All About Trial of Labor After Cesarean Delivery (TOLAC)

Dr. Roland Baiza

Hi, I’m Roland Baiza. I’m one of the physicians at Academy Women’s Healthcare with another informational, educational post and video from our office.

Today we’re going to talk about VBAC or TOLAC, which are both acronyms for trial of labor after cesarean section.

This has become a very important subject in the United States because the C-section rate has grown from 5% in the 1970s to as high as 31% a few years ago, and as a result, we have an increased number of patients who have to face this very difficult decision.

C-Section Rates in Colorado

Just so you know, in Colorado, the primary C-section rate, that is, for someone who goes into labor for the first time, it’s 18%.

Our office has a C-section rate that hovers around 10 to 11%, so we’re very proud about that.

Benefits of TOLAC

So what are the benefits of a trial of labor after C-section?

Well, the first thing is that a trial of labor after C-section, we’ll call that a TOLAC, has a much better risk profile than having a repeat C-section.

You have decreased risk of infection, bleeding, hemorrhage, and the complications associated with surgery.

The downside is if you a trial of labor after C-section and it’s unsuccessful, you have more complications than you do if you have a repeat C-section.

So the very important key is that you have to be a good candidate for a TOLAC so that you can get the benefit of that particular procedure.

TOLAC Success Rates

So the success rate is quoted as 70 to 85%, but it should be noted that is based on your historical … that is based on historical success rates of all patients, and they don’t apply to everybody universally, because it’s really dependent on why your first C-section was done.

So for example, if it was a non-laboring indication, for example, a breach presentation, then your success rate does approach 85%.

However, if it was a labor complication, specifically where you stopped dilating or the baby did not descend normally into the pelvis, your success rate is closer to 60 to 70%.

So the question then becomes: are you a good candidate? Because the risk of this procedure are significant.

TOLAC Complications

If you have a TOLAC and you have a complication, the complication that we’re most concerned about is called a uterine rupture or uterine dehiscence, where the incision of the uterus, which is the weakest part of the uterus now, can tear open during labor.

And the results of that can be catastrophic, anything from hysterectomy to maternal or even fetal death or neurological complications. So we don’t enter this decision lightly.

And so the risk for that uterine rupture are really determined by a couple of things:

  • What type of incision was made at your first C-section?
  • And then the other comorbid conditions, or other things that complicate your delivery?

So this is one of those discussions you really have to sit down with your physician and discuss – are you a good candidate?

People who have increased risk of complications from a TOLAC is going to be people over 35 who have a BMI over 35, people who have other comorbid conditions like hypertension, diabetes, or you have a large baby greater than 350 grams, which is going to be approximately ten pounds.

So if you’re going to attempt a TOLAC, what you would like is your total success rate to be estimated to be around 60 to 70% or above.

If it’s below that, you might consider repeat C-section.

But if it’s above that, you sound like you might be a good candidate for a TOLAC.

In any case, what we want you to do is sit down and talk to your physician, discuss all the pros and cons, and really look at this information completely.

Putting TOLAC Risk In Perspective

This .5 to 1% number of rupture is, sounds like a small number, but the way to put this in perspective is that that means you have a 1 in 500 risk of having a major complication.

And the way to put that in perspective:

If you’re driving a car and you knew that every 1 out of 500 times you were going to get into a major car accident, how would you approach driving?

So we want you to put this into perspective because this is your life, your baby, and your family.

Other TOLAC Considerations

So again, future considerations for you are:

  • How many deliveries you’re going to have?
  • Where you’re going to deliver?
  • Risks of the particular procedure for your family?
  • Your comorbid conditions.

Once again, please sit down and talk to your physicians.

TOLAC Conclusion

We at Academy Women’s Healthcare do support TOLAC and women’s choice to decide that for their family.