Success rate and obstetric outcomes of trial of labor after cesarean delivery—Decision-tree analysis

Background: Pregnant women with a previous cesarean delivery (CD) may opt for a trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery (ERCD). This study aimed to evaluate the success rate, and maternal, and perinatal outcomes of TOLAC and to develop a predictive decision-tree algorithm for successful TOLAC. Methods: A retrospective study was conducted in a tertiary medical center and included all women with one prior CD who delivered between 2008 and 2019. Maternal and perinatal outcomes were compared between successful and failed TOLAC and ERCD groups. A decision-tree algorithm was constructed using the χ² automatic interaction detection method. Results: Of 10 325 women with one prior CD (out of 103 542 deliveries), the rate of successful TOLAC, defined as vaginal birth after cesarean (VBAC), was 81.92%. Symptomatic uterine rupture occurred in 55 women (0.98%), with no cases of hysterectomy, or maternal or neonatal death. The decision tree identified key predictors of VBAC success, including maternal age, gestational age at delivery, and history of vaginal delivery. Women with a prior vaginal delivery had the highest likelihood of VBAC (90.3%). The overall accuracy of the model was 82.7%. Conclusions: This study demonstrated a high rate of TOLAC attempts and VBAC success in a tertiary medical center with experienced staff and close monitoring. Uterine rupture was rare and not associated with severe maternal or neonatal morbidity or mortality. The decision-tree algorithm provides a practical tool to predict successful TOLAC, supporting individualized care and informed decision making.