Maternal and neonatal outcomes for women with a history of two caesarean deliveries undergoing trial of labour vs elective repeat caesarean: a retrospective study with two delivery protocols

Abstract

Objective: Caesarean section (CS) rates are rising worldwide, with previous CS being the primary indication. The CS rate in Italy is among the highest in the western world. Repeat CS is associated with significant morbidities. Although evidence is abundant regarding the safety of a trial of labour after one CS, there is a paucity of data regarding a trial of labour after two CSs. The objective of this study was to examine maternal and neonatal outcomes among women with two previous CSs who underwent either repeat CS or a trial of labour within two different inclusion protocols. Methods: This retrospective cohort study covered the period from 2015 to 2025 in a large teaching hospital. From 2015 to 2020, a new protocol allowed a trial of labour after two previous CSs (TOLA2C) in selected women (Period 1). Starting in 2021 (Period 2), a revised protocol allowed induction of labour (either mechanical or pharmacological) and epidural pain control. Patients undergoing CS were classified as elective, urgent or emergency. Maternal birth mode, and maternal and neonatal outcomes were recorded. Results: Between 2015 and 2025, 23,094 women delivered at Santo Spirito Hospital, Pescara (Italy). Of these, 489 patients who delivered at ≥ 34 weeks of gestation who had undergone two previous CSs were eligible for inclusion in this study: 268 patients in Period 1 (2015–2020) and 221 patients in Period 2 (2021–2025). The rate of TOLA2C rose from 9% in Period 1 to 23% in Period 2 (p ≤ 0.0001). Indications for previous CS and emergency CS rates did not differ significantly between the two periods within the elective CS and TOLA2C groups. Uterine rupture occurred in one labouring patients in the TOLA2C group during Period 1, and in a patient enrolled for an elective CS in Period 2. Two fetal demises occurred in Period 2 in the elective CS group: one due to uterine rupture in an eclamptic patient, and one due to cord thrombosis. Conclusion: This study compared two protocols for TOLA2C in women requesting a vaginal birth, and showed increased rates for TOLA2C and vaginal birth after two caesarean sections (i.e. successful TOLA2C) with a more liberal protocol. Although underpowered to detect rare adverse outcomes, this study suggests that TOLA2C can be a reasonably safe option and should be offered to women.