Original Article

Outcomes of Spontaneous Labor in Women

Undergoing Trial of Labor after Cesarean as
Compared with Nulliparous Women:
A Retrospective Cohort Study
Sarah C. Lassey, MD1 Julian N. Robinson, MD1 Anjali J. Kaimal, MD, MAS2 Sarah E. Little, MD1

1 Division of Maternal-Fetal Medicine, Department of Obstetrics and Address for correspondence Sarah C. Lassey, MD, Department of
Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts Obstetrics and Gynecology, Brigham and Women’s Hospital, 75
2 Division of Maternal-Fetal Medicine, Department of Obstetrics and Francis Street, Boston, MA 02115 (e-mail: slassey@partners.org).
Gynecology, Massachusetts General Hospital, Boston, Massachusetts

Am J Perinatol

Abstract Objective The objective of this study was to compare spontaneous labor outcomes in

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women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better
counsel women.
Study Design A 4-year retrospective cohort. We included women at term in spontaneous
labor with vertex singletons and no more than one prior cesarean delivery. In
planned secondary analysis, we focused on a subset of women with a prior cesarean
and a predicted likelihood of a successful vaginal delivery of 70% or more based on the
Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator.
Results Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing
TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p < 0.001).
Severe maternal hemorrhage (1.5 vs. 0.2%; p ¼ 0.02) and uterine rupture (1.9 vs. 0.0%;
p < 0.01) were more likely in the TOLAC group. For the subset of women with a
Keywords predicted likelihood of VBAC of 70% or more, there were no differences in cesarean
► TOLAC delivery (16.7 vs. 14.7%; p ¼ 0.51), maternal, or immediate neonatal complications.
► VBAC Conclusion Women undergoing TOLAC were more likely to have a cesarean delivery,
► maternal hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of
► neonatal VBAC were no more likely to experience these outcomes. These findings help
► outcomes contextualize the risks of TOLAC for women considering this option.

The cesarean delivery rate has risen significantly in the
United States since the 1970s.1 Currently, nearly one-third
of births occur by cesarean delivery.1 This increase in cesar-
ean delivery is associated with a concomitant decrease in the
rate of trial of labor after cesarean (TOLAC), as many women
elect for a repeat cesarean delivery regardless of their a priori
likelihood of vaginal birth after cesarean (VBAC) based on
clinical characteristics.1–4 The American College of Obste-
tricians and Gynecologists states that most women with one
prior low transverse cesarean are candidates for TOLAC and
should be counseled regarding this option, but that “the
ultimate decision to undergo TOLAC or a repeat cesarean
delivery should be made by the patient in consultation with
her health care provider.”5
Multiple factors influence a woman’s decision to undergo
TOLAC including concern for cesarean delivery during labor,
perceived safety, past labor experience, provider comfort,
and accessibility to care.5,6 Women with a prior cesarean
section have the option to either TOLAC or have a repeat
cesarean section. In an attempt to inform patient and pro-
vider decision making in the setting of a prior cesarean,
studies have compared TOLAC delivery with elective repeat

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Spontaneous Labor in Women Undergoing TOLAC as Compared with Nulliparous Women
cesarean delivery. These studies have shown that with each
cesarean delivery, maternal morbidity and pregnancy risk
increase.7,8 However, this type of comparison does not allow
the risks of TOLAC to be put in context in comparison to the
risks of labor in other populations for whom the expectation
is that labor will be undertaken. While a repeat cesarean
delivery versus a TOLAC is the clinical choice that women
with a prior cesarean are facing, the comparison to other
laboring groups, and in particular nulliparous women, offers
the opportunity to assess the excess risks of labor and vaginal
delivery in women with a prior cesarean on a systems level.
Some have suggested that comparing the risks of labor in
women with a prior cesarean to the risks for nulliparous
women would be useful to avoid inappropriately placing TOLAC
in a separate category of risk9 without taking into account the
baseline risks associated with labor. There remains a lack of
information, however, comparing labor outcomes for women
with a prior cesarean delivery to nulliparas.8,10 We sought to
address this evidence gap by comparing the outcomes of
spontaneous labor in women with a prior cesarean and nulli-
parous women. Our hypothesis was that spontaneously labor-
ing TOLACs and nulliparas would have similar rates of cesarean
delivery as well as maternal or neonatal complications. If the
outcomes were different for the overall group of TOLACs as
compared with nulliparas, we also wanted to further stratify
those undergoing TOLAC based on predicted likelihood of VBAC
based on the Maternal-Fetal Medicine Units (MFMU)–Eunice
Kennedy Shriver National Institute of Child Health and Human
Development calculator to see whether there was a subset of
women undergoing TOLAC in which the risks of labor were
similar to that among a nulliparous population.
Methods
Our cohort included women at term in spontaneous labor
with vertex singletons and no more than one prior cesarean
delivery. We identified women at both Brigham and Women’s
Hospital and Massachusetts General Hospital who presented
in labor from January 1, 2011, to December 31, 2014. This
research project was approved by the Partners Institutional
Review Board.
For inclusion into the TOLAC group, women had to present
in spontaneous labor with vertex singletons. We defined term
pregnancy as 370/7 to 416/7 weeks. Women were excluded if
they had a prior vaginal delivery, more than one prior cesarean
delivery, or if their current labor was induced. Women were
excluded if they declined trial of labor or were deemed not to
be candidates for TOLAC, such as those with abnormal pla-
centation or breech presentation. The cohort sample size of
606 TOLACs was determined by including all qualifying deliv-
eries during the time period (►Supplementary Fig. 1, avail-
able in the online version). The TOLACs were then matched to
the subsequent nulliparous woman at term who presented in
labor at the same institution.
Maternal and neonatal demographics, clinical character-
istics, and outcomes were abstracted from the medical
record and were evaluated for the current delivery as well
as the prior delivery for women in the TOLAC group. The
American Journal of Perinatology
Lassey et al.
primary outcome was need for cesarean delivery during
labor. Secondary outcomes included both maternal and
neonatal morbidities. Maternal morbidity included severe
hemorrhage (estimated blood loss [EBL] >1,500 mL), infec-
tion, higher order laceration (third or fourth degree perineal
laceration), shoulder dystocia, episiotomy, uterine rupture,
and need for additional procedures. Uterine rupture was
defined as a full-thickness disruption of the uterine wall with
associated changes in the maternal or fetal status. The length
of the second stage of labor and operative delivery rates were
also recorded. Neonatal outcomes included admission to
neonatal intensive care unit (NICU) or triage, birth weight,
and Apgar <7 at 5 minutes. All women in the study were
given oxytocin (Pitocin), if indicated, per hospital policy,
which was similar at the two institutions, with initial dosing
of oxytocin (Pitocin) of 2 mU/min with an increase of 1 to
2 mU/min every 15 minutes and a recommended maximum
dose of oxytocin (Pitocin) of 20 mU/min. Intrauterine pres-
sure catheters were used at the discretion of the provider.
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Regional anesthesia was available for women at both institu-
tions if desired and commonly used.
As a secondary analysis, we used the MFMU-VBAC calcu-
lator for assessment of our TOLAC candidates and for stra-
tification of candidates.11 Previous studies have found a
threshold predicted success rate where morbidity for
women undergoing TOLAC is similar to those undergoing
elective repeat cesarean delivery.12 Thus, we compared
TOLAC populations at various thresholds of predicted suc-
cess to the entire nulliparous population to investigate
whether there was a subset of women undergoing TOLAC
with outcomes that were similar to nulliparous women.
Sample size was determined by including all eligible
women undergoing TOLAC during the time period and
matching them 1:1 with the subsequent nullipara admitted
in labor. Power was calculated post hoc. We had 80% power to
detect a 35% increase in cesarean delivery rate in the TOLAC
group. For the subset of women with a predicted likelihood of
VBAC of 70% or more, we had 80% power to detect a twofold
increase in cesarean delivery.
Distribution of demographic and clinical characteristics
was compared using chi-square tests and Fischer’s exact
testing where appropriate. A Student’s t-test was used to
assess significance of differences in the mean values of
continuous variables. Standard univariate analyses were
performed. For all analyses, a two-sided significance level
of <0.05 was considered statistically significant. Multivari-
able analyses were also performed using logistic regression
to compare the odds of cesarean delivery for women under-
going TOLAC to nulliparous women accounting for baseline
differences in obstetric risk factors. Analyses were performed
using SAS 9.3 (Cary, NC).
Results
Our cohort included 1,212 women: 606 TOLACs and 606
nulliparas. During our study period, there were 4,870 women
with prior cesarean deliveries; 4147 were excluded based on
eligibility requirements. Of the remaining 723 women, 117
 Spontaneous Labor in Women Undergoing TOLAC as Compared with Nulliparous Women Lassey et al.

declined trial of labor when presenting in labor, resulting in 606
participants (►Supplementary Fig. 1, available in the online
version). These were matched with the next nulliparous woman
at term presenting in spontaneous labor at the same institution.
►Table 1 compares demographic characteristics for the
TOLACs and nulliparas. Women undergoing TOLAC were
older (31.5 vs. 29.3 years; p < 0.01), heavier (pre-pregnancy
body mass index [BMI] 26.1 vs. 24.7; p < 0.01), more likely to
be black (16.9 vs. 11.8%; p < 0.01) or Hispanic (17.4 vs.
15.3%; p < 0.01), and more likely to have diabetes (4.1 vs.
1.3%; p < 0.01) or hypertension (6.4 vs. 3.3%; p < 0.01).
There was no significant difference in gestational age at
the time of spontaneous labor.
Our primary outcome, cesarean delivery during labor,
occurred more frequently in women undergoing TOLAC
(25.7 vs. 14.7%, p < 0.001). Maternal and neonatal complica-
tion rates were similar with the exception of the risk of
severe hemorrhage (1.5 vs. 0.2%; p ¼ 0.02) and uterine rupture
(12 out of 606 women [1.9%] vs. 0 out of 606 woman [0.0%];
In our cohort, the predicted likelihood of VBAC from the
MFMU-VBAC calculator ranged from 22.0 to 84.7% with a
median of 61.4%. Overall, 20.6% of the women undergoing
TOLAC had a predicted likelihood of less than 50%
(►Supplementary Fig. 2, available in the online version). We
plotted the cesarean delivery rate at various thresholds of
predicted likelihood of VBAC in the women undergoing TOLAC
(►Fig. 1). As shown, at approximately a predicted likelihood of
60% the lower bound CI approaches the average for nulliparous
women and at approximately a predicted likelihood of 70% or
more the mean rate of cesarean delivery for women under-
going TOLAC appears no different from nulliparous women.
The group with a predicted likelihood of VBAC of 70% or more
accounted for 29.7% of our sample. Comparing these women to
all nulliparas, there was no difference in cesarean delivery rate
(16.7 vs. 14.7%; p ¼ 0.51) or maternal or immediate neonatal
complications (►Table 3).

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p < 0.01), which were more likely in women undergoing
TOLAC (►Table 2). However, even among the 12 women
undergoing TOLAC who did have a uterine rupture, there
were low rates of maternal/neonatal morbidity; 2 out of 12
(16.7%) neonates were admitted to the NICU, 1 out of 12 (8.3%)
had a 5-minute Apgar <7, and 2 out of 12 women (16.7%) had
an EBL > 1,500 mL.
In a multivariable logistic regression model account-
ing for baseline differences in BMI, age, race, and comorbi-
dities (diabetes and hypertension), women undergoing
TOLAC remained more likely to undergo cesarean delivery
(odds ratio: 1.75; 95% confidence interval [CI]: 1.24–2.74;
p < 0.01).
Discussion
As a group, women undergoing TOLAC were more likely to
have a cesarean delivery (25.7 vs. 14.7%, p < 0.001) and to
experience severe hemorrhage (1.5 vs. 0.2%; p ¼ 0.02) or
uterine rupture (1.9 vs. 0.0%; p < 0.01). However, in women
with a predicted likelihood of VBAC of 70% or more using the
MFMU-VBAC calculator, there were no differences in the
need for cesarean delivery in labor, maternal, or neonatal
morbidity.
Our TOLAC candidates were older, heavier, and more
likely to have diabetes or hypertension. Despite these differ-
ences, our data also showed that our observed VBAC rates
were consistently higher than predicted rates using the

Table 1 Demographic characteristics of nulliparas versus TOLACs

Nulliparas TOLACs p-Value

N ¼ 606 N ¼ 606
Age 29.3 (23.8–34.8) 31.5 (26.6–36.4) <0.01
BMI 24.7 (19.9–29.5) 26.1 (20.8–31.5) <0.01
Race
Asian 75 (12.5%) 89 (14.8%) <0.01
Black 71 (11.8%) 102 (16.9%)
Hispanic 92 (15.3%) 105 (17.4%)
White 351 (58.3%) 291 (48.3%)
Other 13 (2.2%) 16 (2.7%)
Maternal comorbidities
Diabetes 8 (1.3%) 25 (4.1%) <0.01
Hypertension 20 (3.3%) 39 (6.4%) 0.01
Fetal characteristics
Fetal anomalies 6 (1.0%) 13 (2.2%) 0.11
Gestational age (mean, 95% CI) 39.6 wk (38.6–40.6) 39.5 wk (38.5–40.5) 0.30
Birth weight (mean, 95% CI) 3,333 g (2,929–3,737) 3,417 g (2,993–3,841) <0.01

Abbreviations: BMI, body mass index; CI, confidence interval; TOLACs, trial of labor after cesareans.

American Journal of Perinatology

Spontaneous Labor in Women Undergoing TOLAC as Compared with Nulliparous Women Lassey et al.

Table 2 Outcomes for nulliparas versus TOLACs

Nulliparas TOLACs p-Value

N ¼ 606 N ¼ 606
Mode of delivery
Cesarean delivery 89 (14.7%) 156 (25.7%) <0.01
Operative delivery 68 (11.2%) 71 (11.8%)
Vaginal delivery 449 (74.1%) 379 (62.5%)
Length of second stage of labor 1.36 h (0.40–2.32) 1.27 h (0.35–2.19) 0.19
Maternal complication
Abruption 3 (0.6%) 8 (1.7%) 0.22
Chorioamnionitis 61 (12.6%) 63 (13.1%) 0.82
Severe hemorrhage 1 (0.2%) 9 (1.5%) 0.02
Severe laceration 25 (4.1%) 23 (3.8%) 0.77
Shoulder dystocia 9 (1.9%) 8 (1.7%) 0.81
Uterine rupture 0 (0.0%) 12 (1.9%) 0.29

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Any complication 97 (16.0%) 111 (18.3%) <0.01
Neonatal complication
Admission to NICU 15 (2.5%) 26 (2.6%) 0.12
5-min Apgar <7 9 (1.5%) 9 (1.5%) 0.98

Abbreviations: NICU, neonatal intensive care unit; TOLACs, trial of labor after cesareans.

MFMU-VBAC calculator (►Fig. 1). This higher than predicted
success score is likely due in part to the fact that we only
included women in spontaneous labor and excluded labor
induction, whereas the population studied to create the
VBAC calculator included 26% labor induction. Therefore,
our results are generalizable only to this spontaneous labor
subset. However, we similarly excluded nulliparous women
undergoing labor induction. Given potentially different
thresholds clinicians may have to induce women undergoing
TOLAC, we felt that using women in spontaneous labor was a
more accurate comparison and still provides meaningful
information for counseling women with a prior cesarean
Fig. 1 Cesarean delivery rates by vaginal birth after cesarean (VBAC)
success prediction.
delivery prenatally about their outcomes should they pre-
sent in spontaneous labor.
Patients considering TOLAC may be reassured to know
that if they present in spontaneous labor, their labor out-
comes are similar to those of nulliparous women. Further, it
may provide additional encouragement to women with a
likelihood of VBAC of 70% or more to know that their rate of
cesarean delivery in labor is actually equivalent to nullipar-
ous women. Our desire was not to encourage a cut-off at 70%
success (whereby women with a prior cesarean delivery and
a lower predicted success score are not encouraged to
TOLAC), as choosing a TOLAC is a reasonable option for
many with women with a less favorable predicted likelihood
based on other clinical characteristics and patient prefer-
ence. Rather, we felt that understanding the group of women
with a prior cesarean delivery who are similar to nulliparous
women in terms of obstetric outcomes in labor may provide
reassurance and encouragement to undergo TOLAC in these
women who are excellent candidates and at the lowest risk of
morbidity.
Of note, our uterine rupture rate of 1.9% in women under-
going TOLAC is higher than found in previous studies.7 The
exact reasons for this are unknown. It may be due to chance
as uterine rupture is a rare outcome or may in part be due to
the fact that there were many poor candidate TOLACs (with a
low predicted success score) in our cohort. However, even
among the 12 women undergoing TOLAC who did have a
uterine rupture, there were low rates of maternal/neonatal
morbidity.
Our study is not without limitations. Clinical character-
istics and outcomes were ascertained from the medical

American Journal of Perinatology

 Spontaneous Labor in Women Undergoing TOLAC as Compared with Nulliparous Women Lassey et al.

Table 3 Outcomes for nulliparas versus good candidate TOLACs

Nulliparas Good candidatea TOLACs p-Value

N ¼ 606 N ¼ 180
Mode of delivery
Cesarean delivery 89 (14.7%) 30 (16.7%) 0.52
Operative delivery 68 (11.2%) 21 (11.6%)
Vaginal delivery 449 (74.1%) 129 (71.7%)
Length of second stage of labor 1.36 h (0.40–2.32) 1.32 h (0.35–2.29) 0.70
Maternal complication
Abruption 3 (0.6%) 2 (1.4%) 0.32
Chorioamnionitis 61 (12.6%) 16 (11.2%) 0.65
Severe hemorrhage 1 (0.2%) 1 (0.6%) 0.41
Severe laceration 25 (4.1%) 5 (2.8%) 0.41
Shoulder dystocia 9 (1.9%) 3 (2.1%) 0.74
Uterine rupture 0 (0.0%) 2 (1.1%) 0.05

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Any complication 97 (16.0%) 28 (15.6%) 0.88
Neonatal complication
Admission to NICU 15 (2.5%) 4 (2.4%) 0.71
5-min Apgar <7 9 (1.5%) 1 (0.6%) 0.47

Abbreviations: NICU, neonatal intensive care unit; TOLACs, trial of labor after cesareans.
a
Good candidate TOLACs are those with a predicted success of 70% or more.

record and therefore relied on clinical coding. However, References

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coded outcome and each chart was reviewed to assess
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a prior cesarean delivery make informed choices that are
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