Factors Associated with Failed Trial of Labor after Cesarean, among Women with Twin Gestation—A Multicenter Retrospective Cohort Study

Abstract

Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40–0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36–19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65–1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01–20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries

“…The authors concluded that compared to the remifentanil-PCA control, the use of EA decreases the incidence of CS for the delivery of both fetuses in twin gestation, as well as the frequency of combined CS and vaginal delivery for the birth of the second twin. Similarly, it was recently shown that in parturients with twin gestation attempting a trial of labor after a previous CS, using EA may decrease the risk of a repeat CS [ 46 , 47 ].…”

Vaginal Birth after Caesarean (VBAC)

“…Ford et al showed an increase (0.9%) scar rupture compared with the lower value in singleton with one previous lower segment scar [51,55]. In a recent multicenter retrospective cohort study with a sample size of 160 women with twin A in vertex position with a single previous lower segment caesarean section, Peled et al [56] stated that successful VBAC in selected twin was achieved in 86.3% while Levin et al [41] reported a success VBAC rate of 31.3% in women with twins who attempted VBAC with no prior vaginal delivery.…”

Predictors and Risks of Vaginal Birth after Cesarean Section: Insights from a Regional Referral Hospital in Uganda

“…TOLAC, on the other hand, is known to raise the chance of uterine rupture. According to expert opinion, TOLAC is the best treatment for women who do not have multiple risk factors [22]. However, the patient should be informed about the availability of an obstetrician and anesthetist on-site.…”