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Recording available 2/16-5/2

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Poster Session 2

Category: Operative Obstetrics

Poster Session 2

(533) Women with Higher-Order Cesareans and risks of TOLAC (WHOTOLAC)

Wednesday, February 11, 2026

3:30 PM - 5:00 PM

Submitting Author and Presenting Author(s)

Joshua Brunton, DO (he/him/his)

MFM Fellow
Virginia Commonwealth University
Richmond, Virginia, United States

Coauthor(s)

ES

Edward H. Springel, MD

Associate Professor
Virginia Commonwealth University
Richmond, Virginia, United States

Objective:
To evaluate whether the risk of uterine rupture is increased in patients undergoing trial of labor after cesarean (TOLAC) with ≥3 prior cesarean deliveries, and to compare associated maternal and neonatal outcomes to elective repeat cesarean delivery (ERCD).

Study Design:
We conducted a retrospective cohort study using U.S. Vital Statistics Natality data from 2014 to 2023. We included singleton, nonanomalous live births at 34–42 weeks to women aged 18–50 with a history of ≥3 prior cesareans. Patients were grouped by delivery approach: TOLAC or ERCD.

Results:
Among 442,049 eligible patients, 20,614 underwent TOLAC and 421,435 underwent ERCD. The TOLAC cohort was matched similarly in age (32.28 vs. 32.33 years; p = 0.142) and BMI (32.47 vs. 32.50 kg/m²; p < 0.001). Gravidity was higher in the TOLAC group (5.54 vs. 5.30; p < 0.001), with a similar number of prior cesareans (3.29 vs. 3.30; p = 0.865). Gestational age at delivery was slightly earlier (37.84 vs. 37.95 weeks; p < 0.001). TOLAC patients were more often non-Hispanic (71.4% vs. 67.5%; p < 0.001). Uterine rupture was more common with TOLAC (n = 62 RR 1.75, 95% CI: 1.35–2.27; p < 0.001), but transfusion (RR 0.78) and hysterectomy (RR 0.70) were less likely. ICU admission was similar (RR 0.89; p = 0.264), while chorioamnionitis was more frequent (RR 3.37; p < 0.0001). Neonatal outcomes were worse with TOLAC, including higher rates of NICU admission (RR 1.11), ventilation, antibiotic use (RR 1.34), and seizures (RR 2.19; p = 0.0017).

Conclusion:
Among patients with ≥3 prior cesarean deliveries, TOLAC was associated with a significantly higher risk of uterine rupture compared to ERCD, though overall rates remained low. Interestingly, TOLAC was also associated with lower risks of transfusion and hysterectomy. Despite these maternal findings, TOLAC was linked to higher rates of neonatal morbidity, including NICU admission, respiratory support, and antibiotic use. These data highlight the complex risk-benefit considerations when counseling patients with higher-order cesareans on the choice between TOLAC and ERCD.