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Candidate
Guide
Senior resident guide
 Cragin’s dictum,1916 “once a cesarean, always a
cesarean”
 In 1910, Mason and Williams –
 The strength of healed cesar...
 Cragin himself witnessed VBAC in a woman in whom he
did the cesarean NY Med . 1916;104:1–3
 Rethinking the Dictum : Cas...
 Elective repeat cesarean Delivery (ERCD) – Also called
ERCS (Elective Repeat Cesarean Section)
 Trial of labor after ce...
The available data is limited by 3 important factors
 No Prospective, Randomized trials of TOL V/S ERCD
available so far
...
-Review previous
medical records &
operative notes,
-Assess risks & benefits
Points to be discussed Special considerations
Make patient understand the maternal &
perinatal risks & benefits of VBAC V/...
VBAC ERCD
72- 76% chance of success Able to plan the delivery on a known
date
If successful, shorter hospital stay &
conva...
VBAC ERCD
10-15% chance of instrumental delivery
& perineal tear requiring suturing
Increases likelihood of cesarean deliv...
VBAC ERCD
<1% risk of transient respiratory
morbidity (<ERCD)
Avoids 0.1% risk of antepartum still
birth since delivery is...
VBAC ERCD
0.1% risk of antepartum still birth
beyond 39 wks while awaiting
spontaneous labor
1-3% risk of transient respir...
 Largest & most comprehensive Study is conducted by
Landon et al
 Done in women enrolled in NICHD Maternal-Fetal
Medicin...
N Engl J Med 2004,351:2581
Complication Trial of labor ERCD Normal labor
Uterine rupture 0.7% 0 0.012%
Gradeil F et al,ur ...
N Engl J Med 2004; 351:2581–9.
VBAC Failed TOLAC
Uterine rupture 0.1% 2.3%
Uterine dehiscence 0.1% 2.1%
Hysterectomy 0.1% ...
Outcome TOL ERCD
Antepartum
stillbirth
37-38 wk 0.4% 0.1%
39 wk or more 0.2% 0.1%
Intrapartum stillbirth
37-38wk 0.02% 0
3...
 Previous 1 LSCS
 Clinically adequate pelvis
 No other uterine scar / previous rupture
 Physician immediately availabl...
 VBAC success rate - 75.3% (in 2 or > previous LSCS)
Uterine Rupture rate – 1.7%
Miller et al. (1994)
 In a meta-analysi...
 Comparison of outcome of trial of labor after previous
two Caesarean sections V/S previous one Cesarean
sections – A Pro...
 Several studies support VBAC in Twins with a success
rate 69-84%
 Rate of uterine rupture was not found significantly
h...
“ERCD is associated with better perinatal outcome in a
previous LSCS with Breech presentation in current
pregnancy”
-A lar...
 Suspected macrosomia (>4000g) is not a
contraindication for TOL but decreases success rate of
VBAC -Elkousy et al(2003)
...
 No significant difference in the outcome of the next
pregnancy
Chapman et al, Ohel et al, Hauth et al
 Few studies alth...
Other Factors
 Maternal obesity
– Decreases probability of VBAC
- BMI >40 associated with 61% chances of successful VBAC
...
Related to Previous Cesarean Delivery
 Previous classical or T /J shaped uterine incision
 Previous uterine rupture
 Ut...
Obstetric or Medical complication
 Malpresentation
 Antepartum hemorrhage- Placenta praevia, Placenta accreta
 Severe P...
ACOG practice bulletin 2010
Increased probability of success of TOLAC
Prior vaginal birth
Spontaneous onset of Labor
Decre...
 Factors increasing likelihood of success
Maternal age < 40
Prior vaginal delivery
Favorable cervix, spontaneous labor...
Factors decreasing risk of failure
 Age <40
 Prior vaginal delivery
 Indication for previous cesarean other than failur...
 Grobman & colleagues (2007)
Developed a nomogram to predict a successful TOL
& maternal morbidity based on a questionnai...
http://www.nialls.com/VBACPred2.aspx
 Defined as “A primary cesarean delivery at maternal
request in the absence of any medical or obstetrical
indication”.
(A...
 Lower incidence of endometritis/ transfusions
 Lower Neonatal / Perinatal Morbidity
 Fewer Infant Birth Injuries durin...
 Take detailed informed written consent
 To be conducted in a suitably staffed & equipped setting
with the facility for ...
 Continuous fetal monitoring by CTG (II A)
 Intrauterine pressure catheters - not routinely useful
 Oxytocin should be ...
 Most Dreaded complication of TOLAC
 Relative risk of uterine rupture in TOL compared to
ERCD is 2.07
 Maternal and or ...
 Uterine rupture – Complete disruption of all layers of
uterus associated with one/more of the following-
 Hemorrhage re...
 Most Reliable First sign is - “Non reassuring fetal
heart tracing”
 Most Specific sign is - Persistent variable fetal h...
 Classical signs (Unreliable)
 Maternal tachycardia,
 Hypotension,
 Hematuria,
 Pain over previous incision site
 Va...
Factors Rate of uterine rupture
Type of scar
Classical 12% ( Rosen et al )
Low transverse (Kerr) 1% (Mc Mohan et al)
Low v...
Factors Rate of Uterine Rupture
Interdelivery interval Shipp T et al Am J Obstet Gynecol.2001;184:S71
<18 months 2.3%
>18 ...
Factors Rate of Uterine Rupture
Macrosomia (>4kg) 1.6% v/s 1% (statistically not significant)
(Obs Gynecol 2003;188(6):516...
Rozenberq P et al , Lancet :1996 ;347(8997):281-4
Lower uterine
segment thickness
Number of
cases
Number of
ruptures
> 4.5...
Factors Rate of Uterine Rupture
( v/s Spontaneous Labor )
Oxytocin
Induction 2.3% v/s 0.7%
Augmentation 1% v/s 0.4% ( comp...
 Cost of failed TOLAC is more than successful TOL or repeat
cesarean
 If rupture rate > 3.2%, the increased infant
morbi...
ACOG practice bulletin 2010
 Most women with previous 1 LSCS are candidates for
VBAC & Should be counseled about VBAC & o...
 VBAC is recommended in previous 2 LSCS with low transverse
scar and previous 1 LSCS with twins
 ECV for breech is not c...
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
Vaginal Birth After Cesarean Delivery
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Vaginal Birth After Cesarean Delivery

  1. 1. Candidate Guide Senior resident guide
  2. 2.  Cragin’s dictum,1916 “once a cesarean, always a cesarean”  In 1910, Mason and Williams –  The strength of healed cesarean section scars of guinea pigs & cats tested by subjecting to increasing weights.  Rupture was noted in the muscle but not the scar in 100% cases.  Kerr’s low transverse uterine incision – 1921 – reduced maternal mortality from sepsis & hemorrhage -Gave greater strength to healed incision site
  3. 3.  Cragin himself witnessed VBAC in a woman in whom he did the cesarean NY Med . 1916;104:1–3  Rethinking the Dictum : Case in 1930s gave an excellent review on VBAC showing 70% success rate in British population J Obstet Gynaecol Br Commonw. 1971;78:203–14  In U.S., till 1970, patients with previous cesarean were mostly delivered by elective repeat cesarean – leading to Five-fold increase in rate of cesarean deliveries  From 1980 onwards, reappraisal of the situation, careful selection of candidates for VBAC began  First guideline was formed by ACOG in 1999
  4. 4.  Elective repeat cesarean Delivery (ERCD) – Also called ERCS (Elective Repeat Cesarean Section)  Trial of labor after cesarean (TOLAC) This can have 2 outcomes  Successful TOLAC – Vaginal Birth After Cesarean Delivery (60 to 80%)  Failed TOLAC - Emergency cesarean Delivery
  5. 5. The available data is limited by 3 important factors  No Prospective, Randomized trials of TOL V/S ERCD available so far  Adverse maternal or perinatal outcomes are rare & large study populations are necessary to observe a significant difference in outcomes  The woman’s choice to attempt a TOLAC is heavily influenced by her health-care provider & local resources - leading to selection bias in published reports
  6. 6. -Review previous medical records & operative notes, -Assess risks & benefits
  7. 7. Points to be discussed Special considerations Make patient understand the maternal & perinatal risks & benefits of VBAC V/S ERCD Assess patient’s attitude towards the rare but serious adverse outcomes Presence of contraindications to VBAC Any complicating obstetric factors -Placenta praevia -Fetal malpresentations -Cervical fibroid -Maternal medical disorders -Previous classical scar -Previous uterine rupture -Previous peri-operative complications if any -Unknown scar, etc. Likelihood of a successful VBAC Mostly if previous vaginal birth/successful VBAC Her plans for future pregnancies Personal preference & motivation to achieve vaginal birth or ERCD
  8. 8. VBAC ERCD 72- 76% chance of success Able to plan the delivery on a known date If successful, shorter hospital stay & convalescence Lower risk of vaginal tears & no worsening of pelvic floor support & continence mechanisms Increased likelihood of vaginal delivery in future pregnancies Surgical sterilization can be done at the same time Lower risk of transfusion (1%) & endometritis (1.8%) as compared to failed TOLAC
  9. 9. VBAC ERCD 10-15% chance of instrumental delivery & perineal tear requiring suturing Increases likelihood of cesarean delivery in future pregnancy Failed TOLAC increases maternal morbidity Longer hospital stay & convalescence 0.5% of risk of uterine scar rupture – most dreaded complication 0.1- 2% chances of serious surgical complications like bladder injury 24-28% of chance of emergency cesarean delivery Increased risk of surgical complications with each subsequent cesarean delivery due to adhesions, placenta praevia/accreta Higher risk of blood transfusion(1.7%) & endometritis(2%) No . Of CD Placenta praevia 1 1% 2 1.7% 3 2.3% >3 2.8% Any no. 1.2% No. of CD AHRQ Publication No. 10- E003March 2010 Placenta accreta 1 0.3-0.6%( not significant) 2 or more 1.4% 5 or more 6.74%
  10. 10. VBAC ERCD <1% risk of transient respiratory morbidity (<ERCD) Avoids 0.1% risk of antepartum still birth since delivery is undertaken at the commencement of 39th week
  11. 11. VBAC ERCD 0.1% risk of antepartum still birth beyond 39 wks while awaiting spontaneous labor 1-3% risk of transient respiratory morbidity 0.04% risk of delivery related perinatal death 0.08% of HIE (Hypoxic ischaemic encephalopathy) during labor
  12. 12.  Largest & most comprehensive Study is conducted by Landon et al  Done in women enrolled in NICHD Maternal-Fetal Medicine Units Network, 1999-2002  In TOLAC group , n= ~18000  In ERCD group, n= ~16000  This study includes all women who had a prior cesarean delivery & who had a singleton pregnancy at 20 weeks or more of gestation or whose infant had a birth weight of at least 500 g  Women undergoing Cesarean for other indications were excluded
  13. 13. N Engl J Med 2004,351:2581 Complication Trial of labor ERCD Normal labor Uterine rupture 0.7% 0 0.012% Gradeil F et al,ur J Obstet Gynecol Reprod Biol. Aug 1994; Uterine dehiscence 0.7% 0.5% Hysterectomy 0.2% 0.3% 0.14% ACOG2002 Thromboembolic disease 0.04% 0.1% Transfusion 1.7% 1% Endometritis 2.9% 1.8% 1-2% Parkland Hospital Maternal deaths 0.02% 0.04% Other adverse events (broad-ligament hematoma, cystotomy, bowel injury, and ureteral injury) 0.4% 0.3% Maternal deaths in TOL were 3 in no. & were due to 1.Severe PIH with hepatic failure 2.Sickle cell crisis with cardiac arrest 3.PPH None of them could be directly attributed to TOL Hysterectomy in ERCD(47)- 1.Atony(17) 2.Placenta accreta(12) 3.Unexplained hemorrhage(5) 4.Extension / laceration(2) 5.Myoma (3) 6.cancer(5) 7.Others (3) Maternal deaths in ERCD were 7 in no. Two of them could be attributed to cesarean (Hemorrhage & Anesthesia complications)
  14. 14. N Engl J Med 2004; 351:2581–9. VBAC Failed TOLAC Uterine rupture 0.1% 2.3% Uterine dehiscence 0.1% 2.1% Hysterectomy 0.1% 0.5% Transfusions 1.2% 3.2% Endometritis 1.2% 7.7% Thromboembolic diseases 0.1% 0.02% Maternal death 0.01% 0.04% Other maternal adverse events 0.01% 1.3% Maternal complications
  15. 15. Outcome TOL ERCD Antepartum stillbirth 37-38 wk 0.4% 0.1% 39 wk or more 0.2% 0.1% Intrapartum stillbirth 37-38wk 0.02% 0 39wk or more 0.01% 0 HIE 0.08 0 Neonatal death 0.08% 0.05% N Engl J Med 2004; 351:2581–9.
  16. 16.  Previous 1 LSCS  Clinically adequate pelvis  No other uterine scar / previous rupture  Physician immediately available throughout active labor, capable of monitoring labor, performing an emergency cesarean delivery  Availability of anesthesia & personnel for emergency cesarean delivery ACOG practice bulletin 2010
  17. 17.  VBAC success rate - 75.3% (in 2 or > previous LSCS) Uterine Rupture rate – 1.7% Miller et al. (1994)  In a meta-analysis,  VBAC success rate – 71.1% ( Previous 2 LSCS )  Uterine rupture rate – 1.4% S Tahseen, M Griffiths -BJOG 2010;117:5–19.  No conclusive evidence available on methods of induction or augmentation of labor
  18. 18.  Comparison of outcome of trial of labor after previous two Caesarean sections V/S previous one Cesarean sections – A Prospective clinical Trial is undergoing at AIIMS by Dr Prerna under guidance of Prof Neerja Bhatla  So far, 2 women with previous 2 LSCS have had successful Trial of labor  Both of them were induced with PGE2 (0.5mg) at 39- 40wks
  19. 19.  Several studies support VBAC in Twins with a success rate 69-84%  Rate of uterine rupture was not found significantly high - Miller et al and Strong et al  ACOG 2010 - “Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC”
  20. 20. “ERCD is associated with better perinatal outcome in a previous LSCS with Breech presentation in current pregnancy” -A large multicentric trial by Hannah et al.-  External Cephalic Version (ECV) is not contraindicated – ACOG 2010 Flamm BL, Am JObstet Gynecol 1991;165:370–2, Sela HY, Eur J Obstet Gynecol Reprod Biol 2009;142:111–4  SOGC (Society of obstetricians & gynaecologists of Canada) discourages VBAC in Breech
  21. 21.  Suspected macrosomia (>4000g) is not a contraindication for TOL but decreases success rate of VBAC -Elkousy et al(2003)  Success rate of 60% is observed -Zelop et al. Am J Obstet Gynecol 185:903, 2001
  22. 22.  No significant difference in the outcome of the next pregnancy Chapman et al, Ohel et al, Hauth et al  Few studies although found increased risk of uterine rupture, no sufficient data available Durwald & Mercier, Bujold et al  Longterm outcomes of CORONIS Trial (A large randomised multicentre fractional, factorial trial) & CAESAR Trial (Caesarean section surgical techniques: a randomised factorial trial) are awaited
  23. 23. Other Factors  Maternal obesity – Decreases probability of VBAC - BMI >40 associated with 61% chances of successful VBAC Hibbard et al, Juhas et al  History of postpartum fever after Caesarean section - 3 fold increase in rupture Shipp T et al Am J Obstet Gynecol.2001;184:S71  Mullerian duct anomalies – 8% risk of rupture Ravasia et al, Am J ObstetGynecol. 1999;181:877–881  Maternal age - <30yrs (Decrease risk of uterine rupture : 0.5% v/s 1.4%) Shipp T et al Am J Obstet Gynecol.2001;184:S71. -Their relationship to the risk of uterine rupture have been examined in small studies, but definitive conclusions cannot yet be drawn.
  24. 24. Related to Previous Cesarean Delivery  Previous classical or T /J shaped uterine incision  Previous uterine rupture  Uterine surgeries involving full muscle thickness (Hysterotomy, Preterm LSCS, myomectomy with cavity opened.  No consistent evidence available for incidence of uterine rupture in Laparoscopic v/s open myomectomy)  Previous >2 LSCS (VBAC in previous 3 LSCS has been reported as early as in1979 but not enough evidence available)  Unknown scar – In the absence of previous operative records, a detailed history may be taken Most common incision, however is, low transeverse & VBAC is reasonable Obstet Gynecol.1994;84:255–258
  25. 25. Obstetric or Medical complication  Malpresentation  Antepartum hemorrhage- Placenta praevia, Placenta accreta  Severe PIH/eclampsia  Placental insufficiency (IUGR, Oligohydramnios)  Medical disorders like HTN, Heart disease, Renal disease, Asthma, Seizure disorders, Thyroid disorders (Grobmann et al – Inconsistent evidence, VBAC can be given) Contracted pelvis/CPD Inability to perform emergency cesarean due to insufficient staffing / facilities
  26. 26. ACOG practice bulletin 2010 Increased probability of success of TOLAC Prior vaginal birth Spontaneous onset of Labor Decreased probability of success Recurrent indication for initial cesarean delivery ( Dystocia, CPD) Increased maternal Age Nonwhite ethnicity Gestational age > 40 weeks Maternal obesity Pre-eclampsia Short interpregnancy interval Increased neonatal birth weight
  27. 27.  Factors increasing likelihood of success Maternal age < 40 Prior vaginal delivery Favorable cervix, spontaneous labor Prior cesarean for non recurrent indication  Factors decreasing likelihood of success Increased no of prior cesarean deliveries Gestational age > 40 weeks Birth weight > 4 kg Induction or augmentation of labor
  28. 28. Factors decreasing risk of failure  Age <40  Prior vaginal delivery  Indication for previous cesarean other than failure of progress  Cervical effacement at admission > 75%  Cervical dilatation at admission > 4cm Score 0-2 has success rate of 49% & for 8-10, 95% Flamm ,Obstet gynecol 1994;83:927-32
  29. 29.  Grobman & colleagues (2007) Developed a nomogram to predict a successful TOL & maternal morbidity based on a questionnaire in a term gestation with previous 1 LSCS -A score >60 has a 75-80% chances of a successful vaginal delivery Obstetrics and Gynecology, volume 109, pages 806-12, 2007
  30. 30. http://www.nialls.com/VBACPred2.aspx
  31. 31.  Defined as “A primary cesarean delivery at maternal request in the absence of any medical or obstetrical indication”. (ACOG–American College of Obstetrician and Gynecologists, Committee Opinion, Number 394, December 2007) -ACOG states Elective cesareans are justified options -FIGO(2003) entails CDMR ‘a positive right of women’
  32. 32.  Lower incidence of endometritis/ transfusions  Lower Neonatal / Perinatal Morbidity  Fewer Infant Birth Injuries during Delivery  Better Maternal Postpartum Satisfaction & Psychological Wellbeing  Better Sexual Health in the Immediate Postpartum Period & in some cases, long term  Reduced or Avoided Urinary Incontinence & Fecal Incontinence  Less damage to pelvic floor, vaginal tearing, episiotomy, and risk of future pelvic organ prolapse
  33. 33.  Take detailed informed written consent  To be conducted in a suitably staffed & equipped setting with the facility for emergency cesarean delivery 24x7 & neonatal resuscitation  An Obstetrician, Anesthesiologist & pediatrician should be immediately available  PGE 2 may be used to induce labor with caution.  IV access, adequate blood cross matched  Monitor maternal BP, PR & ST every 15 min
  34. 34.  Continuous fetal monitoring by CTG (II A)  Intrauterine pressure catheters - not routinely useful  Oxytocin should be used with caution (In AIIMS - low dose, starting from 1mIU/min is being used for augmentation)  No contraindication for epidural analgesia – does not reduce success or mask signs of rupture  Regular review of partogram by senior obstetrician  Routine postpartum exploration of scar - not needed
  35. 35.  Most Dreaded complication of TOLAC  Relative risk of uterine rupture in TOL compared to ERCD is 2.07  Maternal and or fetal morbidity of rupture 10-25%  In rupture, 1.5/10,000 risk of perinatal death & 4.8/10,000 risk of hysterectomy
  36. 36.  Uterine rupture – Complete disruption of all layers of uterus associated with one/more of the following-  Hemorrhage requiring surgical exploration  Hysterectomy, Injury to the bladder  Extrusion of any part of feto-placental unit  Cesarean delivery for suspected uterine rupture  Cesarean delivery for fetal distress  Uterine dehiscence – Asymptomatic uterine disruption (complete or incomplete) having no effect on mother or neonate
  37. 37.  Most Reliable First sign is - “Non reassuring fetal heart tracing”  Most Specific sign is - Persistent variable fetal heart deceleration.
  38. 38.  Classical signs (Unreliable)  Maternal tachycardia,  Hypotension,  Hematuria,  Pain over previous incision site  Vaginal bleeding  Dramatic loss of station Low sensitivity, high specificity
  39. 39. Factors Rate of uterine rupture Type of scar Classical 12% ( Rosen et al ) Low transverse (Kerr) 1% (Mc Mohan et al) Low vertical (Kronig) 0.8%-1.1% (N Engl J Med 2001;345:3–8) (Adair et al, Shipp et al) Myomectomy scar with cavity open or transfundal surgeries 10% Number of Previous LSCS BJOG 2010;117:5–19 1 LSCS 0.8% 2 LSCS 1.4%
  40. 40. Factors Rate of Uterine Rupture Interdelivery interval Shipp T et al Am J Obstet Gynecol.2001;184:S71 <18 months 2.3% >18 months 1% Previous vaginal delivery Zelop et al Prev 1 LSCS v/s Prev 1LSCS+ vaginal birth 1.1% v/s 0.2% Prev 2 LSCS v/s Prev 2 LSCS + vaginal birth 3.9% V/S 2.5% ( statistically not significant) Previous h/o rupture Lower segment 6% Upper segment 32% Factors known at the outset of pregnancy
  41. 41. Factors Rate of Uterine Rupture Macrosomia (>4kg) 1.6% v/s 1% (statistically not significant) (Obs Gynecol 2003;188(6):516) Postdatism v/s Term deliveries (Obs Gynecol 2005;(106):700-8) Spontaneous 1% v /s 0.5% (Statistically not significant) Induced 2.6% v/s 2.1% (statistically not significant) Preterm Lower rates Twin pregnancy Similar rates, but 2 fold increased risk of dehiscence Breech & ECV Results not definitive
  42. 42. Rozenberq P et al , Lancet :1996 ;347(8997):281-4 Lower uterine segment thickness Number of cases Number of ruptures > 4.5 mm 278 0 3.6 – 4.5 mm 177 3 (2%) 2.6 – 3.5 mm 136 14 (10%) 1.6 – 2.5 mm 51 8 (16%) Current pregnancy characteristics
  43. 43. Factors Rate of Uterine Rupture ( v/s Spontaneous Labor ) Oxytocin Induction 2.3% v/s 0.7% Augmentation 1% v/s 0.4% ( comparable) ACOG Committee opinion no:271, apr 2002 Prostaglandin E2 1.3% v/s 0.7% ( comparable) Prostaglandin E1 5.6% Intracervical foley’ catheter Safe Also recommended in second trimester induction Mifepristone Under evaluation Exposure to oxytocin before the active stage of labor may increase risk of rupture No co-relation with initial dose, maximal dose, dose titration, time at maximum dose Goetzl et al, Obs Gynecol 2001; 97(3):384
  44. 44.  Cost of failed TOLAC is more than successful TOL or repeat cesarean  If rupture rate > 3.2%, the increased infant morbidity/mortality of attempted TOLAC exceeded the benefits of reduced cost  TOLAC is cost effective if the rate of successful vaginal delivery >74%  So careful patient selection is necessary before planning TOL Obs Gynecol 2001;97:932-41
  45. 45. ACOG practice bulletin 2010  Most women with previous 1 LSCS are candidates for VBAC & Should be counseled about VBAC & offered TOLAC  Epidural analgesia for labor may be used as part of TOLAC  Misoprostol should not be used for 3rd trimester cervical ripening or labor induction in patients with previous cesarean delivery or major uterine surgeries ACOG Guidelines Level A Evidence
  46. 46.  VBAC is recommended in previous 2 LSCS with low transverse scar and previous 1 LSCS with twins  ECV for breech is not contraindicated in previous LSCS  Scars other than low transverse/ low vertical scars or those in whom Vaginal delivery is contraindicated (eg.placenta accreta) are contraindications for VBAC  Induction of labor for maternal/fetal indication remains an option  Previous unknown uterine scar is not a contraindication unless there is high suspicion of classical cesarean delivery ACOG practice bulletin 2010 There are no areas of significant difference as compared to RCOG Guidelines -2007 -RCOG also encourages trial in 3 or more previous cesarean deliveries
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