Download PDF
CC BY-NC-ND 4.0 · Geburtshilfe Frauenheilkd
DOI: 10.1055/a-2513-6562
GebFra Science
Original Article

Successful Trial of Labor After Two Caesarean Sections (TOLA2C): Analysis of a Delivery Protocol with Feto-Maternal Outcome

Erfolgreiche vaginale Entbindung nach 2 vorangegangenen Sectiones caesareae (TOLA2C): Analyse eines Entbindungsprotokolls mit fetomaternalem Outcome
Maximilian Brandstetter 
1   Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria (Ringgold ID: RIN31545)
,
Andreas Brandstetter
2   Department of Obstetrics and Gynecology, Sankt Josef Hospital, Vienna, Austria
,
Sabine Kainz-Schultes
2   Department of Obstetrics and Gynecology, Sankt Josef Hospital, Vienna, Austria
,
Volker R. Jacobs
1   Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria (Ringgold ID: RIN31545)
,
Claudius Fazelnia
1   Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria (Ringgold ID: RIN31545)
,
Thorsten Fischer
1   Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria (Ringgold ID: RIN31545)
,
Gerhard Bogner
1   Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria (Ringgold ID: RIN31545)
› Author Affiliations
› Further Information
Also available at
  Permissions and Reprints

Abstract

Introduction

The majority of obstetrical clinics do not offer a trial of labor after two Caesarean sections (TOLA2C) due to concerns about fetal and maternal complications such as uterine rupture or asphyxia. This study aimed to establish a delivery protocol for safely undergoing TOLA2C and analyzed predictors for a successful vaginal delivery.

Methods

Analysis of retrospectively collected data of all pregnant women after two consecutive Caesarean sections was performed at the Obstetrics Department of a tertiary community hospital from January 2013 until December 2022. Those who desired TOLA2C were screened by a senior obstetrician and had to consent to a delivery protocol consisting of five pre- and eight peripartum criteria. Maternal demographic data, indications for previous Caesarean sections and feto-maternal outcome parameters were compared between the successful TOLA2C group and the intrapartum Third-Caesarean section group.

Results

In the study period, 385 women planned a delivery after two consecutive CS. Following the protocol, 358 patients (93.0%) were scheduled as elective repeat CS, while 27 (7.0%) attempted vaginal delivery. In this TOLA2C group, 17 women (63.0%) successfully delivered vaginally. In contrast, ten failed vaginal attempts (37.0%) resulted in nine intrapartum repeat CS and one intrapartum emergency CS. Women with prior vaginal delivery had a higher chance of a successful TOLA2C (p = 0.04). In comparison, women with a previous CS due to the indication of arrested labor had a higher risk for intrapartum repeat CS (p = 0.02). No fetal or maternal death occurred, and no major complications were observed.

Conclusion

Under the specified conditions, TOLA2C is safe for mother and fetus, and successful vaginal delivery is feasible.

Zusammenfassung

Einleitung

Die Mehrheit der Entbindungskliniken bieten keinen Wehenversuch nach 2 vorangegangenen Sectiones caesareae (Trial of Labor after two Caesarean sections, TOLA2C) aufgrund der Bedenken hinsichtlich möglicher fetaler und mütterlicher Komplikationen wie Uterusruptur und Asphyxie. Ziel dieser Studie war es, ein Entbindungsprotokoll für eine sichere TOLA2C zu entwickeln sowie die Prädiktoren für eine erfolgreiche vaginale Entbindung zu analysieren.

Methoden

Es wurde eine Analyse der retrospektiv gesammelten Daten aller schwangeren Frauen durchgeführt, die bereits 2 Sectiones caesareae erlebt hatten und zwischen Januar 2013 und Dezember 2022 in der geburtshilflichen Abteilung eines kommunalen Krankenhauses der Tertiärversorgung entbanden. Die Frauen, die eine TOLA2C wünschten, wurden von einem erfahrenen Geburtshelfer überprüft und mussten einem Entbindungsprotokoll mit 5 prä- und 8 peripartalen Kriterien zustimmen. Die mütterlichen demografischen Daten, die Indikationen für die vorangegangenen Kaiserschnittentbindungen sowie die fetomaternalen Ergebnisparameter der erfolgreichen TOLA2C-Gruppe und der intrapartalen Dritte-Sectio-Gruppe wurden verglichen.

Ergebnisse

Im Studienzeitraum planten 385 Frauen eine Entbindung nach 2 aufeinanderfolgenden Kaiserschnittentbindungen. Laut Protokoll wurde bei 358 Patientinnen (93,0%) eine elektive erneute CS geplant, während 27 (7,0%) eine vaginale Entbindung versuchten. Aus dieser TOLA2C-Gruppe haben 17 Frauen (63,0%) erfolgreich vaginal entbunden. Dagegen gab es 10 erfolglose Versuche einer vaginalen Entbindung (37,0%), die intrapartal zu 9 erneuten Kaiserschnittentbindungen und einer Notsectio führten. Bei Frauen, die schon einmal vaginal entbunden hatten, war die Chance eines erfolgreichen TOLA2C höher (p = 0,04). Dafür war das Risiko für eine erneute intrapartale Kaiserschnittentbindung höher bei Frauen, die schon einmal eine Indikation für eine Sectio caesarea hatten wegen Geburtsstillstand (p = 0,02). Es gab keine fetale Mortalität oder Müttersterblichkeit, und es wurden keine schwerwiegenden Komplikationen beobachtet.

Schlussfolgerung

Unter den vorgegebenen Bedingungen ist TOLA2C ein sicherer Entbindungsmodus für Mutter und Kind, und eine erfolgreiche vaginale Entbindung ist möglich.

Keywords

Caesarean section - TOLA2C - feto-maternal morbidity - delivery mode

Schlüsselwörter

Sectio caesarea - TOLA2C - fetomaternale Morbidität - Entbindungsmodus


Publication History

Received: 27 September 2024

Accepted after revision: 08 January 2025

Article published online:
07 February 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Molina G, Weiser TG, Lipsitz SR. et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA 2015; 314: 2263-2270
    CrossrefPubMedSearch in Google Scholar
  • 2 Betran AP, Torloni MR, Zhang JJ. et al. WHO Statement on Caesarean Section Rates. BJOG 2016; 123: 667-670
    CrossrefPubMedSearch in Google Scholar
  • 3 Horgan R, Hossain S, Fulginiti A. et al. Trial of labor after two cesarean sections: A retrospective case–control study. J Obstet Gynaecol Res 2022; 48: 2528-2533
    CrossrefPubMedSearch in Google Scholar
  • 4 Statistik Austria. Pressemitteilung: 12.849–147/22 Nahezu jedes dritte Neugeborene kam 2021 per Kaiserschnitt zur Welt [Internet]. 2022 Accessed August 18, 2023 at: https://www.statistik.at/fileadmin/announcement/2022/07/20220707MedMerkmaleGeborene2021.pdf
    PubMedSearch in Google Scholar
  • 5 Betrán AP, Vindevoghel N, Souza JP. et al. A Systematic Review of the Robson Classification for Caesarean Section: What Works, Doesn’t Work and How to Improve It. PLoS One 2014; 9: e97769
    CrossrefPubMedSearch in Google Scholar
  • 6 Leo RD, Gamba DL, Manzoni P. et al. Vaginal Birth after Two Previous Cesarean Sections versus Elective Repeated Cesarean: A Retrospective Study. Am J Perinat 2020; 37 (Suppl. 02) S84-S88
    Thieme ConnectPubMedSearch in Google Scholar
  • 7 ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol [Anonym]. 2010; 116: 450-463
    CrossrefPubMedSearch in Google Scholar
  • 8 Royal College of Obstetricians and Gynaecologists (RCOG). RCOG Green-topGuideline No. 45: Birth after previous caesarean birth. 2015 Accessed January 07, 2016 at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf
    PubMedSearch in Google Scholar
  • 9 Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (Replaces guideline Number 147), February 2005. Int J Gynaecol Obstet 2005; 89: 319-331
    CrossrefPubMedSearch in Google Scholar
  • 10 Reif P, Brezinka C, Fischer T. et al. Labour and Childbirth After Previous Caesarean Section. Geburtshilfe Frauenheilkd 2016; 76: 1279-1286
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Wagner SM, Bicocca MJ, Mendez-Figueroa H. et al. Neonatal and maternal outcomes with trial of labor after two prior cesarean births: stratified by history of vaginal birth. J Matern Fetal Neonatal Med 2022; 35: 6013-6020
    CrossrefPubMedSearch in Google Scholar
  • 12 Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)–a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010; 117: 5-19
    CrossrefPubMedSearch in Google Scholar
  • 13 Roux L, Chiemlewski MC, Lassel L. et al. Trial of labor versus elective cesarean delivery for patients with two prior cesarean-sections: a retrospective propensity score analysis. Eur J Obstet Gynecol Reprod Biol 2023; 287: 67-74
    CrossrefPubMedSearch in Google Scholar
  • 14 Macones GA, Cahill A, Pare E. et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?. Am J Obstet Gynecol 2005; 192: 1223-1228
    CrossrefPubMedSearch in Google Scholar
  • 15 Asakura H, Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol 1995; 85: 924-929
    CrossrefPubMedSearch in Google Scholar
  • 16 Haumonte JB, Raylet M, Christophe M. et al. French validation and adaptation of the Grobman nomogram for prediction of vaginal birth after cesarean delivery. J Gynecol Obstet Hum Reprod 2018; 47: 127-131
    CrossrefPubMedSearch in Google Scholar
  • 17 Grobman W, Lai Y, Landon M. et al. Does Information Available at Admission for Delivery Improve Prediction of Vaginal Birth after Cesarean?. Am J Perinatol 2009; 26: 693-701
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Landon MB, Leindecker S, Spong CY. et al. The MFMU Cesarean Registry: Factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005; 193: 1016-1023
    CrossrefPubMedSearch in Google Scholar
  • 19 Rotem R, Hirsch A, Sela HY. et al. Maternal and Neonatal Outcomes Following Trial of Labor After Two Previous Cesareans: a Retrospective Cohort Study. Reprod Sci 2021; 28: 1092-1100
    CrossrefPubMedSearch in Google Scholar
  • 20 Landon MB, Spong CY, Thom E. et al. Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery. Obstet Gynecol 2006; 108: 12-20
    CrossrefPubMedSearch in Google Scholar
  • 21 Davidson C, Bellows P, Shah U. et al. Outcomes associated with trial of labor after cesarean in women with one versus two prior cesarean deliveries after a change in clinical practice guidelines in an academic hospital. J Matern Fetal Neonatal Med 2020; 33: 1499-1504
    CrossrefPubMedSearch in Google Scholar
  • 22 Dombrowski M, Illuzzi JL, Reddy UM. et al. Trial of Labor After Two Prior Cesarean Deliveries: Patient and Hospital Characteristics and Birth Outcomes. Obstet Gynecol 2020; 136: 109-117
    CrossrefPubMedSearch in Google Scholar
  • 23 Grobman WA, Sandoval G, Rice MM. et al. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol 2021; 225: 664.e1-664.e7
    CrossrefPubMedSearch in Google Scholar
  • 24 Cobec IM, Rempen A, Anastasiu-Popov DM. et al. How the Mode of Delivery Is Influenced by Patient’s Opinions and Risk-Informed Consent in Women with a History of Caesarean Section? Is Vaginal Delivery a Real Option after Caesarean Section?. J Clin Med 2024; 13: 4393
    CrossrefPubMedSearch in Google Scholar
  • 25 Maroyi R, Nyakio O, Buhendwa C. et al. Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited-resource setting. Int J Gynecol Obstet 2023; 162: 266-272
    CrossrefPubMedSearch in Google Scholar
  • 26 Yee LM, Costantine MM, Rice MM. et al. Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates. Obstet Gynecol 2017; 130: 1285-1294
    CrossrefPubMedSearch in Google Scholar
  • 27 Louwen F, Wagner U, Abou-Dakn M. et al. Caesarean Section. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/084, June 2020). Geburtshilfe Frauenheilkd 2021; 81: 896-921
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 Cobec IM, Varzaru VB, Kövendy T. et al. External Cephalic Version–A Chance for Vaginal Delivery at Breech Presentation. Medicina 2022; 58: 1619
    CrossrefPubMedSearch in Google Scholar
  • 29 Impey ORE, Greenwood CEL, Impey LWM. External cephalic version after previous cesarean section: A cohort study of 100 consecutive attempts. Eur J Obstet Gynecol Reprod Biol 2018; 231: 210-213
    CrossrefPubMedSearch in Google Scholar
  • 30 Flamm BL, Fried MW, Lonky NM. et al. External cephalic version after previous cesarean section. Am J Obstet Gynecol 1991; 165: 370-372
    CrossrefPubMedSearch in Google Scholar