Abstract overview:
The rate of cesarean sections (CS) is increasing worldwide, including operative deliveries after a previous CS. Each subsequent operative delivery increases the risk of maternal complications, such as rupture of the uterine scar, abnormal placentation in subsequent pregnancies and adhesions.

Aims and objectives:
The aim of the study was to describe the population of women who decide to attempt labor after at least three cesarean deliveries and to identify factors that promote the success of this type of labour.

Method:
This retrospective study involved the analysis of medical records of women admitted to a tertiary-level maternity hospital between 2017 and 2024. The inclusion criterion was a history of three or more previous cesarean deliveries. Women with a diagnosis of intrauterine fetal demise at the time of admission were excluded. Multivariate logistic regression was used to identify factors associated with successful VBA3C. The outcome variable was the mode of birth. Based on literature review, three predictors were included: epidural anesthesia, history of prior vaginal birth, and spontaneous labor onset. Due to the limited sample size (n = 62), the number of predictors was restricted to ensure model stability.

Results:
Of the 62 women who attempted VBA3C, 32 (51.6%) achieved vaginal labor. In the logistic regression analysis, it was found that the use of epidural anesthesia (OR = 22.88; p = 0.006) and a history of previous vaginal birth (OR = 20.34; p = 0.008) significantly increased the chances of a successful VBAC. Spontaneous onset of labor did not reach statistical significance.

Conclusion:
VBAC after three or four CS is possible, especially if the woman has a history of successful vaginal birth. Each birth requires individual maternal risk management considering potential complications resulting from multiple cesarean sections. Epidural can contribute significantly to the success of vaginal birth.