What Does the Research Say About VBAC Safety and Success?

By Birth & Baby University · Last updated: October 2026 · 3 min read

Families with a prior cesarean often hear conflicting messages about vaginal birth after cesarean (VBAC): that it is risky, that it is possible, that their hospital does not offer it. The evidence offers a clear map of possibilities and risks, but with an important caveat: nearly all of it is observational. This article summarizes what is known and what that means for support.

Key takeaways

• A large prospective U.S. cohort found symptomatic uterine rupture in 0.7 percent of trials of labor, with higher perinatal risk than elective repeat cesarean but low absolute risk.
• A 2026 meta-analysis reported a pooled VBAC success rate of 67.7 percent with very high heterogeneity (I2 98.7 percent).
• The Cochrane review found no usable randomized evidence: the only data were from 22 women with very low event rates.
• ACOG states that VBAC is associated with decreased maternal morbidity and fewer complications in future pregnancies, and that candidacy depends on individual factors.

What the research says

Risks of a trial of labor

The landmark 2004 Maternal-Fetal Medicine Units cohort compared 17,898 women who attempted vaginal delivery with 15,801 who had elective repeat cesarean. Symptomatic uterine rupture occurred in 124 women (0.7 percent) who labored. Hypoxic-ischemic encephalopathy occurred in 12 term infants after a trial of labor and none after elective repeat cesarean, seven of these cases following rupture (0.46 per 1,000 trials of labor at term), including two neonatal deaths. Endometritis (2.9 percent versus 1.8 percent) and transfusion (1.7 percent versus 1.0 percent) were more frequent with labor; hysterectomy and maternal death did not differ significantly. The authors concluded absolute risks are low but perinatal risk is greater with labor.

A 2024 meta-analysis of 13 articles found significantly higher uterine rupture with trial of labor (OR 2.01, 95% CI 1.48 to 2.74) and no significant differences in hysterectomy, transfusion, postpartum infection, postpartum hemorrhage or NICU admission. A 2026 systematic review of 31 studies (one randomized trial) estimated a higher but very imprecise rupture risk (RR 6.86, 95% CI 0.72 to 65.07) and low or very low certainty for most comparisons. A 2025 French single-hospital cohort (2,424 women) found less severe postpartum hemorrhage and NICU admission with intended trial of labor, but an adjusted increase in uterine rupture (adjusted OR 2.08, 95% CI 1.24 to 3.58). These studies differ in settings and methods, and their outcomes should not be averaged by eye.

Success rates

The 2026 review’s pooled success rate of 67.7 percent (95% CI 61.8 to 73.6 percent) masks wide variation between populations and hospitals. ACOG’s Practice Bulletin 205 says several factors increase the likelihood of a failed trial of labor, which is itself associated with more maternal and perinatal morbidity than successful VBAC or elective repeat cesarean, so assessing both likelihood of success and individual risk is important when deciding who is an appropriate candidate. The bulletin also states that VBAC is associated with decreased maternal morbidity and fewer complications in future pregnancies, and with a lower overall cesarean rate at the population level.

Why there is no randomized answer

The Cochrane review found two randomized trials (320 women), but outcome data for only one trial of 22 women, with no usable comparison. Its authors state that the evidence comes from non-randomized studies prone to bias and that randomized trials are needed.

What this means for doulas

• Be accurate about uncertainty. Neither “VBAC is safe” nor “VBAC is dangerous” fits. Absolute risks are low, differences exist and the evidence is observational.
• Do not advise on candidacy. The care team assesses factors such as the type of prior incision and spacing, and local resources like on-site emergency surgery.
• Support both paths. Some families choose elective repeat cesarean, some choose a trial of labor, and both deserve respect and preparation.
• Know the local picture. Hospital policies, staffing and provider comfort affect access. Help clients ask where care is available.

Putting the evidence into practice

• Encourage clients to ask their provider for an individualized estimate of success and risks, and to understand how it was calculated.
• Ask what monitoring and emergency readiness the hospital has for a trial of labor.
• Prepare for a flexible plan that includes how the family will feel if labor leads to cesarean.
• After birth, offer emotional support whatever the outcome, including for grief about a hoped-for VBAC that did not happen.

The bottom line

VBAC is a reasonable option for many people after individual assessment, with low absolute risks of serious harm and some benefits compared with repeat cesarean, but strong randomized evidence does not exist. Doulas support best by helping families get clear information and by respecting their choices.

This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• Landon MB, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. New England Journal of Medicine 2004. Read the source
• Chen X, et al. The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: a meta-analysis. Medicine 2024. Read the source
• Gyokova E, et al. Trial of Labor After Cesarean and Vaginal Birth After Cesarean: a systematic review and meta-analysis of maternal and neonatal outcomes. Medicina 2026. Read the source
• Chatzistergiou K, et al. Maternal and neonatal outcomes in women undergoing trial of labor after cesarean (TOLAC) compared with elective repeat cesarean section (ERCS): a cohort study. BMC Pregnancy and Childbirth 2025. Read the source
• American College of Obstetricians and Gynecologists. Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology 2019. Read the source
• Dodd JM, et al. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2013. Read the source

Supporting families making complex birth choices is central to doula work. See the training and mentorship options on the For Doulas page.

More for professionals: the Professionals Blog.