can you have a natural birth after 2 c-sections?

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
S Tahseen 1 , M Griffiths
Affiliations

PMID: 19781046 DOI: 10.1111/j.1471-0528.2009.02351.x

Abstract

Background: Trial of vaginal birth after Caesarean (VBAC) is considered acceptable after one caesarean section (CS), however, women wishing to have trial after two CS are generally not allowed or counselled appropriately of efficacy and complications.

Objective: To perform a systematic review of literature on success rate of vaginal birth after two caesarean sections (VBAC-2) and associated adverse maternal and fetal outcomes; and compare with commonly accepted VBAC-1 and the alternative option of repeat third CS (RCS).

Search strategy: We searched MEDLINE, EMBASE, CINAHL, Cochrane Library, Current Controlled Trials, HMIC Database, Grey Literature Databases (SIGLE, Biomed Central), using search terms Caesarean section, caesarian, C*rean, C*rian, and MeSH headings 'Vaginal birth after caesarean section', combined with second search string two, twice, second, multiple.

Selection criteria: No randomised studies were available, case series or cohort studies were assessed for quality (STROBE), 20/23 available studies included.

Data collection and analysis: Two independent reviewers selected studies and abstracted and tabulated data and pooled estimates were obtained on success rate, uterine rupture and other adverse maternal and fetal outcomes. Meta-analyses were performed using RevMan-5 to compare VBAC-1 versus VBAC-2 and VBAC-2 versus RCS.

Main results: VBAC-2 success rate was 71.1%, uterine rupture rate 1.36%, hysterectomy rate 0.55%, blood transfusion 2.01%, neonatal unit admission rate 7.78% and perinatal asphyxial injury/death 0.09%. VBAC-2 versus VBAC-1 success rates were 4064/5666 (71.1%) versus 38 814/50 685 (76.5%) (P < 0.001); associated uterine rupture rate 1.59% versus 0.72% (P < 0.001) and hysterectomy rates were 0.56% versus 0.19% (P = 0.001) respectively. Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel-Haenszel).

Conclusions: Women requesting for a trial of vaginal delivery after two caesarean sections should be counselled appropriately considering available data of success rate 71.1%, uterine rupture rate 1.36% and of a comparative maternal morbidity with repeat CS option.
Comment in

Can vaginal birth after caesarean be justified?
Smith A. BJOG. 2010 Oct;117(11):1426-7; author reply 1427-8. doi: 10.1111/j.1471-0528.2010.02681.x. PMID: 20840694 No abstract available.

Similar articles

Vaginal birth after Caesarean versus elective repeat Caesarean for women with a single prior Caesarean birth: a systematic review of the literature.
Dodd J, Crowther C. Aust N Z J Obstet Gynaecol. 2004 Oct;44(5):387-91. doi: 10.1111/j.1479-828X.2004.00257.x. PMID: 15387856 Review.
Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success.
Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA. BJOG. 2010 Mar;117(4):422-7. doi: 10.1111/j.1471-0528.2010.02498.x. Epub 2010 Jan 28. PMID: 20374579
[Trial of labor after two cesarean sections: the policy in Israel and four years experience].
Kogan L, Dior U, Eizenberg N, Ezra Y. Harefuah. 2011 Nov;150(11):862-5, 874. PMID: 22428209 Review. Hebrew.
Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland.
Fitzpatrick KE, Kurinczuk JJ, Bhattacharya S, Quigley MA. PLoS Med. 2019 Sep 24;16(9):e1002913. doi: 10.1371/journal.pmed.1002913. eCollection 2019 Sep. PMID: 31550245 Free PMC article.
Vaginal birth after cesarean: new insights.
Guise JM, Eden K, Emeis C, Denman MA, Marshall N, Fu RR, Janik R, Nygren P, Walker M, McDonagh M. Evid Rep Technol Assess (Full Rep). 2010 Mar;(191):1-397. PMID: 20629481 Free PMC article. Review.