Vaginal birth after cesarean
Keywords:Previous cesarean, Repeat cesarean, Scar tenderness, Scar rupture, TOLAC, VBAC
Background: A heightened awareness must be present among the clinicians while taking the decision to perform the first cesarean section, as it decides the future obstetric career of the women. Because of the rise in cesarean section rate in recent decades, the question of how to manage the subsequent deliveries becomes important. Vaginal birth after cesarean (VBAC) has long been proposed as an alternative measure to reduce repeat cesarean rate. Our present study aims to assess the predictive factors of successful VBAC and study the risks and benefits involved.
Methods: A prospective observational study was conducted to assess the success of VBAC and its outcome in GMERS Medical College and Hospital, Ahmedabad. A total of 100 pregnant women with history of previous one cesarean section who fulfilled the criteria for vaginal delivery were recruited for study and the outcome was analyzed.
Results: The success rate of VBAC was 58% while failed TOLAC which ended up in emergency repeat cesarean section was 42%. Vaginal delivery either before or after the history of previous cesarean section, neonatal birth weight between 2.5-3kg, and admission during active phase of labour were associated with successful VBAC. There were 2 cases of partial scar rupture diagnosed peroperatively. The commonest indication of repeat cesarean section was non progress of labour (45.2%) followed by fetal distress (16.7%). The neonatal morbidity rate was similar in both groups due to limited prolonged unsuccessful trial in our study. There was no maternal and neonatal mortality.
Conclusions: To reduce the escalating rate of total cesarean section worldwide, VBAC is an alternative option which should be encouraged in carefully selected patients. However, it should be carried out in a well equipped institute with close fetal monitoring and availability of blood and trained personnel. Thus “once a cesarean section, always a hospital delivery” and not, “once a cesarean section, always a cesarean section”.
Cragin EB. Conservatism in obstetrics. NY Med J 1916;104:1-3.
American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116:450.
Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labour among women with prior caesarean delivery. N Engl J Med. 2004;345:3-8.
World Health Organization. Caesarean sections should only be performed when medically necessary. News Release. 2015;10.
Betran AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990e2014. PLoS One. 2016;11:e0148343.
Cunningham Leveno, Bloom Hauth. Caesarean delivery and peripartum hysterectomy. In: Cunningham Leveno, Bloom Hauth, eds. Williams Obstetrics. 23rd ed. New York: McGraw-Hill Professional; 2010:544.
Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat caesarean delivery versus trial of labour: a prospective multicenter study. Obstet Gynecol. 1994;83(6):927-32.
Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes. Cesarean rates in Taiwan. 44 H.-T. Tsai, C.-H. Wu. Taiwanese J Obstet Gynecol. 2017;56:41e45. 2004e2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010;8:71.
Metz TD, Stoddard GJ, Henry E, Jackson M, Holmgren C, Esplin S. How do good candidates for trial of labor after cesarean (TOLAC) who undergo elective repeat cesarean differ from those who choose TOLAC? Am J Obstet Gynecol. 2013;208(6):458.e1e6.
Grant D. Physician financial incentives and cesarean delivery: new conclusions from the healthcare cost and utilization project. J Health Econ. 2009;28:244e50.
Bangal VB, Giri PA, Shinde KK, Gavhane SP. Vaginal birth after cesarean section. N Am J Med Sci. 2013;5(2):140.
Jani RS, Munshi DS. Management of pregnancy with previous lower segment Caesarean section in Modern obstetric practice. NHL J Med Sci. 2013;2(2):59-63.
George A, Arasi KV, Mathai M. Is vaginal birth after cesarean delivery a safe option in India? Int J Gynecol Obstet. 2004;85:42-3.
Sen S, Malik S, Salhan S. Ultrasonographic evaluation of lower uterine segment thickness in patients of previous cesarean section. Int J Gynaecol Obstet. 2004;87:215-9.
Crowther CA, Dodd JM, Hiller JE, Haslam RR, Robinson JS. Birth after caesarean study group. planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial. PLoS Med. 2012;9(3):e1001192.
Weinstein DW, Benshushan A, Tanos V, Zilberstein R, Rojansky N. Predictive score for vaginal birth after cesarean section. Am J Obstet Gynecol. 1996;174:192-8.
Bujold E, Gauthier RJ. Risk of uterine rupture associated with an interdelivery interval between 18 and 24 months. Obstet Gynecol. 2010;115:1003-6.
Birara M, Gebrehiwot Y. Factors associated with success of vaginal birth after one caesarean section (VBAC) at three teaching hospitals in Addis Ababa, Ethopia: a case control study. BMC Pregnancy Childbirth. 2013;13:31.
Doshi HU, Jain RK, Vazirani AA. Prognostic factors for successful vaginal birth after caesarean section - Analysis of 162 cases. J Obstet Gynecol India. 2010;60(6):498-502.
Raja JF, Bangash KT, Mahmud G. VBAC Scoring: Successful vaginal delivery in previous one Jain R. Int J Reprod Contracept Obstet Gynecol. 2018;7(7):2596-2602.
Merrill BS, Gibbs CE. Planned vaginal delivery following cesarean section. Obstet Gynecol. 1978;52(1):50-2.
Mishra N, Taori N, Misri A. Fetomaternal outcome of pregnancy with previous cesarean section. J Evolution Med and Dent Sci. 2014;3(47):11369-78.
Guiliano M, Closset E, Therby D, LeGoueff F, Deruelle P, Subtil D. Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur J Obstet Gynecol Reprod Biol. 2014;179:130-4.
Cunningham FG, Levono KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Caesarean delivery and peripartum hysterectomy. In: Editors, Williams Obstetrics. 23rd ed. New York: McGraw Hill Medical; 2010:544-567.
Ball E, Hinshaw K. The current management of vaginal birth after previous cesarean delivery. Obstet Gynecol. 2007;9:77-82.
Tan PC, Subramaniam RN, Omar SZ. Labor and perinatal outcome in women at term with one previous lower-segment Cesarean: A review of 1000 consecutive cases. ANZJ Obstet Gynaecol. 2007;47(1):31-6.