VBAC After Two or More Cesareans: What the Evidence Tells Us

When vaginal birth after cesarean (VBAC) is discussed, the conversation typically centres on people with one prior cesarean. But what about those who have had two, three, or even more cesarean births? Is vaginal birth still a possibility? What does the research say about the safety and success of attempting labour after multiple cesareans?

For families who have experienced more than one cesarean and desire a vaginal birth, finding accurate, evidence-based information can be challenging. Many hospitals and providers do not offer trial of labour after cesarean (TOLAC) to people with multiple prior cesareans, and the topic is often surrounded by more uncertainty and caution than TOLAC after a single cesarean. Yet the research that does exist suggests that for carefully selected candidates, VBAC after two or more cesareans—sometimes called VBA2C, VBA3C, or more generally, VBAC after multiple cesareans (VBAmc)—can be a reasonable option.

In this article, we'll examine what the evidence tells us about success rates, uterine rupture risk, factors that influence outcomes, and how to approach decision-making when you've had more than one cesarean.

The Historical Context: How Did We Get Here?

Understanding why VBAC after multiple cesareans is treated differently than VBAC after one cesarean requires a brief look at history. For much of the 20th century, the prevailing belief in obstetrics was "once a cesarean, always a cesarean." This philosophy, articulated in 1916, held that the uterine scar from a cesarean made all future vaginal births too risky to attempt.

As cesarean techniques evolved—particularly the shift from classical (vertical) incisions to low transverse incisions—this absolute prohibition began to soften. By the 1980s and 1990s, research demonstrated that VBAC after one cesarean was safe and effective for most people, and VBAC rates rose substantially.

However, as VBAC rates increased, so did reports of uterine rupture, particularly in cases involving induction with prostaglandins or in people with multiple prior cesareans. A backlash followed, and VBAC rates plummeted in the early 2000s. Many hospitals stopped offering VBAC entirely, and those that continued often restricted it to people with only one prior cesarean.

This restrictive approach has persisted in many settings, even as research has accumulated suggesting that VBAC after multiple cesareans can be safe for appropriate candidates. The gap between the evidence and clinical practice is particularly pronounced for this population.

What Do the Guidelines Say?

Professional organisations have taken varying positions on VBAC after multiple cesareans, reflecting both the available evidence and the practical considerations of clinical care.

The American College of Obstetricians and Gynaecologists (ACOG) has stated that TOLAC after two prior cesareans may be considered in appropriate candidates, provided they meet criteria for TOLAC and are counselled about the somewhat higher risk of uterine rupture. ACOG notes that the evidence on TOLAC after two cesareans is more limited than after one cesarean but does not consider multiple cesareans an absolute contraindication.

The Royal College of Obstetricians and Gynaecologists (RCOG) in the United Kingdom similarly states that women with two prior cesareans may be offered TOLAC after appropriate counselling about the increased risk of uterine rupture and the limitations of the available evidence.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) has also indicated that TOLAC may be considered for people with two prior low transverse cesareans, with individualised counselling and informed consent.

Despite these permissive guidelines, many individual hospitals and providers choose not to offer TOLAC after multiple cesareans, often citing liability concerns, limited experience, or the more limited evidence base. This creates significant barriers for families seeking this option and contributes to the perception that VBAC after multiple cesareans is more dangerous than the evidence suggests.

Success Rates: What Does the Research Show?

One of the most important questions for anyone considering VBAC after multiple cesareans is: What are my chances of achieving a vaginal birth? The research provides some helpful answers.

VBAC Success After Two Cesareans

Multiple studies have examined success rates for TOLAC after two cesareans, and the findings are generally encouraging. Success rates typically range from 62 to 75 per cent, which is only slightly lower than the 70 to 85 per cent success rates commonly reported for TOLAC after one cesarean.

A large retrospective study published in Obstetrics and Gynaecology examined over 25,000 women attempting TOLAC, including more than 1,000 with two prior cesareans. The success rate for those with two prior cesareans was 71.1 per cent, compared to 76.5 per cent for those with one prior cesarean. This difference is statistically significant but relatively modest in absolute terms.

Another study examining over 800 women with two prior cesareans found a success rate of 74.6 per cent, remarkably similar to the success rate in women with one prior cesarean in the same institution. The authors concluded that TOLAC after two cesareans should be offered to appropriate candidates.

A systematic review and meta-analysis pooling data from multiple studies found an overall VBAC success rate of approximately 71 per cent after two cesareans. The authors noted that while this is lower than after one cesarean, the majority of attempts still result in vaginal birth.

VBAC Success After Three or More Cesareans

Research on TOLAC after three or more cesareans is more limited, reflecting the relative rarity of this situation and the even more restrictive policies that often apply. However, the available evidence suggests that vaginal birth is still achievable for a substantial proportion of those who attempt it.

Case series and retrospective studies have reported success rates ranging from approximately 60 to 80 per cent for TOLAC after three or more cesareans, though these studies typically involve smaller numbers of participants. The wide range in reported success rates likely reflects differences in patient selection, institutional practices, and the factors that led to the previous cesareans.

One study examining outcomes after three prior cesareans found a success rate of 79.3 per cent among those who attempted TOLAC, suggesting that with appropriate selection, high success rates are achievable even in this population.

Factors That Influence Success

As with TOLAC after one cesarean, several factors influence the likelihood of success after multiple cesareans. Having a prior vaginal birth is among the most powerful predictors of success. People who have previously given birth vaginally—whether before or between their cesareans—have substantially higher success rates than those who have never had a vaginal birth. Some studies report success rates of 85 to 90 per cent or higher for people with a prior vaginal birth attempting TOLAC after multiple cesareans.

Spontaneous labour onset is also associated with higher success rates compared to induced labour, as is a favourable cervical status at admission. The indication for the prior cesareans matters as well: people whose cesareans were for non-recurring indications (such as breech presentation or fetal distress) may have higher success rates than those whose cesareans were for failure to progress, which could recur.

Uterine Rupture Risk: Understanding the Numbers

The primary safety concern with TOLAC after multiple cesareans is the risk of uterine rupture. Because there are multiple scars on the uterus, there is a theoretical reason to believe that the risk might be higher than after a single cesarean. What does the research actually show?

Rupture Rates After Two Cesareans

Studies examining uterine rupture rates after two cesareans have found rates ranging from approximately 0.9 to 1.8 per cent, compared to approximately 0.5 to 0.7 per cent after one cesarean. This represents a modest absolute increase—roughly a doubling of the baseline risk—but the overall rate remains relatively low.

The large study in Obstetrics and Gynaecology mentioned earlier found a rupture rate of 0.9 per cent after two cesareans, compared to 0.7 per cent after one cesarean. Another study found a rupture rate of 1.36 per cent after two cesareans. A meta-analysis estimated the rupture rate at approximately 1.36 per cent after two cesareans.

To put these numbers in perspective: at a rupture rate of approximately 1 to 1.5 per cent, roughly 98 to 99 out of every 100 people attempting TOLAC after two cesareans will not experience uterine rupture. The risk is real and warrants discussion, but it is not dramatically higher than after one cesarean, and the absolute risk remains low.

Rupture Rates After Three or More Cesareans

Research on rupture rates after three or more cesareans is more limited, and the estimates vary more widely. Some studies have found rupture rates similar to those after two cesareans (around 1 to 2 per cent), while others have reported higher rates. The small sample sizes in these studies make precise estimates challenging.

One study examining outcomes after three cesareans found a rupture rate of 1.2 per cent, which was not significantly different from the rate after two cesareans. However, the authors cautioned that the small numbers limited the precision of this estimate.

Given the limitations of the evidence, counselling about rupture risk after three or more cesareans involves more uncertainty than after one or two cesareans. The best current estimate is that the risk is modestly elevated compared to after a single cesarean, but the absolute risk appears to remain below 2 to 3 per cent for most candidates.

Context for Rupture Risk

When considering rupture risk after multiple cesareans, it's important to keep several points in context. First, rupture risk is not the only relevant safety consideration. Repeat cesarean surgery carries its own risks, including surgical complications, longer recovery, and, importantly, increased risks in future pregnancies. With each additional cesarean, the risks of placenta accreta spectrum disorders, hysterectomy, and other serious complications increase substantially.

A study examining outcomes of repeat cesarean found that the risk of placenta accreta increased from approximately 0.2 per cent with a second cesarean to 2.1 per cent with a fourth cesarean and 6.7 per cent with a sixth or more cesarean. The risk of hysterectomy followed a similar pattern. These are serious complications with potentially life-threatening consequences.

When weighing the risks of TOLAC after multiple cesareans against the risks of repeat cesarean, both sides of the equation matter. For someone who desires future pregnancies, avoiding an additional cesarean may reduce the risk of placenta accreta and other complications in subsequent pregnancies.

Second, the factors associated with increased rupture risk are similar after multiple cesareans as after one cesarean. Induction with prostaglandins, oxytocin augmentation, and prior classical uterine incision all increase rupture risk. Spontaneous labour and prior vaginal birth are associated with a lower risk. Careful candidate selection and labour management can help optimise safety.

Maternal and Neonatal Outcomes Beyond Rupture

While uterine rupture receives the most attention in discussions of TOLAC safety, other outcomes matter as well. What does the research show about overall maternal and neonatal outcomes after TOLAC following multiple cesareans?

Maternal Outcomes

Studies comparing maternal outcomes between TOLAC and repeat cesarean after multiple cesareans generally find that successful VBAC is associated with shorter hospital stays, faster recovery, lower rates of infection, and lower rates of blood transfusion compared to repeat cesarean. These benefits are similar to those seen with VBAC after one cesarean.

When TOLAC is unsuccessful, and cesarean becomes necessary during labour, outcomes are generally similar to those with planned repeat cesarean, though some studies suggest modestly higher rates of certain complications such as transfusion or infection. This is consistent with the pattern seen after one cesarean.

Overall, the maternal outcome data support the idea that for people who are good candidates and who successfully achieve VBAC, there are meaningful benefits compared to repeat cesarean. The challenge is that success cannot be guaranteed in advance, and some who attempt TOLAC will ultimately require cesarean.

Neonatal Outcomes

Research on neonatal outcomes after TOLAC following multiple cesareans is more limited but generally reassuring. Studies have not found significantly higher rates of serious neonatal complications after TOLAC compared to planned repeat cesarean, though the power to detect small differences is limited given the relatively rare nature of serious neonatal morbidity.

As with TOLAC after one cesarean, the primary neonatal risk is related to uterine rupture. When rupture occurs, the baby may experience oxygen deprivation with potential for serious injury. The risk of serious neonatal injury or death due to uterine rupture is estimated at approximately 0.02 to 0.04 per cent of TOLAC attempts—very rare in absolute terms, but a serious consideration.

Studies specifically examining neonatal outcomes after TOLAC following two cesareans have found no significant differences in Apgar scores, neonatal intensive care unit admission rates, or perinatal mortality compared to TOLAC after one cesarean. This suggests that with appropriate monitoring and access to emergency cesarean, neonatal outcomes can be favourable.

Candidate Selection: Who Is a Good Candidate?

Not everyone with multiple prior cesareans is an equally good candidate for TOLAC. Careful assessment of individual circumstances can help identify those most likely to have a successful and safe experience.

Favourable Factors

Prior vaginal birth is the single strongest predictor of TOLAC success after multiple cesareans. Someone who has given birth vaginally—whether before their first cesarean, between cesareans, or as a VBAC—has demonstrated that their pelvis can accommodate a baby and that their uterus can tolerate labour. Success rates in this group often exceed 85 per cent.

Prior cesareans for non-recurring indications, such as breech presentation, placenta previa, or fetal distress, suggest that the circumstances leading to the previous cesareans may not be present in the current pregnancy. This is generally a favourable sign.

Spontaneous labour onset is associated with higher success rates and lower rupture risk compared to induction. If possible, awaiting spontaneous labour is generally preferable.

A prior low transverse uterine incision for each cesarean is important. If any of the prior cesareans involved a classical or T-shaped incision, TOLAC is generally contraindicated due to substantially higher rupture risk.

Adequate interpregnancy interval may be associated with lower rupture risk, though the evidence on this is not definitive. Some guidelines suggest that an interval of at least 18 to 24 months between a cesarean and subsequent conception is preferable.

A singleton pregnancy in vertex (head-down) presentation at term is generally considered a criterion for TOLAC candidacy.

Factors That Warrant Caution

Prior classical or T-shaped uterine incision is generally considered a contraindication to TOLAC due to rupture rates of 4 to 9 per cent or higher. If you are uncertain about the type of incision from a prior cesarean, obtaining the operative report is essential.

An unknown uterine scar type, particularly if records cannot be obtained, creates uncertainty that may affect the risk-benefit calculation.

Prior uterine rupture is typically considered a contraindication to subsequent TOLAC, though the evidence is limited, and individual circumstances may vary.

A short interpregnancy interval, particularly less than 12 months, may be associated with a higher rupture risk in some studies.

Need for induction, particularly with prostaglandins, increases both the likelihood of unsuccessful TOLAC and the risk of uterine rupture. If induction is necessary, mechanical methods and oxytocin are generally preferred over prostaglandins.

Medical conditions that may preclude vaginal birth for other reasons should be considered in the overall assessment.

Finding a Supportive Provider

One of the greatest challenges for people seeking VBAC after multiple cesareans is finding a care provider who is willing to support this choice. Many hospitals and providers do not offer TOLAC after more than one cesarean, and even those who do may have limited experience with this population.

When seeking care, several strategies may be helpful. Starting the search early in pregnancy allows more time to find an appropriate provider and to establish a relationship before labour. Asking directly about the provider's experience with and willingness to support TOLAC after multiple cesareans during initial consultations can save time and emotional energy.

Seeking out providers and hospitals known for supporting VBAC can increase the likelihood of finding willing support. Midwifery practices, birth centres that accept VBAC candidates, and hospitals with higher VBAC rates may be more likely to offer TOLAC after multiple cesareans. VBAC support groups and community resources may be able to provide recommendations.

If your current provider is not supportive, seeking a second opinion is always an option. Different providers may have different perspectives and comfort levels.

Being prepared to discuss the evidence can be helpful. Some providers may not be familiar with the research on TOLAC after multiple cesareans or may hold outdated views. Coming to appointments with information about the evidence, including relevant studies or guidelines, can facilitate productive conversations.

Understanding that informed consent applies here as everywhere is important. If you have been fully informed of the risks and benefits and wish to attempt TOLAC, your autonomy to make this decision should be respected. If a provider is unwilling to support your choice, they should refer you to someone who can, rather than simply refusing care.

Emotional Considerations

For many people who have experienced multiple cesareans, the desire for a vaginal birth is about more than statistics. Previous cesarean experiences may have been traumatic, disappointing, or disempowering. The desire to experience vaginal birth may be connected to healing from those experiences, to wanting a different postpartum recovery, or to simply wanting the experience of physiologic birth.

These motivations are valid and deserve respect. At the same time, pursuing VBAC after multiple cesareans can be emotionally challenging. Facing scepticism from providers, navigating the search for supportive care, and managing uncertainty about the outcome all take a toll.

If you are considering VBAC after multiple cesareans, surrounding yourself with supportive people can make a significant difference. A doula experienced with VBAC, a therapist familiar with birth-related issues, supportive family members, and connections with others who have pursued similar paths can all provide valuable support.

It is also worth reflecting on your feelings about the possible outcomes. TOLAC after multiple cesareans does not always result in vaginal birth—success rates, while encouraging, still mean that approximately 25 to 35 per cent of attempts will end in cesarean. Considering how you might feel about a cesarean after labour, and what would help you cope with that outcome if it occurs, is part of the preparation process.

Some people find that the process of attempting TOLAC is valuable regardless of the outcome—that the experience of labouring, of having their wishes respected, and of having tried is meaningful in itself. Others feel strongly that they need the vaginal birth to feel complete. Understanding your own perspective can help you make the decision that is right for you.

What About Home Birth or Birth Centre After Multiple Cesareans?

For families considering VBAC after multiple cesareans, questions sometimes arise about the birth setting. Is a home birth or birth centre birth an option with this history?

The research on out-of-hospital VBAC after multiple cesareans is extremely limited. Most birth centres and home birth midwives who accept VBAC candidates apply similar selection criteria to those used for VBAC after one cesarean, and many have policies that limit or exclude candidates with multiple prior cesareans.

The theoretical concerns about out-of-hospital birth after multiple cesareans are similar to those for any VBAC: the need for rapid access to cesarean capability in the event of uterine rupture or other complications. Given the modestly elevated rupture risk after multiple cesareans, some argue that the hospital setting is particularly important for this population.

At the same time, some midwives and families do choose out-of-hospital birth after multiple cesareans, making informed decisions based on individual risk factors, distance to emergency services, and personal values. If you are considering this path, a thorough discussion of the risks, benefits, and alternatives with a qualified midwife, as well as careful planning for emergency transfer, is essential.

Questions to Discuss with Your Care Provider

If you are considering TOLAC after multiple cesareans, here are some questions that may help facilitate informed decision-making.

What do you recommend for my situation, and why? Understanding your provider's perspective and reasoning is the starting point.

What are my individual success odds based on my history? Factors such as prior vaginal birth, indication for previous cesareans, and cervical status at term all influence success rates.

What is my individual rupture risk based on my history? The number of prior cesareans, the type of uterine incisions, and other factors affect rupture risk.

What type of uterine incision was used in each of my prior cesareans? Obtaining operative reports to confirm incision type is important if there is any uncertainty.

What are the risks of another cesarean for me, including risks in future pregnancies? Understanding both sides of the equation supports informed consent.

What monitoring will you use during labour, and what signs will you watch for? Understanding the approach to labour monitoring can help you feel prepared.

Under what circumstances would you recommend a caesarean during labour? Knowing the decision points in advance can reduce uncertainty.

What happens if I go past my due date? Discussing the approach to post-term pregnancy, including options for expectant management versus induction, is important.

The Bottom Line

VBAC after two or more cesareans is a reasonable option for carefully selected candidates, supported by a growing body of research. Success rates are encouraging—typically 60 to 75 per cent, and higher for those with prior vaginal birth. Uterine rupture risk is modestly elevated compared to after one cesarean but remains relatively low in absolute terms, typically ranging from 1 to 2 per cent.

The decision to attempt TOLAC after multiple cesareans is deeply personal and depends on individual circumstances, values, and preferences. The evidence supports offering this option to appropriate candidates, and professional guidelines from major obstetric organisations affirm that multiple cesareans are not an absolute contraindication to TOLAC.

For those considering this path, finding a supportive provider is often the greatest practical challenge. Many hospitals and practitioners do not offer TOLAC after multiple cesareans, despite the evidence suggesting it can be safe and effective. Persistence, self-advocacy, and connecting with VBAC-supportive resources may be necessary.

When weighing this decision, it's important to consider the full picture. The risks of TOLAC—including the possibility of uterine rupture and the chance of needing a cesarean after labour—must be balanced against the risks of repeat cesarean surgery. These include surgical complications, longer recovery, and importantly, escalating risks in future pregnancies such as placenta accreta spectrum disorders and hysterectomy. For someone planning additional pregnancies, avoiding another cesarean may carry significant long-term benefits.

Ultimately, the right choice is the one that aligns with your individual circumstances, values, and informed understanding of the evidence. Whether you choose to attempt TOLAC or to proceed with a planned cesarean, that decision deserves to be supported with accurate information, respectful care, and recognition of your autonomy.

References and Further Reading

For those who wish to explore the evidence further, several key resources may be helpful. The American College of Obstetricians and Gynaecologists publishes practice bulletins on vaginal birth after cesarean that include discussion of TOLAC after multiple cesareans. The Royal College of Obstetricians and Gynaecologists offers similar guidance documents. Published studies in journals such as Obstetrics and Gynaecology, the American Journal of Obstetrics and Gynaecology, and BJOG provide the primary research on outcomes after TOLAC following multiple cesareans.

Organisations such as the International Cesarean Awareness Network (ICAN) provide support and resources for families navigating cesarean recovery and VBAC decisions. Evidence-based resources such as Evidence Based Birth offer accessible summaries of the research on VBAC and related topics.

Whatever path you choose, you deserve care that respects your autonomy, provides accurate information, and supports you through one of life's most transformative experiences. The evidence on VBAC after multiple cesareans, while not as extensive as after one cesarean, offers hope and options for those who desire a vaginal birth after more than one surgical delivery.

This article is intended for informational purposes only and does not constitute medical advice. Individual circumstances vary, and decisions about mode of delivery should be made in consultation with a qualified healthcare provider who can assess your specific situation.