VAGINAL DELIVERY WITH VACUUM EXTRACTION

AFTER CAESAREAN SECTION : A CASE REPORT

Febianza Mawaddah Putri
Department of Obstetric & Gynecology, RSUP Fatmawati
State Islamic University Syarif Hidayatullah Jakarta

INTRODUCTION

For much of the 20th century, most people believed that a woman who had previously
undergone a caesarean delivery would require a repeat caesarean delivery for future
pregnancies.1 However, evidence has shown that many women who have had a cesarean
delivery can safely deliver vaginally in subsequent pregnancies. Advantages of this approach
include avoidance of major surgery, lower risk of hemorrhage and infection, and shorter
recovery periods. It appears that many women who have previously undergone cesarean
delivery can safely attempt a trial of labor to have a vaginal delivery in subsequent
pregnancies.2

In order to minimize the risks that may occur in VBAC, there are some things to think
about: appropriate patient selection, calculating risks and benefits, and educating patients in
choosing the type of labor. The things that affect the success of VBAC are gestational age,
first SC indication, history of pervaginal birth, birth type and also the Bishop Score. 3

Recently case report research or journal of VBAC in Indonesia is relatively low. The
number of VBAC in Indonesia is still unknown and the rate of cesarean delivery some big
hospitals is still high, therefore this topic is important to discussed. The purpose of this case
report was to describe a vaginal birth after caesarean (VBAC) procedure for an 29-year-old
female who has a history of caesarean section.

CASE DESCRIPTION

Ny JL, 39 yo, comes to hospital because of contraction and history of C-section 1x

(referred from Mutia midwife). Admitted 9 months of pregnancy. LMP December 22 th 2016,
EDD September 29th 2017. ANC regularly in midwifery every month. USG 1x at September
6th 2017 ~ 39+2. Contraction since 20 hours before admission. Has an active fetal movement.
No complaints about mucous and blood spots from genitalia, water broke, vaginal discharge,
urinate abnormality, and fecal abnormality. No complaints about headache, upper abdominal
pain, blurred vision in this pregnancy. Patient has 1 prior caesarean section delivery in 5
years ago (2012) due to premature rupture of membrane.

Physical examination found FUH 33 cm, EFW 3410 gram, His 2-3x/10’/30-35’’,
FHR 148 bpm, bloody show (+), Ø 9 cm cervix dilation, head in H III-IV, amniotic
membrane (+). Laboratory in normal range. USG Singleton live, head presentation, EFW
3500 gram. CTG category I.

Since the 2nd stage of labor, because of inadecuate contractions, the vacuum extraction
performed since the requirements was fullfiled. The VBAC with vacuum extraction was done
successfully with the result born baby girl, bw 3500 grams, bl 50 cm, and AS 8/9. Amniotic
fluid was clear, the placenta born completely, and the uterine showed good contraction. There
were no sign of uterine ruptur during and after the vaginal birth. Installed IUD birth control
PP. After the labor, patient and her baby was in a good condition in a ward.

After three days of follow up, the patient complained hurt on the perineum stitched
(Vas 1-2). Patient urinate spontanously, the breastmilk could flow out, the breasts showed no
signs of infection, no complain about urination and defecation. Generalized status was
normal; fundal height was measured about 2 fingers below umbilical, the uterus contraction
was good; in inspection showed vulve-uretra were calm and no active bleeding. Patient was
given cefixime 2x200mg PO, metronidazole 3x500mg, Na diclofenac 2x50 mg, misoprostol
3x20 mcg, lactulose 3xCI, hemobion 1x1, nutrion with HCHP 1700 kcal. Now patient and the
baby in good condition and have been discharged from hospital.

DISCUSSION

Mrs.JL, 29 yo, with diagnosis active phase of stage I on G2P1A0 39 wga. Singleton
live head fetal presentation, prior caesarean section 1x, interval of delivery time 5 years.
Patient was tried the TOLAC (Trial of Labor After Cesarean). The method that patient
attemped for delivery in this pregnancy was VBAC with some consideration.
Patient came to the hospital already in partu with Ø 9 cm cervical dilatation, regular
contraction, and good fetal condition. The patient admitted that she has previous low-
transverse cesarean delivery and no history of previous uterine rupture. Based on RCOG
Green-top Guideline no.45, VBAC is appropriate for and may be offered to the majority of
women with a singleton pregnancy of cephalic presentation at 37 weeks or beyond who have
had a single previous lower segment caesarean delivery, with or without a history of previous
vaginal birth. Since Fatmawati hospital is a type A hospital, they have a good facilities and
infrastructures for emergency cesarean delivery.
In the prior pregnancy, there was a difficulities and need to attemped cesarean delivery.
But, in this pregnancy the patient had no contraindication to attempt VBAC. Beside, the
patient admitted that there was no complication on her first cesarean delivey. During this
pregnancy there are no problem and both mother and baby. Based on the fetal conditions, on
physical examination found that the fetal heart rate showed about 142 bpm which means
there is no emergency situation on the baby. USG predict that the fetal weight is about 3500
grams, means that no sign of macrosomia and enabled to be delivered by VBAC.
The patient had been counted of VBAC score to predict the success rate of this labor
method. The VBAC score is 6, means that the VBAC success rate is 89%. Therefore, for this
case the decision to choose VBAC had been correct rather to choose ERCS.

Indication of vacuum extraction for this patient is due to maternal condition which is
slow progress in the second stage due to poor contraction and/or maternal fatigue. The
requirement for vacuum extraction was fullfiled which is head presentation, head in Hodge 3-
4, amniotic membrane has broken. Therefore, for this case the decision to perform vacuum
extraction is appropriate.

CONCLUSION & LIMITATION

VBAC technique for delivery in this case is appropriate. The maternal and fetal
factors was good for VBAC. Based on the VBAC score, the total score was 6 which is the
probability of success in these patients was 89%. The decision to perform vacuum extraction
is appropriate due to inadecuate contraction since the requirement of vacuum was fullfiled.

Professional health care who has been chosen as the personal health care during the
antenatal care should give the information about selection the delivery methode for next labor
especially the patients who had prior cesarean delivery. The information that should be
informed is potential risks and benefits to each methode.
FUTURE DIRECTION

Investigation of the long-term effect of VBAC procedure would be beneficial.

ACKNOWLEDGEMENT

The author acknowledges dr. Arvid Tardan, SpOG, for his supervision in this case
report, RSUP Fatmawati, for permitting collecting data, and the patient for participating in
this case report.

REFERENCE

1. Royal College of Obstetricians & Gynaecologists. Birth After Previous Caesarean

Birth. RCOG Green-top Guideline no.45. 2015.
2. American College of Obstetricians and Gynecologists. ACOG practice bulletin no.
115. Vaginal birth after previous cesarean delivery. Obstet Gynecol.
2010;116(2):452.
3. American Academy of Family Physicians. Clinical Practice Guideline: Planning for
Labor and Vaginal Birth After Cesarean. AAFP guideline. 2014.