Successful vaginal birth after two or more cesareans versus failed trial of labor: A systematic review and meta-analysis of maternal and fetal outcomes

OBJECTIVE: To assess maternal and neonatal outcomes associated with a failed versus successful (VBAC-2). DATA SOURCES: A systematic search across Pubmed, Embase and Cochrane was conducted up to October 2025, supplemented by backward snowballing. STUDY SELECTION: Studies with pregnant women with a two or more previous cesarean deliveries undergoing a trial of labor were included. No restrictions were applied. DATA COLLECTION: Data on maternal and neonatal outcomes and risk and protective factors were extracted. The DerSimonian and Laird random effects model was applied, reporting Odds Ratios (OR) with 95% confidence intervals. Heterogeneity was evaluated using I2 statistics and the Cochran Q test. Methodological quality was appraised using the Cochrane Risk-of-bias tool for non-randomized trials (ROBINS-I). DATA SYNTHESIS: Out of 4065 studies screened, 12 studies (n= 3429) were included. We observed higher odds of postpartum hemorrhage (OR 1.98), maternal transfusion (OR 3.29), uterine rupture (OR 6.47), and neonatal intensive care unit admission (OR 6.44) in the VBAC-2 failure group. Epidural anesthesia (OR 0.56) and a history of previous vaginal birth (OR 0.27) were identified as protective factors, while a higher Body Mass Index was a risk factor for VBAC- 2 failure. CONCLUSIONS: These findings highlight the critical need for comprehensive patient counseling, risk assessment, and heightened clinical vigilance to optimize care strategies in this high-risk population.