Trial of Labor After Cesarean (TOLAC/VBAC)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Prior incision type + contraindications + preference/capability
   Prior uterine incision type? Contraindications? Capability and preference?
   • One (or, after evaluation, two) low transverse uterine incision, no contraindication, emergency cesarean capability → Eligible → TOLAC can be offered
   • Prior classical/inverted-T/extensive fundal incision, uterine rupture history, placenta previa, other contraindication to vaginal birth → Contraindication/choice → elective repeat cesarean
   • Eligible but patient chooses repeat cesarean → Contraindication/choice → elective repeat cesarean
2. [End] Eligible → TOLAC can be offered
   Eligible → TOLAC can be offered: success ~60–80% (higher with prior vaginal birth/spontaneous labor); uterine rupture risk ~0.5–0.9% (one low transverse incision); avoid misoprostol induction, use oxytocin cautiously; requires immediate cesarean and continuous monitoring capability; full informed shared decision-making.
3. [End] Contraindication/choice → elective repeat cesarean
   Contraindication present (classical incision rupture risk 2–9%, uterine rupture history, placenta previa, etc.) or patient choice → elective repeat cesarean (ERCD); schedule at an appropriate gestation (generally ≥39 weeks unless an indication warrants earlier).

Source guidelines & references

• Vaginal birth after cesarean (ACOG Practice Bulletin 205 TOLAC/VBAC)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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