What VBAC planning means

VBAC planning involves preparing for a vaginal birth after a previous cesarean delivery. Vaginal birth after cesarean (VBAC) is the attempt to deliver vaginally after a previous cesarean section. When the attempt succeeds, it is called a TOLAC (trial of labor after cesarean). Therefore, these terms are not interchangeable, though they are often used that way in casual conversation. A TOLAC is the process. A VBAC is the outcome.

The conversation about VBAC planning matters because approximately 32 percent of all births in the United States are cesarean deliveries, and a significant proportion of those patients will want to explore vaginal birth in a subsequent pregnancy (Source: CDC, 2023). The decision is not simple, and it is not one-size-fits-all. Some patients are excellent candidates for VBAC and are not offered the option because their provider does not support it or their hospital does not have the capacity. Conversely, other patients are poor candidates and are not adequately counseled about the risks.

The ACOG states that most patients with one previous low-transverse cesarean incision are candidates for VBAC and should be counseled about the option (Source: ACOG, 2024). However, this is a guideline, not a guarantee. Your individual eligibility depends on factors that go beyond the type of uterine incision, and this guide walks through each of those factors for your VBAC planning.

VBAC planning: eligibility factors

The single most important factor in VBAC planning is the type of uterine incision from your previous cesarean. A low-transverse incision (horizontal cut in the lower segment of the uterus) carries the lowest risk of uterine rupture during a subsequent labor. This is the most common type of cesarean incision, used in the majority of cesarean deliveries.

Uterine incision types and VBAC eligibility

A classical incision (vertical cut in the upper segment of the uterus) or a T-shaped incision significantly increases the risk of uterine rupture. Therefore, patients with these incision types are generally not candidates for TOLAC, and the recommendation against attempting VBAC is strong (Source: ACOG, 2024). If you do not know what type of incision you have, request your operative report from your previous cesarean. This document specifies the uterine incision type, and it is essential information for VBAC planning.

Other VBAC eligibility factors

Other factors that influence VBAC planning eligibility include the following. First, the number of previous cesareans. Patients with two previous low-transverse cesareans may still be candidates for TOLAC, though the data is more limited and some providers decline to support VBAC in this scenario. Additionally, the reason for the previous cesarean. If your first cesarean was for a non-recurring indication (such as breech presentation or fetal distress with a small baby), your likelihood of successful VBAC is higher than if the cesarean was for a recurring indication (such as cephalopelvic disproportion or arrest of dilation). Moreover, the interval between pregnancies. A shorter interdelivery interval (less than 18 months from delivery to conception) may be associated with slightly higher risk, though the evidence is mixed.

Factors that decrease VBAC success probability include advanced maternal age (over 35), obesity (BMI over 30), and delivery of a macrosomic infant (estimated fetal weight over 4,000 grams). These factors do not automatically disqualify you from TOLAC, but they affect the risk-benefit calculation that you and your provider will make together during VBAC planning.

VBAC planning success rates

The overall success rate for TOLAC (trial of labor resulting in vaginal delivery) is approximately 60 to 80 percent, depending on patient characteristics (Source: ACOG, 2024). That range is wide because success depends on the factors discussed in the previous section. A patient with one previous cesarean for breech presentation, a low-transverse incision, and a prior vaginal delivery has a success probability at the higher end of that range. Conversely, a patient with two previous cesareans for arrest of dilation, no prior vaginal delivery, and an estimated large baby has a success probability at the lower end.

Strongest predictor of VBAC success

One predictor that deserves specific attention in VBAC planning. A prior vaginal delivery, whether before or after the cesarean, is the strongest single predictor of VBAC success. Patients who have delivered vaginally at least once have success rates of 85 to 90 percent in subsequent TOLAC attempts. This is because a prior vaginal delivery demonstrates that the pelvis is adequate for vaginal birth and that the patient’s labor pattern can progress to delivery.

VBAC calculator tool

The ACOG has developed a VBAC calculator that estimates individualized success probability based on patient characteristics. This tool is available through the Maternal-Fetal Medicine Units (MFMU) network and can be discussed with your provider. It is not a guarantee. However, it is a statistical estimate that informs the risk-benefit conversation during VBAC planning.

VBAC planning risks you need to understand

The risk that dominates VBAC planning is uterine rupture. This is a serious complication in which the uterine scar from a previous cesarean opens during labor. The rate of uterine rupture for patients with one previous low-transverse cesarean attempting TOLAC is approximately 0.5 to 0.9 percent, or roughly 1 in 200 to 1 in 100 (Source: ACOG, 2024). For patients undergoing an elective repeat cesarean (planned cesarean without labor), the risk of uterine rupture is significantly lower, approximately 0.2 to 0.3 percent.

Understanding uterine rupture risk

Uterine rupture is a life-threatening emergency for both the parent and the baby. It requires immediate cesarean delivery and can result in hysterectomy, hemorrhage, and, in rare cases, death. The absolute risk is low, but the consequences are severe. Therefore, this is why ACOG recommends that TOLAC be attempted only in facilities equipped to perform an emergency cesarean delivery, and why some providers and hospitals decline to support VBAC.

Other VBAC planning risks

Other risks of TOLAC include infection (similar to or slightly lower than repeat cesarean), the need for an unplanned cesarean during labor (which carries the combined risks of both labor and surgical delivery), and the psychological impact of a failed TOLAC attempt. Some patients experience a failed TOLAC as a traumatic event, particularly if the subsequent cesarean is performed emergently. This is a valid concern and deserves acknowledgment, not dismissal.

Risks of elective repeat cesarean

The risks of elective repeat cesarean include surgical complications (infection, hemorrhage, blood clots, injury to surrounding organs), a longer recovery period, increased risk of placental abnormalities in future pregnancies (placenta previa and placenta accreta spectrum), and the cumulative risk of multiple abdominal surgeries if you plan additional children. The risk of placenta accreta, a condition in which the placenta attaches abnormally to the uterine wall, increases with each cesarean delivery and can result in life-threatening hemorrhage requiring hysterectomy (Source: ACOG, 2024).

Neither option is risk-free. The VBAC planning decision depends on which set of risks you and your provider consider more acceptable given your individual circumstances.

VBAC planning questions for your provider

If you are considering VBAC, bring a specific list of questions to your first or second prenatal visit. Do not wait until the third trimester, because you need time to make decisions about your provider, your birth facility, and your birth plan.

Questions about provider VBAC experience

What is your VBAC rate, and what factors do you consider when counseling patients about TOLAC? This question reveals whether your provider supports VBAC in general and what their threshold is for recommending it. A provider who has a low VBAC rate may have legitimate clinical reasons, or they may have a practice style that favors repeat cesarean. Therefore, you deserve to understand which is the case.

Based on my previous operative report, am I a candidate for TOLAC? If your provider has not reviewed your operative report, request that they do so before making a recommendation. The type of uterine incision is the single most important piece of information for VBAC planning eligibility, and it cannot be determined from external scars or patient recall alone.

Questions about hospital VBAC support

What is the VBAC success rate at this hospital, and what is the rate of emergency cesarean after failed TOLAC? Hospital-level data varies. Some facilities have robust VBAC programs with high success rates. Others have limited experience and higher conversion rates. Therefore, knowing the institutional context helps you set realistic expectations.

Under what circumstances would you recommend induction for a VBAC patient, and what methods do you use? Induction of labor in a TOLAC patient is a nuanced decision. Some induction methods (such as misoprostol) are contraindicated in patients with a previous cesarean because they increase the risk of uterine rupture. Others (such as mechanical dilation with a Foley balloon or low-dose oxytocin) may be acceptable in certain situations. Your provider should be able to explain their approach clearly.

Questions about monitoring during VBAC

What is the hospital’s policy on continuous fetal monitoring during TOLAC? Continuous electronic fetal monitoring is generally recommended during TOLAC because changes in the fetal heart rate pattern can be an early sign of uterine rupture. Therefore, understand what this means for your mobility during labor and whether the hospital uses telemetry monitoring that allows movement.

Hospital requirements for VBAC planning

Not all hospitals support TOLAC. The ACOG recommends that facilities offering VBAC have the immediate capacity to perform an emergency cesarean delivery, which means an operating room, anesthesia provider, and surgical team available within minutes (Source: ACOG, 2024). Some smaller hospitals or birth centers do not meet this requirement and will not accept patients for TOLAC.

Verifying hospital VBAC capabilities

Before choosing a birth facility, verify the following. First, does the hospital have a written policy supporting TOLAC? Additionally, is an obstetric anesthesiologist available 24 hours a day? Moreover, what is the average decision-to-incision time for emergency cesareans at this facility? Finally, is there a blood bank on-site or immediately accessible? These are not hypothetical concerns. They are the infrastructure that makes VBAC planning safe.

Alternative options if hospital doesn’t support VBAC

If your provider supports VBAC but your hospital does not, you have options. You can deliver at a different facility that supports TOLAC. You can seek a provider at a VBAC-supportive hospital. You can consider a home birth with a qualified midwife, though this option carries additional risk considerations that the ACOG does not recommend for TOLAC patients (Source: ACOG, 2024). Therefore, the decision about where to deliver is as important as the decision about whether to attempt VBAC, because the safety of TOLAC depends on the availability of emergency surgical intervention.

One practical detail that is easy to overlook. If you are planning a VBAC and go into labor before your scheduled prenatal visit, call the hospital before arriving. Confirm that they are accepting TOLAC patients and that the necessary resources are available that day. Some hospitals have temporary restrictions on VBAC admissions based on staffing or surgical capacity.

VBAC versus repeat cesarean comparison

The following table summarizes the key differences between attempting TOLAC and planning an elective repeat cesarean delivery. This is a general comparison. However, your individual risk profile may shift the balance in either direction.

This table is a starting point for discussion with your provider. It does not account for your specific medical history, your previous birth experience, or your personal values and preferences. Those factors matter as much as the population-level statistics during VBAC planning.

Emotional factors in VBAC planning

The VBAC planning decision is not purely clinical. Your previous birth experience shapes how you approach this decision, and that experience may have been traumatic. Some patients pursue VBAC because their first cesarean felt like a loss they want to reclaim. Conversely, others avoid VBAC because the memory of labor is associated with fear or pain. Both motivations are understandable, and neither should be dismissed as irrational.

Processing previous birth trauma

If your previous cesarean was traumatic, consider speaking with a therapist who specializes in perinatal mental health before making your VBAC planning decision. Unprocessed birth trauma can influence your decision-making in ways that are not immediately obvious. You may avoid TOLAC because of fear that has not been examined, or you may pursue TOLAC with the expectation that a vaginal birth will resolve feelings about the cesarean that require separate processing.

Managing outside opinions

If your partner or family members have strong opinions about VBAC, acknowledge their input while recognizing that the decision is yours. Your partner may be anxious about the risk of uterine rupture. Your mother may have opinions based on her own birth experience decades ago. Your provider may have a practice pattern that favors one approach. All of these perspectives contain information. However, none of them should override your informed decision after you have received complete, balanced counseling from your provider.

Processing a failed TOLAC

One final consideration. If you attempt TOLAC and it does not result in a vaginal delivery, this is not a failure. It is a medical outcome. Approximately 20 to 40 percent of TOLAC attempts result in cesarean delivery, and the reasons vary (Source: ACOG, 2024). Some patients process a failed TOLAC without difficulty. However, others experience grief, disappointment, or a sense that their body “failed” them. These feelings are valid and may benefit from support, whether from a therapist, a support group, or a trusted friend who understands the complexity of birth expectations.

Related articles about birth planning

• Birth preferences advocacy
• Birth partner support during labor
• Returning to sex after childbirth

Additional resources for VBAC planning

• ACOG – Vaginal Birth After Cesarean
• Childbirth Connection – VBAC Resources

Conclusion

VBAC planning requires information that you may not have gathered yet. Request your previous operative report. Understand your individual risk factors. Ask your provider specific questions about their experience, their hospital’s capabilities, and their recommendations for your situation. The decision between TOLAC and elective repeat cesarean is not a test of courage or a measure of your commitment to vaginal birth. It is a medical decision based on your anatomy, your history, your values, and the resources available to you.

The ACOG’s position is clear: most patients with one previous low-transverse cesarean are candidates for VBAC, and the option should be offered (Source: ACOG, 2024). Whether you choose to pursue it is a decision that belongs to you, made with full information and without coercion from any direction.

Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. The decision to attempt VBAC should be made in consultation with your obstetric provider, who can evaluate your individual medical history and circumstances. If you are pregnant and considering VBAC, discuss this option with your provider as early in your pregnancy as possible.

Frequently Asked Questions About VBAC Planning