What are the guidelines for Trial of Labor After Cesarean (TOLAC)?

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Guidelines for Trial of Labor After Cesarean (TOLAC)

Women with one previous transverse low-segment cesarean section should be offered a trial of labor after cesarean (TOLAC) with appropriate discussion of risks and benefits, provided there are no contraindications. 1, 2

Candidate Selection for TOLAC

  • Previous vaginal birth is the strongest predictor of successful vaginal birth after cesarean (VBAC), with approximately 74% of women who attempt TOLAC having a successful vaginal birth 3, 4
  • Women who have had a previous VBAC have an even greater chance of success compared to those who have not 3
  • TOLAC is appropriate for most women who have had one or two cesarean deliveries with low transverse uterine incisions 3, 1
  • Multiple gestation, diabetes mellitus, suspected fetal macrosomia, and post-term pregnancy are not contraindications to TOLAC 1, 2

Safety Requirements for TOLAC

  • TOLAC should be conducted in a hospital where timely cesarean delivery is possible 1, 2
  • Hospitals should have a written policy regarding notification and consultation for physicians responsible for possible emergency cesarean section 1, 2
  • An approximate timeframe of 30 minutes should be considered adequate for setup of urgent laparotomy if needed 1, 2
  • Continuous electronic fetal monitoring is recommended during TOLAC 1, 2

Anesthetic Considerations

  • Neuraxial techniques (epidural or spinal) should be offered to patients attempting VBAC 3
  • Early placement of a neuraxial catheter is appropriate for women attempting VBAC, as it can be used later for labor analgesia or anesthesia if operative delivery becomes necessary 3
  • An intravenous infusion should be established before initiating neuraxial analgesia and maintained throughout the duration of the analgesic or anesthetic 3

Labor Management During TOLAC

  • Oxytocin augmentation is not contraindicated in women undergoing TOLAC 1, 2
  • Medical induction with oxytocin may be associated with increased risk of uterine rupture and should be used carefully after appropriate counseling 1, 2
  • Prostaglandin E2 (dinoprostone) is associated with increased risk of uterine rupture and should not be used except in rare circumstances 1, 2
  • Misoprostol (Cytotec) should not be used for cervical preparation or induction of labor in women with previous cesarean delivery due to high risk of uterine rupture 3, 1, 2
  • A Foley catheter may be safely used for cervical ripening in women planning TOLAC 1, 2

Risk Factors for Uterine Rupture

  • Short interpregnancy interval (delivery within 18-24 months of previous cesarean) increases the risk of uterine rupture 1, 2
  • Labor induction carries varying risks of uterine rupture depending on the method used:
    • Oxytocin: 1.1% risk (95% CI, 0.9% to 1.5%) 4
    • Prostaglandin E2: 2% risk (95% CI, 1.1% to 3.5%) 4
    • Misoprostol: significantly higher risk, contraindicated 4, 1

Documentation and Informed Consent

  • The intention to undergo TOLAC should be clearly documented, with the previous uterine scar clearly marked on the prenatal record 1, 2
  • Every effort should be made to obtain the previous cesarean operative report to determine the type of uterine incision used 1, 2
  • If the scar type is unknown but the likelihood of a low transverse incision is high, TOLAC can be offered 1, 2
  • The process of informed consent with appropriate documentation should be an important part of the birth plan 1, 2

Management of Suspected Uterine Rupture

  • Suspected uterine rupture requires urgent attention and expedited laparotomy to decrease maternal and perinatal morbidity and mortality 1, 2
  • Signs of uterine rupture may include fetal heart rate abnormalities, abdominal pain, vaginal bleeding, or loss of station of the presenting part 5

Outcomes and Benefits

  • Short-term maternal outcomes are as good or better with TOLAC/VBAC compared to repeat cesarean delivery 3
  • Perinatal mortality is slightly higher with TOLAC compared to repeat cesarean delivery 3
  • Repeat cesarean delivery increases long-term risk of abnormal placentation, hysterectomy, and surgical complications compared with VBAC 3

Special Considerations

  • TOLAC in women with more than one previous cesarean section is likely to be successful but carries a higher risk of uterine rupture 1, 2
  • Physicians should discuss reasons for previous cesarean delivery when counseling patients about TOLAC 3
  • Predictive scoring models have limited value in determining which women have a greater risk of cesarean delivery 3

References

1
Research

Guidelines for vaginal birth after previous Caesarean birth.

Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2005

2
Research

SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (Replaces guideline Number 147), February 2005.

International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2005

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Predictors and Considerations for Vaginal Birth After Cesarean Section

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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