Trial of labor after three previous cesarean sections: Is it really something crazy? Result of a systematic review and meta-analysis

Background:

Performing a trial of labor (TOL) after one or even, in selected cases, two cesarean sections is considered a feasible way of delivery. Nonetheless, an accurate counselling about potential maternal and fetal risks should be ensured. We recently performed an uncomplicated spontaneous vaginal birth in two women undergoing a TOL after three cesarean sections (CS). The counselling and management of women seeking for a natural birth in such an exceptional condition could be very challenging, as this instance is becoming nowadays a very rare event.

Objective:

To perform a systematic literature review and meta-analysis on success rate and associated adverse maternal and fetal outcomes during a TOL after 3 or more CS.

Search strategy:

We searched MEDLINE and Scopus using search terms “Caesarean section”, “caesarian”, “C*rean”, “C*rian”, and “Vaginal birth after caesarean section”, combined with second search string “three”, “thrice”, “third” and “multiple”.

Results:

Among 706 items identified in the preliminary research, we found 6 articles that met the inclusion criteria and presented information about success rate of TOLAC after 3 or more CS and associated adverse outcomes. The analysis included 368 cases. The overall success rate among the included studies was 73,9% (95% CI 58 – 83%). Limited data about adverse outcomes were reported. One large study considering 241 TOLAC reported a prevalence of uterine ruptures of 1.2% (95% CI 0 – 4%).

Conclusions:

Even if the evidence in the literature is quite limited, a TOLAC after three cesarean sections could be considered an acceptable choice in selected cases.