Trial of labour versus repeat caesarean in women with one uterine scar: a systematic review and meta-analysis

Abstract Caesarean delivery rates now exceed 30% in most high-income countries, producing a large cohort of women who face a choice between trial of labour after caesarean (TOLAC) and elective repeat caesarean delivery (ERCD) in a subsequent pregnancy. We performed a meta-analysis of studies published January 2021 – March 2026 to estimate the pooled vaginal birth after caesarean (VBAC) success rate and compare maternal and neonatal outcomes between strategies. Thirty-two studies ( N = 1,287,757 women) met pre-specified inclusion criteria. Risk of bias was assessed with the Newcastle–Ottawa Scale (NOS); pooled odds ratios (OR) with 95% confidence intervals (CI) used the DerSimonian–Laird random-effects model. The pooled VBAC success rate was 72.4% (95% CI 69.8–74.9%; I² = 63%). Uterine rupture was more frequent with TOLAC than ERCD (0.47% vs. 0.026%; OR 7.21, 95% CI 4.89–10.62; I² = 41%). TOLAC was associated with lower odds of postpartum haemorrhage requiring transfusion (OR 0.68, 95% CI 0.54–0.86) and wound infection (OR 0.52, 95% CI 0.39–0.70). NICU admission rates were not significantly different when both groups delivered at ≥ 39 weeks (OR 0.89, 95% CI 0.71–1.11). A lower uterine segment (LUS) thickness ≥ 3.0 mm was associated with a VBAC success rate of 76.8% and a rupture rate of 0.31%. Individualised, LUS-informed risk stratification is more consistent with this evidence than blanket institutional restriction of TOLAC.