I am honored to share expert guidance in this feature published on October 28, 2024, where I discussed the rising rate of C-sections in India, the safety of choosing a VBAC, and the crucial guidelines mothers must follow to ensure a safe trial of labour after cesarean (TOLAC). The article highlights WHO recommendations, national C-section statistics, and expert-backed advice on when a VBAC can be a safe and successful option. Here are the key insights I provided:

• According to WHO, C-section rates ideally should not exceed 10%, but globally rates have reached 20–21%. In India, C-section rates have risen from 21% (2015–16) to beyond 30% in recent years.
• Multiple factors contribute to the rising C-section rate, including literacy, hospital systems, financial incentives, sociocultural reasons, and medical implications.
• TOLAC (Trial of Labour After Caesarean) should be offered as an option for eligible women. VBAC is the successful vaginal birth outcome of TOLAC, while CBAC refers to cesarean delivery after a failed TOLAC.
• The success rate of TOLAC is approximately 52–70%, while the risk of scar rupture is only 0.4–1% — significantly lower than commonly feared.
• VBAC is safe when conducted under strict protocols, with expert obstetricians, full-time availability of anesthesiologists, and immediate access to a well-equipped operation theatre.
• A detailed history of the previous C-section — including the indication for surgery — must be evaluated before offering TOLAC.
• The current pregnancy must be free of complications, and the onset of labour must be spontaneous for the mother to qualify.
• Mothers should be thoroughly counselled on the benefits, process, and risks of TOLAC, including the rare but possible complication of scar rupture.
• Continuous fetal monitoring, mother’s vital monitoring, the use of partogram, and immediate response to fetal bradycardia are essential for safe TOLAC.
• The success rate of TOLAC improves significantly with expert hands, proper hospital setup, and correct patient selection.

Process of TOLAC:

• The pregnancy follows a routine course similar to any other pregnancy.
• The key difference is the selection of a skilled obstetric team and a hospital equipped for emergency intervention.
• Labour must begin spontaneously; induction is generally avoided.
• Continuous CTG (cardiotocography) and maternal monitoring is mandatory.
• Fetal bradycardia is often the earliest sign of scar rupture and requires immediate action.
• Epidural analgesia may be safely offered for labour pain relief.

Benefits of Successful TOLAC (VBAC):

• Shorter hospital stay
• Lower maternal morbidity
• Lower financial burden
• Fewer abdominal complications
• Reduced risk of transient tachypnea (TTN) in newborns

Risks Involved:

• VBAC: Maternal and fetal risks are very low.
• CBAC: Risks are similar to a planned elective C-section.
• Scar rupture (0.3–1%): Though frightening, this risk is extremely low and can be further minimized by expert monitoring and timely surgical intervention.

With expert medical teams, strict monitoring, and clear protocols, TOLAC is a safe and beneficial choice for many pregnant women. Increasing the acceptance of TOLAC can significantly reduce unnecessary C-sections and lower the financial and medical burden for mothers across the country.

In the current scenario, financial structures in private hospitals often incentivize C-sections over normal deliveries. If insurance and compensation frameworks begin valuing TOLAC and VBAC equally, more hospitals and obstetricians will be motivated to implement safe VBAC protocols — ultimately improving national childbirth outcomes.