In a subsequent pregnancy after a prior uterine rupture (through and through scar involving all layers), the most appropriate counseling regarding mode of delivery is:

• A Trial of labor is not contraindicated if the uterus has healed well on ultrasound
• B Delivery should be by cesarean at 38–40 weeks, same timing as first cesarean
• C VBAC is acceptable if the initial rupture was at the lower segment only
• D Elective cesarean at 36–37 weeks is recommended due to recurrence risk up to 32% ✓

Explanation

A prior complete uterine rupture (transmural, involving all layers) is an absolute contraindication to trial of labor in subsequent pregnancy (unlike lower segment cesarean scar where TOLAC is offered). Recurrence risk of rupture after complete rupture is 32–50% in subsequent pregnancy, representing an unacceptable risk. Elective repeat cesarean is planned at 36–37 weeks to pre-empt labor onset, earlier than the standard 39 weeks for routine repeat cesarean because the risk of labor-onset rupture begins before term. In contrast, a classical (vertical) uterine scar has a 4–9% rupture risk and also warrants cesarean at 36–37 weeks. The key distinction is between a transverse lower segment scar (0.5–0.9% rupture risk in TOLAC) vs. a classical or complete rupture scar.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.