OBJECTIVE: To evaluate the trends, safety, and feasibility of a trial of labor after cesarean (TOLAC) among kidney and liver transplant recipients. METHODS: This was a retrospective cohort study using the Transplant Pregnancy Registry International. It included recipients of a kidney or liver transplant with a live-birth pregnancy ≥20 weeks following a prior cesarean, with births between 1967 and 2019 from 289 hospitals, primarily in North America. The primary outcomes of severe maternal morbidity (SMM) and neonatal composite morbidity were compared between those with repeat cesarean deliveries (RCDs), vaginal births after cesarean (VBACs), and failed TOLAC. Multivariable regression was conducted to calculate odds ratios and 95% confidence intervals. RESULTS: The 243 deliveries included in this study were composed of 80.7% RCDs, 10.3% VBACs, and 9.1% with failed TOLAC, with similar demographics between groups. There was no significant difference in incidence of SMM (RCD, 1.0%
VBAC, 4.0%
failed TOLAC, 0%
P = 0.48) or neonatal composite morbidity (RCD, 15.2%
VBAC, 11.5%
failed TOLAC, 4.5%
P = 0.45) between groups. No cases of uterine rupture or neonatal death occurred. Trends in TOLAC demonstrate that the TOLAC rate has declined from 35% in 1989-1994 to 13% in 2014-2019. CONCLUSIONS: In this cohort of transplant recipients, TOLAC resulted in successful vaginal delivery over half the time, and did not increase the risk of maternal or neonatal morbidity compared with RCD. We encourage offering transplant recipients a trial of labor after appropriate counseling to decrease the overall rate of cesarean delivery and morbidity in this high-risk population.