Vaginal Birth after Two Previous Cesarean Sections versus Elective Repeated Cesarean: A Retrospective Study

Abstract

Objective Trial of labor after cesarean delivery (TOLAC) is a common practice worldwide but the evidence is still scant regarding this practice in women who underwent 2 previous cesareans. The purpose of this study is to retrospectively review our experience with vaginal birth after two previous cesarean sections (VBA2C), with specific attention to the indications for previous cesarean and to the women's motivation for attempting trial of labor. Study Design This was a retrospective cohort study conducted in a primary care hospital between January 2011 and December 2019. Inclusion criteria were: singleton pregnancies, absence of morphological abnormalities at ultrasonographic screening of the second trimester (or at any other stage of pregnancy), and two previous cesarean sections. Results The final analysis included 114 cases for maternal and neonatal outcomes. In total, 40.4% of women chose trial of labor after two cesarean delivery (TOLA2C group). TOLA2C was associated with a success rate of 76.1%, a higher gestational age at birth, and a shorter hospital stay, compared with elective repeated cesarean delivery group. There were no significant differences in the rate of Apgar scores at 5 minutes <7 between both groups. The percentage of successful TOLA2C in women with prior vaginal delivery was 92.8%. Factors related to failed TOLA2C included failure to progress (3/11, 27.3%), nonreassuring fetal heart rate (3/11, 27.3%), and no onset of spontaneous labor after premature rupture of membranes (5/11, 45.4%). In the group of TOLA2C, more than 70% accepted to travel more than 45 minutes to reach our hospital, with the aim to attempt VBA2C. Conclusion TOLA2C is a possible option for both mothers and neonates in selected cases. Adequate counseling about pros and cons of TOLA2C is mandatory. The woman's motivation represents a key element to determine the success of VBA2C. Key Points

Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited‐resource setting

“…However, these studies were limited by small sample sizes and were retrospective in nature. The present study is the first large, prospective cohort study to examine TOLA2C in a low‐resource setting and supports professional society recommendations for TOLA2C when individualized counseling is provided and key criteria are met 3,16 …”

“…This success rate is within the range of the known threshold of 65%–85% in women who have had one or two previous CSs 4,5,18 . Previous studies 7,18 in medium‐ and high‐resource countries have also shown encouraging rates: 62.8% in Poland, 18 71% and 76.1% in Italy, 3,7 and 88% in Israel 19 . However, these studies were limited by small sample sizes and were retrospective in nature.…”

“…It is well known that when TOLA2C is possible, it results in a high rate of vaginal delivery and low maternal and fetal morbidity in the most cases 3,5 . We did not find in this series a statistically significant difference between perineal soft tissue tear in patients with successful TOLA2C, Apgar at 5 min, and route of delivery ( P ˂ 0.05).…”

“…Prior research demonstrated high numbers of emergency CSs in this population that often resulted from patients' trialing labor unattended at home 18 . Thus, it is critical to provide adequate education and birth preparation during prenatal visits and proper support during labor and delivery 3,19 …”

Evaluating the Success Rate of Vaginal Delivery After Caesarean Section

“…A prior cesarean section is the most common indication of ERCS (Kietpeerakool et al, 2019). The success rate of VBAC ranges from 60% to 80 %( De Leo et al, 2020). In unsuccessful cases, serious complications such as uterine rupture are associated with morbidity (Levin et al, 2020).…”