American Academy of Family Physicians Announces Updated Guideline on Trial of Labor After Cesarean

LEAWOOD, Kan. -- Updating its 1995 policy, the American Academy of Family Physicians today released an updated clinical practice guideline on trial of labor after cesarean (TOLAC). Key updates to the guideline include recommendations that prostaglandins should not be used for cervical ripening or induction and that TOLAC should not be restricted only to facilities with available surgical teams present throughout labor. The guideline does state, however, that a management plan should be in place for each woman undergoing TOLAC in case of uterine rupture or other potential emergencies requiring rapid cesarean section.

The objective of the guideline is to provide an evidence-based clinical practice guideline for pregnant women and their families, maternity care professionals, facilities and policy-makers. The updated guideline is published as a supplement to the online version of the July/August issue of Annals of Family Medicine.

With births by cesarean accounting for approximately 28 percent of all births, the AAFP's TOLAC guideline offers pregnant women giving birth in facilities that follow the guideline, especially those in rural areas, the option of attempting vaginal birth without mandating the presence of a surgical team.  Often, women in rural areas are not given the option of TOLAC because of previous assumptions that a surgical team must be present for these women to attempt to deliver vaginally. The guideline states that TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there are no studies that show these additional resources result in improved outcomes.  This recommendation differs from that of the American College of Obstetricians and Gynecologists (ACOG) in that the ACOG guideline states patients attempting vaginal birth after cesarean (VBAC) should have "physicians immediately available to provide emergency care."

"The AAFP's TOLAC guideline reflects family medicine's patient-centered approach to care, while continuing the AAFP's dedication to promoting evidence-based medical practices," said Dr. Mary Frank, AAFP President. "This will better inform the discussion a pregnant woman has with her family physician."

To develop the updated guideline, the AAFP's Commission on Clinical Policies and Research convened a panel of family physicians with particular expertise in this area of maternity care to review the available evidence on TOLAC using the Agency for Healthcare Research and Quality "Evidence Report on Vaginal Birth After Cesarean (VBAC)." The panel also conducted a systematic review of articles published since the evidence report was released.