By Ahizechukwu C. Eke, MD, PhD, MPH
Synopsis: In twin pregnancies among women with two prior cesarean deliveries, there were no significant differences observed in adverse maternal or neonatal outcomes, yet the probability of a successful vaginal birth stood at 37.8%.
Source: Mustafa HJ, Abiad M, Grobman WA, et al. Trial of labor after cesarean delivery in individuals with twin pregnancies and two prior cesarean deliveries. Obstet Gynecol. 2025;145(3):325-334.
The practice of a trial of labor after cesarean (TOLAC), the process in which a woman attempts a vaginal birth after previously having undergone a cesarean delivery, varies across the United States.1,2 The epidemiology of TOLACs in the United States presents a complex picture shaped by clinical guidelines, patient preferences, and evolving obstetric practices.
Although the American College of Obstetricians and Gynecologists (ACOG) offers cautiously supportive guidelines for TOLAC after two cesarean deliveries under specific conditions, the actual uptake varies significantly across different regions and healthcare settings.3 Nationally, the success rate of vaginal birth after cesarean (VBAC) is approximately 73.4%, and has been influenced by factors such as the perceived risk of uterine rupture, which, although low, is a serious concern and occurs in approximately 0.88% to 1.10% of such cases.2,4,5
The overall declining VBAC rates in the United States reflect a broader hesitancy, dropping from a high in the late 1990s as the result of litigation concerns and increasing emphasis on patient safety.3 Data indicate a significant variation in TOLAC rates among different ethnicities, socio-economic groups, and hospital settings, suggesting disparities in the access to and the provision of this option to women who might be suitable candidates for attempting a VBAC.6,7
From a medical and procedural standpoint, the consideration for TOLAC after two cesarean deliveries hinges on numerous factors, including the types of previous uterine incisions, inter-delivery interval, maternal age, and any coexisting medical conditions, which could influence the outcomes of a vaginal birth attempt.3 Optimal candidates typically are those with a prior vaginal delivery and a previous cesarean involving a low transverse incision.3 The decision to proceed with TOLAC also must consider potential risks, such as uterine rupture, which, although rare, carries significant morbidity for both mother and child.
Counseling about TOLAC should include a balanced discussion of these risks and benefits, tailored to the woman’s health status and personal birth preferences. Hospitals and practitioners must have the capability to provide immediate surgical intervention should complications arise during a trial of labor, a requirement that can limit the availability of TOLAC in smaller or less-equipped facilities. Because of the scarcity of data on the outcomes of TOLAC in women with twin gestation and two prior cesarean deliveries, Mustafa and colleagues undertook this research.8
This was a cross-sectional study that analyzed data from the National Center for Health Statistics and the Centers for Disease Control and Prevention (CDC), spanning January 2014 to December 2021.8 This comprehensive dataset, derived from the U.S. Standard Certificate of Live Birth, encompasses a wide range of characteristics, including paternal, maternal, prenatal, labor, and obstetric details, sourced from the national birth registry. Women with up to two prior cesarean deliveries met inclusion criteria, while women with higher-order multiple gestations (more than two fetuses), women with more than two prior low transverse cesarean deliveries, those with a history of one or more classical cesarean deliveries, and neonates with major structural anomalies or chromosomal abnormalities, were excluded.
The study established four comparative groups based on the number of prior cesarean deliveries and the type of delivery (either elective or attempted TOLAC). The groups included twin gestations with two prior cesarean deliveries attempting TOLAC; twin gestations with one prior cesarean delivery attempting TOLAC; twin gestations with two prior cesarean deliveries undergoing elective cesarean; and singleton gestations with two prior cesarean deliveries attempting TOLAC. Statistical methods, such as variance analysis and logistic regression, were used to examine outcome differences between these groups and to adjust for potential confounders, such as maternal age, body mass index (BMI), and medical history. The Bonferroni method was applied to control for multiple comparisons in determining the significance of the results.
Between 2014 and 2021, out of 92,665 pregnant women in the database, 632 women with twin gestations and two prior cesarean deliveries attempted TOLAC. These women had a higher average parity (mean 3.7, P < 0.001) compared to other groups. The success rate of VBAC in this group was 37.8% (239/632), which was significantly lower than the 61.5% (2,271/3,693) success rate in women with twin pregnancies and one prior cesarean delivery, and 58.0% (45,834/78,969) in those with singleton pregnancies and two prior cesarean deliveries (P < 0.001).
The rates of labor induction and augmentation were lower in women with twin pregnancies and two prior cesarean deliveries (13.1% and 10.8%, respectively) compared to those with one prior cesarean delivery (25.6% and 19.7%, respectively) and those with singleton pregnancies (14.7% and 15.1%, respectively; P < 0.001). Moreover, the likelihood of delivery at gestational ages of less than 28 weeks, 28-31 weeks, and 32-36 weeks was higher in the twin TOLAC group compared to those opting for an elective cesarean delivery (5.5% vs. 3.2%, 9.2% vs. 6.7%, and 35% vs. 32.8%, respectively).
There were no cases of uterine rupture among the 632 TOLAC attempts, a rate consistent with other groups (P > 0.999). After adjusting for covariates, the odds of achieving a VBAC were more than twice as high in women with twin pregnancies and one prior cesarean delivery (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 2.01-2.90) and those with singleton pregnancies and two prior cesarean deliveries (aOR, 2.23; 95% CI, 1.88-2.65) compared to those with twin pregnancies and two prior cesarean deliveries. There were no significant differences in composite maternal morbidity (consisting of blood transfusion, uterine rupture, unplanned hysterectomy, and admission to the intensive care unit) between the groups.
Commentary
This study explored the outcomes of TOLAC among women with twin gestations and two prior cesarean deliveries. These women, who had a higher average parity than others, showed a relatively lower success rate for VBAC compared to women with either twin pregnancies and one prior cesarean or singleton pregnancies and two prior cesarean deliveries. The induction and augmentation rates for labor were notably lower in this group, and they also showed a higher probability of delivering at earlier gestational ages than those opting for an elective cesarean delivery.
Despite the complexities, no uterine ruptures occurred, aligning with the rates in other studied groups. The analysis highlighted that while the chances of achieving a VBAC were substantially higher in other groups, the overall maternal morbidity did not differ significantly across the groups, indicating a nuanced balance of risks and outcomes in managing twin pregnancies with prior cesarean deliveries through TOLAC.
The analysis of TOLAC among women with twin gestations and two prior cesarean deliveries in this cohort revealed a VBAC success rate of 37.8%, considerably lower than the 61.5% observed in twin pregnancies with one prior cesarean delivery and 58.0% in singleton pregnancies with two prior cesarean deliveries. This disparity in success rates underscores the increased complexity and challenges associated with managing TOLAC in women with a history of multiple cesarean deliveries and twin pregnancies.9,10
The notably lower induction and augmentation rates in this specific cohort (13.1% and 10.8%, respectively) compared to those with one prior cesarean delivery (25.6% and 19.7%, respectively) and singleton pregnancies (14.7% and 15.1%, respectively) suggest a more cautious approach taken by healthcare providers, likely because of concerns over potential complications such as uterine rupture, which, although not observed in this study, remains a significant risk factor for patients undergoing TOLAC. These findings highlight the critical need for a tailored, cautious approach when managing labor in this high-risk group, prioritizing safety while considering the potential benefits of a successful VBAC.
From a clinical perspective, these results have significant implications for patient counseling and decision-making in labor management. The absence of uterine rupture in the studied group, consistent across all categories, provides a reassuring safety profile for TOLAC under well-monitored conditions. However, the variable success rates and lower likelihood of labor induction and augmentation in women with twin gestations and two prior cesarean deliveries necessitate clear communication regarding the realistic expectations and potential risks associated with attempting a VBAC in such circumstances. These data empower healthcare providers to offer evidence-based guidance, helping patients make informed decisions aligned with their personal health scenarios and preferences.
Additionally, the increased likelihood of preterm delivery in the study group suggests a need for proactive perinatal care and preparation, emphasizing the importance of monitoring and intervention strategies to optimize maternal and neonatal outcomes.
The adoption of TOLAC in women with twin gestations and two prior cesarean deliveries remains a complex decision, heavily influenced by individual risk assessments and available clinical guidelines. ACOG provides guidance for TOLAC, generally encouraging it as an option for eligible women, including those with two previous low transverse cesarean deliveries.3 However, specific recommendations for women with twin gestations under these circumstances are less clear and often require careful consideration of the maternal and fetal risks vs. benefits.
Given the lower success rates of VBAC in this particular group — as observed in recent studies — and the associated risks, including the potential for preterm labor, the decision to proceed with TOLAC should be highly individualized.9,11 It involves thorough counseling about the possible outcomes and close monitoring during labor.
In settings where multidisciplinary support and immediate surgical intervention are available, TOLAC might be considered, but it generally requires a cautious approach to balance the desire for a vaginal birth against maternal and fetal safety. This strategy aligns with the principle of shared decision-making endorsed by ACOG, highlighting the importance of patient-centered care in complex obstetric scenarios.
Ahizechukwu C. Eke, MD, PhD, MPH, is Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore.
References
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2. Deshmukh U, Denoble AE, Son M. Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: An expert review. Am J Obestet Gynecol. 2024;230(3S):S783-s803.
3. [No authors listed]. ACOG Practice Bulletin No. 205: Vaginal birth after cesarean delivery. Obstet Gynecol. 2019;133(2):e110-e127.
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5. Sugai S, Yamawaki K, Haino K, et al. Incidence of recurrent uterine rupture: A systematic review and meta-analysis. Obstet Gynecol. 2023;142(6):1365-1372.
6. Attanasio LB, Paterno MT. Racial/ethnic differences in socioeconomic status and medical correlates of trial of labor after cesarean and vaginal birth after cesarean. J Womens Health (Larchmt). 2021;30(12):1788-1794.
7. Wetzler SR, Tavella NF, McCarthy L, et al. Social disparities in delivery choice among patients with history of cesarean. Sex Reprod Healthc. 2024;41:101011.
8. Mustafa HJ, Abiad M, Grobman WA, et al. Trial of labor after cesarean delivery in individuals with twin pregnancies and two prior cesarean deliveries. Obstet Gynecol. 2025;145(3):325-334.
9. Lopian M, Kashani-Ligumski L, Cohen R, et al. Twin TOLAC is an independent risk factor for adverse maternal and neonatal outcome. Arch Gynecol Obstet. 2021;304(6):1433-1441.
10. Kabiri D, Masarwy R, Schachter-Safrai N, et al. Trial of labor after cesarean delivery in twin gestations: Systematic review and meta-analysis. Am J Obstet Gynecol. 2019;220(4):336-347.
11. Dick A, Lessans N, Ginzburg G, et al. Induction of labor in twin pregnancy in patients with a previous cesarean delivery. BMC Pregnancy Childbirth. 2023;23(1):538.