Trial of labor in women with two previous caesarian sections: a challenge

Introduction: A trial of labor after a cesarean (TOLAC) section is a maternal choice with previous caesarian section. However, for those with 2 previous scars, there are pros and cons to allowing the patient for vaginal birth after caesarian section (VBAC) in view of increasing complications. The incidence of SC in Indonesia has been increasing over the year. In addition, several studies have shown an increased risk of problems in subsequent pregnancies in mothers with a history of cesarean section. Thus VBAC in 2 previous scars becomes a alternative choice for a certain patient.
Case Illustration: We reported 3 cases of TOLAC; Three of the cases were planned for vaginal birth after caesarian section (VBAC) since prenatal periode Case 1: A 30-year-old woman, G3P2, 39 weeks with two times previous cesarean section. Cardiotocography was normal. The patient was closely monitoring the signs of uterine rupture during labor, and after 7 hours, she had a successful VBAC without complication. Born female baby with body weight 4000 with a good, mother and baby were in good condition. Case 2: A 38-year-old woman, G6P4A1, 41 weeks pregnant with two previous vaginal deliveries and had two previous CS before the current pregnancy. The patient was closely monitored of vital signs and signs of uterine rupture. Cardiotocography is normal. After 8 hours later, she had a successful VBAC without complication, born a male baby with a body weight of 3500gr, with good APGAR score. Case 3: A 35-year-old woman, G3P2A0, had two previous CS admitted at 39 in the latent phase of labor with a cervical dilatation of 2 cm. The labor progressed to second stage after 9 hours. After a hour attempted to conduct delivery, the fetus was still not delivered. Catheterization was performed and found haematuria and proceded with emergency CS due to suspect a uterine rupture. Intraoperatively, the uterine rupture was noted at lower anterior of uterine corpus size 2x1 cm and a repair was performed
Conclusion: VBAC can be considered in patients with two previous c-sections with after proper selection, close monitoring and adequate counseling. Prenatal care is a concern for pregnant women to prevent complications and reduce maternal and fetal morbidity and mortality. The VBAC decision returned to personalization and adequate assessment and counseling are mandatory.