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 χ2 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.