A 32-year-old multigravida (G3P2) at 38 weeks gestation is counseled regarding delivery options. She has a history of one prior vaginal delivery and one prior cesarean section for non-recurrent indication (fetal distress). Her current pregnancy is uncomplicated with a singleton vertex presentation. Which of the following is NOT a contraindication to trial of labor after cesarean (TOLAC) in this patient?

Explanation

## Contraindications to Trial of Labor After Cesarean (TOLAC) ### Understanding TOLAC Eligibility **Key Point:** TOLAC is appropriate for carefully selected candidates with low risk of uterine rupture and good prognosis for vaginal delivery. Absolute and relative contraindications exist. ### Evaluation of Each Option **Option 1: Recurrent indication for prior cesarean (e.g., cephalopelvic disproportion)** - **Clinical Pearl:** If the original indication for cesarean section is likely to recur (e.g., CPD, maternal pelvic anatomy, fetal anomaly), TOLAC is contraindicated. - This patient's prior cesarean was for fetal distress (non-recurrent), so this is NOT her situation. - However, a recurrent indication IS a contraindication to TOLAC. - This is a CONTRAINDICATION. **Option 2: Classical (vertical) uterine incision on prior cesarean** - **High-Yield:** Classical incisions carry a 4–9% risk of uterine rupture (vs. 0.3–1% for low-transverse incisions). - **Key Point:** Classical incision is an ABSOLUTE contraindication to TOLAC. - Planned repeat cesarean section is required. - This is a CONTRAINDICATION. **Option 3: Maternal age >35 years** - **Clinical Pearl:** Advanced maternal age alone is NOT a contraindication to TOLAC. - ACOG guidelines do not list maternal age as a contraindication. - Older maternal age may be associated with other comorbidities (hypertension, diabetes), but age itself does not preclude TOLAC eligibility. - Success rates for VBAC are similar across age groups when other factors are favorable. - This is NOT a contraindication. **Option 4: Unknown type of prior uterine incision** - **Key Point:** If the type of uterine incision from the prior cesarean is unknown, TOLAC is contraindicated because a classical incision cannot be excluded. - The risk of uterine rupture is unacceptably high if the incision type is uncertain. - This is a CONTRAINDICATION. ### Summary Table: TOLAC Contraindications | Factor | Contraindication? | Reason | |---|---|---| | Recurrent indication | **Yes** | Likelihood of repeat indication | | Classical incision | **Yes** | 4–9% rupture risk | | Maternal age >35 | **No** | Age alone does not affect VBAC success | | Unknown incision type | **Yes** | Cannot exclude classical incision | | Prior vaginal delivery | **No** | Favorable prognostic factor | | Uncomplicated current pregnancy | **No** | Favorable prognostic factor | **Mnemonic for TOLAC Contraindications: "CLUELESS"** - **C**lassical incision - **L**abor induction (relative, in some cases) - **U**nknown incision type - **E**xtensive uterine surgery (myomectomy, etc.) - **L**ow transverse incision (actually FAVORABLE) - **E**xternal cephalic version (relative) - **S**ingle prior low-transverse incision (FAVORABLE) - **S**uccessive vaginal deliveries (FAVORABLE) **High-Yield:** This patient is a good candidate for TOLAC: prior vaginal delivery (favorable), non-recurrent indication for prior cesarean (favorable), uncomplicated current pregnancy, and age >35 is NOT a contraindication.