Trial of Labor After Cesarean Delivery in Individuals With Twin Pregnancies and Two Prior Cesarean Deliveries
Authors: Mustafa Hiba J. , Abiad May , Grobman William A. , Mosesso Kelly M. , Daggy Joanne K. , Javinani Ali , Khalil Asma , Berghella Vincenzo , Landon Mark B. , Shamshirsaz Alireza A. 
Published: January 2025

OBJECTIVE:
To investigate short-term maternal and neonatal outcomes in individuals with twin pregnancies and two prior cesarean deliveries who underwent trial of labor after cesarean (TOLAC).

METHODS:
A cross-sectional study of live-birth data was conducted between 2014 and 2021 in the United States. Individuals with more than two prior cesarean deliveries and multiple gestations higher than twins were excluded. The inclusion criteria were individuals with twin pregnancies who had two prior cesarean deliveries and underwent TOLAC. Comparison groups included 1) individuals with twin pregnancies and two prior cesarean deliveries who underwent elective cesarean delivery, 2) those with twin pregnancies and one prior cesarean delivery who underwent TOLAC, and 3) those with singleton pregnancies and two prior cesarean deliveries who underwent TOLAC. The primary outcomes were composite measures of maternal and neonatal morbidity. Investigated maternal outcomes included chorioamnionitis, transfusion, hysterectomy, uterine rupture, and admission to the intensive care unit. Vaginal birth after cesarean (VBAC) was also evaluated. Neonatal outcomes included a 5-minute Apgar score 3 or higher, assisted ventilation, admission to the neonatal intensive care unit, use of surfactant or antibiotics, and seizures. Univariable and multivariable analyses were conducted. Bonferroni adjustment was applied, and adjusted P<0.05 was considered significant.

RESULTS:
A total of 92,665 pregnant individuals and 106,361 neonates were included in the analysis. Vaginal birth after cesarean was achieved in 37.8% (239/632) of individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC, compared with 61.5% (2,271/3,693) of individuals with twin pregnancies and one prior cesarean delivery who underwent TOLAC and 58.0% (45,834/78,969) of individuals with singleton pregnancies and two prior cesarean deliveries who underwent TOLAC (P<.001). Both composite maternal and neonatal morbidity were not significantly different between other twin groups and individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC. None of the 632 individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC had uterine rupture. After adjustments with covariates, the odds of VBAC were more than twice as great in individuals with twin pregnancies and one prior cesarean delivery (adjusted odds ratio [aOR] 2.41; 95% CI, 2.01–2.90) and in those with singleton pregnancies and two prior cesarean deliveries (aOR 2.23; 95% CI, 1.88–2.65) compared with individuals with twin pregnancies and two prior cesarean deliveries.

CONCLUSION:
No significant difference in adverse maternal or neonatal outcomes were detected in twin pregnancies among individuals with two prior cesarean deliveries, although the chance of VBAC was 37.8%.