Original Article

Vaginal Birth After Caesarean Section

(VBAC): A Descriptive Study From Middle
East
G Puliyath
Keywords

caesarean section, trial of labour., vbac

Citation

G Puliyath. Vaginal Birth After Caesarean Section (VBAC): A Descriptive Study From
Middle East. The Internet Journal of Gynecology and Obstetrics. 2009 Volume 12 Number 2.
Abstract

The study, conducted in the tertiary care military hospital of Muscat, Sultanate of Oman,
describes the outcome of vaginal birth after caesarian section (VBAC) in women with a
previous caesarean. The women opted for trial of labor was subjected to obstetric protocol of
the hospital. Of the 370 women on trial of scar, 74.86% had successful vaginal delivery and
25.14% had emergency caesarean section. Majority (93%) had spontaneous onset of labor
and it was induced in the rest with prostaglandin E2 vaginal gel. VBAC was higher in those
with a prior vaginal birth and was poor among women operated upon earlier for failed
progress of labour or cephalopelvic disproportion. But for one maternal death due to sickle
cell crisis, no serious complications occurred for mother or the baby. To conclude, if women
with previous single caesarean section for nonrecurring indication are subjected to trial of
labor, around 75% could have successful vaginal delivery.

Introduction

Vaginal birth after a previous caesarean section is a safe option for many women (1). This is
true in several countries, especially in the Middle East where the reproductive pattern is
characterized by a pregnancy starting at an early age and high fertility throughout the
reproductive years. Therefore after a caesarean section, many women prefer a vaginal birth in
order to reduce the consequences and complications of multiple caesarean sections especially
for continuing fertility. However, the proportion of women who opt vaginal delivery globally
after a prior caesarean delivery has decreased rapidly because of concern about safety (2).
The decline in VBAC is not without clinical implications. Multiple caesarean sections are
associated with complications such as placenta previa and placenta accreta which increases
morbidity and mortality.

Methods
The study to analyze the outcome of trial of labour after a previous caesarean section was
conducted from September 2005 to December 2007 in a tertiary care military hospital in
Muscat, Sultanate of Oman. Majority of women with previous one caesarean section,
attending the antenatal clinic preferred to deliver vaginally. They presented at the antenatal
clinic regularly and most of them had records of previous delivery. Counseling was given for
all women regarding the advantages and disadvantages of vaginal birth after caesarean
section (VBAC). The hospital policy is to give trial of labour for all women with previous
single caesarean section, unless there is an indication for repeat caesarean section. Therefore
all women who had a successful VBAC would attempt a second VBAC, unless they had a
previous scar dehiscence or adherent placenta . Individuals with a previous caesarean section
who were given a trial of labour were identified from delivery suite records and information
collected from computerized data sheet which was then statistically analyzed. Those women
who delivered in the hospital were monitored in the delivery suite with 1:1 mid wifery staff
and continuous cardiotocography. All round services of anaesthesia, operation theatre and
neonatology care were available. The hospital protocol is to wait till 41 completed weeks for
starting induction of labor in an otherwise uncomplicated pregnancy. The expected date of
delivery was confirmed by early ultrasound scan. Those women selected for induction of
labour were given prostaglandin E 2 vaginal gel 1 gm and the same dose repeated at six
hourly intervals for maximum three doses. Oxytocin acceleration was administered according
to the uterine contractions.

Statistical Analysis

The association of various maternal characteristics with VBAC was assessed by using chi-
square test. Yates correction for continuity was carried out in 2 by 2 tables.

Results

The number of women with a previous single caesarean section delivered during the study
period was 399 among a total delivery of 2412, which constituted 16.54% of the total
deliveries. Among them, trial of labor was attempted in 370 women (92.73%) and the others
were elective caesarean section mainly done for abnormal presentations, placenta praevia,
and severe intrauterine growth retardation or on request. Trial of labour included two cases of
intrauterine fetal death and nine breech presentations. VBAC success rate was 74.86%. This
is consistent with published reports (3, 4, and 6). Emergency caesarean section was done in
25.14%. Fetal distress was the main indication for emergency caesarean section (39.7%)
followed by failed progress of labor (33.3%). Only three women were willing for sterilization
operation at the time of caesarean section and they had more than five children. Among
vaginal deliveries, three were assisted breech deliveries (0.8%), 18 vacuum deliveries (4.8%)
and four women who were selected for vaginal birth delivered in the car before reaching the
hospital (birth before arrival) (1%).

Figure 1
Table 1 . Vaginal birth among women on trial of scar and other maternal characteristics
There was no difference in the successful VBAC across age groups. The maximum parity
observed in this study was a woman with 17 children. She had a caesarean section for the
fifth delivery for fetal distress followed by 12 successful VBAC. VBAC success is more with
those who had an earlier successful vaginal birth (5, 6). In 72% of vaginal deliveries the
perineum was intact. First-degree perineal laceration was seen in 7.8% of cases and second
degree lacerations in 6.1%. Right medio lateral episiotomy was done for 12.7% of vaginal
deliveries. The hospital does not follow routine episiotomy. There was no significant
association between birth weight and successful VBAC. With low birth weight babies (birth
weight less than 2500g), VBAC was 68.75%. It was 78.26% for birth weight in the range
2500 to 4000g. Those with more than 4Kg, VBAC was 67.86% (P-value = 0.111). The result,
though not statistically significant, does not confirm to the general observation that increasing
birth weight is associated with more caesarean section (7). VBAC success rate was poor in
previous caesarean indication of failed labour progress and cephalopelvic disproportion (58%
and 44% respectively). In those who have had breech presentation, PIH and fetal distress,
there was high success rate – (77%, 85% and 78%, respectively). It is consistent with
published data (6). Successful VBAC is more seen in those who delivered female babies
(79.67% versus 70.5%). However, it is not statistically significant (P-value = 0.058) and in
disagreement with the finding of the male fetus being a poor predictive factor for successful
VBAC (6).A short birth interval was not associated either with uterine rupture or success of
VBAC. No relation was observed between gestational ages and VBAC outcome. In those
with 37 to 40 completed weeks of gestation, VBAC was 70.21% and in less than 37 weeks
VBAC was 58.80%. With completed 40 weeks and above VBAC rate was 62.50%. It is
known that there is a slight increase in failure of VBAC in those after 40 weeks. (8)

Blood loss was more than 500ml in 1.9% of trial of scar and blood transfusion rate was
1.08%. Only one case of uterine rupture was reported and rate comparable to that from other
reports (2, 9). Induction of labor with prostaglandin E2 vaginal gel was attempted in 26
patients (7%) and 17 cases delivered by successful VBAC (65.3%). There was no increase in
scar tenderness, scar dehiscence or uterine rupture either in the induction group or
acceleration by Oxytocin. This is similar to the study by Pathadey et al in United Kingdom
(10). In their study, the VBAC rate was 79% among 81 induced patients. There were few
complications and no cases of uterine rupture .However, literature review showed that
women with previous one caesarean section attempting a trial of labour who require
induction have a higher rate of caesarean section and have a slightly increased risk of uterine
rupture (11-13). A case of maternal death occurred in this study. The cause of death was not
related to obstetric conditions and was a third gravida with sickle cell disease who developed
multiorgan failure following sickling crisis. Admission to neonatal intensive care unit was
comparable in successful VBAC and emergency caesarean section group. The five-minute
APGAR score less than seven was observed in three babies of VBAC group and two among
the emergency caesarean section group. None of the deliveries were complicated by
postpartum sepsis or thromboplebitis. Routine prophylactic antibiotics and
thromboprophylaxis is administered for all emergency caesarean sections in the hospital.

Discussion

It is generally accepted that vaginal delivery is associated with lower maternal morbidity and
mortality as against caesarean section (2). The morbidity associated with successful vaginal
birth is about one-fifth that of elective caesarean. Perinatal risk is more after a failed trial of
labour compared to elective repeated caesarean section without labour (2). Failed trials of
labour, with subsequent caesarean section involve almost twice the morbidity of elective
section. The information is important for counseling women about their choices of delivery
after a previous caesarean section. The adverse events include chorioamnionitis, postpartum
endometritis, and uterine rupture requiring hysterectomy, blood transfusion, perinatal and
neonatal deaths and neonatal neurological impairment. Many of these adverse events seen in
trial of scar are attributable to the failure of labour and the requirement for a repeated
emergency caesarean section. However, in this study there were fewer complications noted in
those who underwent emergency caesarean section after a trial of labour.

There is a significant reduction in trial of scar globally due to concerns of safety especially
attributed to uterine rupture (2). Patients should be counseled that uterine rupture can occur
before labour starts and planning a repeat section is no guarantee of safety. The decline in
VBAC is seen in many countries may be due to a reduction in trial of labour attempts and not
due to a change in success rate. The US National Centre for Health Statistics shows that, after
reaching a maximum of 28.3% in 1996, the VBAC rate has declined, and was only 12.7% in
2002 (27). Various studies showed that the chances of successful planned VBAC are 72-76%
(3). Maternal satisfaction is more after vaginal delivery (14, 15). The discussion of uterine
rupture therefore should not discourage pregnant women in attempting vaginal delivery (16).
The lower morbidity in 75% of women who successfully give birth vaginally means that the
overall women who opt for a planned vaginal birth after caesarean section suffer only half of
the morbidity of women who undergo an elective caesarean section. Babies born by elective
caesarean are at increased risk of breathing difficulties, respiratory distress syndrome (RDS)
and iatrogenic prematurity which increases the neonatal morbidity and mortality. There is
also a 1-9% risk of injury to the baby by surgeon’s knife. Mothers are at increased risk of
infection, hemorrhage, thrombo embolism, bladder lacerations, need for hysterectomies and
longer recovery period from a caesarean surgery compared to a vaginal birth. Even an
elective caesarean section had 2.84-fold greater chance of maternal death as compared to
vaginal birth. There is increased risk of placental abruption, placenta praevea, and adherent
placenta in subsequent pregnancies, a reduction in future fertility and an increased incidence
of ectopic pregnancies associated with multiple caesarean sections (17, 25).

A number of factors are associated with successful vaginal birth after a single caesarean
section. Previous vaginal birth was the single best predictor for successful VBAC (5-8).
Success of VBAC is less if the prior indication was non-progression of labor and
cephalopelvic disproportion (7). High success was noted in those with non-recurrent
indications such as prior breech presentation with cephalic presentation in current pregnancy.
Literature search showed that maternal age of more than 30 years, male fetus, no prior
vaginal delivery, prostaglandin induction, excessive weight gain during pregnancy and
maternal body mass index of more than 30 are associated with poor VBAC success rate (7-9,
20-21). One study showed that VBAC success rate is more with preterm gestation with less
uterine rupture chances (18). However an underdeveloped lower uterine segment in the
preterm uterus represents a risk for later rupture, even if the incision is transverse. Literature
search also showed that increase in baby weight is associated with increased caesarean
section rate. No such difference is noticed in this study. A short inter delivery interval was
associated with a decrease in the rate of successful VBAC in patients whose labour were
induced, a difference was not found in those who underwent spontaneous labour (19). It is
also associated with high chance of uterine rupture. There was no influence for the inter
delivery interval in this study. Concerning complications, one of the concerns for the patients
and health care providers for VBAC is the risk of uterine rupture. The incidence of uterine
rupture after trial of scar is less than 1% from various studies. Induction of labor with
prostaglandin is a risk factor for uterine rupture (11-12, 22). The hypothesis is that
prostaglandin induces biochemical changes in the uterine scar favoring dissolution,
predisposing the uterus to rupture at the scar of lower uterine segment (23). Sequential use of
prostaglandin and oxytocin can increase the chance of uterine rupture. The recommendation
for optimal caesarean section rate of 10-15% was made by WHO in 1985 (26). However, the
rate of caesarean section is rising in many countries over the past 10 years. Even though the
successful VBAC is considered safer than routine repeat caesarean section, the enthusiasm
for VBAC is found to be decreasing now due to several reasons. Many women demand for
repeat elective caesarean section in order to avoid a painful natural birth. This is mainly due
to inadequate patient information. Caesarean operation is now considered to be a safe surgery
due to safe anesthesia, better surgical technique, and antibiotic and thrombo prophylaxis.
Therefore many doctors also prefer to do caesarean section in order to avoid litigation.
Generally women worldwide prefer to have two or three children and do sterilization
operation. They opt for an elective caesarean section. However in the Middle East countries
like Oman, caesarean section on demand is very less. In this study only two women requested
caesarean section. Majority requests trial labour, because they prefer to have a large family
due to cultural reasons. According to Ministry of Health protocol, Sultanate of Oman,
sterilization is advised at fifth caesarean section and after two previous caesarean sections, an
elective caesarean section is recommended. Therefore, most women do not like repeat
caesarean section as it reduces the future fertility. In this study, despite giving counseling
about the pros and cons of VBAC especially regarding uterine rupture, most women selected
an option of trial of scar.

Conclusion

The study shows the high success of VBAC and the fewer complications. Many women in
the study were multiparous with a prior vaginal birth. Prior vaginal birth is a good predictor
for the outcome of VBAC. Notwithstanding the limited sample size, no adverse maternal or
fetal effects were observed with induction of labour with prostaglandin E2 vaginal gel and
acceleration with oxytocin. Trial of scar is still an option for individuals desirous of more
pregnancies dependant on religious and cultural factors. Provided there are no
contraindications, a woman with a previous caesarean section can be offered a trial of labour
after adequate patient information. The various factors affecting the success of VBAC can be
used for counseling women with previous one caesarean section. Long-term consequences of
multiple caesarean sections should always be considered when making a decision (24). For a
woman with a single prior caesarean section who plans only one additional pregnancy, a
strategy of elective repeat section may be preferred because it results in fewer hysterectomies
and other complications mentioned earlier than a VBAC attempt. In women desirous of more
children, complications of caesarean section like increased risks of placenta previa, placenta
accreta in future pregnancies appears to outweigh the immediate risks of VBAC attempt (28).
The experience from Oman showed that VBAC still has a role to maintain a woman’s fertility
and also to reduce morbidity and mortality associated with multiple caesarean sections.
Appropriate counseling for women would reduce elective caesarean section..

Acknowledgments

The author would like to thank Dr.Gokulam Nandini and Dr.Upma Shankar of the Armed
Forces Hospital, Muscat, Sultanate of Oman for their expert opinion in preparation of this
manuscript.

References

1. Editorial: Vaginal delivery after caesarean section. BMJ 2004; 329:359-360.

2. Landon MB, Hauth JC, Leveno KJ, Catherine et al. Maternal and perinatal outcomes
associated with a trial of labor after prior caesarean delivery. N Eng J Med (2004); 351:2581-
2589.
3. National Institute for Clinical Excellence (NICE) guideline for Caesarean Section- 2004
4. Hoffman MK, Sciscione A, Srinivasana M, Shackelford DP, Ekbladh L. Uterine rupture in
patients with a prior cesarean delivery: the impact of cervical ripening. Am J Perinatol
(2004); 21(4): 217-22.
5. Ghaffari A, Ahmed BB. Safety of vaginal birth after cesarean delivery. Int J Gynec & Obst
(2006); 92 (1): 38 – 42.
6. Landon(ochrostat): Factors affecting the success of trial labor after previous caesarean. Am
J Obstet Gynecol (2005); 193: 1016.
7. The MFMU Cesarean Registry: Impact of fetal size on trial of labor success for patients
with previous cesarean for dystocia. Am J Obstet Gynecol (2005); 195(4): 1127 – 1131.
8. Coassolo KM, Stamilio DM, Pare E, Peipert JF. Safety and efficacy of VBAC at or beyond
40 weeks gestation. Obstetrics and Gynaecology (2005); 106: 700-706.
9. Risk of uterine rupture during labour among women with a prior caesarean delivery.N Engl
J Medicine 2001;345;3-8
10. Pathadey, Vanwoerdone. Induction of labor after a previous caesarean section, a
retrospective study J Obstet Gynecol (2005); 25: 662.
11. Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin HG, Kamaci M. Eight years’ experience of
uterine rupture cases. J Obstet Gynaecol (2005); 25: 458-461.
12. Kayani SI, Alfirevic Z. Uterine rupture after induction of labor in women with PCS.
BJOG (2005); 112: 451.
13. McDonagh MS, Osterweil P, Guise JM. The benefits and risks of inducing labour in
patients with prior caesarean delivery: a systematic review BJOG (2005); 112(8): 1007-15.
14. Dunn C, O’Herlihy. Comparison of maternal satisfaction following vaginal delivery after
caesarean section and caesarean section after previous vaginal delivery. European Journal of
Obstetrics & Gynecology and Reproductive Biology (2005); 121(1): 56 – 60.
15. Hassan A. Trial of scar and VBAC. J Ayub med coll Abbottabad (2005); 17: 57.
16. Sur S, Mackenzie IZ. Does discussion of possible scar rupture influence preferred mode
of delivery after CS? JOG (2005): 25: 338.
17. Macones GA, Peipert J, Nelson DB, et al. Maternal complications with vaginal birth after
cesarean delivery: a multicenter study. Am J Obstet Gynecol (2005); 193(5): 1656-62.
18. Quinones JN, Stamilio DM, Pare E, et al. The effect of prematurity on VBAC success and
maternal morbidity ACOG (2005); 105: 519.
19. Huang WH, Nakashima DK, Rumney PJ, Keegan KA. Inter-delivery interval and the
success of VBAC. ACOG (2002); 99: 41-44.
20. Juhasz G, Gyamfi C, Gyamfi P, Tocce K, Stone JL. Effect of body mass index and
excessive weight gain on the success of VBAC. OG (2005);106: 741.
21. Goodall, Ahn J, Chapa J, Hibbard J. Obesity as a risk factor for failed trial of labor in
patients with previous cesarean delivery . Am J Obstet Gynecol (2005); 192(5): 1423-26.
22. SOGC clinical practice guidelines for VBAC
23. Catalin S, Buhimschilrnia A, Patel BS, Andrew M, P.Weiner MCP. Rupture of the uterine
scar during term labour: contractility or biochemistry? BJOG (2005); 112: 38.
24. Paré E, Quiñones JN, Macones GA. Vaginal birth after caesarean section versus elective
repeat caesarean section: assessment of maternal downstream health outcomes. Int J Gyn
Obst (2005); 89: 319.
25. Mukherjee SN. Rising caesarean section rate -Review article. J obstet gynaecol India
(2006); 56(4): 298-300.
26. WORLD HEALTH ORGANISATION. Appropriate technology for birth. Lancet (1985);
436-7.
27. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final
data for 2002. Natl Vital Stat Rep (2003); 52(10):1-113.
28. Pare E, Quinones JN, Macones GA. Vaginal birth after caesarean section versus elective
repeat caesarean section: Assessment of maternal downstream health outcomes. BJOG
(2006); 113: 75-85.

 {full_citation}

Author Information

Geetha Puliyath, MD, MRCOG.

Department of Obstetrics & Gynaecology, Armed Forces Hospital Muscat

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Keywords:

 Administrative data;
 England;
 trial of labour;
 vaginal birth after caesarean

Objectives

To investigate the demographic and obstetric factors associated with the uptake and success
rate of vaginal birth after caesarean section (VBAC).

Design

Cohort study using data from Hospital Episode Statistics.

Setting

English National Health Service.

Population

Women whose first birth resulted in a live singleton delivery by caesarean section between 1
April 2004 and 31 March 2011, and who had a second birth before 31 March 2012.

Methods

Logistic regression to estimate adjusted odds ratios (OR).

Main outcome measures

Attempted and successful VBAC.

Results

Among the 143 970 women in the cohort, 75 086 (52.2%) attempted a VBAC for their
second birth. Younger women, those of non-white ethnicity and those living in a more
deprived area had higher rates of attempted VBAC. Overall, 47 602 women (63.4%) who
attempted a VBAC had a successful vaginal birth. Younger women and women of white
ethnicity had higher success rates. Black women had a particularly low success rate (OR,
0.54; 95% confidence interval [CI], 0.50–0.57). Women who had an emergency caesarean
section in their first birth also had a lower VBAC success rate, particularly those with a
history of failed induction of labour (OR, 0.59; 95% CI, 0.53–0.67).

Conclusion
In this national cohort, just over one-half of women with a primary caesarean section who
were eligible for a trial of labour attempted a VBAC for their second birth. Of these, almost
two-thirds successfully achieved a vaginal delivery.

BJOG: An International Journal of Obstetrics & Gynaecology

Special Issue: Management of pregnancy after caesarean section

Volume 121, Issue 2, pages 183–192, January 2014

Am J Med Sci. 2013 Feb; 5(2): 140–144.

doi:  10.4103/1947-2714.107537

PMCID: PMC3624716

Vaginal Birth after Cesarean Section

Vidyadhar B Bangal, Purushottam A Giri,1 Kunaal K Shinde, and Satyajit P Gavhane

Author information ► Copyright and License information ►

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Abstract

Background:

The rate of primary cesarean section (CS) is on the rise. More and more women report with a
history of a previous CS. A trial of vaginal delivery can save these women from the risk of
repeat CS.

Aims:

The study was conducted to assess the safety and success rate of vaginal birth after CS
(VBAC) in selected cases of one previous lower segment CS (LSCS).

Materials and Methods:

The prospective observational study was carried out in a tertiary care teaching hospital over a
period of two years. One hundred pregnant women with a history of one previous LSCS were
enrolled in the study.

Results:

In the present study, 85% cases had a successful VBAC and 15% underwent a repeat
emergency LSCS for failed trial of vaginal delivery. Cervical dilatation of more than 3 cm at
the time of admission was a significant factor in favor of a successful VBAC. Birth weight of
more than 3,000 g was associated with a lower success rate of VBAC. The incidence of scar
dehiscence was 2% in the present study. There was no maternal or neonatal mortality.

Conclusion:

Trial of VBAC in selected cases has great importance in the present era of the rising rate of
primary CS especially in rural areas.
N Am J Med Sci. 2013 Feb; 5(2): 140–144.
doi:  10.4103/1947-2714.107537
PMCID: PMC3624716

Vaginal Birth after Cesarean Section

Vidyadhar B Bangal, Purushottam A Giri,1 Kunaal K Shinde, and Satyajit P Gavhane

Keywords: Lower segment cesarean section, Rural India, Scar dehiscence, Trial of labor, Vaginal birth
after cesarean section

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Introduction

Vaginal birth after cesarean section (VBAC) is one of the strategies developed to control the
rising rate of cesarean sections (CSs). It is a trial of vaginal delivery in selected cases of a
previous CS in a well-equipped hospital.[1] In 1916, Cragin popularized the dictum, “once a
caesarean section, always a caesarean section”.[2] That was the era of the classical CS. In the
present era of lower segment caesarean section (LSCS), cesarean-related morbidity and
mortality are significantly reduced. The dictum now is “once a caesarean section, always an
institutional delivery in a well-equipped hospital”. The reasons which led to the reversal of
the old dictum are based upon the newer concepts of the assessment of scar integrity, fetal
well-being, and improved facilities of emergency CS.[3]

Nevertheless, a previous CS does cast a shadow over the outcome of future pregnancies.[4]
With present techniques and skill, the incidence of cesarean scar rupture in subsequent
pregnancies is very low. The strength of the uterine scar and its capacity to withstand the
stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in
advance. These cases require the assessment and supervision of a senior obstetrician during
labor.[5] Hence, the present study was undertaken to assess the success and safety of VBAC
in selected cases of one previous LSCS and to evaluate the maternal and fetal outcome in
these cases.

Go to:

Materials and Methods

This prospective observational study was carried out at a tertiary care teaching hospital
located in a rural area of central India from January 2010 to December 2011. This hospital
gets referrals of high-risk cases from neighbouring villages and townships. About 6,000
deliveries take place annually in the hospital with the rate of CS ranging between 22 and
24%. A total of 100 cases of a previous CS were selected either from the outpatient
department (booked) or in labor (unbooked). Booked cases were regularly followed up in the
antenatal clinic and the unbooked patients, who reported directly for labor, were then
assessed for a trial of vaginal delivery. A study protocol was submitted to the institutional
ethical committee of the Pravara Institute of Medical Sciences, and approval was sought
before start of the study.
Cases with a single previous transverse lower uterine segment scar with adequate size of
pelvis were included in the study after informed consent. Cases with previous classical or
inverted T-shaped incision on the uterus, previous two or more LSCSs, with other uterine
scars, history of previous rupture of the uterus or scar dehiscence, contracted pelvis or
cephalopelvic disproportion, and those having other medical or obstetrical complications
associated with pregnancy were excluded from the study. A total of 100 cases that fulfilled
the selection criteria were enrolled in the study. All cases and their close relatives were
explained about the advantages of vaginal birth over elective CS. They were also explained
about the risk of scar dehiscence and the need for emergency CS, if trial of vaginal delivery
failed. Written informed consent was obtained at the time of enrolment in the study. The
patients were asked to come for regular antenatal checkups and were advised to plan their
delivery in the hospital where the study was conducted. Hematological and serological
investigations and obstetric sonography were performed during antenatal visits. The women
were advised to get admitted in the ward, one week prior to their expected date of delivery.
After going through the record related to her previous CS, a decision regarding VBAC was
taken by a senior obstetrician in the later weeks of pregnancy or during labor. The cases
selected for VBAC were monitored carefully during labor by continuous electronic fetal
monitoring. All the cases were provisionally prepared for emergency CS. Intrapartum
monitoring was done by using the standard partograph of the World Health Organization
(WHO). Four-hourly internal examinations were performed to assess the progress, and
special attention was paid toward the evidence of scar dehiscence or rupture. The trial of
vaginal delivery was continued till there was satisfactory progress. The trial was terminated
by emergency repeat CS, when there was evidence of unsatisfactory progress, scar
tenderness, or fetal distress. Cases with successful VBAC delivery were kept in the hospital
for five days and those who required repeat CS were kept for seven days after the operation.
All cases received broad-spectrum antibiotics (injection ampicillin 500 mg intravenously and
injection metronidazole 500 mg intravenously six-hourly) for either five or seven days.

Statistical analysis

Relevant information on maternal and fetal parameters including outcome of the present
pregnancy (age, parity, registration status, interval between present pregnancy and previous
CS, place, indication, and outcome of previous CS, mode of delivery in the present
pregnancy, and maternal and perinatal outcome) in individual cases was collected in a
structured pro-forma, entered in Microsoft Office Excel format, and statistical analysis was
performed using SPSS software (version 16.0). All values were expressed in the form of
proportion and percentages.

Go to:

Results

It was observed that eighty percent women had registered themselves for antenatal care, 30%
women were carrying their second pregnancy, 45% their third pregnancy, and another 25%
their forth pregnancy. The interval between a previous CS and the present pregnancy was
more than two years in 77% of the cases. Eighty-five percent cases of previous CSs delivered
vaginally, whereas 15% required a repeat CS [Table 1].
Table 1

Mode of delivery following trial of vaginal birth after cesarean section

It was seen that the women with cervical dilatation of more than 3 cm at the time of
admission in the hospital had a better chance (90%) of vaginal delivery than women with a
dilatation of less than 3 cm (60%). The success rate of vaginal birth after a previous CS done
for nonrecurrent indications like fetal distress, malpresentations, pre-eclampsia, premature
rupture of membranes, and postdated pregnancy was in the range of 80 to 90%, whereas the
success rate of vaginal birth after previous CS done for indications like nonprogress of labor
or borderline cephalopelvic disproportion was in the range of 60 to 70% [Table 2].

Table 2

Indication of previous caesarean section and outcome of trial of VBAC in present pregnancy

The average duration of labor was less than 10 hours in 94% cases, who delivered vaginally
as compared to 80% cases requiring a repeat CS. The indications of a repeat CS were fetal
distress (46%), scar dehiscence (13%), undiagnosed cephalopelvic disproportion (13%), and
labor abnormalities like protracted active phase, cervical dystocia, and malrotation of head
[Table 3]. It was further observed that women with a previous vaginal delivery had a better
chance (90%) of a successful VBAC as compared to women who did not have a previous
vaginal delivery (77%). A birth weight of more than 3,000 gm was associated with a lower
success rate of VBAC. In the present study, there were two cases of scar dehiscence, one case
of broad ligament hematoma, and one case of cervico-vaginal laceration. Two cases required
blood transfusion. Four babies had birth asphyxia. There was no stillbirth or neonatal death.
The average duration of hospital stay for women having a successful VBAC was lower (4.59
days) than women who required a repeat CS (8.40 days).
Table 3

Indication of repeat emergency LSCS in cases of failed trial of VBAC

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Discussion

With the significant rise in the incidence of primary CS for various indications, an increasing
proportion of the pregnant women coming for antenatal care report with a history of a
previous CS. These women belong to a high-risk group due to the risk of a scar rupture. The
obstetrician is always in a dilemma regarding the mode of delivery in these cases.
Assessment of the individual case with regard to the possibility of a successful VBAC is
necessary while taking the decision. The unending dilemma of an obstetrician is about the
management of subsequent labor, once the patient has a scar on the uterus. Some suggest an
elective CS for such cases, whereas others choose a trial of labor. Many take a middle route,
that is, individualization of case. By far, the greatest problem for the attendant in subsequent
labor is the integrity of the uterine scar.[6] Uterine rupture has the potential for causing
serious harm to the pregnant woman as well as the baby. This is the most important risk to be
noted, but the advantage which the vaginal delivery imparts largely outweighs the risks
associated with a repeat CS. The maximum percentage of cases in the present study were in
the age group of 21 to 30 years as compared to other age groups, reflecting the child-bearing
age of most of the women. The interval between the previous cesarean and the present
pregnancy was more than two years in 77% cases, whereas it was less than two years in 23%
of the cases. Shipp et al.[6] studied the risk of scar dehiscence in relation to the interval
between a previous CS and the present pregnancy. He reported that the rate of scar rupture
was 2.3%, when the interval was less than 18 months as compared to 1%, when the interval
was more than 18 months. Similarly, in the present study, the rate of scar rupture was 2% and
the interval was less than two years. In the present study, the commonest indication for a
previous CS was fetal distress. The success rate of VBAC in these cases was 83%. Similar
results (68 to 83%) have been reported by other workers.[7–9] The success rate of VBAC in
cases with a previous CS for cephalopelvic disproportion was 85% in the present study,
which was much higher than reported by other workers (25 to 77%).[7,10–12] It could be
because of the over diagnosis of cephalopelvic disproportion in previous pregnancies. In this
study, the success of VBAC in cases with a previous CS done for breech presentation was
80%. Studies by Jansen et al.[10] and Phelan et al.[7] have reported similar results. The
success of VBAC in the present study was 85%. This result was comparable with the results
of other studies reported by Riva and Teich,[13] Dayal V,[14] Allahabadia,[15] Phelan et al.,
[7] and O Sullivan.[16] In our study, the rate of a repeat CS was 15% and commonest
indication was fetal distress. Phelan et al.[7] and Dayal V.[14] reported a lower (15%) rate of
fetal distress requiring CS.
The success rate of VBAC in cases augmented with oxytocin was 83%. Dayal V[14] reported
that the success rate of VBAC in cases induced with oxytocin depend on the Bishop's score.
Flamm et al.[17] reported that the use of oxytocin for induction or augmentation is safe in
cases of previous CSs, when the infusion of oxytocin is well monitored. Lao et al.[18] studied
the safety of induction of labor in women scheduled for trial of labor. They concluded that
higher rates of infusion of oxytocin increase the rate of scar rupture, and that the use of a
standard rate of infusion is useful in increasing the success rate of VBAC. In the present
study, there were two cases of scar rupture. Both cases had a spontaneous onset of labor and
oxytocin was not used in them.

The success rate of VBAC was significantly higher (93 as against 7%) in cases with cervical
dilatation of more than 3 cm as against less than 3cm at the time of admission. Landon et al.,
[19] Demianczuk et al.,[20] and Pickhardt et al.[21] reported similar findings in their studies.
In the present study, the rate of successful VBAC in cases with previous normal vaginal
delivery was 91%. Landon et al.,[19] Kraiem et al.,[22] Whiteside DC et al.,[23] Bedoya, et
al.[24] and Phelan et al.[7] reported that a previous vaginal delivery was the greatest
predictor for a successful VBAC. There were two cases of scar dehiscence and one case each
of cervicovaginal laceration and broad ligament hematoma. Cases with scar dehiscence were
managed by CSs. Obara et al.[25] reported two cases of ruptured uterus (0.93%) in their
study of 214 cases of a previous CSs. Phelan et al.[7] reported scar dehiscence in 1.9% cases
and uterine rupture in 0.3% cases. Dayal V[14] reported a higher rate (4.2%) of scar rupture.
Palerme GR and Freidman EA et al.[26] reported that the incidence of uterine rupture was
2.2% with classical CS, 1.3% with lower segment cesarean and 0.07% with lower segment
transverse scar.

The American college of Obstetricians and Gynecologists (ACOG)[27] estimated the risk of
uterine rupture in women with a previous CS and concluded that the lower segment caesarean
scar has a minimum risk (0.2-1.5%) of rupture during vaginal delivery. There was no
maternal mortality in the present study. Neonatal morbidity in the form of a low Apgar score
(<6) was observed in 4% babies. One of these four babies was born by ventouse extraction
for prolonged second stage of labor, due to maternal exhaustion and poor maternal bearing
down. The remaining three babies were born by emergency CS, following failed trial of
vaginal delivery. One CS was performed for scar dehiscence and the other two were
performed for fetal distress. Two babies had a tight loop of cord around the neck. All three
caesarean babies had developed meconium aspiration, which resulted in birth asphyxia. There
was no associated co-morbidity in these babies. All the four babies born with low Apgar
score were kept in the neonatal intensive care unit. They received prophylactic antibiotics and
breast feeding and were discharged from hospital with their mothers. Morbidity was three
times more in cases which required a repeat CS than those with a successful VBAC delivery.
Similar observations were reported in other studies.[14,25] There was no perinatal mortality
in the present study. Phelan et al.,[7] in his study of 1,796 cases, reported a perinatal
mortality of 4.5/1,000 deliveries. It was observed that the success rate of VBAC depends on
the birth weight of the baby. The success rate of VBAC decreased (18.7%) significantly when
the birth weight was more than 3000 gm. Similar observations were made by other workers.
[19,23,28–30] The average duration of hospital stay for VBAC was 4.59 days, whereas it was
six days for instrumental deliveries, and 8.4 days for cases requiring repeat CS. Benson et al.
[31] carried out a survey of the benefits of a successful VBAC and found out that a shorter
hospital stay in a VBAC delivery has a positive impact on the psychology of the woman and
decreases the total cost of hospitalization. Similar observations were made by other workers.
[32,33]
In spite of the ongoing efforts by the government to promote the norm of the small family,
there is a perennial desire for more number of children, especially male children among the
rural uneducated population. Many women do not accept sterilization even during the second
CS. This decision exposes them to the development of complications related to scar rupture
in subsequent pregnancy and labor. If women are explained about the option of VBAC and
told about the risk associated with a repeat CS, many CSs can be avoided. VBAC should be
encouraged in selected cases to reduce the risk of a repeated CS.[34] Many obstetricians
running private nursing homes do not conduct VBAC deliveries, with the fear of scar rupture
and subsequent medico-legal litigations. They ignore the possible increase in the risk of scar
rupture with two previous CSs, the incidence of which has risen over the last few decades.
They also need to be educated about the long-term implications of preferring repeat CSs over
VBAC deliveries. For the aforementioned reasons, conducting VBAC deliveries has a special
significance among the rural uneducated population.

Limitations

The limitation of the study lies in the fact that the study was carried out in a tertiary care
centre, where there is adequate manpower to supervise each delivery, reducing complication
rates of VBAC. Similar results may not be replicated at centres other than tertiary care
centres.

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Conclusion

Majority of the cases of previous CS done for nonrecurrent indication can be delivered safely
by the vaginal route, without any major complication to the mother and the newborn, in an
institution having facilities for emergency CSs. It has been proved to be a safe alternative to
repeat an elective CS.

Go to:

Acknowledgment

The authors express their deep sense of gratitude to the management of the Pravara Medical
Trust and the Principal, Rural Medical College, Loni, Maharashtra, India.

Go to:

Footnotes

Source of Support: Nil.

Conflict of Interest: None declared.

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References
1. Pickrell K. An inquiry into the history of cesarean section. Bull Soc Med Hist (Chicago) 1935;4:414.
2. Cragin EB. Conservatism in Obstetrics. N Y Med J. 1916;104:1–3.

3. Rozenberg P, Goffinet F, Phillippe HJ, Nisand I. Ultrasonographic measurement of lower uterine

segment to assess risk of defects of scarred uterus. Lancet. 1996;347:281–4. [PubMed]

4. Kerr JM. The technique of caesarean section with special reference to the lower uterine segment
incision. Am J Obstet Gynecol. 1926;12:729.

5. Scwarz O, Paddock R, Bortnick AR. The caesarean scar: An experimental study. Am J Obstet
Gynecol. 1938;36:962–5.

6. Shipp TD, Zelop CM, Repke JT, Cohen A, Lieberman E. Inter delivery interval and risk of
symptomatic uterine rupture. Obstet Gynecol. 2001;97:175–80. [PubMed]

7. Phelan JP, Clark SL, Diaz F, Paul RH. Vaginal birth after caesarean. Am J Obstet Gynecol.
1987;157:1510–5. [PubMed]

8. Saraogi R, Vaidya PR. Partogram in cases of previous caesarean section. J Obstet Gynecol India.
1979;29:745–9.

9. Hoskins IA, Gomez JL. Correlation between maximum cervical dilatation at caesarean delivery and
subsequent vaginal birth after caesarean delivery. Obstet Gynaecol. 1997;89:591–3. [PubMed]

10. Jansen FW, Van Roosmalen J, Keirse MJ, Bennebroek Gravenhorst J. Vaginal delivery following
caesarean section. Ned Tijdschr Geneeskd. 1989;133:666–9. [PubMed]

11. Jarrel MA, Ashmead G. Vaginal delivery after caesarean section. Obstet Gynecol. 1928;65:628.

12. Cosgrave R. Management of pregnancy and delivery after caesarean section. J Am Med Assoc.
1951;145:884–8. [PubMed]

13. Riva HL, Teich JC. Vaginal delivery after caesarean section. Am J Obstet Gynaecol. 1961;81:501.
[PubMed]

14. Dayal V. Trial of vaginal delivery in cases of single previous cesarean section. J Obstet Gynecol.
1985;35:445–50.

15. Allahabadia GN, Ambiye VR, Shanbaug AM. Vaginal birth following caesarean section. J Obstet
Gynecol India. 1989;39:782–6.

16. Sullivan O MJ, Fumia F, Holsinger K, McLeod AG. Vaginal delivery after caesarean section. Clin
Perinatol. 1981;8:131–43. [PubMed]

17. Flamm BL, Dunnett C, Fischermann E, Quilligan EJ. Vaginal delivery following caesarean section:
Use of oxytocin augmention and epidural aneasthesia with internal tocodynamic and internal foetal
monitoring. Am J Obstet Gynecol. 1984;148:759–63. [PubMed]

18. Lao TT, Leung BF. Labour Induction for planned vaginal delivery in patients with previous
caesarean section. Acta Obstet Gynecol Scand. 1987;66:413–6. [PubMed]
19. Landon MB, Leindecker S, Spong CY, Hauth JC, Bloom S, Varner MW, et al. The MFMU caesarean
registry: Factors affecting the success of trial of labour after previous caesarean delivery. Am J
Obstet Gynecol. 2005;193:1016–23. [PubMed]

20. Demianczuk NN, Hunter DJ, Taylor DW. Trial of labour after previous cesarean section. Prognostic
indicators of outcome. Am J Obstet Gynaecol. 1982;142:640–2. [PubMed]

21. Pickardt MG, Martin JN, Maydrech EF. Vaginal birth after caesarean delivery: Are there useful
and valid predictors of success or failure? Am J Obstet Gynecol. 1992;166:1811–9. [PubMed]

22. Kraiem J, Ben Brahim Y, Chaabane K, Sarraj N, Chiha N, Falfoul A. Indicators for successful vaginal
delivery after caesarean section: A proposal of a predictive score. Tunis Med. 2006;84:16–20.
[PubMed]

23. Whiteside DC, Mahan CS, Cook JC. Factors associated with successful vaginal delivery after
caesarean section. J Reprod Med. 1983;28:785–8. [PubMed]

24. Bedoya C, Bartha JL, Rodriguez I, Fontan I, Bedoya JM, Sanchez-Ramos J. A trial of labour after
caesarean section in patients with or without prior vaginal delivery. Int J Gynecol Obstet.
1992;39:285–9. [PubMed]

25. Obara H, Minakami H, Koike T, Takamizawa S, Matsubara S, Sato I. Vaginal birth after caesarean
delivery. Results in 310 pregnancies. J Obstet Gynaecol. 1998;24:129–34. [PubMed]

26. Palerme GR, Freidman EA. Rupture of the gravid uterus in the third trimester. Am J Obstet
Gynecol. 1977;50:594–7.

27. ACOG practice bulletin. Vaginal birth after previous cesarean delivery. No. 2, October 1998.
Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians
and Gynecologists. Int J Gynaecol Obstet. 1999;64:201–8. [PubMed]

28. Irani FF, Matliya MV. Outcome of labour following previous caesarean section. J Obstet Gynecol
India. 1971;32:651–5.

29. Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E. Outcome of trial of labour following
caesarean delivery among women with foetuses weighing>4000 grams. Am J Obstet Gynecol.
2001;185:903–5. [PubMed]

30. Ollendorff DA, Goldberg JM, Minogue JP, Socol ML. Vaginal birth after caesarean section for
arrest of labor. Is success determined by maximum cervical dilatation during the prior labour? Am J
Obstet Gynaecol. 1988;159:636–9. [PubMed]

31. Horowitz BJ, Stanley W, Lippmann L. Once a cesarean, always a caesarean. Obstet Gynaec
Survey. 1981;36:592–7.

32. Traynor JD, Peaceman AM. Maternal hospital charges associated with trial of labour versus
elective repeat caesarean section. Birth. 1998;25:81–4. [PubMed]

33. Gibbs CE. Planned vaginal delivery following caesarean section. Clin Obstet Gyn. 1980;23:507.
[PubMed]
[Maternal benefits and risks of trial of labor versus elective repeat caesarean delivery in
women with a previous caesarean delivery].
(PMID:23159201)
Beucher G, Dolley P, Lévy-Thissier S, Florian A, Dreyfus M
Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Caen, avenue
Côte-de-Nacre, 14033 Caen cedex 9, France. beucher-g@chu-caen.fr
Journal de Gynecologie, Obstetrique et Biologie de la Reproduction [2012, 41(8):708-726]
Type: Journal Article, Review, English Abstract (lang: fre)
DOI: 10.1016/j.jgyn.2012.09.028
Abstract
OBJECTIVE: To assess maternal outcomes during trial of labor (TOL) and elective repeat
caesarean delivery (ERCD) in women with a previous caesarean delivery.

METHODS: French and English publications were searched using PubMed and Cochrane
Library.

RESULTS: Maternal mortality remains a very rare event regardless of the planned mode of
delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many
studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure
of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of
complete uterine rupture significantly increases with TOL versus ERCD but it remains low at
about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-
surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned
mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood
transfusion, data are heterogeneous because of the nature of the populations studied. These
risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous
thrombo-embolic complications and infections (endometritis and maternal fever) appears to
be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the
additional presence of obesity (EL2). While maternal morbidity progressively increases with
the number of iterative caesarean sections, maternal morbidity in TOL after a previous
caesarean delivery decreases with the number of successful TOL (EL2).

CONCLUSION: In patients with a previous caesarean delivery, the risks of maternal

complications are rare and similar between TOL and ERCD. There is an increased risk of
complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk
balance in most cases and its success reduces the risk of short and long-term maternal
complications (EL3).