Introduction
Rates of cesarean deliveries (CD) have substantially increased in recent
decades to approximately 21% of births worldwide1with the most common indication for CD being a previous uterine
scar2. Repeat CD is associated with significant
morbidities including: the need for blood transfusion, bowel and bladder
injury and placenta previa with its related
complications3,4. In 1980, the National Institute of
Child Health and Human Development Conference on Childbirth concluded
that vaginal delivery (VD) after a CD is a relevant alternative.
Successful vaginal birth after CD (VBAC) compared to elective repeat CD
is associated with fewer complications. However, a failed trail of labor
after CD (TOLAC) is associated with serious complications. Therefore,
efforts are made in order to identify the best candidates for
TOLAC5.The American College of Obstetrics and Gynecology (ACOG) committee
opinion from 1994 on the issue of TOLAC stated that TOLAC after two or
more previous CDs should not be discouraged.6Thereafter, institutions consented and allowed TOLAC following two
previous CD7–10. Subsequently, the ACOG guidelines
from 201911 maintains that it is reasonable to
consider parturients with two previous low segment transverse (LSTCS) CD
as appropriate candidates for TOLAC following a thorough individual
consultation assessing their previous and current obstetrical history
and their probability of achieving a successful VBAC.
Initiated in 2000, our medical center follows a strict protocol
regarding TOLAC in parturients who previously had 2 CD. There is a
paucity of data regarding maternal and neonatal risks associated with
TOLAC in this specific population. The purpose of this study was to
investigate the outcomes of TOLAC following two CD versus a third repeat
elective CD and to explore factors associated with successful TOLAC.