Trial of Labor and Vaginal Delivery Rates in Women With Prev CS

JOGNN
REVIEW
Trial of Labor and Vaginal Delivery

Rates in Women with a Prior Cesarean
Karen B. Eden, Mary Anna Denman, Cathy L. Emeis, Marian S. McDonagh, Rongwei Fu, Rosalind K. Janik,
Alia R. Broman, and Jeanne-Marie Guise
Correspondence
Karen B. Eden, PhD,
Department of Medical
Informatics and Clinical
Epidemiology, Oregon
Health and Science
University, 3181 SW Sam
Jackson Park Rd, Portland,
OR 97229.
edenk@ohsu.edu
ABSTRACT
Keywords
VBAC
trial of labor
pregnancy
predictors
cesarean
evidence review
Data Extraction and Synthesis: The search yielded 3,134 abstracts: 69 full-text papers on TOL and vaginal birth
after cesarean (VBAC) rates and 10 on predictors of TOL. The TOL rate in U.S. studies was 58% (95% CI [52, 65])
compared with 64% (95% CI [59, 70]) in non U.S. studies. The TOL rate in the U.S. was 62% (95% CI [57, 66]) for
studies completed prior to 1996 and dropped to 44% (95% CI [34, 53]) in studies launched after 1996, p = .016. In U.S.
studies, 74% (95% CI [72, 76]) of women who had a TOL delivered vaginally. Women who had a prior vaginal birth or
delivered at a large teaching hospital were more likely to be offered a TOL.
Objective: To evaluate evidence on trial of labor (TOL) and vaginal delivery rates in women with a prior cesarean and
to understand the characteristics of women offered a trial of labor.
Data Sources: MEDLINE, DARE, and Cochrane databases were searched for articles evaluating mode of delivery for
women with a prior cesarean delivery published between 1980 and September 2009.
Study Selection: Studies were included if they involved human participants, were in English, conducted in the United
States or in developed countries, and if they were rated fair or good base on U.S. Preventive Services Task Force
(USPSTF) criteria.
Conclusions: Although the TOL rate has dropped since 1996, the rate of vaginal delivery after a TOL has remained
constant. Efforts to increase rates of TOL will depend on patients understanding the risks and benefits of both options.
Maternity providers are well positioned to provide key education and counseling when patients are not informed of their
options.
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Accepted March 2012
Karen B. Eden, PhD, is an

associate professor in the
Oregon Evidence-based
Practice Center,
Department of Medical
Informatics and Clinical
Epidemiology, Oregon
Health and Science
University, Portland, OR.
Mary Anna Denman, MD,
MCR, is an assistant
professor in the Department
of Obstetrics and
Gynecology, Oregon Health
and Science University,
Portland, OR.
(Continued)
Disclosure: The authors report no conflict of interest

or relevant financial relationships.
http://jognn.awhonn.org
rior to 1996, in the United States, the number of women having a vaginal birth after cesarean (VBAC) reached an all-time high of 28%
(Menacker, Declercq, & Macdorman, 2006). However, with the release of information on uterine rupture in 1996 (McMahon, Luther, Bowes, & Olshan,
1996), the number of women undergoing a trial of
labor (TOL) began to steadily decline. In 1999, the
American College of Obstetricians and Gynecologists (ACOG; 1999) recommended that hospitals
offering VBAC should have a surgical team immediately available throughout labor. Some hospitals
unable to provide an immediate surgical response
and concerned about liability during labor prohibited the practice of VBAC, which left some women
with no option for a TOL (Scott, 2010; Shorten,
2010). In one study, the authors reported that
prior to the 1999 ACOG guideline, 24% of eligible women in California hospitals had a TOL, and
immediately following the release, 13.5% of eligible women made the attempt, p < .001 (Zweifler
et al., 2006). When questioned, a majority (85%) of

physicians cited the updated ACOG guideline as
one of many most important factors to consider
when recommending VBAC (Coleman, Erickson,
Schulkin, Zinberg, & Sachs, 2005). The culmination of these events led to a national VBAC rate of
8.3% in 2007 (Martin et al., 2010).
A reduction in the national VBAC rate could be
attributed to fewer women having TOLs (fewer
providers and hospitals offering TOLs or fewer
women at eligible sites being allowed TOLs), fewer
women who have TOLs and who deliver vaginally,
and/or a combination of factors. Because not all
settings allow TOL, this report provides a systematic review of the literature regarding TOL rates
and the subsequent vaginal delivery rates in settings that allowed it. Because of variation in the
rate of TOL, we evaluated underlying health care
barriers (and enablers) found in the literature that
may have affected whether women were offered a

C 2012 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses
583
REVIEW
TOL and VBAC rates
TOL. This systematic review was part of a larger

evidence report on VBAC conducted to inform the
U.S. 2010 National Institutes of Health (NIH) Consensus Development Conference: Vaginal Birth
After Cesarean: New Insights (Guise, Denman,
et al., 2010; Guise, Eden, et al., 2010).
Methods
Data Sources
Cathy L. Emeis, PhD,

CNM, is an assistant
professor in the School of
Nursing, Oregon Health
Portland, OR.
Marian S. McDonagh,
PharmD, is an associate
professor in the Oregon
Evidence-based Practice
Center, Department of
Medical Informatics and
Clinical Epidemiology,
Oregon Health and Science
Rongwei Fu, PhD, is an
associate professor in the
Oregon Evidence-based
Practice Center,
Department of Public
Health and Preventive
Medicine and the
Department of Emergency
Medicine, Oregon Health
Portland, OR.
Rosalind K. Janik, BA, is a
project manager at Epic
Systems Corporation,
Verona, WI.
Alia R. Broman, BA, is a
student at the medical
school at the University of
Colorado, School of
Medicine, Aurora, CO.
Jeanne-Marie Guise, MD,
MPH, is an associate
director for the Oregon
Evidence-based Practice
Center and an associate
professor in the Department
of Medical Informatics and
Clinical Epidemiology,
Department of Obstetrics
and Gynecology and
Department Public Health
and Preventive Medicine,
Oregon Health and Science
584
Together with a medical librarian, we searched

MEDLINE, Database of Abstracts of Reviews of
Effectiveness (DARE), and the Cochrane Library
from 1980 to September 2009 using methods described previously (Guise, Denman, et al., 2010;
Guise, Eden, et al., 2010). The search was limited
to publications after 1980 when the NIH held a
consensus conference that concluded that VBAC
was an acceptable option and resulted in changes
in practice. The searches included variations of
the terms VBAC, prior cesarean, and trial of labor. Additional articles were identified from reference lists of reviews and editorials and through the
peer review process. The abstracts retrieved from
the searches were then entered into an electronic
database. This search was part of a larger search
that addressed several topics for the evidence report related to TOL and VBAC rates, predictors of
TOL and VBAC, benefits and harms to mothers
and infants for TOL, and repeat cesarean (Guise,
Denman, et al.; Guise, Eden, et al.).
Study Selection
Full-text studies were included if they explicitly reported on eligibility for TOL and if they provided
data for computing the TOL rate or vaginal delivery
rate after a TOL at the study sites. We were particularly interested in studies that provided information on influencing factors and predictors of TOL.
Non-U.S. studies were included if the study was
conducted in a developed country because the
available technology and medical response were
thought to be similar to the United States and were
published in English (The World Factbook, 2008).
Two investigators reviewed each full-text article for
inclusion or exclusion. We excluded studies that
included women without a prior cesarean delivery, nulliparous patients, 10 participants or fewer,
breech delivery, exclusive focus on preterm delivery or low birth weight, multiple gestation, or
abortions.
Data Extraction and Quality Rating

Reviewers rated the quality of each study using
criteria developed by the U.S. Preventive Services
Task Force (USPSTF) and the National Health Service Centre for Reviews and Dissemination (Harris
et al., 2001; Healthy Inclusion, 2001). Two reviewers independently reviewed the studies. When
reviewers disagreed, a final rating was reached
through discussion and consensus of the whole
team. Studies that were rated as poor quality were
excluded from analyses. Parameters that were
particularly important for TOL and VBAC rates
were clear definition of eligibility for TOL, comparable groups, reliable and valid outcomes, unbiased assessment of measures, follow-up long
enough for outcome to occur, acceptable level
of attrition (40%), and adjustment for potential
confounders (Guise, Denman, et al., 2010; Guise,
Eden, et al., 2010). For studies reporting on the
factors influencing or predicting TOL, clear definition of all factors was critical (Guise, Eden, et al.).
Data from included papers were extracted by one
researcher into evidence tables and verified by a
second.
Analysis
Meta-analyses were conducted using a random
effects model (DerSimonian & Laird, 1986) to summarize TOL and vaginal delivery rates. Statistical
heterogeneity was assessed by using the standard chi-squared test and the I2 statistic (the
proportion of variation in study estimates due to
heterogeneity rather than sampling error) (Higgins, Thompson, Deeks, & Altman, 2003; Higgins, Thompson, Higgins, & Thompson, 2002).
To explore heterogeneity, we performed subgroup
analyses and meta-regression (Sutton, Abrams,
Jones, Sheldon, & Song, 2000; Thompson &
Sharp, 1999) to evaluate whether the summary
estimates differed by study-level characteristics,
including U.S. versus non-U.S. population, gestational age of the population (term vs. any gestational age), and year of data collection of the
study.
Results
As shown in Figure 1, of 3,134 citations identified
in searches, 963 full-text papers were reviewed
and 69 studies that contained adequate data to
compute the TOL and/or vaginal delivery rate, and
10 studies on predictors of TOL met the inclusion
and quality standards. We included 19 studies of
good quality and 50 studies of fair quality that provided evidence on TOL and VBAC rates (Table 1).
The majority (7 of 10) of the studies providing
evidence on individual predictors were of good
quality (Cameron, Roberts, & Peat 2004; Chang,
Stamilio, & Macones, 2008; DeFranco et al., 2007;
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
REVIEW
Eden, K.B. et al.
Figure 1. Search and Selection of Literature for TOL rate and Vaginal Delivery Rate after TOL.
TOL = trial of labor; VBAC = vaginal birth after cesarean.
a
Searched databases included MEDLINE, Cochrane and DARE.
Many studies are included in more than one topic area. Adapted with permission from Guise, J. M., Eden, K., Emeis, C., Denman,
M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal birth after cesarean: New insights. Evidence Report/Technology
Assessment No. 191 (AHRQ publication no. 10-E001). Rockville, MD: Agency for Healthcare Research and Quality. Also adapted
with permission from Wolters Kluwer. from Eden, K.B., (2010). New insights on vaginal birth after cesarean, can it be predicted?
Obstetrics & Gynecology, 116(4), 967981.
Harper et al., 2009; Kabir, Pridjian, Steinmann,

Herrera, & Khan, 2005; McMahon et al., 1996;
Pang, Law, Leung, Lai, & La 2009), and the remainder (3 of 10) were fair quality (Bujold, 2001;
Hueston & Rudy, 1994; Selo-Ojeme, Abulhassan,
Mandal, Tirlapur, & Selo-Ojeme 2008).
TOL Rate
Thirty-five studies consisting of 10 prospective
and 25 retrospective cohort studies provided data
on TOL rates (Table 1). These studies included
661,765 women and provided a combined TOL
rate of 61% (95% CI [57, 65]). However, the rates
of TOL significantly varied across the studies ranging from 28% to 82% (p < .0001) with an I2
for between-heterogeneity of greater than 99%
(Figure 2). Results from metaregression indicated
that TOL rates differed significantly by gestational
age and year of study (p < .05) but not by study
design (retrospective vs. prospective) or country.
As shown in Figure 2, the overall TOL rate in studies conducted in the United States was 58% (95%
JOGNN 2012; Vol. 41, Issue 5
CI [52, 65]), compared with 64% (95% CI [59, 70])

among women in studies conducted outside the
U.S (p = .158).
The overall TOL rate in all studies of term deliveries
was 53% (95% CI [47, 59]). This was significantly
lower than the TOL rate (66%; 95% CI [61. 70])
from studies that included women of any gestational age (p = .002). Stratification by country and
by gestational age (Figure 2) revealed that term
rates were lower than studies of any gestational
age in U.S. and non-U.S. studies but was only statistically significant in studies conducted outside
the United States (p = .001).
Because concerns about uterine rupture emerging after 1996 could affect candidate selection
for TOL and perhaps improve VBAC rates, studies were grouped by the years when the data
were collected: completed before 1996, included
1996, and started after 1996. The TOL rate was
62% (95% CI [57, 66]) among nine U.S. studies
completed before 1996 (Fisler, Cohen, Ringer, &
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TOL and VBAC rates
Table 1: Evidence for TOL and Vaginal Delivery Rates

Study
Quality
U.S. or
Cohort
Evidence
Evidence for
Non-U.S.
Design
for TOL
Vaginal Delivery
after TOLa
586
Bais, 2001
Fair
Non
Prospective
Cameron, 2004
Good
Non
Retrospective
Caughey, 1999
Fair
US
Retrospective
Costantine, 2009
Good
US
Retrospective
De Franco, 2007
Good
US
Retrospective
Delaney, 2003
Fair
Non
Retrospective
DiMaio, 2002
Fair
US
Retrospective
Dinsmoor, 2004
Fair
US
Retrospective
Durnwald, 2004a
Fair
US
Retrospective
Durnwald, 2004b
Fair
US
Retrospective
El-Sayed, 2007
Fair
US
Retrospective
X (Term)
Elkousy, 2003
Fair
US
Retrospective
X (Term)
Fisler, 2003
Fair
US
Retrospective
Flamm, 1987
Fair
US
Retrospective
Flamm, 1994
Good
US
Prospective
Gonen, 2006
Fair
Non
Retrospective
Goodall, 2005
Fair
US
Retrospective
Gregory, 1999
Good
US
Retrospective
Gregory, 2008
Fair
US
Retrospective
X (Term)
Gyamfi, 2004
Good
US
Retrospective
X (Term)
Hammoud, 2004
Fair
Non
Retrospective
Hashima, 2007
Fair
US
Retrospective
X (Term)
X
X (Term)
X
X
X
X (Term)
X
X
X (Term)
X
Hendler, 2004
Good
Non
Prospective
Hibbard, 2006
Good
US
Prospective
Hollard, 2006
Good
US
Retrospective
Hook, 1997
Good
US
Prospective
Horenstein, 1984
Fair
US
Retrospective
Horenstein, 1985
Fair
US
Retrospective
Hoskins, 1997
Fair
US
Retrospective
Huang, 2002
Fair
US
Retrospective
X (Term)
Hueston, 1994
Fair
US
Retrospective
Jakobi, 1993
Good
Non
Prospective
Johnson, 1991
Fair
US
Retrospective
Juhasz, 2005
Fair
US
Retrospective
Kugler, 2008
Fair
Non
Retrospective
Landon, 2006
Fair
US
Prospective
Learman, 1996
Good
US
Retrospective
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
X
X
X (Term)
X
X (Term)
REVIEW
Eden, K.B. et al.
Table 1: Continued
Study
Quality
U.S. or
Cohort
Evidence
Evidence for
Non-U.S.
Design
for TOL
Vaginal Delivery
after TOLa
Lieberman, 2004
Fair
US
Prospective
Locatelli, 2004
Good
Non
Retrospective
Loebel, 2004
Fair
US
Retrospective
X (Term)
Macones, 2005
Fair
US
Retrospective
McMahon, 1996
Good
Non
Retrospective
McNally, 1999
Fair
Non
Retrospective
Nguyen, 1992
Fair
US
Retrospective
Obara, 1998
Fair
Non
Retrospective
Ouzounian, 1996
Fair
US
Retrospective
Pang, 2009
Good
Non
Retrospective
Pathadey, 2005
Fair
Non
Retrospective
Phelan, 1987
Fair
US
Prospective
Pickhardt, 1992
Fair
US
Retrospective
X
X
X (Term)
Raynor, 1993
Fair
US
Retrospective
Rozenberg, 1996
Good
Non
Prospective
Rozenberg, 1999
Fair
Non
Prospective
Sakala, 1990
Fair
US
Retrospective
Selo-Ojeme, 2008
Fair
Non
Retrospective
X (Term)
Smith, 2002
Good
Non
Retrospective
X (Term)
Smith, 2005
Good
Non
Retrospective
X (Term)
Socol, 1999
Fair
US
Retrospective
Spaans, 2002
Fair
Non
Retrospective
Stovall, 1987
Fair
US
Prospective
Strong, 1996
Fair
Non
Prospective
Troyer, 1992
Fair
US
Retrospective
X (Term)
van Gelderen, 1986
Fair
Non
Prospective
Vinueza, 2000
Fair
US
Retrospective
Weinstein, 1996
Good
Non
Retrospective
Wen, 2004
Fair
Non
Retrospective
Yetman, 1989
Fair
US
Retrospective
Yogev, 2004
Fair
Non
Retrospective
Zelop, 2001
Fair
US
Retrospective
X (Term)
Note. TOL = trial of labor.

a
Unless noted by Term, the studies accepted women of all gestational ages (term and preterm).
Lieberman, 2003; Flamm, Goings, Liu, & WoldeTsadik, 1994; Gregory, Korst, Cane, Platt, & Kahn,
1999; Hook, Kiwi, Amini, Fanaroff, & Hack, 1997;
Hueston & Rudy, 1994; Phelan, Clark, Diaz, &
Paul, 1987; Pickhardt et al., 1992; Stovall, Shayer,

Solomon, & Anderson, 1987; Troyer & Parisi,
1992), 63% (95% CI [58, 67]) for U.S. studies that
included 1996 (DeFranco et al., 2007; Durnwald &
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TOL and VBAC rates
Figure 2. Trial of labor in studies conducted in the United States and outside the United States. Adapted with permission from Guise, J. M., Eden, K., Emeis,
C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal birth after cesarean: New insights. Evidence Report/Technology Assessment No. 191
(AHRQ publication no. 10-E001). Rockville, MD: Agency for Healthcare Research and Quality.
Mercer, 2004b; Loebel, Zelop, Egan, & Wax, 2004;

Macones et al., 2005; Socol & Peaceman, 1999),
and 44% (95% CI [34, to 53] for U.S. studies initiated after 1996 (DiMaio, Edwards, Euliano, Treloar,
& Cruz, 2002; Gregory et al., 2008; Landon et al.,
2006). The TOL was significantly lower than the
rate prior to 1996 (p = .016) or that included 1996
(p = .019) (Figure 3). A similar trend was present
for non-U.S. studies (Figure 3).
Almost all studies providing TOL rates were conducted in tertiary care centers such as teaching hospitals with residents and 24-hour anesthesia teams available; therefore, findings have
limited applicability to rural settings. We found
two retrospective studies completed before 1996
(Hueston & Rudy, 1994; McMahon, 1996) that reported reduced attempts (TOL rates ranging from
36%41%) for rural settings compared with urban and/or teaching settings (TOL rates ranged
from 60%69%). In one retrospective study completed 1998 to 2001 (Cameron, 2004), the authors
reported that rural sites had a TOL rate of 47%
compared with 55% for a perinatal center setting. Finally, a retrospective study launched and
588
completed in 2001 indicated that 70% of repeat

cesarean deliveries (RCD) in rural settings were
potentially unnecessary compared with 61% in urban teaching settings that is consistent with findings above (Kabir, 2005). The authors in this study
coded a cesarean as potentially unnecessary
if it lacked an associated discharge diagnosis to
justify it. A diagnosis of a prior cesarean delivery
alone was not considered sufficient justification for
a repeat cesarean. Although we could not statistically analyze these results, they suggest that the
rates of TOL are lower in rural settings than nonrural settings and that the TOL rates across sites
may have dropped since 1996.
Vaginal Delivery Rate with TOL

Sixty-seven studies including 14 prospective cohort studies and 53 retrospective cohort studies (Table 1) provided data on VBAC rate from
368,304 women. The range in VBAC rates across
studies inside and outside the United States was
49% for a high-birth-volume hospital in London
(Selo-Ojeme, 2008) to 87% for a national study of
U.S. birth centers (Lieberman, 2004) (Figures 5
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
REVIEW
Eden, K.B. et al.
Figure 3. Global trial of labor rates have dropped over time.

Adapted with permission from Guise, J. M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010).
Vaginal birth after cesarean: New insights. Evidence Report/Technology Assessment No. 191 (AHRQ publication no. 10-E001).
Rockville, MD: Agency for Healthcare Research and Quality.
and 6), and the overall summary estimate for

the vaginal delivery rate from the random effects model was 74% (95% CI [72, 75]). However, there was significant heterogeneity among
included studies (p < .001) with I2 = 98.6%.
Metaregression was conducted to assess the association between vaginal delivery rates with TOL
and country, gestation, true cohort (study included
TOL and elective repeat cesarean delivery [ERCD]
vs. studies of TOL only), and by years when the
data were collected. None of these factors could
explain the variation among studies. The summary

estimates were similar: for the 43 studies conducted in the United States, 74% (95% CI [72, 76])
of women had a vaginal delivery compared to 73%
(95% CI [71, 74]) for the 24 studies conducted outside the United States (Table 1). In examining the
gestational age for enrolled patients, the summary
estimates were again similar: for the 18 studies of
term deliveries, 73% (95% CI [71, 75]) of women
delivered vaginally compared to 74% (95% CI [72,
76]) for the 49 studies that included preterm and
term deliveries (Table 1).
Figure 4. TOL and vaginal delivery rates with TOL over time.
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TOL and VBAC rates
Figure 5. Rate of vaginal delivery with TOL in studies conducted in the United States.
Reprinted with permission from Guise, J. M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010).
Using only the subset of the U.S. studies that provided data to compute the TOL and vaginal delivery rates with TOL, the rates were ordered by
year the data collection was launched (ranged
between 19822002) and plotted together on the
same chart, Figure 4. With the exception of one
retrospective study that focused on costs of de-
590
livery for a cohort of 204 women with a prior

low transverse cesarean (DiMaio, 2002, shown in
Figure 4), the TOL rates in U.S. studies (shown
by the diamonds) have dropped dramatically over
the last 15 years. The first drop was seen after
1996 when McMahons (1996) evidence on uterine
rupture and other complications was published.
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
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Eden, K.B. et al.
Figure 6. Rate of vaginal delivery with TOL in studies conducted outside the United States.
Reprinted with permission from Guise, J. M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010).
A second dramatic decrease was seen in two

multisite cohort studies that enrolled patients after
the 1999 ACOG guideline on VBAC was released
(Gregory et al., 2008; Landon et al., 2006). However, during the same time period of 1982 to 2002,
the vaginal delivery rates with TOL (shown by the
squares) have remained relatively constant, fluctuating around 70%.
Although the evidence is lean, these findings suggest that practice changed with the emersion of
new evidence (McMahon, 1996) and a new VBAC
guideline (ACOG, 1999). We then examined the
studies for ways that practice may have changed,
for example, not allowing women with more than
one prior cesarean or a certain type of scar to have
a TOL, reduction in either induction, or epidural
use. Many studies did not report the proportion
of women with more than one prior cesarean or
who had a certain type of scar or the proportion
who were induced or had epidurals (DiMaio, 2002;

Gregory, 1999; Gregory et al., 2008; Loebel, 2004;
Pickhardt et al., 1992; Troyer & Parisi, 1992). Descriptively, it appeared that studies enrolled fewer
and fewer women with more than one prior cesarean over time. Studies completed before 1996
reported that 19% (Stovall, 1987) to 23% (Phelan, 1987) of women with a TOL had more than
one prior cesarean. For studies launched in 1996,
between 9% (Macones et al., 2005) and 19% (DeFranco et al., 2007) of women with a TOL had
more than one cesarean. However, the large National Institute of Child Health and Human Development Maternal - Fetal Medicine Units Network
(MFMU) study launched in 1999 reported only 5%
of women had more than a single prior cesarean
(Landon et al., 2006). We did not observe a consistent change over time in TOL eligibility based
on type of scar (DiMaio, 2002; Durnwald & Mercer, 2004b; Flamm, 1994; Landon et al., 2006;
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Women delivering in hospitals with higher delivery volumes,

tertiary care centers, and teaching hospitals were more likely to
have a trial of labor.
Loebel, 2004; Macones et al., 2005; Phelan, 1987;

Stovall, 1987; Troyer & Parisi, 1992), use of induction, (DeFranco et al., 2007; Durnwald & Mercer,
2004b; Hook, 1997; Landon et al., 2006; Phelan,
1987; Stovall, 1987) or epidural (Durnwald & Mercer, 2004b; Fisler, 2003; Landon et al., 2006; Stovall, 1987).
Most evidence of TOL and vaginal delivery rates
after TOL are from studies based in large tertiary
care centers and are highly variable. Because
the vaginal delivery rate has not improved with
a smaller pool of women, we sought evidence
on whether characteristics of the delivery system
or the patient contributed to the decision about
whether a TOL was offered.
What Factors Contributed to an Option

of a TOL?
Six good cohort studies (Cameron, 2004; Chang,
2008; DeFranco et al., 2007; Harper et al., 2009;
McMahon, 1996; Pang, 2009), three fair quality
cohort studies (Bujold, 2001; Hueston & Rudy,
1994; Selo-Ojeme, 2008), and one good quality
cross-sectional study (Kabir, 2005) reported factors that may have contributed to whether women
were offered a TOL. Two themes emerged from
these studies related to site of delivery and the
womans history of a prior vaginal delivery.
Women delivering in hospitals with higher delivery volumes, tertiary care centers, and teaching
hospitals were more likely to have a TOL (Table 2)
(Cameron, 2004; DeFranco et al., 2007; Hueston
& Rudy, 1994; McMahon, 1996). Delivery volume
in teaching hospitals predicted TOL in one retrospective cohort study conducted in 1990 and
1991, even when adjusted by race, employment,
marital status, and obstetric risk (Hueston & Rudy,
1994).
Level of care also appeared to influence the decision for a TOL (Table 2). In one study women had
an increased likelihood of TOL if they delivered
at a Level 5 or 6 hospital (metro district hospital
for high-risk mothers/babies or perinatal center)
and a decreased likelihood at a Level 4 or below
(metro district for moderate-risk mothers/babies,
rural, and private hospitals) (Cameron, 2004). In
592
this study of Australian deliveries during 1998 to

2001 (Cameron, 2004), predictors of TOL were
evaluated for 14,350 charts of women eligible for
TOL by the ACOG standards (1999). In a separate study conducted in Nova Scotia, Canada, between 1986 and 1992, researchers similarly found
that women in community and regional hospitals
were one half as likely to have a TOL as women delivering in tertiary care centers (McMahon, 1996).
The presence of a residency program consistently
improved the likelihood that women were offered
TOLs (DeFranco et al., 2007; Kabir, 2005) when
compared to settings without residency programs.
In a secondary analysis of a retrospective study
(conducted in 19962000) (DeFranco et al., 2007)
of 17 hospitals, women delivering in hospitals that
did not have an obstetric/gynecology residency
program were less likely to have a TOL (odds ratio
[OR] = .88, CI [0.82, 0.95]) even when adjusting
for age, obstetric history, birth weight, gestational
age, and maternal risks. In another secondary
analysis of the Agency for Healthcare Research
and Qualitys (AHRQ) 2001 Healthcare Cost and
Utilization Project (HCUP) National Inpatient Sample database, investigators reported that women
had a reduced likelihood of TOL if they were delivered in rural or nonteaching urban hospitals (Kabir,
2005). These investigators identified all women
who had unnecessary RCDs (had no discharge
indication, ICD-9 code, for a cesarean) as a way
to quantify the number of women who may not
have been offered a TOL; the database includes
data from 33 states. In this study, a prior cesarean
alone was not considered as sufficient justification
for a RCD. With this definition, 65% of RCDs were
considered unnecessary and overall bed size of
the hospital was not related to unnecessary RCDs.
When providers consider whether to offer the option of a TOL after a prior cesarean, careful attention is given to prior obstetric history in estimating likelihood of VBAC. Three retrospective
cohort studies, (Cameron, 2004; McMahon, 1996;
Pang, 2009) and a secondary analysis (Harper
et al., 2009) of a large retrospective study (Macones et al., 2005) examined whether obstetric
factors such as number of prior vaginal deliveries or gestational age at the prior cesarean
predicted whether women had a TOL (Table 3).
The likelihood of TOL increased (OR ranged from
1.51 to 6.67) for women with prior vaginal deliveries (Cameron, 2004; McMahon, 1996; Pang,
2009) whereas it decreased for women who had
a prior cesarean before 34 weeks gestational age
(Harper et al., 2009).
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
REVIEW
Eden, K.B. et al.
Discussion
Vaginal delivery rates for women who had a TOL
have remained constant over the same time period. Since 1996, the number of women who had
a TOL at sites still offering TOLs fell to less than
one half of those eligible. Among women who had
a TOL, 74% delivered vaginally. The vaginal delivery rate with TOL in this updated evidence report is
consistent with the previously reported rate (76%)
in the 2003 evidence report on VBAC (Guise et al.,
2003). The newer evidence suggests that many
women who would have delivered vaginally had
elective cesarean deliveries either by own choice
or because of barriers in the health system. It is
important to note that the TOL and vaginal delivery rates with TOL summarized in this report were
obtained from sites that still provided TOLs. Our
reported vaginal delivery rates with TOL will exceed reported national VBAC rates that include
sites that limit (or prohibit) TOLs.
With newly issued concluding consensus statements, rates of TOL may again increase for stud-
Since 1996, the number of women who had a trial of labor at

sites still offering this option fell to less than one half of those
eligible.
ies launched after 2010. The 2010 Consensus Development Panel on VBAC urged that barriers to
TOL be removed to again give a woman an opportunity to make an informed choice with her
provider: We recommend that hospitals, maternity care providers, healthcare and professional
liability insurers, consumers, and policymakers
collaborate on the development of integrated services that could mitigate or even eliminate current
barriers to TOL (U.S. Department of Health and
Human Services, 2010, p. 3).
Although some barriers are obvious to the patient,
for example, the hospital will not allow TOLs, efforts are needed to address less obvious barriers
(to the patient), such as liability to the provider.
In a survey of ACOG fellows, 41% of the 639
Table 2: Characteristics of Delivery Sites and Likelihood of TOL

Author, Year
Characteristic
Adjusted Odds
95% CI
Ratio for TOL

Volume of Deliveries
Hueston & Rudy, 1994
252 women with prior CD/2y
1.00
Referent
0.46
0.29, 0.74
0.57
0.38, 0.85
0.38
0.25, 0.56
Level 6 (Perinatal center)
1.00
Referent
Level 5 (High-risk care)
1.22
1.09, 1.37
Level 4 (moderate-risk care)
0.90
0.81, 0.99
0.66
0.58, 0.74
Private
0.45
0.41, 0.50
Hospital Level
Cameron, 2004
Level 13 (Rural)
McMahon, 1996
Tertiary care
1.00
Referent
Regional hospital
0.50
0.50, 0.60
Community hospital
0.40
0.30, 0.50
Obstetrics/Gynecology Residency program
1.00
Referent
No program
0.88
0.82, 0.95
Teaching Status
DeFranco, 2007
Note. CD = cesarean delivery; CI = confidence interval; TOL = trial of labor; y = year(s).

Adapted with permission from Guise, J. M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal
birth after cesarean: New insights. Evidence report/technology assessment no. 191 (AHRQ publication no. 10-E001). Rockville, MD:
Agency for Healthcare Research and Quality.
a
96% rural hospitals.
593
REVIEW
TOL and VBAC rates
Many patients may not be aware of risks and benefits or

prepared to advocate for their desired mode of delivery.
respondents cited fear of liability as one of many

most important factors to consider in advising
patients about whether to have a TOL (Coleman
et al., 2005). Similarly, investigators of a retrospective cohort study (Yang, Mello, Subramanian,
& Studdert, 2009) estimated that a decrease of
$10,000 (in 2003 dollars) in the malpractice premium (equivalent to a 20%25% average premium
decrease for OB/GYNs) would have translated to
1,600 more VBACs and 6,000 fewer cesarean deliveries (including 3,600 fewer primary cesarean
deliveries), nationally in 2003.
The dawn of the economic recession in 2007 may
have augmented provider and insurer rationale for
low TOL rates over the past 3 years. In a time
where most businesses are looking to cut costs
and fear of litigation remains high, changing policy to allow VBAC may be viewed as too risky
financially to implement. In addition to decreasing
TOL rates, it is important to note a striking decline in the U.S. birth rate since 2007. The April
2010 Pew Research Center birth trends report
(compiled using data from the 25 states with final 2008 birth numbers) shows that the national
U.S. birth rate grew steadily from 2003 to 2007,
then sharply declined by 2% from 2007 to 2008,
and has steadily decreased since (Livingston &
Cohn, 2010). Popular media outlets, such as The
New York Times and National Public Radio have
explored this topic, noting that many women are

focusing more on contraceptive use than family
growth because they are concerned about the
cost of raising children in a down economy (Associated Press, 2010; Siegal, 2010). As individual hospitals lose revenue due to declining birth
rates, it will be interesting to analyze the effect of
the 2010 Clinical Management Guidelines (ACOG,
2010) on TOL.
Nursing Implications
National guidelines on VBAC from the Royal College of Obstetricians and Gynaecologists in the
United Kingdom and Womens Hospital Australasia (Australia) emphasize the importance of offering women information so that they can discuss the childbirth options (Foureur, Ryan, Nicholl,
& Homer, 2010). Although U.S. providers report
knowing the risks and benefits of VBAC and RCD
(Coleman et al., 2005), it is not clear that many
patients are aware of such risks and benefits or
are prepared to advocate for their desired mode of
delivery. Perinatal nurses, nurse practitioners, and
certified nurse midwives are well positioned to assess womens knowledge about delivery options
and their associated risks and benefits. When
knowledge is lacking, they can provide education
and counseling to address this need.
The importance of informing patients also
emerged in the vision statement from Childbirth
Connections Transforming Maternity Care, a collaboration of 100 national leaders representing obstetrics, nurse-midwifery, maternity nursing, family
medicine, health policy, health economics, quality,
Table 3: Past Obstetric Factors as Predictors of Trial of Labor

Author, Year Study Design
Characteristic
Adjusted odds
95% CI
Ratio or Relative
Risk for VBAC
Number of Previous Vaginal Deliveries
Cameron, 2004, Retrospective Cohort
McMahon, 1996, Retrospective Cohort
Pang, 2009, Retrospective Cohort
1 Prior VD
1.51
1.35, 1.68
2 Prior VDs
2.35
1.92, 2.86
3 Prior VDs
2.94
2.23, 3.88
1 Prior VD
3.20
Not reported
2 Prior VDs
4.00
Not reported
History of VD
6.67
2.70, 16.67
Note. CI = confidence interval; VD = vaginal delivery; VBAC = vaginal birth after cesarean.
Reprinted with permission from Guise, J. M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal
birth after cesarean: New insights. Evidence Report/Technology Assessment No. 191 (AHRQ publication no. 10-E001). Rockville, MD:
Agency for Healthcare Research and Quality.
594
JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x
REVIEW
Eden, K.B. et al.
patient safety, childbirth education, maternal fetal

medicine, and health consumer advocacy (Carter
et al., 2010). One of the guiding principles for their
2020 vision presented in April 2009 was to provide women with the opportunity to make informed
choices (Carter et al.). To make this vision a reality, future work is needed in creating evidencebased patient education products (brochures, decision aids) designed using plain language so that
women feel informed and prepared to enter into a
dialog about birth choice. Additionally, future work
is needed to integrate these tools into current clinical practice and may require health care providers
to adopt a shared style of decision making that
uses this new technology (Shorten, 2010). Less
than a year after the Childbirths Connections vision statement was presented, the NIH VBAC Consensus Development panel echoed the same sentiment but with an emphasis on shared decision
making among informed patients and providers:
Information, including risk assessment, should be
shared with the woman at a level and pace that she
can understand. When both TOL and ERCD are
medically equivalent options, a shared decision
making process should be adopted and, whenever possible, the womans preference should be
honored (U.S. Department of Health and Human
Services, 2010, p. 33).
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Acknowledgment
Based on a systematic evidence review conducted for and presented to the National Institutes
of Health Consensus Development Conference
on Vaginal Birth After Cesarean: New Insights.
Funded by the Agency for Healthcare Research
and Quality (AHRQ), Contract No. HHSA 2902007-10057-I, Task Order No. 4 for the Office of
Medical Applications of Research at the National
Institutes of Health. The findings and conclusions
in this document are those of the authors, who are
responsible for its content, and do not necessarily
represent the views of AHRQ. No statement in this
report should be construed as an official position
of AHRQ or of the U.S. Department of Health and
Human Services.
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JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Trial of Labor and Vaginal Delivery Rates in Women With Prev CS

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JOGNN

Trial of Labor and Vaginal Delivery

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Karen B. Eden, PhD, is an

Disclosure: The authors report no conflict of interest

et al., 2006). When questioned, a majority (85%) of

TOL and VBAC rates

TOL. This systematic review was part of a larger

Cathy L. Emeis, PhD,

Together with a medical librarian, we searched

Data Extraction and Quality Rating

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Eden, K.B. et al.

Searched databases included MEDLINE, Cochrane and DARE.

Obstetrics & Gynecology, 116(4), 967981.

Harper et al., 2009; Kabir, Pridjian, Steinmann,

JOGNN 2012; Vol. 41, Issue 5

CI [52, 65]), compared with 64% (95% CI [59, 70])

TOL and VBAC rates

Table 1: Evidence for TOL and Vaginal Delivery Rates

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Eden, K.B. et al.

van Gelderen, 1986

Note. TOL = trial of labor.

JOGNN 2012; Vol. 41, Issue 5

Paul, 1987; Pickhardt et al., 1992; Stovall, Shayer,

TOL and VBAC rates

Mercer, 2004b; Loebel, Zelop, Egan, & Wax, 2004;

completed in 2001 indicated that 70% of repeat

Vaginal Delivery Rate with TOL

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Eden, K.B. et al.

Figure 3. Global trial of labor rates have dropped over time.

and 6), and the overall summary estimate for

explain the variation among studies. The summary

JOGNN 2012; Vol. 41, Issue 5

TOL and VBAC rates

livery for a cohort of 204 women with a prior

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Eden, K.B. et al.

A second dramatic decrease was seen in two

JOGNN 2012; Vol. 41, Issue 5

who were induced or had epidurals (DiMaio, 2002;

TOL and VBAC rates

Women delivering in hospitals with higher delivery volumes,

Loebel, 2004; Macones et al., 2005; Phelan, 1987;

What Factors Contributed to an Option

this study of Australian deliveries during 1998 to

JOGNN, 41, 583-598; 2012. DOI: 10.1111/j.1552-6909.2012.01388.x

Eden, K.B. et al.

Since 1996, the number of women who had a trial of labor at

Table 2: Characteristics of Delivery Sites and Likelihood of TOL

Ratio for TOL

252 women with prior CD/2y

135 women with prior CD/2y

179 women with prior CD/2y

193 women with prior CD/2y

Level 6 (Perinatal center)

Level 5 (High-risk care)

Level 4 (moderate-risk care)

Obstetrics/Gynecology Residency program

Note. CD = cesarean delivery; CI = confidence interval; TOL = trial of labor; y = year(s).

JOGNN 2012; Vol. 41, Issue 5