Maternal and neonatal outcomes following trial of labor after two previous cesareans: a retrospective cohort study.

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Objective: To evaluate the maternal and neonatal outcomes of parturients attempting trial of labor (TOL) after two previous cesarean deliveries (CD) Design: A retrospective computerized database cohort study. Setting: A single tertiary center between 2005 and 2019. Population: Parturients attempting TOL after two CD were compared to parturients opting for elective third repeat CD. TOL after two CD was allowed only for those who met all the criteria of our departments’ protocol. Methods: A univariate analysis was conducted and was followed by a multivariate analysis. Main outcome measures: A composite of adverse maternal and neonatal outcomes. Results: A total of 2719 eligible births following two CD were identified, of which 485 (17.8%) had attempted TOL. Overall, successful vaginal delivery rate following two CDs was 86.2%. Uterine rupture rates were higher among those attempting TOL (0.6% vs 0.1% p=0.04). However, rates of hysterectomy, re-laparotomy, blood product infusion and intensive care unit admission did not differ significantly between the groups. Neonatal outcomes following elective repeat CD were less favorable (specifically, neonatal intensive care unit admission and composite adverse neonatal outcome). Nonetheless, when controlling for potential confounders, an independent association between composite adverse neonatal outcome and an elective repeat CD was not demonstrated. In a subgroup analysis, diabetes mellitus and hypertensive disorders of pregnancy were found independently associated with failed TOLAC. Conclusion: When following a strict protocol, TOL after two CD is a reasonable alternative and associated with favorable maternal and neonatal outcomes

Trial of labor after two previous cesarean deliveries is a reasonable alternative to elective repeat cesarean when following a strict protocol, despite a slightly higher risk of uterine rupture.