Vaginal birth after two cesarean sections (VBAC-2) under a standardized protocol: success rates, safety, and cesarean after spontaneous labor as an alternative

BACKGROUND: An increasing number of women with two previous cesarean sections are seeking personalized delivery options. However, evidence on the safety of a vaginal birth after two cesarean sections (VBAC-2) under standardized, non-induction protocols remains limited. This study aimed (1) to assess success rates and safety of vaginal birth after two cesarean sections (VBAC-2) under a standardized non-induction protocol and (2) to compare maternal and neonatal outcomes between elective repeat cesarean (ERCS-2) and cesarean after spontaneous labor onset (CSAOL-2). METHODS: We conducted a retrospective single-center cohort study including women with singleton pregnancies between 36 + 0 and 41 + 6 weeks and two prior low-transverse cesareans (2014–2025). Counseling followed a predefined protocol. VBAC-2 was only offered with spontaneous labor onset. Primary outcomes were VBAC-2 success (intent-to-treat) and intraoperative uterine rupture or dehiscence. Secondary outcomes were maternal morbidity, blood loss, and neonatal outcomes. RESULTS: Of 390 women, 107 intended VBAC-2. 33 achieved vaginal birth (16 spontaneous, 17 forceps), corresponding to a success rate of 30.8% (intent-to-treat). No complete rupture occurred among VBAC-2 attempts. Across the cohort, the overall complete rupture rate was 1.0%, and dehiscence occurred in about 8.2%. Mean blood loss was significantly lower after successful VBAC-2 compared with repeat cesarean (371 ml vs. 473 ml; p < 0.001). CSAOL-2 showed no excess maternal or neonatal morbidity compared with ERCS-2 although a non-significant numerical increase in complete uterine rupture was observed. CONCLUSION: VBAC‑2 is feasible under strict selection and standardized non‑induction conditions, but success rates are modest and instrumental delivery is frequent. In this underpowered cohort, no complete uterine ruptures occurred among VBAC‑2 attempts. CSAOL-2 did not show statistically significant differences in maternal or neonatal morbidity compared with ERCS-2; however, these findings do not provide a sufficient medical rationale to routinely wait for the onset of labor solely in order to perform a cesarean delivery. This approach may be reserved for women who remain undecided about mode of delivery despite comprehensive counseling.