Experience on Trial of Labor and Vaginal Delivery After Two Previous Cesarean Sections: A Cohort Study from a Limited-resource Setting

Objective: To determine the success rate of trial of labor after two cesarean sections (TOLA2C) in the low-resource setting of the Democratic Republic of Congo (DRC) and to describe factors associated with success and related complications.

Methods: A prospective cohort study was conducted from 2015 to 2020 in a teaching hospital. Patients who underwent TOLA2C were followed across prenatal visits, onset of spontaneous labor, and delivery. Demographics and clinical characteristics were documented. Pearson and Fisher χ tests were used. Predictors of successful vaginal delivery were determined by logistic regression (P ˂ 0.05).

Results: Among 532 patients, the success rate of TOLA2C was 405 (76.1%). Factors associated with success included birth spacing ≥24 months (adjOR: 2.02 ; 95% CI 1.14-3.56; P = 0.015), previous vaginal delivery (adjOR: 5.02; 95% CI 2.71-9.31; P ˂ 0.001), intercalated vaginal delivery (adjOR: 5.15; 95% CI 2.28-11.65; P ˂ 0.001), cervical dilation >6 cm (adjOR: 2.37; 95% CI 1.92-6.05; P = 0.031) and/or complete dilation on arrival in the delivery room (adjOR: 1.96; 95% CI 1.33-11.45; P = 0.047) and oxytocin stimulation (adjOR: 4.24; 95% CI 1.82-9.91; P ˂ 0.001). No association with hemorrhage, uterine rupture, transfer to neonatology, or maternal-neonatal deaths was observed.

Conclusions: TOLA2C is possible in a low-resource setting with a high success rate and low rates of complications. Patient selection and obstetrical team competency are required.