Background <p>Trial of labor after cesarean (TOLAC) is often recommended as an alternative to elective repeat cesarean section (ERCS) in women with a single prior cesarean section. This retrospective cohort study aimed to compare obstetrical outcomes between TOLAC and ERCS in a French hospital setting.</p> Methods <p>Women with a single prior cesarean delivery, cephalic presentation, and term pregnancies (≥ 37 weeks) between 2019 and 2024 were included. Women were analyzed according to their initially intended mode of delivery (TOLAC or ERCS), irrespective of the final delivery route, to reflect a real-world, decision-based clinical approach. Primary outcomes were uterine rupture, severe postpartum hemorrhage (PPH), and neonatal intensive care unit (NICU) admission. Statistical methods included chi-square tests, Student’s t-tests, and Firth’s penalized logistic regression for rare events.</p> Results <p>In total, 2,424 women were included, with 2,146 undergoing TOLAC and 278 undergoing ERCS. Severe PPH occurred less frequently in the TOLAC group (5.6%) than in the ERCS group (10.4%, <i>p</i> = 0.002), with adjusted analysis confirming a significant reduction in risk (adjusted OR: 0.45, 95% CI: 0.31–0.69, <i>p</i> &lt; 0.001). NICU admissions were also lower in the TOLAC group (6.5% vs. 13.3%, <i>p</i> &lt; 0.001; adjusted OR: 0.45, 95% CI: 0.31–0.69, <i>p</i> &lt; 0.001). Uterine rupture rates were low and showed no significant difference in unadjusted analysis (1.7% TOLAC vs. 1.1% ERCS, <i>p</i> = 0.622), though adjusted models indicated an increased risk with TOLAC (adjusted OR: 2.08, 95% CI: 1.24–3.58, <i>p</i> = 0.005).</p> Conclusion <p>The findings suggest that obstetrical practice concerning TOLAC, in a French tertiary care maternity unit, is associated with lower rates of severe PPH and NICU admission compared to ERCS, with a slightly increased risk of uterine rupture. These results support offering TOLAC as a safe and beneficial option for eligible women.</p>