Outcome of a labor trial for women with a history of two cesarean sections: a retrospective cohort study

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The global rise in cesarean section (CS) rates has led to an increasing number of women with multiple prior CSs. Despite evidence supporting trial of labor after two cesareans (TOLA2C), it remains underused in many settings owing to concerns about complications such as uterine rupture. This study aimed to compare the outcomes of TOLA2C andelective repeat cesarean section (ERCS) and identify factors associated with successful vaginal birth after two CSs (VBA2C). Methods. This retrospective cohort study included 333 women with two or more previous cesarean sections who gave birth between January 2021 and December 2023. Women with multiple pregnancies were excluded. Patients were categorized into the ERCS and TOLA2C groups. Data on maternal characteristics, birth outcomes, and complications were extracted from digital medical records. Results. A total of 333 women fulfilled the study criteria. Among them, 295 (88.6 %) underwent ERCS, whereas 38 (11.4 %) attempted TOLA2C. The success rate of VBA2C was 60.5 % (23/38), whereas 39.5 % (15/38) required an unplanned CS. Uterine rupture was documented in one TOLA2C patient (2.7 %) and 17 ERCS patients (5.8 %). No maternal deaths or embolic events were reported, and only one hysterectomy and one case of intrauterine infection occurred. Generally, there were no significant differences in maternal or neonatal complications between the two groups. Conclusion. There was no difference in maternal or neonatal morbidity among patients in our study population with two previous CSs who opted for TOLA2C versus ERCS. In conclusion, TOLA2C should be discussed in appropriate cases as an alternative mode of delivery. Trial of labor after cesarean section Vaginal birth after cesarean section history of two cesarean deliveries Figures Figure 1 Introduction As rates of cesarean section (CS) have increased worldwide over the last 3 decades, more women are having multiple CSs. In Germany, for example, more than 33% of CSs in 2022 were due to a previous cesarean delivery ( 1 ). However, compared with vaginal deliveries, cesarean deliveries carry a greater risk of maternal mortality and morbidity. Reports show an 8- to 10-fold increased risk of maternal mortality with CS compared with that with vaginal birth ( 2 ). Vaginal birth after CS (VBAC), even after multiple CSs, reduces the overall number of CSs and the complications associated with them ( 3 ), and the American College of Obstetricians and Gynecologists (ACOG) supports Trial of Labor after Cesarean (TOLAC) in women with two prior low transverse CSs in selected cases ( 14 ). Although outcomes of trials of vaginal delivery after two CSs (TOLA2C) have been published over the last two decades ( 4 , 5 , 6 ), the subject of VBAC after 2 CSs has not received due consideration among obstetricians. In Germany, where this study was conducted, many hospitals do not offer the option of a vaginal delivery after a cesarean section, which explains the higher rate of complications, especially uterine rupture, than does an elective repeat cesarean section (ERCS). This study aimed to compare vaginal births and repeat CS after two or more previous CSs, identifying factors that predict successful vaginal births. The study also examines the risks and benefits associated with TOLA2C to provide information for obstetricians, gynecologists, and pregnant women, facilitating evidence-based decisions in selecting the appropriate mode of delivery. Methods For our retrospective cohort study, data from St. Hedwig Hospital, Department of Obstetrics and Gynecology, University of Regensburg, covering the period from January 1, 2021, to December 31, 2023, were used. Births after two or more previous cesarean sections were selected from the birth registers. Each patient was assigned an internal number to anonymize the data. Medical history, birth parameters, and complications were retrieved via the software “Viewpoint 6TM” (GE Healthcare, Chicago) and “SAP Logon 770” (SAP-SE, Germany). The Ethics Committee of the University of Regensburg reviewed this retrospective study and raised no objections (reference number: 25-4365-104). All participants gave informed consent to data collection, storage in a database and data analysis. The inclusion criteria were pregnancies after more than one previous cesarean section, including patients with vaginal deliveries, secondary and primary repeat cesarean sections, preterm births, uterine ruptures or malformations, and cases with fetal abnormalities. The only exclusion criterion was multiple pregnancies. The final cohort consisted of 333 women who gave birth to 333 newborns after 2 or more CSs in their past. The cohort was then divided into two groups on the basis of the intended mode of birth: planned CS and TOLAC. The TOLAC group was analyzed in more detail and further divided into those who had successful VBAC and those who had unplanned repeated CS (Fig. 1 ). Investigated parameters and analysis: This study documented several key maternal and birth parameters. Maternal data included age, BMI (body mass index), number of pregnancies and births, previous vaginal deliveries, and the presence of conditions such as hypertension, gestational diabetes and smoking. The birth parameters included labor induction, gestational age, newborn birth weight, umbilical cord pH, Apgar score and length of hospital stay. The primary outcomes were the frequency of TOLA2C attempts and the success rate of vaginal births. The secondary outcomes included complications such as post-partum hemorrhage (PPH) (bleeding > 1000 ml), blood transfusions, uterine rupture, hysterectomy, embolic events, amniotic infection and maternal or neonatal death. The collected data were statistically analyzed via the program “R version 4.4.0.” Descriptive statistics were obtained for both the entire cohort and the individual subgroups. For all metric data, the means with standard deviations and the medians with interquartile ranges were calculated. Comparisons between different patient groups were performed via the following tests: the Wilcoxon‒Mann‒Whitney test (for nonnormally distributed metric data), the Welch two-sample t test (for normally distributed metric data), the chi-square test (for nominal data with all expected frequencies ≥ 5), and Fisher’s exact test (for nominal data with at least one expected frequency < 5). A significance level of < 5% was considered statistically significant. Results ERCS vs. TOLA2C During the study period, a total of 10,109 births occurred at the University Hospital St. Hedwig, Regensburg, Germany. . Among them, 343 births occurred in women with a history of two or more CSs, representing approximately 3.4 % of all deliveries. After 10 multiple pregnancies were excluded, the final study cohort consisted of 333 patients. The patient cohort was divided into two groups on the basis of the intended mode of delivery (Tab. 1). The first group included 295 (88.6 %) women who chose the ERCS as a mode of delivery, and the second group included 38 (11.4 %) women who opted for the TOLAC. Only one of the TOLAC patients had more than 2 CSs in their medical history. Twenty-three women (60.5 %) with TOLA2C had a successful VBAC, and 15 women (39.5 %) had a failed trial. Table 1: Maternal characteristics Characteristic ERCS (N = 295 1 ) TOLA2C (N = 38 1 ) p value Maternal age (in years) Mean (±SD) Median (IQR) 33.6 (±4.5) 34.0 (31.0 – 37.0) 33.7 (±4.6) 34.0 (30.3 – 36.0) > 0.9 2 BMI (kg/m 2 ) Mean (±SD) Median (IQR) 28 (±7) 27 (23 – 32) 26 (±5) 25 (22 – 29) 0.13 2 Gravidity Mean (±SD) Median (IQR) 4.29 (±1.56) 4.00 (3.00 – 5.00) 3.66 (±0.88) 3.00 (3.00 – 4.00) 0.016 2 Parity Mean (±SD) Median (IQR) 3,57 (±1,04) 3.00 (3,00 – 4,00) 3.13 (±0.41) 3.00 (3.00 – 3.00) 0.003 2 Prior vaginal delivery (%) 40 (14 %) 3 (7.9 %) 0.4 3 Gestational hypertension (%) 6 (2,0 %) 0 (0 %) > 0.9 3 Gestational diabetes (%) 61 (21 %) 5 (13 %) 0.2 4 Smoking (%) 35 (12 %) 1 (2,7 %) 0.10 3 1 n (%) 2 Wilcoxon rank sum test 3 Fisher’s exact test 4 Pearson’s chi-square test Abbreviations: ERCS = elective repeat cesarean section, TOLA2C = trial of labor after 2 cesareans, BMI= body mass index, SD = standard deviation, IQR = interquartile range The comparison of characteristics between the two main groups revealed no significant differences in age or BMI between the groups. In the ERCS group, 40/295 (14 %) women had a previous vaginal delivery, whereas in the TOLA2C group, 3/38 (7.9 %) (p= 0.4) had a previous delivery. Newborns in the TOLA2C group had a greater mean birth weight (3298 vs. 3113 g, p= 0.039) and mean gestational age (273 vs 262 days, p value <0.001) than did those in the planned CS group. The gestational age in this study ranged from 162--295 days. Moreover, the umbilical cord pH was significantly lower in women who opted for a vaginal delivery than in those who chose an elective CS (7.24 vs 7.30, p= <0.001). However, the mean value remained within the reference range and did not indicate fetal asphyxia. The Apgar scores at 5 and 10 min were not significantly different between the groups. Maternal morbidity and mortality: Postpartum hemorrhage was observed in 16 patients, with 3 patients in the TOLA2C group and the remaining patients in the CS group. Of these, only three women who underwent a CS required a blood transfusion. The difference in both parameters was not significant. Nontatal uterine rupture was documented in 18 patients, with just one instance in the TOLA2C group (2.7 %). A hysterectomy was necessary in a single patient following an ERCS. Additionally, one case of triple I (intrauterine infection or inflammation) was recorded in the TOLA2C group. Throughout the entire study period, no cases of embolism or maternal death were reported (Tab. 2). Table 2: Maternal and neonatal outcomes n ERCS (n = 295 1 ) TOLAC (n = 38 1 ) p value Gestational age (in days) Mean (±SD) Median (IQR) 333 262 (±15) 266 (260 – 270) 273 (±22) 277 (270 – 284) < 0.001 2 Birth weight (in gr.) Mean (±SD) Median (IQR) 332 3113 (±634) 3166 (2784 – 3520) 3298 (±693) 3382 (2975 – 3734) 0.039 2 Umbilical cord pH Mean (±SD) Median (IQR) 330 7.30 (±0.04) 7.30 (7.28 – 7.33) 7.24 (±0.08) 7.25 (7.19 – 7.31) < 0.001 2 APGAR-Score (5 min) Mean (±SD) Median (IQR) 333 9.37 (±1.30) 10.00 (9.00 – 10.00) 9.37 (±1.00) 10.00 (9.00 – 10.00) 0.5 2 APGAR-Score (10 min) Mean (±SD) Median (IQR) 333 9.68 (±0.93) 10.00 (10.00 – 10.00) 9.71 (±0.61) 10.00 (10.00 – 10.00) 0.7 2 Duration of Hospital stay (in days) Mean (±SD) Median (IQR) 333 5.40 (±5.84) 4.00 (4.00 – 5.00) 4.45 (±1.84) 4.00 (4.00 – 5.00) 0.4 2 PPH > 1000 ml 333 13 (4.4 %) 3 (7.9 %) 0.4 3 Blood transfusion 332 3 (1.0 %) 0 (0 %) > 0.9 3 Uterine rupture 332 17 (5.8 %) 1 (2.7 %) 0.7 3 Hysterectomy 332 1 (0.3 %) 0 (0 %) > 0.9 3 Embolism 332 0 (0 %) 0 (0 %) Triple I 332 0 (0 %) 1 (2.7 %) 0.11 3 Death 332 0 (0 %) 0 (0 %) 1 n (%) 2 Wilcoxon rank sum test 3 Fisher’s exact test 4 Pearson’s chi-square test Abbreviations: ERCS = elective repeat cesarean section, TOLA2C= trial of labor after 2 cesarean sections, APGAR= appearance, pulse, grimace, activity, respiration. PPH = postpartum hemorrhage Triple I =intrauterine infection or inflammation or both Failed TOLAC2 vs. VBAC2 (Tab. 3) There were no significant differences between the two groups in terms of maternal age or BMI. Within the cohort, there were three women with two CSs and at least one previous vaginal birth. All three women with a history of prior spontaneous birth successfully delivered vaginally. Labor induction was performed in 11 % of the cases and was equally distributed between the VBAC and secondary CS groups. Two induction methods were used: a cervical ripening balloon and oxytocin. The length of hospital stay was significantly shorter in the VBAC2 group, with a mean duration of 3.78 days, compared with 5.47 days for women with failed TOLAC2 (p = 0.015). There were no significant differences in neonatal outcomes between the groups. However, newborns in the VBAC2 group had a significantly greater APGAR score at 10 minutes than those in the failed TOLAC2 group did (9.87 vs. 9.47, p = 0.027). Maternal morbidity and mortality: PPH occurred in 3 VBAC2 patients (13 %), and uterine rupture was documented in one VBAC2 patient (4.5 %). Additionally, one patient developed Triple I, requiring a secondary CS (6.7 %). No cases of blood transfusion, hysterectomy, embolism, or neonatal or maternal death were recorded in the TOLAC group. Table 3: Failed TOLA2C vs. VBAC Failed TOLA2C (n = 15 1 ) VBAC (N = 23 1 ) p value Maternal age (in years) Mean (±SD) Median (IQR) 34.8 (±5.3) 35.0 (32.0 – 38.0) 33.0 (±4.1) 33.0 (29.5 – 35.5) 0.3 2 BMI (kg/m 2 ) Mean (±SD) Median (IQR) 26.4 (±5.0) 26.2 (22.7 – 29.3) 25.8 (±5.7) 24.8 (21.7 – 27.8) 0.6 3 Gravidity Mean (±SD) Median (IQR) 3.53 (±0.92) 3.00 (3.00 – 4.00) 3.74 (±0.86) 4.00 (3.00 – 4.00) 0.3 3 Parity Mean (±SD) Median (IQR) 3.00 (±0.00) 3.00 (3.00 – 3.00) 3.22 (±0.52) 3.00 (3.00 – 3.00) 0.10 3 Prior vaginal delivery 0 (0 %) 3 (13 %) 0.3 4 Gestational hypertension 0 (0 %) 0 (0 %) Gestational diabetes 3 (20 %) 2 (8.7 %) 0.4 4 Smoking 0 (0 %) 1 (4.5 %) > 0.9 4 Induction of labor 2 (13 %) 2 (8.7 %) > 0.9 4 Gestational age (in days) Mean (±SD) Median (IQR) 274 (±15) 272 (268 – 285) 272 (±26) 277 (275 – 282) 0.6 3 Birth weight (in gr.) Mean (±SD) Median (IQR) 3261 (±556) 3200 (2765 – 3600) 3322 (±781) 3480 (3145 – 3775) 0.3 3 Umbilical cord-pH Mean (±SD) Median (IQR) 7.27 (±0.06) 7.29 (7.26 – 7.32) 7.22 (±0.08) 7.21 (7.17 – 7.29) 0.057 2 Head circumference (in cm) Mean (±SD) Median (IQR) 34.97 (±1.42) 34.50 (34.0 – 36.0) 34,87 (±3.43) 35.50 (34.75 – 36.50) 0.3 3 APGAR-Score (5 min) Mean (±SD) Median (IQR) 9.00 (±1.25) 10.00 (8.00 – 10.00) 9.61 (±0.72) 10.00 (9.00 – 10.00) 0.2 3 APGAR-Score (10 min) Mean (±SD) Median (IQR) 9.47 (±0.74) 10.00 (9.00 – 10.00) 9.87 (±0.46) 10.00 (10.00 – 10.00) 0.027 3 Duration of the hospital stay(in days) Mean (±SD) Median (IQR) 5.47 (±2.03) 5.00 (4.00 – 7.00) 3.78 (±1.38) 4.00 (3.00 – 4.50) 0.015 3 PPH > 1000 ml 0 (0 %) 3 (13 %) 0.3 4 Blood transfusion 0 (0 %) 0 (0 %) Uterine rupture 0 (0 %) 1 (4.5 %) > 0.9 4 Hysterectomy 0 (0 %) 0 (0 %) Embolism 0 (0 %) 0 (0 %) Triple I 1 (6,7 %) 0 (0 %) 0.4 4 Death 0 (0 %) 0 (0 %) 1 n (%) 2 Welch two-sample t test 3 Wilcoxon rank sum test 4 Fisher’s exact test Abbreviations: Abbreviations: ERCS = elective repeat cesarean section; TOLA2C= trial of labor after 2 cesarean sections; BMI= body mass index; APGAR= appearance, pulse, grimace, activity, respiration; PPH = postpartum hemorrhage Triple I =intrauterine infection or inflammation or both Discussion The results of our study show that TOLA2C is a possible alternative mode of delivery for women who are willing to deliver vaginally. Our TOLA2C success rate was 60.5 %, which is lower than that reported in several comparable studies (5, 9, 10,11, 12) but higher than the rates reported in the publications by Denjean and Sargent JA (7, 8). The relatively lower success rate in our study may be attributed to the broader inclusion criteria, as only women with multiple pregnancies were excluded. In contrast, studies reporting higher VBAC rates often apply more selective criteria to their study populations. With respect to neonatal outcomes, no significant differences were detected between the TOLA2C and ERCS groups, except for the umbilical cord pH, which was significantly lower in the TOLA2C group and can typically be attributed to the physiological stress associated with vaginal delivery. However, this value remained within the reference range and did not indicate fetal asphyxia. Furthermore, this study revealed similar maternal outcomes in both the TOLA2C group and the ERCS group, which aligns with almost all previous large population studies and meta-analyses (5,9,12). In this study, prior vaginal delivery increased the likelihood of having successful TOLA2C. The induction of labor did not seem to influence the success rate of TOLA2C in our analysis, whereas Horgan reported that the induction of labor after two prior cesarean sections adversely affected successful TOLA2C (5). In the study by Landon et al., the uterine rupture rate in TOLA2C was reported to be 0.9 % (13), whereas higher rates were reported in the studies by Macones, Tahseen, and Horgan—1.8 %, 1.36 %, and 1.2 %, respectively (10, 9, 5). In our study, the rate of uterine rupture was higher at 2.7 % among women who attempted a vaginal delivery. Interestingly, the rate was even greater—5.8 %—in women who opted for an ERCS. This finding suggests that the risk of uterine rupture may not be solely associated with labor and vaginal delivery but rather with a history of two or more prior cesarean sections. Additionally, the exact definition of uterine rupture is still debated. In our cohort, only nonfatal rupture was documented without affecting the mother or the newborn with adverse outcomes. In conclusion, no significant differences in maternal or neonatal morbidity were detected between patients with two previous cesarean sections who underwent TOLA2C and those who chose ERCS. TOLA2C presents a viable option to reduce overall CS rates and the associated maternal risks linked to multiple surgeries. Therefore, in appropriately selected cases, TOLA2C should be actively discussed as an alternative mode of delivery, in line with current ACOG guidelines (14). Limitations and strengths : A key strength of this study lies in the manual data collection process, which enhances the accuracy and reliability of the analyzed data compared with studies relying solely on automated extraction. Furthermore, the absence of significant differences in maternal age and BMI between the TOLA2C and ERCS groups increases the comparability of these cohorts and strengthens the internal validity of the findings. However, this study also has several limitations. The relatively small sample size in the TOLA2C group may have limited the statistical power to detect rare adverse outcomes or to perform extensive subgroup analyses. Additionally, as a single-center study conducted at a tertiary hospital in Germany, the findings may not be generalizable to other settings with different obstetric practices or patient populations. Importantly, the researchers were not involved in counseling patients regarding delivery mode, and it remains unclear whether all eligible women were appropriately offered the option of TOLA2C. This introduces the possibility of selection bias, as the decision to pursue TOLA2C may have been influenced by unmeasured factors, including provider attitudes or institutional policies. Abbreviations ERCS = elective repeat cesarean section CS = Cesarean section VBAC = vaginal birth after cesarean TOLA2C = trial of labor after 2 cesareans BMI = Body-Mass-Index PPH = postpartum hemorrhage Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: Not applicable Authors' contributions: NM analyzed data and wrote the article. LS collected and analyzed data. MK revised the analysis. IA revised the work. AK analyzed the data and revised the work. All authors read and approved the final manuscript. Acknowledgements: Not applicable References IQTIG-Institut für Qualitätssicherung und Transparenz im Gesundheitswesen: Bundesauswertung EJ 2022 nach DeQS-RL Geburtshilfe, 20 Juli 2023 [Internet]. [cited 2024 Jul 22]. Available from: https://iqtig.org/veroeffentlichungen/bundesauswertung/ Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to caesarean delivery. Am J Obstet Gynecol. 2008 Jul;199(1):36.e1-5; discussion 91-2. e7-11. doi: 10.1016/j.ajog.2008.03.007. Epub 2008 May 2. PMID: 18455140. Tahseen S, Griffiths M. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7821068","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546428273,"identity":"ee0e490f-8b99-40ee-9f67-b86a5a61157e","order_by":0,"name":"Nagham Mawas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIiWNgGAWjYHACNiR2BZsciDrwgHgtZ/iMwVoSiNbC2CaX2ABi4NNizn782oOfOQzR/DOSH39gbDNLnx92+CHQFjs53QbsWix7csoNe7cx5M64kWYmwXAuLXfj7TQDoJZkY7MD2LUYHMhJk+AFamm4nWDGwFB2LHfj7ASQlgOJ23BpOf8mTfIvUMv82+mfPzCw/U83nJ3+Ab+WG+nHpEG2bLidYyDB0MaWIC+dQ8CWG2/YpGW3SeRuvP+mTCLhDJvhBumcggMJBnj8cj79meTbbTa5884c3/zhQwWbvPzsdBDDTg6XFgYGHgMgIQFhJ4ADBGwULuUgwP4AlS/fgE/1KBgFo2AUjEQAAO2QZgbMYdUsAAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital St. Hedwig of the Order of St. John, Department of Gynecology and Obstetrics, Regensburg","correspondingAuthor":true,"prefix":"","firstName":"Nagham","middleName":"","lastName":"Mawas","suffix":""},{"id":546428274,"identity":"8ce73115-022a-4db4-bf14-f68d80ad27bc","order_by":1,"name":"Lucia Sattler","email":"","orcid":"","institution":"University Hospital St. Hedwig of the Order of St. John, Department of Gynecology and Obstetrics, Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Lucia","middleName":"","lastName":"Sattler","suffix":""},{"id":546428275,"identity":"b3a1f126-cc4a-498c-b80c-a02ee8ce2d1f","order_by":2,"name":"Maurice Kappelmeyer","email":"","orcid":"","institution":"University Hospital St. Hedwig of the Order of St. John, Department of Gynecology and Obstetrics, Lab of Translational Perinatology, Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Maurice","middleName":"","lastName":"Kappelmeyer","suffix":""},{"id":546428276,"identity":"29459a53-aafd-456f-832c-3a6e26573484","order_by":3,"name":"Ibrahim Abou Tabikh","email":"","orcid":"","institution":"Department of Internal Medicine II - Cardiology, Pneumology, and Internal Intensive Care Medicine, University Hospital Regensburg, Regensburg, Germany.","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Abou","lastName":"Tabikh","suffix":""},{"id":546428277,"identity":"d1370833-f34e-4a19-928c-d46a1abe3ec4","order_by":4,"name":"Angela Köninger","email":"","orcid":"","institution":"University Hospital St. Hedwig of the Order of St. John, Department of Gynecology and Obstetrics, Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Köninger","suffix":""}],"badges":[],"createdAt":"2025-10-09 22:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7821068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7821068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96605912,"identity":"e9ea06ce-4945-4967-ba38-93687ad69b76","added_by":"auto","created_at":"2025-11-24 09:24:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74749,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptOutcomeTOLA2C.docx","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/e7651bdd234d4abc72acedbd.docx"},{"id":96557186,"identity":"7580e807-9572-477c-9eb2-0989798e3ff8","added_by":"auto","created_at":"2025-11-23 11:52:18","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6786,"visible":true,"origin":"","legend":"","description":"","filename":"13927623d4e04f128cbb3d03f3c2b67e.json","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/e4687cd2a31cd46d4ff618e1.json"},{"id":96557188,"identity":"1aa2c054-71d5-40a7-8e81-77433d0ec722","added_by":"auto","created_at":"2025-11-23 11:52:18","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72272,"visible":true,"origin":"","legend":"","description":"","filename":"13927623d4e04f128cbb3d03f3c2b67e1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/85461ad28bc68d45bdc204e6.xml"},{"id":96557184,"identity":"b01270d3-f18b-4199-82d2-846717b7f708","added_by":"auto","created_at":"2025-11-23 11:52:18","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71044,"visible":true,"origin":"","legend":"","description":"","filename":"13927623d4e04f128cbb3d03f3c2b67e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/4e35932771d452b1caee10ff.xml"},{"id":96604997,"identity":"241cbf4e-9316-499c-a3cf-1976f9ec98d0","added_by":"auto","created_at":"2025-11-24 09:17:14","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75000,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/464ea5c1bb868cd50262b0d2.html"},{"id":96557185,"identity":"64e8e776-9e8b-46dc-8046-75c6c542ec25","added_by":"auto","created_at":"2025-11-23 11:52:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33178,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart for this study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/f8a19adf0684f64e5d80f79a.png"},{"id":108161080,"identity":"32de5fad-ec58-4453-812b-8502408ea036","added_by":"auto","created_at":"2026-04-30 04:10:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":360109,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7821068/v1/0caccfc5-d9f0-477b-a05e-81e86d00e897.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome of a labor trial for women with a history of two cesarean sections: a retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs rates of cesarean section (CS) have increased worldwide over the last 3 decades, more women are having multiple CSs.\u003c/p\u003e\u003cp\u003eIn Germany, for example, more than 33% of CSs in 2022 were due to a previous cesarean delivery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, compared with vaginal deliveries, cesarean deliveries carry a greater risk of maternal mortality and morbidity. Reports show an 8- to 10-fold increased risk of maternal mortality with CS compared with that with vaginal birth (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Vaginal birth after CS (VBAC), even after multiple CSs, reduces the overall number of CSs and the complications associated with them (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and the American College of Obstetricians and Gynecologists (ACOG) supports Trial of Labor after Cesarean (TOLAC) in women with two prior low transverse CSs in selected cases (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough outcomes of trials of vaginal delivery after two CSs (TOLA2C) have been published over the last two decades (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), the subject of VBAC after 2 CSs has not received due consideration among obstetricians.\u003c/p\u003e\u003cp\u003eIn Germany, where this study was conducted, many hospitals do not offer the option of a vaginal delivery after a cesarean section, which explains the higher rate of complications, especially uterine rupture, than does an elective repeat cesarean section (ERCS).\u003c/p\u003e\u003cp\u003eThis study aimed to compare vaginal births and repeat CS after two or more previous CSs, identifying factors that predict successful vaginal births. The study also examines the risks and benefits associated with TOLA2C to provide information for obstetricians, gynecologists, and pregnant women, facilitating evidence-based decisions in selecting the appropriate mode of delivery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFor our retrospective cohort study, data from St. Hedwig Hospital, Department of Obstetrics and Gynecology, University of Regensburg, covering the period from January 1, 2021, to December 31, 2023, were used. Births after two or more previous cesarean sections were selected from the birth registers. Each patient was assigned an internal number to anonymize the data. Medical history, birth parameters, and complications were retrieved via the software \u0026ldquo;Viewpoint 6TM\u0026rdquo; (GE Healthcare, Chicago) and \u0026ldquo;SAP Logon 770\u0026rdquo; (SAP-SE, Germany).\u003c/p\u003e\u003cp\u003e The Ethics Committee of the University of Regensburg reviewed this retrospective study and raised no objections (reference number: 25-4365-104). All participants gave informed consent to data collection, storage in a database and data analysis.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were pregnancies after more than one previous cesarean section, including patients with vaginal deliveries, secondary and primary repeat cesarean sections, preterm births, uterine ruptures or malformations, and cases with fetal abnormalities. The only exclusion criterion was multiple pregnancies. The final cohort consisted of 333 women who gave birth to 333 newborns after 2 or more CSs in their past.\u003c/p\u003e\u003cp\u003eThe cohort was then divided into two groups on the basis of the intended mode of birth: planned CS and TOLAC. The TOLAC group was analyzed in more detail and further divided into those who had successful VBAC and those who had unplanned repeated CS (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInvestigated parameters and analysis:\u003c/h2\u003e\u003cp\u003eThis study documented several key maternal and birth parameters. Maternal data included age, BMI (body mass index), number of pregnancies and births, previous vaginal deliveries, and the presence of conditions such as hypertension, gestational diabetes and smoking. The birth parameters included labor induction, gestational age, newborn birth weight, umbilical cord pH, Apgar score and length of hospital stay.\u003c/p\u003e\u003cp\u003eThe primary outcomes were the frequency of TOLA2C attempts and the success rate of vaginal births. The secondary outcomes included complications such as post-partum hemorrhage (PPH) (bleeding\u0026thinsp;\u0026gt;\u0026thinsp;1000 ml), blood transfusions, uterine rupture, hysterectomy, embolic events, amniotic infection and maternal or neonatal death.\u003c/p\u003e\u003cp\u003eThe collected data were statistically analyzed via the program \u0026ldquo;R version 4.4.0.\u0026rdquo;\u003c/p\u003e\u003cp\u003eDescriptive statistics were obtained for both the entire cohort and the individual subgroups. For all metric data, the means with standard deviations and the medians with interquartile ranges were calculated.\u003c/p\u003e\u003cp\u003eComparisons between different patient groups were performed via the following tests: the Wilcoxon‒Mann‒Whitney test (for nonnormally distributed metric data), the Welch two-sample t test (for normally distributed metric data), the chi-square test (for nominal data with all expected frequencies\u0026thinsp;\u0026ge;\u0026thinsp;5), and Fisher\u0026rsquo;s exact test (for nominal data with at least one expected frequency\u0026thinsp;\u0026lt;\u0026thinsp;5). A significance level of \u0026lt;\u0026thinsp;5% was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eERCS vs. TOLA2C\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, a total of 10,109 births occurred at the University Hospital St. Hedwig, Regensburg, Germany. . Among them, 343 births occurred in women with a history of two or more CSs, representing approximately 3.4 % of all deliveries. After 10 multiple pregnancies were excluded, the final study cohort consisted of 333 patients. The patient cohort was divided into two groups on the basis of the intended mode of delivery (Tab. 1). The first group included 295 (88.6 %) women who chose the ERCS as a mode of delivery, and the second group included 38 (11.4 %) women who opted for the TOLAC. Only one of the TOLAC patients had more than 2 CSs in their medical history. Twenty-three women (60.5 %) with TOLA2C had a successful VBAC, and 15 women (39.5 %) had a failed trial.\u003c/p\u003e\n\u003cp\u003eTable 1: Maternal characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eERCS (N = 295\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTOLA2C (N = 38\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMaternal age (in years)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.6 (\u0026plusmn;4.5)\u003c/p\u003e\n \u003cp\u003e34.0 (31.0 \u0026ndash; 37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.7 (\u0026plusmn;4.6)\u003c/p\u003e\n \u003cp\u003e34.0 (30.3 \u0026ndash; 36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (\u0026plusmn;7)\u003c/p\u003e\n \u003cp\u003e27 (23 \u0026ndash; 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (\u0026plusmn;5)\u003c/p\u003e\n \u003cp\u003e25 (22 \u0026ndash; 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.13\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.29 (\u0026plusmn;1.56)\u003c/p\u003e\n \u003cp\u003e4.00 (3.00 \u0026ndash; 5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.66 (\u0026plusmn;0.88)\u003c/p\u003e\n \u003cp\u003e3.00 (3.00 \u0026ndash; 4.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.016\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3,57 (\u0026plusmn;1,04)\u003c/p\u003e\n \u003cp\u003e3.00 (3,00 \u0026ndash; 4,00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.13 (\u0026plusmn;0.41)\u003c/p\u003e\n \u003cp\u003e3.00 (3.00 \u0026ndash; 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.003\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePrior vaginal delivery (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e40 (14 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (7.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.4\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational hypertension (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e6 (2,0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational diabetes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e61 (21 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.2\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSmoking (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e35 (12 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (2,7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.10\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003en (%)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWilcoxon rank sum test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003ePearson\u0026rsquo;s chi-square test\u003c/p\u003e\n\u003cp\u003eAbbreviations: ERCS = elective repeat cesarean section, TOLA2C = trial of labor after 2 cesareans, BMI= body mass index, SD = standard deviation, IQR = interquartile range\u003c/p\u003e\n\u003cp\u003eThe comparison of characteristics between the two main groups revealed no significant differences in age or BMI between the groups. In the ERCS group, 40/295 (14 %) women had a previous vaginal delivery, whereas in the TOLA2C group, 3/38 (7.9 %) (p= 0.4) had a previous delivery.\u003c/p\u003e\n\u003cp\u003eNewborns in the TOLA2C group had a greater mean birth weight (3298 vs. 3113 g, p= 0.039) and mean gestational age (273 vs 262 days, p value \u0026lt;0.001) than did those in the planned CS group. The gestational age in this study ranged from 162--295 days.\u003c/p\u003e\n\u003cp\u003eMoreover, the umbilical cord pH was significantly lower in women who opted for a vaginal delivery than in those who chose an elective CS (7.24 vs 7.30, p= \u0026lt;0.001). However, the mean value remained within the reference range and did not indicate fetal asphyxia. The Apgar scores at 5 and 10 min were not significantly different between the groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal morbidity and mortality:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostpartum hemorrhage was observed in 16 patients, with 3 patients in the TOLA2C group and the remaining patients in the CS group. Of these, only three women who underwent a CS required a blood transfusion. The difference in both parameters was not significant.\u003c/p\u003e\n\u003cp\u003eNontatal uterine rupture was documented in 18 patients, with just one instance in the TOLA2C group (2.7 %). A hysterectomy was necessary in a single patient following an ERCS. Additionally, one case of triple I (intrauterine infection or inflammation) was recorded in the TOLA2C group. Throughout the entire study period, no cases of embolism or maternal death were reported (Tab. 2).\u003c/p\u003e\n\u003cp id=\"_Toc175233024\"\u003eTable 2: Maternal and neonatal outcomes\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eERCS (n = 295\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTOLAC (n = 38\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational age (in days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e262 (\u0026plusmn;15)\u003c/p\u003e\n \u003cp\u003e266 (260 \u0026ndash; 270)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e273 (\u0026plusmn;22)\u003c/p\u003e\n \u003cp\u003e277 (270 \u0026ndash; 284)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBirth weight (in gr.)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3113 (\u0026plusmn;634)\u003c/p\u003e\n \u003cp\u003e3166 (2784 \u0026ndash; 3520)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3298 (\u0026plusmn;693)\u003c/p\u003e\n \u003cp\u003e3382 (2975 \u0026ndash; 3734)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.039\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUmbilical cord pH\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.30 (\u0026plusmn;0.04)\u003c/p\u003e\n \u003cp\u003e7.30 (7.28 \u0026ndash; 7.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.24 (\u0026plusmn;0.08)\u003c/p\u003e\n \u003cp\u003e7.25 (7.19 \u0026ndash; 7.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAPGAR-Score (5 min)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.37 (\u0026plusmn;1.30)\u003c/p\u003e\n \u003cp\u003e10.00 (9.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.37 (\u0026plusmn;1.00)\u003c/p\u003e\n \u003cp\u003e10.00 (9.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.5\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAPGAR-Score (10 min)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.68 (\u0026plusmn;0.93)\u003c/p\u003e\n \u003cp\u003e10.00 (10.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.71 (\u0026plusmn;0.61)\u003c/p\u003e\n \u003cp\u003e10.00 (10.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.7\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDuration of Hospital stay\u003c/p\u003e\n \u003cp\u003e(in days)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.40 (\u0026plusmn;5.84)\u003c/p\u003e\n \u003cp\u003e4.00 (4.00 \u0026ndash; 5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.45 (\u0026plusmn;1.84)\u003c/p\u003e\n \u003cp\u003e4.00 (4.00 \u0026ndash; 5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.4\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePPH \u0026gt; 1000 ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e13 (4.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3 (7.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.4\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBlood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e3 (1.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUterine rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e17 (5.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (2.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.7\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e1 (0.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEmbolism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eTriple I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (2.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.11\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003en (%)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWilcoxon rank sum test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003ePearson\u0026rsquo;s chi-square test\u003c/p\u003e\n\u003cp\u003eAbbreviations: ERCS = elective repeat cesarean section, TOLA2C= trial of labor after 2 cesarean sections, APGAR= appearance, pulse, grimace, activity, respiration. PPH = postpartum hemorrhage Triple I =intrauterine infection or inflammation or both\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFailed TOLAC2 vs. VBAC2 (Tab. 3)\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between the two groups in terms of maternal age or BMI. Within the cohort, there were three women with two CSs and at least one previous vaginal birth. All three women with a history of prior spontaneous birth successfully delivered vaginally.\u003c/p\u003e\n\u003cp\u003eLabor induction was performed in 11 % of the cases and was equally distributed between the VBAC and secondary CS groups. Two induction methods were used: a cervical ripening balloon and oxytocin. The length of hospital stay was significantly shorter in the VBAC2 group, with a mean duration of 3.78 days, compared with 5.47 days for women with failed TOLAC2 (p = 0.015).\u003c/p\u003e\n\u003cp\u003eThere were no significant differences in neonatal outcomes between the groups. However, newborns in the VBAC2 group had a significantly greater APGAR score at 10 minutes than those in the failed TOLAC2 group did (9.87 vs. 9.47, p = 0.027).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003emorbidity\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and mortality:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePPH occurred in 3 VBAC2 patients (13 %), and uterine rupture was documented in one VBAC2 patient (4.5 %). Additionally, one patient developed Triple I, requiring a secondary CS (6.7 %). No cases of blood transfusion, hysterectomy, embolism, or neonatal or maternal death were recorded in the TOLAC group.\u003c/p\u003e\n\u003cp id=\"_Toc175233025\"\u003eTable 3: Failed TOLA2C vs. VBAC\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eFailed TOLA2C (n = 15\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eVBAC (N = 23\u003csup\u003e1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMaternal age (in years)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34.8 (\u0026plusmn;5.3)\u003c/p\u003e\n \u003cp\u003e35.0 (32.0 \u0026ndash; 38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.0 (\u0026plusmn;4.1)\u003c/p\u003e\n \u003cp\u003e33.0 (29.5 \u0026ndash; 35.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26.4 (\u0026plusmn;5.0)\u003c/p\u003e\n \u003cp\u003e26.2 (22.7 \u0026ndash; 29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25.8 (\u0026plusmn;5.7)\u003c/p\u003e\n \u003cp\u003e24.8 (21.7 \u0026ndash; 27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.6\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.53 (\u0026plusmn;0.92)\u003c/p\u003e\n \u003cp\u003e3.00 (3.00 \u0026ndash; 4.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.74 (\u0026plusmn;0.86)\u003c/p\u003e\n \u003cp\u003e4.00 (3.00 \u0026ndash; 4.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.00 (\u0026plusmn;0.00)\u003c/p\u003e\n \u003cp\u003e3.00 (3.00 \u0026ndash; 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.22 (\u0026plusmn;0.52)\u003c/p\u003e\n \u003cp\u003e3.00 (3.00 \u0026ndash; 3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.10\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePrior vaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (20 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (8.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.4\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (4.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eInduction of labor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (8.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eGestational age (in days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e274 (\u0026plusmn;15)\u003c/p\u003e\n \u003cp\u003e272 (268 \u0026ndash; 285)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e272 (\u0026plusmn;26)\u003c/p\u003e\n \u003cp\u003e277 (275 \u0026ndash; 282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.6\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBirth weight (in gr.)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3261 (\u0026plusmn;556)\u003c/p\u003e\n \u003cp\u003e3200 (2765 \u0026ndash; 3600)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3322 (\u0026plusmn;781)\u003c/p\u003e\n \u003cp\u003e3480 (3145 \u0026ndash; 3775)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUmbilical cord-pH\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.27 (\u0026plusmn;0.06)\u003c/p\u003e\n \u003cp\u003e7.29 (7.26 \u0026ndash; 7.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.22 (\u0026plusmn;0.08)\u003c/p\u003e\n \u003cp\u003e7.21 (7.17 \u0026ndash; 7.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.057\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHead circumference (in cm)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34.97 (\u0026plusmn;1.42)\u003c/p\u003e\n \u003cp\u003e34.50 (34.0 \u0026ndash; 36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34,87 (\u0026plusmn;3.43)\u003c/p\u003e\n \u003cp\u003e35.50 (34.75 \u0026ndash; 36.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAPGAR-Score (5 min)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.00 (\u0026plusmn;1.25)\u003c/p\u003e\n \u003cp\u003e10.00 (8.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.61 (\u0026plusmn;0.72)\u003c/p\u003e\n \u003cp\u003e10.00 (9.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.2\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAPGAR-Score (10 min)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.47 (\u0026plusmn;0.74)\u003c/p\u003e\n \u003cp\u003e10.00 (9.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.87 (\u0026plusmn;0.46)\u003c/p\u003e\n \u003cp\u003e10.00 (10.00 \u0026ndash; 10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.027\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDuration of the hospital stay(in days)\u003c/p\u003e\n \u003cp\u003eMean (\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.47 (\u0026plusmn;2.03)\u003c/p\u003e\n \u003cp\u003e5.00 (4.00 \u0026ndash; 7.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.78 (\u0026plusmn;1.38)\u003c/p\u003e\n \u003cp\u003e4.00 (3.00 \u0026ndash; 4.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.015\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003ePPH \u0026gt; 1000 ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.3\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBlood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUterine rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (4.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026gt; 0.9\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eEmbolism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eTriple I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (6,7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.4\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003en (%)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWelch two-sample t test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eWilcoxon rank sum test\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eFisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003eAbbreviations: Abbreviations: ERCS = elective repeat cesarean section; TOLA2C= trial of labor after 2 cesarean sections; BMI= body mass index; APGAR= appearance, pulse, grimace, activity, respiration; PPH = postpartum hemorrhage Triple I =intrauterine infection or inflammation or both\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of our study show that TOLA2C is a possible alternative mode of delivery for women who are willing to deliver vaginally.\u003c/p\u003e\n\u003cp\u003eOur TOLA2C success rate was 60.5 %, which is lower than that reported in several comparable studies (5, 9, 10,11, 12) but higher than the rates reported in the publications by Denjean and Sargent JA (7, 8). The relatively lower success rate in our study may be attributed to the broader inclusion criteria, as only women with multiple pregnancies were excluded. In contrast, studies reporting higher VBAC rates often apply more selective criteria to their study populations.\u003c/p\u003e\n\u003cp\u003eWith respect to neonatal outcomes, no significant differences were detected between the TOLA2C and ERCS groups, except for the umbilical cord pH, which was significantly lower in the TOLA2C group and can typically be attributed to the physiological stress associated with vaginal delivery. However, this value remained within the reference range and did not indicate fetal asphyxia.\u003c/p\u003e\n\u003cp\u003eFurthermore, this study revealed similar maternal outcomes in both the TOLA2C group and the ERCS group, which aligns with almost all previous large population studies and meta-analyses (5,9,12). In this study, prior vaginal delivery increased the likelihood of having successful TOLA2C. The induction of labor did not seem to influence the success rate of TOLA2C in our analysis, whereas Horgan reported that the induction of labor after two prior cesarean sections adversely affected successful TOLA2C (5).\u003c/p\u003e\n\u003cp\u003eIn the study by Landon et al., the uterine rupture rate in TOLA2C was reported to be 0.9 % (13), whereas higher rates were reported in the studies by Macones, Tahseen, and Horgan\u0026mdash;1.8 %, 1.36 %, and 1.2 %, respectively (10, 9, 5). In our study, the rate of uterine rupture was higher at 2.7 % among women who attempted a vaginal delivery. Interestingly, the rate was even greater\u0026mdash;5.8 %\u0026mdash;in women who opted for an ERCS. This finding suggests that the risk of uterine rupture may not be solely associated with labor and vaginal delivery but rather with a history of two or more prior cesarean sections. Additionally, the exact definition of uterine rupture is still debated. In our cohort, only nonfatal rupture was documented without affecting the mother or the newborn with adverse outcomes.\u003c/p\u003e\n\u003cp\u003eIn conclusion, no significant differences in maternal or neonatal morbidity\u0026nbsp;were detected between patients with two previous cesarean sections who underwent TOLA2C and those who chose ERCS. TOLA2C presents a viable option to reduce overall CS rates and the associated maternal risks linked to multiple surgeries. Therefore, in appropriately selected cases, TOLA2C should be actively discussed as an alternative mode of delivery, in line with current ACOG guidelines (14).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eLimitations and\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003estrengths\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key strength of this study lies in the manual data collection process, which enhances the accuracy and reliability of the analyzed data compared with studies relying solely on automated extraction. Furthermore, the absence of significant differences in maternal age and BMI between the TOLA2C and ERCS groups increases the comparability of these cohorts and strengthens the internal validity of the findings.\u003c/p\u003e\n\u003cp\u003eHowever, this study also has several limitations. The relatively small sample size in the TOLA2C group may have limited the statistical power to detect rare adverse outcomes or to perform extensive subgroup analyses. Additionally, as a single-center study conducted at a tertiary hospital in Germany, the findings may not be generalizable to other settings with different obstetric practices or patient populations. Importantly, the researchers were not involved in counseling patients regarding delivery mode, and it remains unclear whether all eligible women were appropriately offered the option of TOLA2C. This introduces the possibility of selection bias, as the decision to pursue TOLA2C may have been influenced by unmeasured factors, including provider attitudes or institutional policies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eERCS = elective repeat cesarean section\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCS = Cesarean section\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVBAC = vaginal birth after cesarean\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;TOLA2C = trial of labor after 2 cesareans\u003c/p\u003e\n\u003cp\u003eBMI = Body-Mass-Index\u003c/p\u003e\n\u003cp\u003ePPH = postpartum hemorrhage\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eEthics approval and consent to participate: Not applicable\u003c/li\u003e\n \u003cli\u003eConsent for publication: Not applicable\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/li\u003e\n \u003cli\u003eCompeting interests: The authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003eFunding: Not applicable\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; contributions: NM analyzed data and \u0026nbsp;wrote the article. LS collected and analyzed data. MK revised the analysis. IA revised the work. AK analyzed the data and revised the work. All authors read and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003eAcknowledgements: Not applicable\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIQTIG-Institut f\u0026uuml;r Qualit\u0026auml;tssicherung und Transparenz im Gesundheitswesen: Bundesauswertung EJ 2022 nach DeQS-RL Geburtshilfe, 20 Juli 2023 [Internet]. [cited 2024 Jul 22]. Available from: https://iqtig.org/veroeffentlichungen/bundesauswertung/\u003c/li\u003e\n\u003cli\u003eClark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to caesarean delivery. Am J Obstet Gynecol. 2008 Jul;199(1):36.e1-5; discussion 91-2. e7-11. doi: 10.1016/j.ajog.2008.03.007. Epub 2008 May 2. PMID: 18455140.\u003c/li\u003e\n\u003cli\u003eTahseen 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 Int J Obstet Gynaecol. 2010 Jan;117(1):5\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eAsakura H, Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol. 1995 Jun;85(6):924-9. doi: 10.1016/0029-7844(95)00078-6. PMID: 7770261.\u003c/li\u003e\n\u003cli\u003eHorgan R, Hossain S, Fulginiti A, Patras A, Massaro R, Abuhamad AZ, Kawakita T, Graebe R. Trial of labor after two cesarean sections: A retrospective case-control study. J Obstet Gynaecol Res. 2022 Oct;48(10):2528-2533. doi: 10.1111/jog.15351. Epub 2022 Jul 6. PMID: 35793784; PMCID: PMC9796916.\u003c/li\u003e\n\u003cli\u003eSpaans WA, van der Vliet LM, R\u0026ouml;ell-Schorer EA, Bleker OP, van Roosmalen J. Trial of labour after two or three previous caesarean sections. Eur J Obstet Gynecol Reprod Biol. 2003 Sep 10;110(1):16-9. doi: 10.1016/s0301-2115(03)00082-4. PMID: 12932864.\u003c/li\u003e\n\u003cli\u003eDenjean S, Reis D, Br\u0026auml;uer M, L\u0026auml;ngler A. Trial of labour after two caesarean sections (TOLA2C) and risk of uterine rupture, a retrospective single centre study. BMC Pregnancy Childbirth. 2024 Sep 3;24(1):576. doi: 10.1186/s12884-024-06763-x. PMID: 39227780; PMCID: PMC11370114.\u003c/li\u003e\n\u003cli\u003eSargent JA, Savitsky LM, Dissanayake MV, Lo JO, Cheng YW, Caughey AB. Gestational Weight Gain during Pregnancy as an Important Factor Influencing a Successful Trial of Labor following Two Previous Cesareans. Am J Perinatol. 2019 May;36(6):588-593. doi: 10.1055/s-0038-1670679. Epub 2018 Sep 19. PMID: 30231273; PMCID: PMC7138436.\u003c/li\u003e\n\u003cli\u003eTahseen 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 Jan;117(1):5-19. doi: 10.1111/j.1471-0528.2009.02351.x. PMID: 19781046.\u003c/li\u003e\n\u003cli\u003eMaroyi R, Nyakio O, Buhendwa C, Mukanga O, Kalunga K, Kanyinda K, Rukunghu N, Mukundane B, Kakusu D, Mwilo M, Mbaya EI, Madarhi C, Walala B, Kakisingi J, Mukwege D. Experience on trial of labor and vaginal delivery after two previous cesarean sections: A cohort study from a limited-resource setting. Int J Gynaecol Obstet. 2023 Jul;162(1):266-272. doi: 10.1002/ijgo.14665. Epub 2023 Feb 21. PMID: 36708063.\u003c/li\u003e\n\u003cli\u003eGarg VK, Ekuma-Nkama EN. Vaginal birth following two cesarean sections. Int J Gynaecol Obstet. 2005 Jan;88(1):53-4. doi: 10.1016/j.ijgo.2004.09.009. PMID: 15617707.\u003c/li\u003e\n\u003cli\u003eMiller ES, Grobman WA. Obstetric outcomes associated with induction of labor after 2 prior cesarean deliveries. Am J Obstet Gynecol. 2015 Jul;213(1):89.e1-89.e5. doi: 10.1016/j.ajog.2015.02.003. Epub 2015 Feb 12. PMID: 25683964.\u003c/li\u003e\n\u003cli\u003eLandon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O\u0026apos;sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM, Gabbe SG; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006 Jul;108(1):12-20. doi: 10.1097/01.AOG.0000224694.32531.f3. PMID: 16816050.\u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019 Feb;133(2):e110\u0026ndash;27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Trial of labor after cesarean section, Vaginal birth after cesarean section, history of two cesarean deliveries","lastPublishedDoi":"10.21203/rs.3.rs-7821068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7821068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eObjective.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe global rise in cesarean section (CS) rates has led to an increasing number of women with multiple prior CSs. Despite evidence supporting trial of labor after two cesareans (TOLA2C), it remains underused in many settings owing to concerns about complications such as uterine rupture. This study aimed to compare the outcomes of TOLA2C andelective repeat cesarean section (ERCS) and identify factors associated with successful vaginal birth after two CSs (VBA2C).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included 333 women with two or more previous cesarean sections who gave birth between January 2021 and December 2023. Women with multiple pregnancies were excluded. Patients were categorized into the ERCS and TOLA2C groups. Data on maternal characteristics, birth outcomes, and complications were extracted from digital medical records.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA total of 333 women fulfilled the study criteria. Among them, 295 (88.6 %) underwent ERCS, whereas 38 (11.4 %) attempted TOLA2C. The success rate of VBA2C was 60.5 % (23/38), whereas 39.5 % (15/38) required an unplanned CS. Uterine rupture was documented in one TOLA2C patient (2.7 %) and 17 ERCS patients (5.8 %). No maternal deaths or embolic events were reported, and only one hysterectomy and one case of intrauterine infection occurred. Generally, there were no significant differences in maternal or neonatal complications between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusion.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThere was no difference in maternal or neonatal morbidity among patients in our study population with two previous CSs who opted for TOLA2C versus ERCS. In conclusion, TOLA2C should be discussed in appropriate cases as an alternative mode of delivery.\u003c/p\u003e","manuscriptTitle":"Outcome of a labor trial for women with a history of two cesarean sections: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-23 11:52:13","doi":"10.21203/rs.3.rs-7821068/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc6929a1-81f2-4863-9ec5-2b854cd6d227","owner":[],"postedDate":"November 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T04:09:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-23 11:52:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7821068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7821068","identity":"rs-7821068","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}