not an indicator of the suitability of TOLAC for a patient. Although a prior vaginal delivery increases the success rate for a successful VBAC, a prior vaginal birth is not a prerequisite for a TOLAC. If the patient desires a repeat cesarean delivery, this should be performed at 39 weeks as a scheduled procedure.