Choosing Between a Repeat Cesarean and a Trial of Labor after Cesarean (TOLAC)

After Cesarean delivery, a woman may choose to have a planned Cesarean birth or choose a trial of labor for vaginal birth. It is likely that 60‐80% of women who try a vaginal birth after Cesarean delivery (VBAC) will be successful. We want you to understand the benefits and risks of your choices. There is some amount of risk that goes along with every pregnancy. These risks are greater for women who have had a prior Cesarean delivery. We share the same goal as you; a healthy baby delivered to a healthy mom. We will make every effort to ensure this.

What are the benefits of successful VBAC compared to a planned Cesarean birth?

• Faster time to heal after birth
• Shorter hospital stay
• Less risk of infection after delivery
• Less chance of blood transfusions
• No chance of problems caused by surgery (infection, injury to bowel or urinary tract, or blood loss)
• Less risk that the baby will have breathing problems
• Quicker return to normal activities because there is no pain from surgery
• Greater chance of having a vaginal birth in future pregnancies
• Less risk of problems with how the placenta attaches in future pregnancies
• Higher rates of successful breastfeeding

What are the risks of VBAC?

• A tear or opening in the uterus (womb) occurs in 5 to 10 women out of every 1,000 low risk women who try VBAC (0.5% to 1.0%).

Risks to the mother if there is a tear in the uterus include:

• Blood loss that may need transfusion
• Damage to the uterus that may need hysterectomy (removal of the uterus)
• Damage to the bladder
• Infection
• Death, which is very rare

Not all tears in the uterus harm the baby. About 7% of the time the baby is harmed when the uterus tears. The most important risks to the baby if there is a tear of the uterus are brain damage and death. In other words, 5 to 10 babies out of every 10,000 VBAC tries will suffer brain damage or death (0.05% to 0.1%) due to uterine rupture.

The risk of your uterus tearing during labor is slightly increased with any of the following:

• Labor that is induced (does not start on its own)
• More than 1 prior Cesarean delivery
• Less than 18 months since your last Cesarean delivery
• An infection at the time of your previous Cesarean

Normal risks of having a vaginal birth are also present for a successful VBAC.

Other risks for the uterus tearing are being researched. Most, but not all, studies have found a slight increased risk for uterine tearing if oxytocin is required to increase the strength or frequency of the uterine contractions during labor that started naturally (spontaneous labor). According to the American College of Obstetricians and Gynecologists, it is still acceptable to VBAC even if you’ve had two prior Cesareans, a larger baby, or twins.

What are the risks of an unsuccessful VBAC?

• If a vaginal birth cannot occur, then a Cesarean birth must be done. Overall, 60‐80% of attempted VBACs are successful.
• A Cesarean section after attempting vaginal delivery has the same types of risks as a planned Cesarean delivery.

In addition, some of the risks of surgery are increased (compared to a planned Cesarean delivery) if a Cesarean is needed after an unsuccessful VBAC trial. These risks include:

• Infection
• Transfusion
• Blood clots in the legs or lungs
• Hysterectomy

What are the risks of a planned Cesarean birth, if that is my choice? 

• The risk that the uterus will tear before a planned cesarean birth is 2 in 1000 (0.2%). Because you have a scar on your uterus from your prior Cesarean birth, you will always be at risk for having a tear in your uterus. The tears usually occur during labor, but can occur without labor.
• Blood loss and possible blood transfusions. This risk may not differ between planned vaginal birth and planned Cesarean birth.
• More scars developing on the uterus. Women with more than two prior Cesarean sections are not offered VBAC trials because of the increasing risk.
• Infection possibly requiring additional hospital days and IV antibiotics.
• Scarring inside the abdomen.
• Injury to organs inside the body.
• Problems with anesthesia.
• Blood clots forming in the veins.
• Risk in later pregnancies of problems with the placental attachment to the uterus. Women with previous Cesarean deliveries are at increased risk for placenta previa, a condition in which the placenta attaches abnormally close to the cervix. In some cases, the placenta may also attach too deeply into the uterine wall, so that it cannot be detached after the delivery of the baby. This condition is called placenta accreta and can result in large blood loss and hysterectomy. This complication is rare but the risk increases drastically with each subsequent Cesarean section.
• Wound separation requiring wound care for several weeks.