Trial of Labor After Cesarean (TOLAC)

What is TOLAC?

Trial of labor after cesarean, or TOLAC, is the alternative to scheduling a repeat c-section after a cesarean. It is the lead up to a vaginal birth after cesarean, or VBAC. It basically means that instead of having a scheduled c-section, you wait for your body to go into labor, and see how labor progresses. If successful, labor will progress to a vaginal delivery.

What do the doctors say about TOLAC?

In 2010, the American Congress of Obstetricians and Gynegologists (ACOG) issued new, more relaxed guidelines for TOLAC and VBAC. These new guidelines state that a trial of labor after a cesarean is safe and appropriate for most women with a previous c-section, including some women with multiple previous c-sections.

The American Academy of Family Physicians (AAFP) has supported TOLAC even longer. In 2005, they issued clinical guidelines for their members that recommends offering a trial of labor to women who have had one previous cesarean delivery with a low transverse incision. The guideline also recommends that physicians and other maternity care professionals explore the risks and benefits associated with a trial of labor with each woman who is a candidate for TOLAC. They also published a tool for doctors and patients to discuss the risks and benefits of having a trial of labor after cesarean.

Can you have a TOLAC?

That, unfortunately, depends less on the professional society's guidelines and more on your local institution's practices, and has everything to do with their insurers' willingness to cover this service. As you may have heard, access to TOLAC and VBAC in the States is limited because medical insurance companies are not willing to cover it, and in fact doctors and hospitals who provide it may risk losing their insurance coverage. If you are hoping for a trial of labor after cesarean, check with your local hospitals whether they offer TOLAC and VBAC.

What are the benefits of TOLAC versus a repeat cesarean?

A trial of labor after cesarean has benefits for both your body and your baby's body, even if you are not successful at a VBAC.

  • A trial of labor after cesarean presumes that your body goes into labor on its own (not induced), so the risk of having a premature baby decreases significantly.
  • Contractions of labor prepare your body for producing breastmilk.
  • Contractions of labor prepare your baby for the outside world, and babies born after a trial of labor have fewer difficulties breathing.

What are the risks of TOLAC versus a repeat cesarean?

The one serious risk of TOLAC versus a repeat cesarean is the risk of uterine rupture. Uterine rupture is exceedingly rare; it occurs in 7-8 women out of 1000, and most uterine ruptures are not fatal. Specifically, 6 out of 100 uterine ruptures result in the baby's death. To put this in another perspective, that means that 2082 out of 2083 babies will survive a trial of labor after cesarean.

To minimize the risk of a uterine rupture, it is best if labor starts on its own (so no inductions), and proceeds at its own pace (so no artificial oxytocin, or pitocin, to speed up labor). It is also best if the mother is not anesthesized (so no epidurals) so that if there is an imminent rupture, she can feel it and report it.

Here is a more detailed discussion of uterine rupture.


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