Trial of labour after cesarean (TOLAC) is planned for a woman with one prior low transverse cesarean section. Which factor is associated with the HIGHEST risk of uterine rupture during TOLAC?

• A Previous cesarean with a single-layer uterine closure
• B Use of prostaglandin (misoprostol) for cervical ripening before TOLAC ✓
• C Use of oxytocin for labor augmentation during TOLAC
• D Interpregnancy interval of less than 18 months

Explanation

Prostaglandin use (especially misoprostol/PGE1) for cervical ripening in women with a prior uterine scar carries the highest risk of uterine rupture (approximately 2–6 times higher than spontaneous or oxytocin-induced labor). The combination of cervical ripening effect and uterotonic action significantly stresses the scar. Prostaglandins are therefore contraindicated for TOLAC. Oxytocin augmentation carries a modestly elevated risk (~3× versus spontaneous labor) but is not absolutely contraindicated. Single-layer closure and short interpregnancy interval carry increased risk but are not as prohibitive as prostaglandin use.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.