Trial of labor versus elective cesarean delivery for patients with two prior cesarean sections: a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA 2020 Flow diagram for the selection of studies and specific reasons for exclusion from the present meta-analysis.

Table 1. Characteristics of included studies for TOLAC-2 vs. ERCS for patients with two prior cesarean-sections.

S. No	Author & Year	Country	Study design	Study duration	Settings	Inclusion criteria	TOLAC − 2 (n)	ERCS (n)	Mean Age_TOLAC-2	Mean Age_ERCS	Parity_TOLAC2	Parity_ERCS	Success rate of vaginal birth	Main outcome measured
1	Novas et al. 1989 [15]	USA	Retrospective Cohort	1986–1987	Personal computer-based perinatal data base system (BPM, Inc., Los Angeles, Calif.),	All patients with more than one previous cesarean section	36	33	NR	NR	NR	NR	29/36 (80%)	Uterine rupture, Hysterectomy, Perinatal death
2	Chattopadhyay et al. 1994 [14]	Saudi Arabia	Prospective Cohort	1986–1992	Maternity and Children’s Hospital, Riyadh, Saudi Arabia.	Women who had a history of two previous non-classical cesarean sections. Expressed a personal preference for vaginal delivery. Clinically assessed to have an adequate pelvis, further confirmed by an erect lateral X-ray pelvimetry indicating a true conjugate measurement greater than 10.5 cm. Ultrasound assessment indicated that the baby's size was less than 3.8 kg. Presented with a vertex fetal presentation at the onset of labor and were admitted before or early in labor with cervical dilatation less than 3 cm.	115	1006	NR	NR	Parity 2 = 23 Parity 3 = 40	NR	103/115 (90%)	Rates of vaginal delivery, scar dehiscence, uterine rupture and associated complications
3	Spaans et al. 2003 [16]	Netherlands	Retrospective Cohort	1988–1997	Amsterdam and Leiden University Medical Centre, Leiden	Retrospective analysis of medical records of women with a history of more than one previous caesarean section	59	187	NR	NR	NR	NR	49/59 (83%)	Uterine rupture, Blood transfusion, Hysterectomy, Maternal morbidity, Apgar score >7 at first minute, NICU admission
4	Macones et al. 2005 [17]	USA	Retrospective Cohort	1996–2000	Both tertiary care hospitals and community hospitals (with and without obstetrics/gynecology residency programs)	Secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery	1082	2888	30.9	32.1	NR	NR	VBAC-2 (74.6%) & VBAC-1 (75.5%)	Blood Transfusion, Uterine rupture, Fever, Birth weight
5	Landon et al. 2006 [18]	USA	Prospective Cohort	1999–2002	National Institute of Child Health and Human Development’s Maternal–Fetal Medicine Units Network	Women with prior cesarean delivery undergoing trial of labor and elective repeat operation	975	6035	30 (26–34)	30 (26–34)	NR	NR	648/975 (66%) in VBAC-2 & 12490/16915 (74%) in VBAC-1	Uterine rupture, Hysterectomy, Transfusion, Maternal morbidity, Term NICU admission, Term intrapartum stillbirth
6	Miller et al. 2015 [19]	USA	Prospective Cohort	1999–2002	19 academic medical centers	Women were included in the present analysis if they had 1 or 2 prior CD, a singleton gestation, and no contraindication to a vaginal delivery (e.g., placenta previa, breech presentation).	152	6010	30.8 ± 5.4	29.9 ± 5.5	NR	NR	75% success in VBAC-2 & 83% in VBAC-1	Maternal and perinatal outcomes including the frequency of VBAC and maternal complications were compared
7	Modzelewski et al. 2019 [20]	Poland	Retrospective Cohort	2010–2017	Anonymous electronic records of all singleton deliveries	Women with previous two cesarean deliveries were identified, and individual. paper records were analyzed to extract data unavailable in electronic records.	35	377	32.4 ± 4.27	35.3 ± 3.83	3.38 ± 0.89	3.07 ± 0.41	22/35 (62.85%)	Uterine rupture, Haemorrhage, Surgical complications, Need of additional haemostatic procedures, Need of transfusion,
8	De Leo et al. 2020 [21]	Italy	Retrospective Cohort	Jan 2011–Dec 2019	San Giacomo Hospital, Castelfranco, Veneto (Italy).	Singleton pregnancies, absence of morphological abnormalities at ultrasonographic screening of the second trimester (or at any other stage of pregnancy), and two previous cesarean sections	46	68	34.6 ± 5.2	34.7 ± 4.5	NR	NR	35/46 (76.1%)	Hospital stay, Apgar scores at 5minutes <7, non-reassuring fetal heart rate, onset of spontaneous labor after premature rupture of membranes
9	Dombrowski et al. 2020 [22]	USA	Retrospective Cohort	2010–2012	comprehensive data set obtained from the California Office of Statewide Health Planning and Development, which consisted of linked information from hospital discharge records (mother and neonate) and birth certificates for births in California	Women with two prior cesarean deliveries were included in the study if they met the following criteria: they had live singleton births at 37–42 weeks of gestation, no congenital anomalies or clear contraindications to trial of labor (such as malpresentation, genital herpes, placenta previa, or vasa previa), no missing or erroneous information on parity (e.g. a parity of less than 2 that contradicts two prior cesarean deliveries), and successful linkage across maternal hospital discharge records, newborn hospital discharge records, and birth certificates.	1228	41543	31.3 ± 5.4	31.1 ± 5.3	Parity 2 = 831 Parity 3 = 230 Parity 4 = 167	Parity 2 = 3943 Parity 3 = 5046 Parity 4 = 2554	484/1228 (39.4%)	Severe maternal morbidity, Length of stay, NICU admission
10	Wagner et al. 2021 [23]	USA	Cross Sectional	2014–2018	U.S. National Vital Statistics linked birth and infant death data.	Term, cephalic, singleton pregnancies with two prior cesarean births.	17,607	17607	30.1 ± 0.5	30 ± 0.5	NR	NR	1285/17607 (7.3%)	Adverse neonatal outcomes (Apgar score <5 at 5 min, assisted ventilation >6 h, neonatal seizures, or neonatal death within 27 days). maternal composite and the cesarean birth rate.
11	Rotem et al. 2021 [24 ]	Israel	Retrospective Cohort	2005–2009	Shaare Zedek Medical Center (SZMC)	Parturients between 24 and 42 weeks of gestations who had two prior CDs and subsequently had vaginal vertex births and parturients who chose to have a repeat elective CD.	485	2234	34.4 ± 4.3	33.49 ± 5.1	5 (4–7)	3 (3–5)	417/485 (86%)	Uterine rupture, rates of hysterectomy, re-laparotomy, blood product infusion, and ICU admission
12	Horgan et al. 2022 [25]	USA	Retrospective Cohort	Jan 2008–Dec 2018	Monmouth Medical Center in New Jersey	Women with a vertex singleton gestation at term and a history of two prior cesarean sections.	82	711	33.1 ± 4.7	33 ± 4.8	4.1 (2.8)	2.1 (0.6)	57/82 (69.5%)	NICU admissions, 5-min APGAR scores <7, uterine rupture rate, maternal morbidity, maternal and neonatal mortalities
13	Roux et al. 2023 [26]	France	Retrospective Cohort	Jan 2013–Dec 2020	Rennes University Hospital	All patients who delivered at a term ≥ 37 SA of a singleton fetus in cephalic presentation and who had previously delivered twice by cesarean section	95	315	NR	NR	2.8 ± 1.3	2.8 ± 1.3	64/95 (67.3%)	Cord pH, cord lactates, Apgar scores, transfer to neonatal unit and deaths, uterine rupture, PPH, deaths.

Abbreviations: PC, Prospective Cohort; RC, Retrospective Cohort; NR, not reported; VBAC, vaginal birth after caesarean; RCS, repeat (third) caesarean section; TOLAC, trial of labor after cesarean section; NICU, Neonatal intensive care unit; PPM, post-partum hemorrhage; Apgar, Appearance, Pulse, Grimace, Activity, and Respiration; CS, cesarean section.

Table 2. Quality assessment of included studies based on Newcastle-Ottawa Scale (NOS).

	Selection					Comparability	Outcome			Result
S. No	First author, publication year	Representative-ness of the exposed cohort	Selection of the non-exposed cohort	Ascertainment of exposure	Demonstration that outcome of interest was not present at start of study	Comparability of cohorts on the basis of the design or analysis	Assessment of outcome	Was follow-up long enough for outcomes to occur	Adequacy of follow up of cohorts	Total score
1	Novas et al. 1989 [15]	1	1	1	1	0	1	0	1	6
2	Chattopadhyay et al. 1994 [14]	1	1	1	1	0	1	1	1	7
3	Spaans et al. 2003 [16]	1	1	1	1	0	1	0	1	6
4	Macones et al. 2005 [17]	1	1	1	1	1	0	1	1
5	Landon et al. 2006 [18]	1	1	1	1	0	1	1	1	7
6	Miller et al. 2015 [19]	1	1	1	1	1	1	0	1	7
7	Modzelewski et al. 2019 [20]	1	1	1	1	1	1	1	1	8
8	De Leo et al. 2020 [21]	1	1	1	1	0	1	1	1	7
9	Dombrowski et al. 2020 [22]	1	1	1	1	1	1	0	1	7
10	Wagner et al. 2021 [23]	1	1	1	1	1	1	0	1	7
11	Rotem et al. 2021 [24]	1	1	1	1	1	1	1	1	8
12	Horgan et al. 2022 [25]	1	1	1	1	1	1	0	1	7
13	Roux et al. 2023 [26]	1	1	1	1	1	1	1	1	8

Figure 2. Funnel plot for maternal outcomes in TOALC-2 versus ERCS groups (a) uterine rupture, (b) hysterectomy, (c) blood Transfusion, (d) post-partum Hemorrhage, and (e) Maternal mortality.

Figure 3. Funnel plot for neonatal outcomes in TOALC-2 versus ERCS groups (a) APGAR score < 7 after 5 min, (b) NICU admission, (c) and Neonatal mortality.

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Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.