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

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.Keywords Complications, uterine rupture, vaginal birth after two caesarean sections.Please cite this paper as: Tahseen 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.

A survey on causes of cesarean sections performed at the university hospitals of Niknafs and Ali-Ibn Abi Talib of Rafsanjan, Iran, in the second trimester of 2014

“…Most women with a history of C-section are able to have a vaginal delivery; therefore, 75 out of 100 women will have successful vaginal deliveries and 25 out of 100 will require repetitive C-sections (31). A meta-analysis reported the success rate of vaginal birth after one C-section as 76.5% and after two Csections as 71.1% (28). Based on available evidence, vaginal birth is a suitable option for many women with a history of C-section with low transverse incision which also has different benefits and risks for the mother and the fetus (32).…”

“…Repetitive elective C-section is one of the main causes of increase in C-sections associated with fetal distress, dystocia (difficult birth), and breech presentation (28). Vaginal birth after C-section was one of the practical solutions introduced in the 1990s by the American College of Obstetricians and Gynecologists (ACOG) in order to reduce maternal and fetal complications of repeated C-section (29).…”

Vaginal birth after caesarean section: why and how?

“…8 A trial of labor is generally not offered after two caesarean section as multiple caesarean sections are associated with many complications like scar integrity and placental complication. 9 Vaginal birth after cesarean section (VBAC) is associated with short period of hospitalization, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery. 7 Several reports have indicated that the absolute risk of uterine rupture, attributable to a trial of labor is about 1 per 1000.…”

An Apparent Lack in Level of Basic Knowledge of Caesarean Section Delivery among Egyptian Females: A Population-Based Cross-Sectional Survey

“…Trial of labor after caesarean (TOLAC) is a reported method to avoid repeated elective CS delivery [25,26]. A systematic review showed that the success rate of TOLAC after one CS was 76.5% and after two CS deliveries was 71.7% [27]. Robust programs to promote TOLAC among medical practitioners and among Egyptian females are necessary to reduce number of unnecessary caesareans.…”