A 28-year-old G2P1 at 37+2 weeks gestation with a previous history of one lower segment cesarean section (LSCS) for cephalopelvic disproportion presents in active labour. Cervical examination reveals 6 cm dilation, 90% effaced, and the fetal head at −1 station. Fetal heart rate is 136 bpm with good variability and accelerations. The patient desires a trial of vaginal delivery after cesarean (TOLAC). What is the most appropriate next step in management?

Explanation

## Clinical Context This is a case of **trial of labour after cesarean (TOLAC)** in a candidate with: - One prior LSCS for CPD (not a contraindication to TOLAC) - Spontaneous labour at term - Normal fetal status - Adequate maternal pelvis (evidenced by progress to 6 cm) - Patient's informed desire for vaginal delivery ## TOLAC Eligibility & Management ```mermaid flowchart TD A[Prior LSCS]:::outcome --> B{Candidate for TOLAC?}:::decision B -->|Contraindications present| C[Planned repeat LSCS]:::action B -->|Eligible + desires TOLAC| D[Informed consent obtained?]:::decision D -->|No| E[Planned repeat LSCS]:::action D -->|Yes| F[Admit for TOLAC]:::action F --> G[Continuous FHR monitoring]:::action G --> H[Access to emergency OR]:::action H --> I{Labour progress?}:::decision I -->|Adequate| J[Vaginal delivery]:::outcome I -->|Arrest disorder| K[Cesarean section]:::urgent I -->|Uterine rupture signs| L[Emergency LSCS]:::urgent ``` ## Key Point **TOLAC is safe and appropriate in eligible candidates** with informed consent, continuous monitoring, and immediate access to emergency cesarean. The indication for the prior cesarean (CPD) does NOT preclude TOLAC in a spontaneously labouring patient with good progress. ## High-Yield Facts | Feature | Candidate for TOLAC | Contraindication to TOLAC | |---------|---------------------|---------------------------| | **Prior indication** | CPD, failed induction, fetal distress | Placenta previa, vasa previa, prior classical incision | | **Uterine scar** | One or two prior LSCS | Three or more prior LSCS; prior uterine rupture | | **Current labour** | Spontaneous onset at term | Induction with prostaglandins (relative) | | **Fetal status** | Reassuring FHR pattern | Abnormal FHR, meconium | | **Monitoring** | Continuous electronic FHR | Not available | ## Clinical Pearl **Success rate of TOLAC is 60–80%** in unselected populations and higher in multiparas and those with spontaneous labour. The patient's progress to 6 cm dilation is a favorable sign of pelvic adequacy and predicts higher VBAC success. ## Warning ~~Automatic repeat LSCS for prior CPD~~ — CPD is NOT an absolute contraindication to TOLAC. Many patients with prior CPD achieve vaginal delivery, especially if they progress in labour. ## Monitoring Requirements 1. **Continuous electronic fetal heart rate monitoring** (mandatory) 2. **Immediate access to emergency operating theatre** (mandatory) 3. **Qualified personnel** for emergency cesarean (obstetrician, anesthetist, pediatrician) 4. **Vigilance for uterine rupture signs**: sudden severe pain, loss of contractions, vaginal bleeding, fetal bradycardia, maternal shock