DEBRE TABOR UNIVERSITY

COLLEGE OF HEALTH SCIENCES

DEPARTEMENT OF MEDICINE

Success Rate and Associated Factors of Vaginal Birth After

Cesarean Section at Debre Tabor Comprehensive Specialized
Hospital, South Gondar Zone, Ethiopia, 2021

By: Gizat Feleke (Medical Intern)

January 21,2021 Debre Tabor, Ethiopia

Success Rate and Associated Factors of Trial of Labor After
Cesarean Section at Debre Tabor Comprehensive Specialized
Hospital, 2021

By: Gizat Feleke (Medical Intern)

Email: seleshfeleke12@gmail.com

Tel: 251918655167

January 21,2021

Debre Tabor, Ethiopia

i
A research paper to be Submitted to Debre Tabor University College of
Medicine and Health Sciences in a Partial Fulfillment of the
Requirements for Degree of Doctor of Medicine.

ii
Success Rate and Associated Factors of Trial of Labor After Cesarean Section
at Debre Tabor Comprehensive Specialized Hospital, 2021

By: Gizat Feleke (Medical Intern)

Advisors: Dr. Yenehun (MD+, OBGYN) and Mrs. Tsion Dessalegn (MSc.),
Debre Tabor University

iii
Declaration

I, hereby declare, undersigned that the work original and a result of my own study has not
been submitted for another degree award in this or any other university or institution.
Name: Gizat Feleke
Signature
Date21/1/2021
E-mail: seleshfeleke12@gmail.com
Place. Debre Tabor University
Date of submission:21/1/2021
Supervisors’ signatures
1).……………
Date……………
2) ………………………
Date……………………………

iv
 1 Contents
List of tables .......................................................................................................................................... vii
ABBREVIATIONS AND ACRONEMS .........................................................................................................viii
ACKNOWLEDGMENT .............................................................................................................................. ix
Abstract .................................................................................................................................................. 1
1 INTRODUCTION ............................................................................................................................... 4
1.1 Back Ground Information ......................................................................................................... 4
1.2 Statement of the problem ........................................................................................................ 5
1.3 Literature Review ..................................................................................................................... 8
1.3.1 Success rate of TOLAC ...................................................................................................... 8
1.3.2 Factors Associated with TOLAC ......................................................................................... 9
1.4 Justification of the Study ........................................................................................................ 11
2 OBJECTIVES.................................................................................................................................... 12
2.1 General Objective .................................................................................................................. 12
2.2 Specific Objectives ................................................................................................................. 12
3 METHODS...................................................................................................................................... 12
3.1 Study Design and Period......................................................................................................... 12
3.2 Study Area ............................................................................................................................. 13
3.3 Source Population .................................................................................................................. 13
3.4 Study Population .................................................................................................................... 13
3.5 Eligibility ................................................................................................................................ 14
3.5.1 Inclusion Criteria: ........................................................................................................... 14
3.5.2 Exclusion criteria: ........................................................................................................... 14
3.6 Sample Size ............................................................................................................................ 14
3.7 Sampling procedure ............................................................................................................... 14
3.8 Variable ................................................................................................................................. 14
3.8.1 Dependent variable ........................................................................................................ 14
3.8.2 Independent variables .................................................................................................... 15
3.9 Operational Definitions .......................................................................................................... 15
3.10 Data Collection tools and procedures ..................................................................................... 16
3.11 Data Quality Control............................................................................................................... 16
3.12 Data Compilation and Analysis ............................................................................................... 16

v
 3.13 Ethical consideration .............................................................................................................. 16
4 RESULTS ........................................................................................................................................ 17
4.1 Socio-demographic characteristics of the respondent ............................................................ 17
4.2 Obstetrics history ................................................................................................................... 17
4.3 Success rate of VBAC .............................................................................................................. 20
4.4 Factors associated with success of VBAC ................................................................................ 20
4.5 Discussions............................................................................................................................. 22
Limitation of the study....................................................................................................................... 24
4.6 Conclusion ............................................................................................................................. 24
4.7 Recommendation................................................................................................................... 25
5 ANEX ............................................................................................................................................. 26
5.1 References ............................................................................................................................. 26
5.2 Questioner ............................................................................................................................. 27

vi
 List of tables
Table 1 Socio demographic characteristics of mothers who had previous one caesarean scare and tried for
VBAC in DTCSH, 2020 ........................................................................................................................ 18
Table 2 Obstetric history of mothers who had previous one caesarean scare and tried for VBAC in
DTCSH, 2020 ....................................................................................................................................... 18
Table 3: Factors significantly associated with success rate of VBAC ..................................................... 21

vii
ABBREVIATIONS AND ACRONYMS
ANC …………………………Antenatal Care

CS…………………………. Cesarean Section

GA………………………. Gestational Age

DTCSH………………. Debre Tabor Comprehensive Specialized Hospital,

LNMP………………………………. Last Normal Menstrual Period

NRFHRP………………. Nonreasuring Fetal Heart Rate Pattern

TOL……………………………………………. Trial of Labor

TOLAC ……………………………………. Trial of Labor After Cesarean

VBAC…………………………………………Vaginal Birth After Cesarean

WHO………………………………………? World Health Organization

viii
ACKNOWLEDGMENT

I would like to pass my gratitude to Dr. Yenehun (MD+, OBGYN) who has helped since
the preparation of my proposal until I finished my research with his constructive ideas
and comments. My deepest appreciation as well as great respect goes to Mrs Tsion
Dessalegn who actively assisted me by directing literature sites and commenting the
whole segments of research.

In doing this research, I have taken the guide lines of some respected persons who
deserve greatest gratitude and finally great thanks reach to my friends who actively
assisted me.

ix
Abstract

Background

Vaginal delivery is the route of delivery by which most of fetuses are delivered. Of the
delivery routes, spontaneous vaginal vertex delivery poses the lowest risk of most
maternal comorbidity, and comparisons with cesarean delivery (1)

Successful vaginal birth after cesarean section is more comfortable than repeat
emergency or elective cesarean section (2)

Cesarean section has classically been defined as delivery of a fetus through a surgically
created incision in the anterior uterine wall (3).

Vaginal delivery after previous one cesarean section for a non-recurring indication has
been described by several authors as safe and having a success rate of 60–80% (4).

Hence many centers are offering TOLAC for candidates leaving the century old dictum
of once cesarean always cesarean (5).

Studies on predictors of success are few and most of them conducted in developed
countries and difficult to generalize.

Objective:
This study was conducted to assess the success rate and associated factors of Trial of
Labor After Cesarean section at Debre Tabor Comprehensive Specialized Hospital,
Debre Tabor, Northern Ethiopia from June 1 – September 30, 2020.

1
Methods

Hospital based cross-sectional retrospective study design was conducted at Debre Tabor
Comprehensive Specialized Hospital to assess success rate of Trial of Labor After
Cesarean section and associated factors among mothers with one previous cesarean
section and offered trial of labor from June 1 – September 30, 2020.

All 46 mothers with one pervious cesarean scar who gave live birth within the study
period were included in the study by their card number documented on card. The data
was collected from patients’ charts registration books, operation registration books and
individual charts after tracing by patient’s medical record number by the researcher.

After checking the completeness, the collected data was entered and coded by using
SPSS software/ version 25. In descriptive statistics tables, mean and frequency were
used. Logistic- regression also used to identify the association between dependent and
independent variables. P-value<0.05, and odds ratio was calculated to identify the
association. Then the data was presented and interpreted.

Result

From a total of 46 mothers who had previous one caesarean scar and have live birth,
about 19 (41.3%) were in the age group 26-35 years with mean age of 30 years and more
than half were urban residents 29 (63%).

Most of the study subjects 27 (58 %) were gravida 3 or 4 and para two 38(82%), majority
of them were term by their gestational age 26(56.5%) and 37(80.4%). had
at least one ANC visit.

Half of the mothers had had station at zero or below at the time of admission 23 (50%)
and about 20(43%) of them had cervical dilatation of 8-10cm at admission,
Unknown indication and non-reassuring fetal heart rate patterns were the commonest
indications for pervious caesarean section 16(34%). The success rate of VBAC in this
study was 30.4%
Previous history of vaginal birth after cesarean section and residency of the pregnant
mother were significant factors associated with success of VBAC.

2
Mothers who live in the urban areas are 81% times unlikely to give successful vagina
birth after one cesarean section.
Those mothers who have previous successful vaginal delivery are 80% times likely to
deliver vaginally after one cesarean section.

Conclusion and recommendation

This study revealed that successful vaginal delivery after one previous cesarean scar is
lower comparing to studies done in other areas of Ethiopia, Africa and different countries
of the world even the standard.
Previous history of successful vaginal delivery and resident of the mother were
significant factors associated with success of VBAC.
It is recommended to include maternal educational and marital status on the patients’
medical record and it is better to prepare a separate registration book for those mothers
who tried TOLAC.

3
 1 INTRODUCTION

1.1 Back Ground Information

Vaginal delivery is the route of delivery by which most of fetuses are delivered. Of the
delivery routes, spontaneous vaginal vertex delivery poses the lowest risk of most
maternal comorbidity, and comparisons with cesarean delivery(1).

Successful vaginal birth after cesarean section is more comfortable than repeat
emergency or elective cesarean section (2).

Antenatal examinations are important in selection for trial of labor, while birth
management can be difficult when the patients present at emergency
condition (1-2).

Cesarean section has classically been defined as delivery of a fetus through a surgically
created incision in the anterior uterine wall. It is the most frequently performed surgical
procedure worldwide (3).

Women eligible for vaginal birth after cesarean (VBAC) section have lower morbidity
rates than women who undergo subsequent elective cesarean sections (CSs). However,
women undergoing intrapartum CS have relatively higher morbidity rates (4).

The most appropriate mode of subsequent delivery of women with prior caesarean birth
continues to be a subject of intense research and debate in contemporary obstetric
practice. This controversy remains a major public health issue because the two options
for delivery [1,4].

Planned elective repeat caesarean or planned vaginal birth in a subsequent pregnancy for
these cohort of woman with a previous caesarean birth are associated with both
significant maternal and perinatal benefits and risks (5).

Vaginal birth after caesarean delivery (VBAC) has long been proposed as a viable
measure to reduce overall caesarean delivery rates in both developed and developing
countries. It has been found to be safe with careful patient selection and good
management of labor with success rates ranging between 60% and 80%(6).

4
 The American College of Obstetricians and Gynecologists (ACOG) provides guidelines
for birth interventions and for treating complications that may arise during VBAC (eg,
uterine rupture and maternal and fetal death); several studies have recommended various
approaches to identify patients who may undergo VBAC (8).

1.2 Statement of the problem

The trend of increasing cesarean section (CS) rates had evoked worldwide attention for
both healthcare workers and general population. Many articles revealed the trend of a
steady rise of CS rates globally in the past 2 decades (1).

According to the World Health Organization (WHO) recommendation, CSs should be

performed only when medically necessary. Unfortunately, this recommendation fails to
reverse the increasing trend of CS rates. Among the group of cesarean deliveries,
repeated CS due to prior one’s account for a remarkable proportion (2).

Vaginal birth after cesarean section (VBAC) is an alternative to repeated CSs. It peaked
during the mid-1990s along with a lower total CS rate (3)

A dramatic drop of the percentage of VBAC since that point of time accompanied with a
steady increase of CS rates was explored till the present time. Several national medical
associations have provided practice guidelines for VBAC. However, the evidence is
inconsistent and the effect on VBAC rates is unclear (4). Women eligible for vaginal
birth after cesarean (VBAC) section have lower morbidity rates than women who
undergo subsequent elective cesarean sections (CSs). However, women undergoing
intrapartum CS have relatively higher morbidity rates. By the beginning of the 20th
century, cesarean delivery had become relatively safe. But, as women survived the first
operation and conceived again, they were now at risk for rupture of the uterine scar. Still,
the specter of rupture did not did not result in strict adherence to repeat cesarean delivery
(5).

5
Many approaches were introduced to diminish cesarean section rates. Vaginal birth after
cesarean section (VBAC) is a route of delivery with diverse agreements (6).

Caesarean delivery has classically been defined as delivery of a fetus through a surgically
created incision in the anterior uterine wall. It is the most frequently performed surgical
procedure worldwide (7).

Previous caesarean section has been found to be the commonest cause of increased
caesarean section rate in many parts of the world [8]. Because of increased risk of
maternal complications with repeat caesarean section and safety of TOLAC, trial of labor
for selected group of patients with previous scar has become a preferred strategy (9).

The most appropriate mode of subsequent delivery of women with prior caesarean birth
continues to be a subject of intense research and debate in contemporary obstetric
practice.(7,8)

This controversy remains a major public health issue because the two options for
delivery: planned elective repeat caesarean or planned vaginal birth in a subsequent
pregnancy for these cohort of woman with a previous caesarean birth are associated with
both significant maternal and perinatal benefits and risks. Vaginal birth after caesarean
delivery (VBAC) has long been proposed as a viable measure to reduce overall caesarean
delivery rates in both developed and developing countries. It has been found to be safe
with careful patient selection and good management of labor with success rates ranging
between 60% and 80% (10).

Vaginal birth after cesarean section (VBAC) is associated with shorter maternal
hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer
thromboembolic events than cesarean delivery.

Women who have undergone a previous cesarean delivery have the option of proceeding
with a trial of labor after cesarean (TOLAC) delivery or planned repeat cesarean delivery
in a subsequent pregnancy (11).

Planned TOLAC may result in labor with vaginal birth (VBAC) or unplanned
intrapartum cesarean delivery. Decision-making regarding mode of delivery must take

6
into consideration the patient's personal preferences, obstetrical history, scientific data on
risks and benefits of TOLAC versus PRCD, and availability of TOLAC in the selected
birth setting (10,11).

Mother’s choice on mode of delivery is the most important single factor in offering trial
of labor. Even those factors found to be associated with successful TOLAC vary from
center to center. In1988 ACOG recommended that, in the absence of a contraindication, a
woman with one previous low transverse cesarean delivery be counseled to attempt labor
in a subsequent pregnancy [11]. Several reports have indicated that the absolute risk of
uterine rupture attributable to a trial of labor is about 1 per 1000 (12).

10% of the obstetric population has had a previous cesarean delivery, more widespread
use of TOLAC has the potential to decrease the overall rate of cesarean delivery.
The purpose of this study is to identify determinants of successful TOLAC in Debre
Tabor compressive specialized Hospital. This is of great help for physicians in the joint
physician-patient decision while offering TOLAC.

7
1.3 Literature Review

1.3.1 Success rate of TOLAC

It has been suggested that about two thirds of women with a prior cesarean delivery are actual
candidates for a TOLAC, most planned repeat operations are influenced by physician discretion
and patient choice. Successful vaginal birth after cesarean section is more comfortable than
repeat emergency or elective cesarean section (10).

Women eligible for vaginal birth after cesarean (VBAC) section have lower morbidity rates than
women who undergo subsequent elective cesarean sections (10,11).

A 60 to 80% success rate of vaginal birth after previous caesarean section has been reported by
many authors if the primary caesarean was done for nonrecurring indications (1,2).

In 2013, the success rate for women in the United States who attempted TOLAC after one
previous cesarean delivery was 70.4 percent and was 51.4 percent for those with two or more
prior cesarean deliveries [13].

In a population-based cohort study of 41,450 women delivering in California hospitals, it is

reported that success rate of TOLAC 74 percent when no maternal, fetal, or placental
complications were present (5-7).

British figures indicate that among women with a prior caesarean section, 33% will successfully
achieve vaginal birth in the subsequent pregnancy. One study in Lahore reported Successful
vaginal delivery after one previous cesarean section is 70% [7].

The rate of successful VBAC among the women who chose TOLAC was 84.93% in a
retrospective study in MacKay Memorial Hospital, Taipei, Taiwan (12).

A retrospective study conducted In Southeastern Anatolia, Turkey in 2015 showed that vaginal
birth after cesarean section was successful in 55% of cases (8).

The VBAC rate of hospitals in sub-Saharan Africa is between 37 to 97%. A Meta-analysis done,
in sub-Saharan countries showed a VBAC success rate of 63–75% (12)

8
A retrospective study done in Ghana Accra hospital showed that the success rate of VBAC is
61.2% (13).

A retrospective study carried out at Usman Danfodiyo University Teaching Hospital, Sokoto-
Nigeria in 2019. the success rate of VBAC is 66.9%. (14).

Based on observational study conducted at Tu Du Hospital in Vietnam in 2014, the success rate
of TOLAC was 54.14% (10). A Meta-analysis done, in sub-Saharan countries showed a TOLAC
success rate of 63–75% [5].

According to Hospital based cross-sectional retrospective study done in 2016 at Attat Lord
Merry Primary Hospital, Gurage Zone, South Ethiopia Successful vaginal delivery after one
previous cesarean scar was 45.5% (11). The VBAC success rate was 49% in a case control study
done in three teaching hospitals in Addis Ababa (9)

1.3.2 Factors Associated with TOLAC

Caesarean rate is increasing in Ethiopia because of the flourishing private hospitals in

major towns. Even though teaching hospitals offer trial of labor for mothers with one
scar, there is no study done which shows the rate of VBAC acceptance and success in
Ethiopian Hospitals (9).

Women with a prior vaginal delivery had an 87% TOLAC success rate, compared with a
61% success rate in women without a prior vaginal delivery.

Previous caesarean section has been found to be the commonest cause of increased
caesarean section rate in many parts of the world [1]. For patients with a prior TOLAC,
the success rate was 93%, compared with 85% in women with a vaginal delivery before
their cesarean birth but who had not had a successful VBAC [2].

9
Because of increased risk of maternal complications with repeat caesarean section and
safety of VBAC, trial of labor for selected group of patients with previous scar has
become a preferred strategy (5).

The prior indication for cesarean delivery clearly impacts the likelihood of successful
VBAC. A history of prior vaginal birth or a nonrecurring condition such as a breech or
fetal distress is associated with the highest success rates for VBAC. Although many
authors have attempted to predict the success of VBAC based on present and prior labor
characteristics, such scoring systems are at best only moderately successful.
Understanding that there is no reliable method to predict success of a TOL for an
individual woman, a number of factors that have been studied are summarized in the
following sections (3).

Success rates for women whose first cesarean delivery was performed for a nonrecurring
indication (breech, Nonreasuring fetal well-being) are similar to vaginal delivery rates for
nulliparous women (4).

Prior cesarean delivery for a breech presentation is associated with the highest reported
success rate of 89 percent. In contrast, prior operative delivery for cephalopelvic
disproportion/failure to progress is associated with success rates ranging from 50 to 67
percent (5-6). Prior vaginal delivery including prior successful VBAC can be considered
the greatest predictor for successful TOL. In one series, prior vaginal delivery had an 87-
percent success rate compared with a 61-percent success in women without a prior
vaginal delivery.

Women with more than one prior cesarean delivery have been demonstrated to
consistently have a lower likelihood of achieving VBAC. Studies reported that a 75-
percent success rate for women with one prior cesarean delivery compared with 62
percent in women with two prior operations. Both labor status and cervical examination
upon admission influence the success of a TOL (11).

A crosectional study done at Attat Lord Merry Primary Hospital, Gurage Zone, South
Ethiopia showed that women who had passage of liquor at admission
, history of vaginal birth after cesarean, cervical dilation at admission and type of

10
 indication for pervious cesarean section were significant factors associated with success
of VBAC (12).

Three fourth (75%) of mothers who had passage of liquor at admission were less likely to
have successful VBAC when compared to no history of passage of liquor at admission.
Those mothers who had history of vaginal birth after cesarean section were almost 2
times more likely to have successful VBAC than counterparts. Those mothers who had
dilated cervix at admission (>=4 cm) were 8 times more likely to have successful VBAC
than counter parts. One third (30%) of mothers with NRFHR as an indication for
pervious cesarean section were less likely to have successful VBAC than those mothers
with unknown indication (11)

A case control study conducted in three teaching Hospitals in Addis Ababa, Ethiopia in
2013 reported that the strongest factor determining success rate of VBAC was cervical
dilatation at admission. Those who were admitted with cervical diameter greater 3 cm
(Active first stage of labor) had a strong likelihood of vaginal delivery than those
admitted at cervical diameter of less than or equal to 3 cm (latent first stage of labor)(8).

The study concluded that the main determinants which affects successful VBAC include
history of stillbirth, history of successful VBAC in the past, rupture of membrane,
absence of meconium, cervical stage of labor at admission, position of the presenting
part, duration of labor, and knowledge of the previous indication for the past cesarean
section (9)

1.4 Justification of the Study

Little has been published about TOLAC in Ethiopia specially in Amhara region as well
as in Debre Tabor Comprehensive Specialized Hospital.

Conducting a research on Success rate and associated factors of Trial of Labor After
Cesarean Debre Tabor Comprehensive Specialized Hospital could help for physicians in
the joint physician-patient decision while offering Trial of Labor After Cesarean section.

11
 This is also important to identify maternal demographic, past and present obstetric
determinants of successful TOLAC in Debre Tabor Comprehensive Specialized Hospital.

The finding could serve as base line information for further study in this area.

2 OBJECTIVES

2.1 General Objective

To assess success rate and associated factors of Trial of Labor After Cesarean section in
Debre Tabor Comprehensive Specialized Hospital in South Gondar Zone, Amhara
region, Ethiopia from June 1 – September 30, 2020.

2.2 Specific Objectives

To determine success rate of Trial of Labor After Cesarean section.

To identify determinant factors for successful Trial of Labor After Cesarean section

3 METHODS

3.1 Study Design and Period

cross-sectional study design was conducted at Debre Tabor Comprehensive Specialized Hospital
in the time period between June 1– September 30, 2020.

12
3.2 Study Area

The study was conducted in Debre Tabor Comprehensive Specialized Hospital which is
located in Keble 01, Debre Tabor Town, South Gondar Zone, Amhara region, 661 km to
north of the capital Addis Ababa (Ethiopia). The Hospital was founded in 1923 by
Norwegian Missionaries and served as General Hospital for many decades and currently
serves approximately 3.5 million people in its catchment area and used as a teaching
hospital for different disciplines of medical and health sciences students of DebreTabor
University. It is changed to comprehensive specialized Hospital by this year ,2013 E.C. It
has five major clinical departments (Internal medicine, surgery, pediatrics, NICU and
Gyn/Obs) and three minor departments (psychiatry, Ophthalmology, and Dentistry) along
with other follow up and special clinics for specific diseases. Currently, it has total of 439
staffs (internist 2, surgeon3, pediatrician 2, GYN/Obs3,150 nurses, 8 Health officers,5
IEOS,36 midwives, 33GP,27 pharmacists, ophthalmic BSc 4, 1 Radiologist,14
Laboratory technician,7 HIT diploma, cleaners 3, admission officer 1, liason 2,
radiographer diploma 5, laboratory aid 2,7 medical laboratories,6 Anesthetist, 1
ophthalmologist, 1 Dentist, 104 administrative staffs (DTCH Administrative office).

3.3 Source Population

All mothers with pervious one cesarean scar who give birth in Debre Tabor
Comprehensive Specialized Hospital

3.4 Study Population

Those selected mothers who had one previous cesarean section who are admitted to
delivery department and indicated for trial of labor at Debre Tabor Comprehensive
Specialized Hospital in the study period.

13
3.5 Eligibility
3.5.1 Inclusion Criteria:
One low transverse previous incision in uterus
Gestational age ≥28 weeks
Singleton pregnancy
Cephalic presentation

3.5.2 Exclusion criteria:

Stillbirth
Congenital malformations
previous uterine surgery like myomectomy

3.6 Sample Size

All mothers with one pervious cesarean scar and give live birth in Debre Tabor
Comprehensive Hospital from June 1 – September 30,2020 were included in the study
which was 46.

3.7 Sampling procedure

The card of those mothers who give vaginal birth after one cesarean section was traced
by their card number documented on logbooks in the labor ward and discharge
summaries on postnatal ward.

Those offered TOLAC and undergo repeat cesarean were identified from the log books in
the labor ward and operation room in the study period.

3.8 Variable
3.8.1 Dependent variable
success rate of VBAC

14
3.8.2 Independent variables
Age

Residence

Gravidity

Parity

ANC follow up

GA
Duration of labor

Cervical dilatation

Station

Pervious indication for cesarean section

Rupture of membrane

Duration of rupture of membrane

History of vaginal birth after cesarea

3.9 Operational Definitions

Successful TOLAC- A vaginal delivery (spontaneous or assisted) in a woman who had

one previous cesarean section.
Failed TOLAC -A condition in which mothers who are a candidate for trial of labor after
one previous cesarean section have opted for repeated cesarean section after she tried
TOLAC for spontaneous onset of labor and when there is intrapartum problem like fetal
problems, poor progress of labor or she decline for TOLAC.

Decline for TOLAC- Those pregnant women who are candidates for TOL and
convinced to labor to deliver vaginally on her ANC follow up and presented at the labor
ward with spontaneous onset of labor and after some time of labor she request for
repeated cesarean section.
15
3.10 Data Collection tools and procedures
The data was collected from patients’ charts registration books, operation registration
books and individual charts after tracing by patient’s number by the researcher. The
information was collected using a structured check list which includes maternal socio
demographic, past and present obstetric experience, mode of delivery.
The check list was prepared in English and information abstracted from medical record
books.

3.11 Data Quality Control

Day to day data quality assurance was carried out during the whole period of data
collection. At the end of each day, the data was reviewed and cross check for
completeness, accuracy and consistency

3.12 Data Compilation and Analysis

After checking the completeness, the collected data was entered and coded by using
SPSS software/ version 25. In descriptive statistics tables, mean and frequency was used.
Logistic- regression also used to identify the association between dependent and
independent variables. P-value<0.05, and odds ratio was calculated to identify the
association. Then the data was presented and interpreted

3.13 Ethical consideration

An Ethical clearance was obtained from a Research Ethics committee of College of
Medicine and Health Sciences, Debre Tabor University.
The permission and agreement consent were taken from Debre Tabor Comprehensive
Specialized Hospital prior to the study after a brief explanation of the purpose of the
study. In addition, other concerned bodies (hospital medical directors and health care
providers) were informed and briefed about the study before the start of data collection.
The anonymity of the patient's medical records was kept confidential

16
4 RESULTS

4.1 Socio-demographic characteristics of the respondent

Data was obtained from a document of 46 mothers with one previous cesarean section with the
response rate of 100%. From a total of 46 mothers who had one previous caesarean scar and give
live birth, about 19 (41.3%) were in the age group 26-35 years with mean age of 30 years and
more than half were urban residents 29 (63%) (Table 1).

4.2 Obstetrics history

Most of the study subjects 27 (58 %) were gravida three or four and para two 38(82%) , majority
of them were term by their gestational age 26(56.5%) and 37(80.4) had at least one ANC visit.
For more than three- fourth of the mothers, they had no passage of liquor at admission and no
history of VBAC 35 (76.1%), 36(78%) respectively.
Half of the study subjects have had station at zero or below at the time of admission 23 (50%)
and about 20(43%) of them had cervical dilatation of 8-10cm at admission. Among those
mothers included in the study, 32 of them underwent cesarean section, the remaining 14 were
delivered vaginally.
Unknown indication and non-reassuring fetal heart rate patterns were the commonest indications
for pervious caesarean section 16(34%).
The exposure variables which were studied in this research were: demographic variables like age
place of residence and obstetric history, past obstetric performance, and current obstetric
variables like Status of membrane, duration of rupture of membrane, cervical status, duration of
labor.

17
Table 1 Socio demographic characteristics of mothers who had previous one caesarean scare and tried for
VBAC in DTCSH, 2020

Variables Category No Percent

age of the mother <25 14 30.4%
26-35 19 41.3%
36-40 9 19.6%
>40 4 8.7%
Residence of the Urban 29 63.0%
mother Rural 17 37.0%

Table 2 Obstetric history of mothers who had previous one caesarean scare and tried for VBAC
in DTCSH, 2020

Variables Frequency Percent

gravidity of the mother 2 0
3-4 27 58.7
>4 18 39.1
4.00 1 2.1
Parity of the mother 1 8 17.4
>=2 38 82.6
ANC follow up yes 37 80.4
No 9 19.7
Gestational age by weeks from 28-36+6 9 19.6
LNMP 37-40 26 56.5
>40 11 23.9

18
Station of the presenting part at above 0 17 37
admission 0 or below 23 50
not done 6 13
cervical dilatation at admission <4cm 12 26.1
4-8cm 20 43.5
8-1ocm 14 30.4
Rupture of membrane at Yes 11 23.9
admission No 35 76.1
duration of rupture of .00 23 50
membrane <=12hrs 6 13
>12hrs 5 10.9
duration of labor <4hrs 20 56.5
>4hrs 26 43.5
indications for previous NRFHRP 16 34.7
cesarean section
malpresentation 7 15.2
CPD 7 15.2
Unknown 16 34.7
previous history of VBAC Yes 10 21.7
No 36 78.2
route of current delivery SVD 14 30.4
CS 32 69.7

19
4.3 Success rate of VBAC

Among 46 study subjects who gave live birth in the study period, 14 of them gave birth vaginally
and the remaining 32 of them underwent repeated cesarean section.

Based on this study the success rate of trial of labor after cesarean section was 30. 4%

4.4 Factors associated with success of VBAC

The association between independent variables and success of VBAC was checked by binary
logistic regression model to identify candidate variables (P<0.05). During bivariate analysis,
residency, cervical dilatation at admission, duration of labor, history of vaginal birth after
cesarean section were candidate variables identified for the final model.
In multivariate logistic regression after it was adjusted for the variables in the model, previous
history of vaginal birth after cesarean section (AOR: 2.31, 95% CI:0. 0.021,0.823) residency of
the pregnant mother ((AOR: 0.218, 95% CI: 0.036,.984)) were significant factors associated
with success of VBAC.
Mothers who live in the urban areas are 78% times less likely to give successful vagina birth
after one cesarean section.
Those mothers who have previous successful vaginal delivery are 2.3 times likely to deliver
vaginally after one cesarean section.

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Table 3: Bivariate and multivariable logistic regression model showing factors associated with
success of VBAC among mothers who had previous one caesarean scare in DTCSH 2021

Variables Success of rate COR

of VBAC 95%CI AOR 95%CI P value

Yes No
Residence of urban 12 17 .189 .218(0.036,.984) .045*
the mother
rural 2 15 1 1 -
Previous Yes 6 8 3.31 2.3(1.231,8.3241) .031*
history of
VBAC No 4 28 1 1 -
Cervical <4cm 1 11 11 2.982(1.124,7.909) .744
dilatation 4-8cm 6 14 2.33 .921(.021,1.342) .132
8-10cm 7 7 1 1 -
Duration of <4hrs 3 9 1.674 1.674(.297,9.422) .559
labor
>4hrs 11 23 1 1 -

(*) Variables with significant association with VBAC

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4.5 Discussions

In this study, majority of mothers were multipara 38(82.1%) despite same age range with
other studies which is high comparing to other reports from Addis Ababa and Nigeria (5),
this difference may be due to lack of family planning in this study subjects.
The ANC visit in this study is about 80.4% which is near to a study done in southern
Ethiopia which is 81%, this closeness might be due to similar understanding of
importance of ANC by pregnant mothers and similar health facility access (11)

Previous caesarean section was said to constitute the highest single indication for
repeated caesarean section because obstetricians still regard vaginal birth after previous
caesarean section as a high-risk option. This study revealed that common mode of
delivery was repeated caesarean section 32 (56.3%), NRFHRP and unknown indications
were the major indication for repeated caesarean section that may be due to inappropriate
diagnoses NRFHRP and poor documentation of previous indication for cesarean section
and inability of the mother to recall the previous indication. This study was conducted
with the main objective of determining success rate and identifying factors associated
with successful vaginal delivery on mothers who offered trial of labor after previous one
caesarean section.
Based on the result, significant factors associated with success of VBAC were previous
history of vaginal birth after cesarean section, and residency of the pregnant mother.
The VBAC success rate vary from place to place 30.4.% (in my study) was smaller than
reported from three teaching hospitals in Addis Ababa (49%), Attat Lord Merry Primary
Hospital, Gurage Zone, Southern Ethiopia (45.5%), sub-Saharan countries showed (63–
75%), 61.2% in Ghana Accra Hospital, 66.9% at Usman Danfodiyo University Teaching
Hospital, Sokoto-Nigeria and 84.93% A in MacKay Memorial Hospital, Taipei, Taiwan. In
my study the success rate of VBAC was lower than the standard accounts 60-80% (12-14).

This discrepancy may be due to the variety types of indication diagnosed and applied for
the previous cesarean section. Most probably if true NRFHRP was an indication for the
previous cesarean section, VBAC would not fail in the next delivery. This indication may

22
not appear during trial of VBAC but sometimes it can be the recurring indication in those
mothers with known chronic illness which causes fetal distress that is why the success rate
is low comparing to other studies since no documentation on maternal chronic illness
status on the chart. The other possible reason for that result could be poor labor ward
facility to follow fetomaternal condition during labor and delivery so that obstetricians
consider every pregnancy with previous cesarean scar is high risk which leads to early
repeated cesarean section in my study area.

In this study, the strongest predictor determining success of VBAC was previous history
of success full vaginal delivery after cesarean section. Many authors reported previous
vaginal birth was the single best predictor for successful VBAC (2,11). In my case those
mothers who has previous history of vaginal delivery are 2.3 times likely to have
successful vaginal delivery in the next pregnancy. This is similar with those studies
conducted in Ethiopia, Africa as well as other different countries of the world (8,11,14).
The other significant factor which determine success of VBAC in this study was place of
residency of the mother. In the result of this study, those mothers who live in the urban
area are 78% times less likely to give vaginal birth after one cesarean section comparing
to those in the rural area. There is no study which showed this association but this
association could be due to inappropriate cesarean section called opted cesarean section.

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 Limitation of the study
1. Unavailability of adequate information on the patient’s medical record like
educational status, marital status.
2. There was no separated logbook in labor and delivery unit for those mothers
who tried TOLAC before this study was started
3. limited number of cases in the study period.
4. Limitation of cross-sectional study like:

– being not useful to events of short duration.

– giving information on prevalence only.

4.6 Conclusion

This study revealed that successful vaginal delivery after one previous cesarean scar is
lower comparing to studies done in other areas of Ethiopia, Africa and different countries
of the world even the standard.
Based on this study, previous history of successful vaginal delivery and resident of the
mother were significant factors associated with success of VBAC.
Those mothers who has previous history of vaginal delivery has high chance of giving
vaginal delivery in the next pregnancy whereas those who live in the urban area are less
likely to give vaginal birth after cesarean section in the next pregnancy.

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4.7 Recommendation

➢ Whenever possible, our women should always be availed of this safer and relatively less
expensive option (when compared to caesarean section) of still fulfilling their cherished
and long-held dream of achieving the more natural vaginal delivery after they have had
one caesarean section.
➢ Adequate patient education and counselling in addition to appropriate patient selection
remains the cornerstone to achieving a high VBAC success rate with minimal adverse
outcomes.
➢ It is recommended to include maternal educational and marital status on the patients’
medical record
➢ It is better to prepare a separate registration book for those mothers who tried TOLAC.
➢ It is better to document clearly the indications for previous cesarean section they have
done and tell to the client about the indication.
➢ It is better to recommend clients to recall the indication for previous cesarean section.

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 5 ANEX

5.1 References

1. American College of Obstetricians and Gynecologists (ACOG): ACOG Practice Bulletin:

vaginal birth after previous cesarean delivery: Clinical management guidelines. Int J Gynecol
Obstetric 2004, 54:197–204.

2. Steven G. Gabbe, MD: Vaginal Birth After Cesarean Delivery, 2017, 7th edition, 20:444.

3.Williams Obstetrics: Prior Cesarean Delivery, 2018 ,25th edition:

4. Up-to-date version 2018, vaginal birth after cesarean delivery: 2018

5. Boulvain M, Fraser WD, Brisson-Carroll G, Faron G, Wollast E: Trial of

labor after caesarean section in sub-Saharan Africa: a meta-analysis.
BJOG 1997, 104:1385–1390
6. Jodie MD, Caroline AC, Janet EH, Ross RH, Jeffery SR: Vaginal birth
after caesarean. BMC Childbirth and Pregnancy 2007, 7:17.
7. Taj G, Sohail N, Cheema SZ, Zahid N, Rizwan S: Review of Study of Vaginal Birth After
Caesarean Section (VBAC). Annals 2008,
14(1):13–16
8. Mehmet Baki senturk, Yusuf cakmak, Halit atac, Mehmet sukru Budak: Factors associated
with successful vaginal birth after cesarean section and outcomes: International Journal of
Women’s Health 2015:7

9.Malede Birara and Yirgu Gebrehiwot: Factors associated with success of vaginal birth
after one caesarean section at three teaching hospitals in Addis Ababa, Ethiopia: a case control
study. BMC pregnancy child birth.2013;13:31

10. Tuan Vo Minh, Hien Nguyen Phuoc: the success rate and associate factors of vaginal birth
after cesarean section at Tu Du Hospital in Vietnam: Prospective observation study. Int J Pregn
& Chi Birth. 2018;4(3):125‒129. DOI: 10.15406/ipcb.2018.04.00096

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11. Siraneh Y, Assefa F, Tesfaye M (2018): Feto-Maternal Outcome of Vaginal Birth after
Cesarean and Associated Factors Among Mothers with Previous Cesarean Scar at Attat Lord
Merry Primary Hospital, Gurage Zone, South Ethiopia. J Preg Child Health 5: 390. Doi

12. Boulvain M, Fraser WD, Brisson-Carroll G, Faron G, Wollast E: Trial of labor after
caesarean section in sub-Saharan Africa: a meta-analysis. BJOG 1997, 104:1385–1390

13. JD Seffah and K Adu-Bonsaffoh: vaginal birth after previous cesarean section: current trends
and outlook in GHANA: journal of the west African college of surgeons

14. E. shehu, aliyu m. chapa, marcus n. mbakwe and abubakar a. panti: vaginal birth after
caesarean section (VBAC): ejpmr, 2019,6(8), 59-64: European Journal of Pharmaceutical and
Medical Research

5.2 Questioner

Table 3: Socio demographic characteristics of mothers who had previous one caesarean
scare and tried for TOLAC at Debre Tabor Comprehensive Specialized Hospital, south
Gondar Zone, June 1 – September 30, 2020

Introduction and consent

Hello. My name is…………………. and I am student of DTU.I am
conducting an institutional based research about success rates of trial of labor after one
previous cesarean section. I would very much appreciate your participation in this study.
Whatever information you provide will be kept strictly confidential, and will not be
shared with

27
 anyone other than me. Participation in this research is voluntary, and if I should come to
any questions you don’t want to answer, just let me know and I will go on to the next
question; or you can stop the interview at any time. However; I hope you will participate
in the study since your views are important
At this time, do you want to ask me anything about the study?
Would you be willing to participate? A, Yes B, No
Signature of the respondent: ----------------------
Interviewer Signature: ------------------------------ Date: --------------------------------.

Sociodemographic and obstetric history of those mothers with one previous cesarean section

MRN Age Gravid Parity GA Indicatio Cervical ROM Durat History Station Duratio
ity n for dilatatio ion of VBAC n of
previous n at ROM labor
C/S admissio
n

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