A 32-year-old multigravida (G3P2) at 39 weeks + 2 days presents with a history of one previous vaginal delivery and one previous lower-segment caesarean section (LSCS) for cephalopelvic disproportion. She is now in early labour with regular contractions every 5 minutes. Cervical examination reveals 4 cm dilatation, 80% effaced, and soft cervix. She wishes to attempt a trial of labour after caesarean (TOLAC). What is the most appropriate management regarding induction of labour?

Explanation

## TOLAC and Oxytocin Use **Key Point:** Induction of labour with oxytocin is **relatively contraindicated** in women attempting TOLAC due to significantly increased risk of uterine rupture. However, **augmentation** of spontaneous labour with oxytocin is considered acceptable with careful monitoring. ### Clinical Distinction: Induction vs. Augmentation | Parameter | Induction | Augmentation | |---|---|---| | Definition | Initiation of labour in non-labouring patient | Enhancement of contractions in spontaneously labouring patient | | Oxytocin use in TOLAC | Contraindicated (relative) | Acceptable with caution | | Uterine rupture risk | Significantly increased | Modestly increased | | Monitoring requirement | Continuous fetal monitoring | Continuous fetal monitoring + uterine activity monitoring | ### Current Scenario Analysis This patient is **already in spontaneous labour** (regular contractions every 5 minutes, cervical changes evident). Her contractions are **adequate** for early labour (every 5 minutes). Therefore: - **No induction is needed** — labour has begun spontaneously - **No augmentation is indicated** — contractions are appropriate for cervical dilatation (4 cm) - **Management:** Allow labour to progress naturally with continuous monitoring **High-Yield:** The ACOG guideline (2019) states that while induction is contraindicated in TOLAC candidates, **augmentation of spontaneous labour** with oxytocin may be used with **continuous fetal heart rate and uterine activity monitoring** and **immediate access to emergency caesarean section**. **Clinical Pearl:** This patient has favourable features for TOLAC success: - Vaginal delivery history (increases TOLAC success to ~70–80%) - Spontaneous labour onset - Adequate cervical ripeness (soft, 80% effaced) - No indication for augmentation yet **Warning:** Aggressive oxytocin use in TOLAC candidates increases uterine rupture risk from ~0.3% to ~1.5%, a 5-fold increase. This is a critical exam concept.