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In July 1999, The American College of Obstetricians and Gynecologists (ACOG) issued Practice Guideline number 5 on vaginal birth after cesarean section (VBAC) and trial of labor (TOL). This updated guideline recommends that a physician be immediately available during a TOL in the rare case of complications. We examined the effect this new guideline would have on physician's VBAC/TOL practices in Utah.1) Explore physician knowledge of ACOG Practice Guideline number 5; 2) Evaluate change in physician's VBAC practices in the previous 12 months; 3) Evaluate physician's ability to comply with ACOG Practice Guideline number 5 recommendations by rural, suburban, and urban location.In spring 2001, we surveyed by mail all physicians practicing obstetrics in Utah. Questions included demographics, hospital data, VBAC/TOL practice patterns and awareness of ACOG Practice Guideline number 5. Physicians were classified as urban, suburban, or rural by their primary delivery hospital.We found 97% of obstetricians and 79% of family physicians were aware of ACOG Practice Guideline number 5. Forty-five percent of all physicians reported a decline in VBAC practices in the preceding 12 months. Urban physicians' use of VBAC/TOL decreased the least, followed by rural and suburban. Eighty-seven percent of physicians had C/S “immediately” available during TOL: urban physicians 100%, suburban 88%, and rural physicians 76%. Emergency C/S delivery was performed fastest at urban hospitals, slower at suburban, and slowest at rural hospitals.Physicians use of VBAC/TOL has changed. TOL is offered less by obstetrical providers in Utah and more repeat C/S are performed since 1999 when ACOG updated this policy guideline. This decline has been more noticeable in suburban and rural hospitals and is consistent with recent national trends. Many rural physicians are unable to comply with ACOG Practice Guideline number 5 recommendations.