What is the most correct statement regarding counseling for a trial of labor after caesarean section (TOLAC) in a patient with a previous cesarean section (CS) for breech presentation?

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Last updated: August 21, 2025 • View editorial policy

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Counseling for Trial of Labor After Cesarean Section (TOLAC)

You should document your discussion of risks and benefits of TOLAC as part of informed consent, as approximately 74% of women who attempt labor after cesarean have a successful vaginal birth. 1

Success Rates and Factors Affecting TOLAC Outcomes

The American Academy of Family Physicians (AAFP) guidelines clearly state that about 74% of U.S. women who try labor after cesarean (LAC) have a successful vaginal birth 1, 2. This success rate is significantly higher than the 40% mentioned in one of the options.

Factors that influence TOLAC success include:

  • Previous vaginal delivery: Women who have had at least one previous vaginal birth have higher rates of successful VBAC 1
  • Labor progression: Success is increased with more progression in labor and higher Bishop scores 1
  • Factors that decrease success:
    • Labor induction using oxytocin 1
    • Infants weighing ≥4,000g (8 lb, 13 oz) 1

Maternal Outcomes with TOLAC vs. Repeat Cesarean

Short-term outcomes

  • Short-term maternal outcomes are as good or better with TOLAC/VBAC compared to repeat cesarean delivery 1
  • Mothers who undergo LAC have a lower risk of death compared to those undergoing repeat cesarean delivery 1
  • Blood loss is generally greater in women undergoing repeat cesarean delivery 1

Long-term outcomes

  • Repeat cesarean delivery increases long-term risks of:
    • Abnormal placentation
    • Hysterectomy
    • Surgical complications 1

Risks Associated with TOLAC

The primary risk of TOLAC is uterine rupture, with rates varying by induction method:

  • Oxytocin: 1.1% (95% CI, 0.9% to 1.5%)
  • Prostaglandin E2: 2% (95% CI, 1.1% to 3.5%)
  • Misoprostol: approximately 13% (contraindicated) 1

Addressing Common Misconceptions

Several statements in the options are incorrect and should be addressed during counseling:

  1. Regarding thromboembolic disease and infection: The evidence does not support that TOLAC increases risk of thromboembolic disease or infection compared to repeat cesarean 1

  2. Regarding satisfaction and pain: There is no evidence that satisfaction is diminished due to pain caused by TOLAC 1

  3. Regarding success rates: The success rate is approximately 74%, not 40% 1

Documentation Requirements

Proper documentation of counseling is essential and should include:

  • Discussion of risks and benefits of both TOLAC and repeat cesarean
  • Assessment of individual risk factors
  • Patient's values and preferences
  • Plans for labor management

Key Pitfalls to Avoid in Counseling

  • Underestimating success rates: Quoting outdated or incorrect success rates (like 40%) may inappropriately discourage women from attempting TOLAC
  • Overemphasizing risks: While risks exist, they should be presented in context with the benefits
  • Failing to document discussions: Documentation is critical for both medical and legal purposes
  • Using misoprostol for induction: This is contraindicated in women with previous cesarean delivery 1

The most appropriate counseling approach is to provide accurate information about risks and benefits, document the discussion thoroughly, and support the patient's informed decision-making process.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Cesarean Section Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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