First things first. There are whole websites, magazine articles, books (and who knows what else) that review this topic. I am quite simply not going to be able to cover everything when it comes to the topic of TOLAC (trial of labor after a cesarean section) or VBAC (vaginal birth after C-section). This small summary page is simply a starting point to look at the pros and cons of considering TOLAC. This is probably a page that will slowly grow as I continue to answer patient questions and there is more information that comes from reputable journals. When you have reviewed this and any other source of information, the first thing you need to do is: DISCUSS THIS WITH A PROVIDER YOU TRUST. In most cases, this is the person who has the best perspective on your personal health and surgical history, your current pregnancy, and your personal goals.
As you probably already know, the idea of TOLAC has long been a controversial one. This was a widely supported medical practice back in the 1990s and then dramatically discouraged in the 2000s. It was back in 2010 when ACOG (American Congress of Obstetrics and Gynecology) came out with a statement in regards to what was considered reasonable and safe for women who wanted to consider a vagina delivery following a C-section. Those guidelines were reaffirmed in 2013 with little or no modification.
Fortunately, there is pretty good science that helps guide women and families toward making the decision that is right for them. Some of the major considerations are:
- The 1% risk of uterine rupture that comes with a trial of labor and the severe risks to mom and baby in those rare cases
- The compared risks of infection, bleeding, injury to mom and baby when comparing VBAC, scheduled C-section, and C-section after a trial of labor
- The change in risk with an induction, history of 2 C-sections, and other pertinent medical history
There are many other considerations that may be detailed further as this webpage develops, but for now, I will leave those extra pieces to you and your provider.
Unfortunately, there is also a lot of culture that can make decision making more difficult. There is plenty that ACOG has not specifically detailed when it comes to considering TOLAC and repeat C-section. When culture comes into the mix, you will see a broad range of what pregnancy providers will recommend when it comes to induction, postdates pregnancy, twins, history of 2 C-sections, etc. Some providers understandably fall back to what they were trained to do back to their residency days. Some providers instinctively guide their patients to what they personally would choose if they were in the same situation. Some providers will guide you to what they consider to be the lowest risk option.
But in the end, this is an important decision that you and your significant other should make with good science and your trusted provider. This is not a decision that you should make based on a blog posting or someone’s personal opinion. It is a topic worth discussing more than once so that you have a good understanding of everything that is involved.
Ryan Dick MD