Trial of Labor After Cesarean (TOLAC)
After delivery by Cesarean section, a woman may choose to have a planned Cesarean birth or choose a trial of labor for vaginal birth (VBAC-vaginal birth after Cesarean). It is likely that 70-80% of women who have a trial of labor after Cesarean (TOLAC) will be successful. Your provider's at Avalon want you to understand the risks and benefits of your choices. There is a certain amount of risk with every pregnancy. We share the same goals as you and your partner—a healthy baby and a healthy mom. We will make every effort to ensure this outcome.
Can all women with a previous Cesarean delivery attempt a TOLAC?
Some women should not attempt a VBAC. If the Cesarean scar is in the upper part of the uterus where the muscles contract, the risk of the uterus tearing (uterine rupture) is high. These women should have repeat scheduled Cesareans and avoid labor. Women with a low transverse uterine incision have a lower risk of uterine rupture and are considered good candidates for TOLAC. The type of scar you have on your skin may not be the same type of scar on the uterus. We will request that you obtain your operative record from your previous Cesarean delivery in order for us to assess the type of uterine incision that was done, and the uterine suture technique (single vs. double layer). If you have had more than 2 Cesarean deliveries, the risk of uterine rupture is increased. For this reason, we do not offer TOLAC to women with more than 2 Cesarean sections.
What are the benefits of TOLAC compared to a repeat Cesarean section?
- Shorter hospital stay
- Less blood loss and less risk of need for transfusion
- Less risk of infection
- No abdominal surgery and its inherent risks
- Less risk of neonatal respiratory issues
- Quicker return to normal activities
- Greater chance of having a future vaginal birth
- Avoidance of problems associated with repeat Cesarean section including hysterectomy, bowel/bladder injury, or abnormal placental complications such as placenta previa or placenta accreta
What are the risks of TOLAC?
- A tear or opening (rupture) in the uterus occurs in 5-10 women out of 1,000 low risk women who attempt a VBAC (0.5-1.0%)
- Risks to the mother if there is a uterine rupture include
- Blood loss requiring transfusion
- Damage to the uterus that may require hysterectomy
- Damage to the bladder
- Blood clots
- Death (rare)
- Risks to the baby if there is a uterine rupture may include brain damage and death. Not all ruptures harm the baby. About 10% of the time there is damage to the baby, or 5-10 babies out of every 10,000 TOLACs will suffer brain damage or death from lack of oxygen to the brain.
- The normal risks of a vaginal birth are also present for VBAC
- The risk of your uterus tearing during labor is increased with any of the following:
- Labor that is induced/augmented
- More than 2 Cesareans
- Less than 18 months since your last Cesarean delivery
- Single layer suture closure on the uterus
- If a vaginal birth does not occur, a Cesarean delivery must then be done. The rate of infection for a failed TOLAC is almost double when a Cesarean delivery is done after labor, rather than before labor.
What are the risks?
- The risk that the uterus will tear before a planned Cesarean birth is 2 in 1000 (0.2%). Because there is a scar in the uterine wall from the Cesarean birth, there is always some risk of rupture. However, this is more common when labor occurs. The risks to you and your baby are the same as if the uterine rupture occurred during a trial of labor.
- Blood loss
- More scarring in the abdomen and on the uterus
- Adhesion development
- Injury to internal organs such as bladder or bowel
- Anesthesia problems
- Blood clots
- Increased risk with later pregnancies of placental complications, such as placenta previa or placenta accreta
If I choose a repeat Cesarean delivery, what can I expect during my recovery?Each woman has her own unique experience with Cesarean delivery and recovery. Many women report that they felt their recovery was easier the second time than after their first Cesarean delivery. This may be due to knowing what to expect afterward, and feeling less fatigued since there was no labor. Still, recovering from major abdominal surgery takes time, and there are restrictions to your activity for several weeks.
How do the risks of TOLAC compare to repeat Cesarean delivery without labor?
- The risk of uterine rupture during a low risk TOLAC is 0.5-1.0%. Because you have a scar on the uterus, there will always be some risk of a tear. The tearing usually occurs during labor. The risk that the uterus will rupture before a planned Cesarean birth is 0.2%. The risks to you and the baby are the same as if the uterus ruptured during labor.
- There is an increased risk of hemorrhage, blood transfusion, infection and hysterectomy in a woman with a repeat Cesarean delivery compared to a VBAC.
- The risk of your baby dying during VBAC is the same as the baby dying during a first labor. There is a higher risk of the baby dying with TOLAC compared to a repeat Cesarean delivery. The overall risk of infant death with TOLAC is 6 out of 10,000 (0.06%) and with a planned repeat Cesarean birth 3 out of 10,000 (0.03%)
What are the chances that a TOLAC will result in a vaginal birth?
- 70-80% of women who have a TOLAC will have a vaginal birth. There is no way to predict who will have a vaginal birth and who will have a repeat Cesarean birth. There are a number of factors that can increase the chances that you will be successful. However, even without any of these factors, the success rate may be as high as 50%.
- Factors that are positive predictors of VBAC include
- Cesarean birth for a reason that is unlikely to happen again, such as breech presentation
- Having had a previous vaginal birth
- Labor that occurs naturally
- Factors that decrease the chance of a successful VBAC include
- Advanced maternal age
- Increasing birth weight
- Maternal obesity
- Pregnancy over 40 weeks gestation
- Short inter-pregnancy interval
- Recurrent indication for initial Cesarean delivery such as failure to dilate or descend
How can I reduce risks and increase my chances of a successful VBAC?
- Early and regular prenatal care is important in helping to reduce risk in all pregnancies.
- Maintaining a healthy weight before conception and keeping weight gain to 20-30 pounds during pregnancy.
- Having at least 18 months between the date of your Cesarean birth and the due date of this pregnancy helps ensure the strength of the uterine scar, and decreases the risk of rupture.
- Having labor occur naturally, rather than using medications to start labor, reduces the risk of uterine rupture. Should induction/augmentation of labor be indicated, your midwife will discuss your situation with you.
Making a decision—TOLAC vs. repeat Cesarean delivery
- Having a vaginal birth is an important goal for some women. For many women, the benefits of a trial of labor outweigh the risks. Women who deliver vaginally have less postpartum discomfort, shorter hospital stays, and describe a feeling of wellness sooner than women recovering from a Cesarean delivery.
- Other women choose Cesarean delivery because they do not want to go through labor. They may be more concerned about the risk of uterine rupture and harm to the baby than the risks of Cesarean birth.
- There may be added benefits and risks to each individual. We want you to discuss these with your partner and your provider.
- If during the TOLAC process you have questions about continuing, we encourage you to speak with your partner and midwife. You may change your mind about VBAC. However, if delivery is about to occur, a Cesarean delivery may not be possible.
- Each woman’s decision is personal. Your midwife is the best source of information on risks and benefits of both TOLAC and planned Cesarean delivery. She will help you and your partner decide what is right for you. The overall goal is always a healthy baby and a healthy mom, regardless of the mode of delivery.
Avalon/Atlantic Health System Policies Concerning TOLAC
- A copy of your Cesarean operative report will be requested in order to assess the type of uterine incision and closure.
- TOLAC/VBAC consents for both Avalon and Morristown Medical Center or Overlook Medical Center will be obtained.
- Upon admission it is a medical center policy that intravenous access be maintained.
- Continuous electronic fetal monitoring tracing will be maintained throughout the labor process.
- The patient may be out of bed, ambulating or in the shower/pool, as long as an adequate fetal monitor tracing can be maintained.
- Epidural anesthesia is available if needed. An anesthesiologist is available at all times in the delivery suite.
- The affiliated physician, or his designee, will be immediately available in the delivery suite, once active labor has been established.