Trial of Labor After Cesarean and Vaginal Birth After Cesarean: A Systematic Review and Meta-Analysis of Maternal and Neonatal Outcomes

Background and Objectives: The rising rate of cesarean delivery worldwide has led to an increasing number of women considering their options for birth after a previous cesarean section. Vaginal birth after cesarean (VBAC) offers potential maternal benefits but remains associated with concerns regarding maternal and neonatal safety. This systematic review and meta-analysis aimed to evaluate VBAC success rates and compare maternal and neonatal outcomes associated with trial of labor after cesarean (TOLAC) and elective repeat cesarean delivery (ERCD). Materials and Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed/MEDLINE, Embase, and CENTRAL were searched for studies published between January 2010 and January 2026. Pooled proportions were calculated for VBAC success rates, while pooled risk ratios (RRs) with 95% confidence intervals (CIs) were used to evaluate comparative outcomes when sufficient data were available. Results: Thirty-one studies, including one randomized controlled trial and thirty observational studies, were included. The overall VBAC success rate was 67.7% (95% CI 61.8–73.6%), although substantial heterogeneity was observed across studies (I2 = 98.7%). No evidence of significant small-study effects was identified. Women undergoing TOLAC had a higher, although imprecisely estimated, risk of uterine rupture compared with those undergoing ERCD (RR 6.86, 95% CI 0.72–65.07). No statistically significant differences were found for maternal transfusion (RR 2.08, 95% CI 0.43–10.14) or postpartum hemorrhage (RR 1.47, 95% CI 0.04–55.03). Neonatal outcomes were reported inconsistently and could not be reliably pooled. Conclusions: VBAC may be an appropriate option for carefully selected women after individualized assessment of the likelihood of successful vaginal birth and the potential risks associated with TOLAC. However, the available evidence is based predominantly on observational studies, and the certainty of evidence for most comparative outcomes remains low or very low. These findings support individualized counselling and shared decision-making while highlighting the need for larger, well-designed comparative studies with standardized outcome reporting.