Trial of Labor After Cesarean (TOLAC) versus Elective Repeat Cesarean Section: A Systematic Review of Maternal and Perinatal Outcomes

Abstract

Introduction: For women with a prior cesarean delivery, the choice between a trial of labor after cesarean (TOLAC) and an elective repeat cesarean section (ERCS) involves a complex balance of risks and benefits. This review synthesizes the evidence on maternal and perinatal outcomes.

Methods: We conducted a systematic review of large, prospective cohort studies comparing planned TOLAC to planned ERCS. The primary outcomes were uterine rupture for TOLAC, and overall severe maternal morbidity and perinatal mortality for both groups.

Results: The review showed that successful vaginal birth after cesarean (VBAC) was associated with the lowest maternal morbidity. TOLAC was associated with a small but significant risk of uterine rupture (approx. 0.5-0.7%), which increased perinatal risk. ERCS was associated with a higher risk of maternal surgical complications and abnormal placentation in future pregnancies.

Discussion: The decision requires careful counseling and patient selection. While TOLAC carries the risk of uterine rupture, ERCS is not without its own short- and long-term risks. A successful VBAC provides the best outcomes.

Conclusion: TOLAC is a safe option for appropriately selected candidates, with successful VBAC associated with the lowest overall morbidity.