How should I counsel a patient with a previous caesarean section regarding the risks and benefits of a trial of labour versus repeat caesarean?

When counselling a patient with a previous caesarean section about the risks and benefits of attempting a trial of labour (TOL) versus having a repeat caesarean section, it is important to provide evidence-based, balanced information tailored to her individual circumstances and preferences.

• Discuss benefits and risks of both options: Explain that both vaginal birth after caesarean (VBAC) and repeat caesarean birth have associated benefits and risks, some of which carry small absolute risks and others greater risks. The patient will need to consider which risks are more acceptable to her based on her values and future pregnancy plans ¹.
• Risks of trial of labour: Planned vaginal birth after caesarean carries a higher risk of uterine rupture compared to repeat caesarean birth. However, electronic fetal monitoring during labour and care in a unit with immediate access to emergency caesarean and blood transfusion services are recommended to manage this risk ¹.
• Risks of repeat caesarean: Repeat caesarean birth carries risks such as fever, bladder and surgical injuries, but these risks do not vary significantly with planned mode of birth. Multiple caesarean births increase the risk of placental adherence problems (e.g., placenta accreta spectrum) in future pregnancies ¹.
• Consider maternal preferences and priorities: The woman’s preferences, concerns, and priorities should be central to the decision-making process, with respectful, accessible information provided early in pregnancy to support informed choice ¹.
• Explain implications for future pregnancies: Inform that after a caesarean birth, the likelihood of caesarean birth in future pregnancies may be increased, and multiple caesareans increase certain risks such as placenta accreta spectrum ¹.
• Offer continuous support and monitoring: For women attempting vaginal birth after caesarean, continuous electronic fetal monitoring and immediate access to emergency caesarean birth are essential to ensure safety ¹.