In 1995 the American College of Obstetricians and Gynecologists (ACOG) published updated guidelines for a vaginal birth after a cesarean. In the guides physicians are strongly encouraged to counsel and encourage women to plan labor rather than schedule a repeat surgery. Based on current evidence almost all women with prior cesareans can plan a VBAC. Here is the summary:

Based on the highest level of evidence found in the data, the following recommendations are provided and gradeed according to the following categories:

A. There is good evidence to support the recommendation.

B. There is fair evidence to support the recommendation.

C. There is insufficient evidence to support the recommendation; however, the recomendation may be made on other grounds.

Success rates

Success rates for VBAC range from 60-80% (A:II-2).

Risks and Benefits

The benefits of a trial of labor outweigh the risks (A: II-2).

Candidates

In the absence of contraindications, a woman with one previous cesarean delivery with a lower transverse uterine incision is a candidate for VBAC and should be counseled and encouraged to undergo a trial of labor (A: II-2).
A woman who has had two or more previous cesarean deliveries with lower transverse uterine incisions, who has no contraindications, and who wishes to attempt vaginal birth should not be discouraged from doing so (B: II-2).

Contraindications

A previous classical uterine incision is a contraindication for VBAC (C: III).
Epidural anesthesia is not a contraindication for VBAC (A: II-2).
Oxytocin use for induction or augmentation of labor is not contraindicated (B: II-3).
Suspicion of macrosomia by itself in a nondiabetic patient should not disqualify a patient from a trial of labor (B: II-2).
Available data are insufficient to determine the risks and benefits of VBAC for patients with multiple gestation, for patients with breech presentation, or for the use of prostaglandin gel (C: II-3; II-2).

Management

Vaginal birth after cesarean delivery should not be limited to large specialty hospital settings. Well-equppoed basic and speciality hospitals with the capacity to respond to intrapartum emergencies are appropriate settings for VBAC (A: II-3).