VBAC, TOLAC, and the Conversation Too Many Women Never Get to Have
Birth is one of the most consequential decisions a woman will ever make.
And when she's already had a cesarean, that decision gets more complicated — not because vaginal birth is off the table, but because too many women are never even allowed to pull up a chair and ask.
That's the part that stays with me.
A patient recently told me she wasn't looking for promises. She wasn't asking anyone to guarantee her a perfect outcome. She wanted a conversation. She wanted someone to look at her history, her body, her pregnancy — and talk to her like a person who deserved information.
Instead, some providers refused to see her at all.
Not "we reviewed your case and have concerns." Not "here's what we'd need to evaluate." Just — no.
That's not medicine. That's dismissal.
First, let's get the language right
VBAC and TOLAC aren't interchangeable, and the difference matters.
VBAC — vaginal birth after cesarean — is the outcome. It's what happened if a person with a prior cesarean gives birth vaginally.
TOLAC — trial of labor after cesarean — is the attempt. It's the decision to labor with the goal of a vaginal birth, knowing the outcome isn't guaranteed.
So when a woman says "I want a VBAC," what she usually means is: I want the chance to try. I want someone to evaluate me. I want to be part of this decision.
No ethical provider can promise the outcome. But any ethical provider can offer the conversation.
What the evidence actually says
A prior cesarean doesn't close every door.
ACOG has long recognized that many women with one prior low-transverse cesarean are candidates for TOLAC — and success rates among appropriately selected patients are often between 60% and 80%.
A successful VBAC means avoiding major abdominal surgery. It often means a shorter recovery, fewer surgical complications, and — critically — fewer risks in future pregnancies. Because repeat cesareans carry increasing risks with each one. That matters enormously for women who want more children.
None of this means VBAC is right for everyone. It means every woman deserves to find out whether it might be right for her.
What about the risks?
They're real. And they deserve honest conversation — not silence.
The most serious concern is uterine rupture. It's uncommon — FIGO's 2025 guidance puts the risk for women with one prior low-transverse cesarean at roughly 0.3% to 0.7% — but it's potentially life-threatening, and it's why TOLAC requires careful evaluation and the right clinical setting.
Real risk leads to counseling. To planning. To individualized care.
It doesn't lead to a door slammed before anyone even asks the question.
Who's a candidate?
That depends on the whole picture — not just the words "previous c-section."
Factors that may support TOLAC include a prior vaginal birth, a cesarean for a nonrecurring reason, spontaneous labor, and adequate time between pregnancies. Factors that may complicate the picture include the type of uterine incision, multiple prior cesareans, or a setting without immediate surgical capability.
Which is exactly why women need individualized counseling. Not blanket refusals.
The access problem is real
Here's what breaks my heart: a lot of women aren't being told "we reviewed your case and this isn't right for you."
They're being told "we don't do that here."
Those are not the same thing.
One is medicine. The other is a system deciding for women before anyone has looked at their records, their history, or their face.
Not all hospitals offer TOLAC. That's a reality. But the answer to "we don't offer it here" should be a referral — not a dead end.
What women deserve
Women deserve accurate information. Complete counseling. Honest risk discussion. Record review. Referrals when a provider doesn't offer TOLAC. And the basic respect of being treated like someone capable of participating in their own care.
A woman asking about VBAC isn't asking for recklessness.
She's asking for what every patient deserves — a real conversation.
Maybe after a thorough review, the right recommendation is a repeat cesarean. That's valid. That's medicine.
But maybe she's a reasonable candidate for TOLAC and nobody told her.
Either way, she deserved to be in the room for that decision.
And as long as women are being turned away before the conversation even starts — that's not just a clinical gap.
It's an access issue. A respect issue. A maternal health issue.
And it won't resolve until we start treating women's questions as the beginning of a conversation, not an inconvenience to be managed.
Want to dig deeper? Here are the sources behind this piece:
· ACOG, Vaginal Birth After Cesarean Delivery (FAQ) — breaks down the difference between TOLAC and VBAC in plain language
· ACOG, Practice Bulletin: Vaginal Birth After Cesarean Delivery — the clinical guidance behind candidacy and counseling
· ACOG, Counseling Regarding Approach to Delivery After Cesarean and the Use of a VBAC Calculator — covers shared decision-making and how providers should be approaching this conversation
· NCBI/StatPearls, Vaginal Birth After Cesarean Delivery (updated 2025) — reviews success rates and clinical considerations
· FIGO, Good Practice Recommendations for Vaginal Birth After Cesarean Section (2025) — where the uterine rupture risk data comes from
· March of Dimes, Vaginal Birth After Cesarean — confirms that not all providers and facilities offer VBAC, and why that's a problem
· CDC/NCHS Provisional Birth Data, 2024 — the source for U.S. cesarean delivery rate statistics
· March of Dimes PeriStats — U.S. cesarean and VBAC rate data
All of these are publicly available. You don't need a medical degree to read them — and you shouldn't have to take anyone's word for it, including mine.
