Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Vaginal birth after one previous caesarean section

in a tertiary institution in Nigeria

AO Aisien & AU Oronsaye

To cite this article: AO Aisien & AU Oronsaye (2004) Vaginal birth after one previous caesarean
section in a tertiary institution in Nigeria, Journal of Obstetrics and Gynaecology, 24:8, 886-890

To link to this article: http://dx.doi.org/10.1080/01443610400018742

Published online: 02 Jul 2009.

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 Journal of Obstetrics and Gynaecology (November 2004) Vol. 24, No. 8, 886–890
OBSTETRICS
Vaginal birth after one previous caesarean section in
a tertiary institution in Nigeria
A. O. AISIEN and A. U. ORONSAYE
Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital,
Benin-City, Edo State, Nigeria
Summary
Vaginal birth after one previous lower segment caesarean section
represents one of the most significant and challenging issues in
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obstetric practice. A 5-year retrospective study was carried out at
the University of Benin Teaching Hospital between January 1999
and December 2003, to determine the incidence, the maternal and
fetal outcome following vaginal delivery after one previous
caesarean section with a view to evaluating its safety and efficacy.
There were 5234 deliveries, with 395 cases of one previous caesarean
section, giving an incidence of 7.5%. The incidences of emergency
caesarean section, elective caesarean section and spontaneous
vaginal delivery following trial of vaginal delivery were 34.7%,
9.4% and 48.1%, respectively. During the study period there were
1317 cases of caesarean section, giving an incidence of 25.2%
caesarean section rate. The incidence of one previous section among
all caesarean section births was 30%. The major morbidity
following vaginal delivery was uterine rupture with an incidence
of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures
occurred before admission because the patients laboured at home.
One maternal death occurred as a result of uterine rupture and
postpartum haemorrhage, giving a maternal mortality ratio of 19/
100 000 and a case fatality rate of 0.3%. The corrected perinatal
mortality rate was 15.2/1000, mainly from obstructed labour,
abruptio placenta and fetal distress. Both maternal and fetal
mortalities from vaginal birth after one previous section were
significantly less than the respective overall maternal and fetal
mortality from the institution. The 1-minute apgar score of babies
delivered by elective section was significantly (P 5 0.001) higher
than the apgar score of babies delivered by emergency section and
vaginally. There was only one patient with wound dehiscence at
elective section without associated perinatal death. Vaginal delivery
following caesarean section is relatively safe. However, women in
developing countries will continue to require counselling to counter
the myths of aversion to operative delivery even at the expense of
losing their lives. Our hospitals should have adequate monitoring
equipment for high-risk pregnancies so that patients and their
babies can be assured of survival.
Introduction
Over the past 30 years there has been a surge in caesarean
section rates in developed countries (Notzon et al., 1987;
Government Statistical Service, 1997). The reasons
advanced are many, including the risk of litigation,
increased availability of medical technology such as fetal
monitoring neonatal facilities and the patient’s demand for
caesarean section (Lomas and Enkin, 1989). Maternity unit
policies to deliver the breech presenting fetus and multiple
pregnancies by caesarean section and, of course, the
Correspondence to: Dr A. O. Aisien, Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, PMB 1111, Benin
City, Edo State, Nigeria. E-mail: aisienao@uniben.edu/aisienao@yahoo.com
ISSN 0144-3615 print/ISSN 1364-6893 online/04/080886-05 # Taylor & Francis Limited, 2004
DOI: 10.1080/01443610400018742
widespread use of repeat elective sections for women who
have had a previous caesarean section (Enkin, 1989;
Wilkinson et al., 1998).
Numerous publications over the years have demonstrated
the relative safety and efficacy of vaginal birth after
caesarean section in an attempt to reduce the rising
caesarean section rate (Enkin, 1989; Paterson and Saunders,
1991; Wilkinson et al., 1998; Rageth et al., 1999). The most
feared complications of pregnancy among women with a
previous caesarean delivery is rupture of the uterine scar and
its accompanying morbidity and mortality for the mother
and the fetus. Ninety per cent of the caesarean sections are
now performed through a low transverse uterine incision
(Dickinson, 1999). In contrast to the past experience with
classical incision, uterine dehiscence and rupture are
uncommon. Figures of 0.5 – 3.3% have been reported in
prospective studies of women undergoing a trial of vaginal
delivery, similar to the rates of 0.5 – 2% seen among women
having an elective caesarean section (Enkin, 1989).
Hospitals in developed countries have accepted vaginal
delivery after one previous caesarean section as standard of
care with a high success rate and safety (McGarry, 1969;
Case et al., 1971; American College of Obstetricians and
Gynecologists, 1995).
In developing countries, an increase in caesarean section
has also been documented (Aisien et al., 2002). There is,
however, a tendency towards larger families perhaps
because of the high perinatal mortality rate (Adeleye,
1982; Harrison et al., 1985; WHO, 1996; Aisien et al.,
2000). Abdominal delivery is not accepted readily as this is
regarded as a failure of womanhood. This results in many
women both booked and unbooked for antenatal care in
hospitals attempting home delivery and only seeking
hospital intervention when delivery is not forthcoming and
labour is already complicated by infection. Within this
context, studies have assessed policies of vaginal delivery
after caesarean section in sub-Saharan Africa (Boulvain et
al., 1997), with the conclusion that vaginal birth after
caesarean section is feasible and relatively safe. One
advantage is that women may be more disposed to attend
hospital for supervision of a subsequent pregnancy. The
current retrospective study reviewed the maternal and fetal
outcome following vaginal delivery after previous caesarean
section in a tertiary institution to evaluate its safety and
efficacy with regard to maternal and fetal outcome.
 Vaginal birth after caesarean section 887

Patients and methods Table I. Age distribution of patients with one previous
Three hundred and ninety-five cases of one previous caesarean section
caesarean section managed in the institution between
January 1999 and December 2003 were analysed. Data for Age group (years) Number Percentage
the study were retrieved from the patient’s obstetric data 5 20 0 0
sheets, labour ward and theatre records. The exclusion 20 – 24 18 4.6
criteria for vaginal birth after caesarean section in the 25 – 29 101 25.6
institution were classical caesarean section, two or more 30 – 34 171 43.3
previous lower segment caesarean sections and malpresenta- 5 35 105 26.5
tions. A previous history of cephalopelvic disproportion, Total 395 100
obstructed labour and cervical dystocia were not indications
for repeat caesarean section.
The University of Benin Teaching Hospital operated
an open-door policy where all pregnant patients, booked Table II. Parity distribution of patients with one
and unbooked, were seen and managed, irrespective of previous caesarean section
their clinical state. Patients who received antenatal care
and delivered in the hospital are regarded as booked Parity Number Percentage
patients and those who did not receive antenatal care in 1 210 53.2
the hospital but came to deliver are classified as 2 80 20.2
unbooked. All booked patients with one previous 3 43 10.9
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caesarean section were assessed thoroughly in the 4 37 9.4

antenatal clinic, based on their obstetric history and
management outcome. They received counselling about
their management options for their index pregnancy.
Patients admitted in labour for trial of vaginal delivery
were managed using partograph for their progress of
labour and were monitored carefully. Pinard’s stethoscope
was used to monitor the fetal heart rate. There was no
electronic fetal monitor available in the labour ward.
Patients with one previous caesarean section who in
addition have prolonged pregnancy, had cervical ripening
with a Foley’s catheter and oxytocin infusion following
rupture of membranes. One previous caesarean section
was not a contraindication to augmentation, stimulation
or induction with oxytocin, but required careful consid-
eration and assessment.
Unbooked cases with one previous caesarean section seen
for the first time in the labour ward were assessed
individually and managed according to the prevailing
circumstances surrounding their admission. Cases of one
previous caesarean section who required an elective repeat
caesarean section had the operation performed at the end of
37 completed weeks of gestation, except those who went
into labour earlier.
Statistical analysis
Statistical analysis of the data generated was with either Z
or w2 tests where applicable, and the level of significance was
set at 5%.
Results
There were 1317 cases of caesarean section among 5234
deliveries, giving a caesarean section rate of 25.2%. There
were 395 cases with one previous caesarean section, an
incidence of 7.5% and 30% among deliveries and caesarean
sections, respectively.
Age and parity distribution of patients with
one previous caesarean section
The age range of the patients was 22 – 43 years with a mean
of 31 + 4.3 years. The parity range was 1 – 8 with a mean of
2 + 1.4 (Tables I and II).
55 25 6.3
Total 395 100
Booking status and educational level of the
women with one previous caesarean section
A total of 84.3% (333) of the patients were booked for
antenatal care and delivered in the hospital, while only
15.7% (62) were unbooked and were admitted as emergency
patients to the labour ward. Of the patients, 99.5% (393)
had formal education ranging from primary school to a
tertiary institution.
Indications for elective caesarean section and
emergency section in women with one
previous caesarean section
Thirty-seven (9.4%) of the patients had an elective
caesarean section. The main indications were contracted
pelvis 19% (seven), transverse lie 13.5% (five), ‘precious
baby’ 13.5% (five), breech presentation 10.8% (four) and
placenta praevia 10.8% (four) (Table III).
Of the 352 patients with a previous caesarean section
scheduled for trial of vaginal delivery, 162 (41%) had an
emergency caesarean section. The main indications were
cephalopelvic disproportion 24.1% (39), fetal distress
16.0% (26) and obstructed labour 14.8% (24). Of these
patients, 15.4% (25) had malpresentations and placenta
praevia. They presented in the labour ward as emergency
and had a caesarean section (Table IV).
Outcome of spontaneous vaginal delivery
One hundred and ninety (48.1%) of the patients with one
previous caesarean section had a spontaneous vaginal
delivery. Of the 54 patients with previous history of
cephalopelvic disproportion who had had a trial of vaginal
delivery, only 27.8% (15) had a spontaneous vaginal
delivery. Also, 50% (17) had a spontaneous vaginal delivery
of the 34 cases with a previous history of obstructed labour.
Two patients diagnosed as cases of cervical dystocia in their
previous pregnancies had a repeat section for a similar
indication.
 888 A. O. Aisien and A. U. Oronsaye

Previous history of vaginal delivery by the patient
significantly (P 5 0.05) increased the spontaneous vaginal
birth rate. One hundred and thirty-three of the patients had
augmentation of labour following inadequate uterine
action, stimulation of labour for spontaneous rupture of
membranes or induction of labour with oxytocin, following
which 61.7% (82) had a spontaneous vaginal delivery
against 36.8% (49) who required an emergency caesarean
section.
Morbidity and mortality following vaginal birth
after caesarean section
There were 6 cases (1.5%) of uterine rupture (three booked
and three unbooked). Three were admitted as cases of
uterine rupture with intrauterine fetal death following a trial
of labour at home. Three patients ruptured their uterus
while on the labour ward. Their babies were, however, alive.
Two of the cases had stimulation and augmentation of
labour with oxytocin. The relative risk of uterine rupture
(0.24) was less among those who had stimulation and
augmentation of labour compared with those who did not.
Three of the six cases of uterine rupture required
hysterectomy with an incidence of 0.8%. There was one
maternal death due to uterine rupture and postpartum
haemorrhage, giving a maternal mortality ratio of 19/
100 000 and a case fatality rate of 0.3%.
During the study period there were 12 cases of uterine
rupture of an unscarred uterus. One of the patients delivered
by elective caesarean section was found to have wound
dehiscence at operation, giving an incidence of 2.7%.

Birth weight of babies

Four hundred and five babies were delivered during the
Table III. Indications for elective section in patients study period, inclusive of 10 twins. Their weights ranged
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without one previous caesarean section from 1.1 to 4.95 kg, with a mean of 3.11 + 0.65 kg. Three
mothers who presented with both twins in cephalic
Indications Number Percentage
presentation also delivered vaginally. The birth weight
Contracted pelvis 7 19.0 distribution of the babies is shown in Table V.
Transverse lie 5 13.5
Precious baby 5 13.5
Breech presentation 4 10.8 Perinatal mortality and morbidity associated
Placenta praevia 4 10.8 with vaginal delivery after previous caesarean
Twin pregnancy 2 5.4 section
Severe pregnancy-induced There were 24 perinatal deaths, 18 of which were
hypertension 2 5.4 intrauterine fetal deaths before admission. Six perinatal
Bad obstetric history 2 5.4 deaths occurred among patients considered for trial of
Uterine fibroid 2 5.4 vaginal delivery. The clinical causes of deaths were
Unstable lie 1 2.7 obstructed labour (two), fetal distress (one), abruptio
Previous uterine placenta (two) and diabetes mellitus in the mother (one)
myomectomy 1 2.7 giving a corrected perinatal mortality rate of 15.2/10 000,
Previous Manchester repair 1 2.7 which was significantly less than the perinatal mortality rate
Previous repair of vesico- for the institution as a whole. None of the patients delivered
vaginal fistula 1 2.7 by elective caesarean section suffered perinatal death. The
Total 37 100 apgar scores of the babies delivered by elective caesarean
section were significantly higher when compared to babies
delivered either by emergency caesarean section or vaginal
delivery.

Table IV. Indications for emergency section in patients

with one previous caesarean section Discussion
This study has shown that the caesarean section rate in the
Indications Number Percentage
institution was 25%. One previous caesarean section
Cephalopelvic disproportion 39 24.1 constituted 30% of all cases of caesarean delivery and
Fetal distress 26 16.0
Obstructed labour 24 14.8
Severe pregnancy-induced Table V. Weight of babies with one previous caesarean
hypertension 16 9.9 section
Failure of progress in labour 11 6.8 Weight group (g) Number Percentage
Breech presentation 10 6.2
Transverse lie 8 4.9 5 1000 0 0
Placenta praevia 7 4.3 1000 – 1499 9 2.2
Abruptio placenta 6 3.7 1500 – 1999 16 4.0
Failed induction 6 3.7 2000 – 2499 27 6.7
Cord accident 3 1.9 2500 – 2999 73 18.0
Cervical dystocia 3 1.9 3000 – 3499 163 40.2
Eclampsia 2 1.2 3500 – 3999 87 21.5
Twin pregnancy 1 0.6 5 4000 30 7.4
Total 162 100 Total 405 100

7.5% of all deliveries. The mean age and parity of the
patients were 31.6 + 4.3 years and 2 + 1.4 respectively. The
booked patients were significantly higher than the
unbooked patients and most of them had had a formal
education.
A high caesarean section rate, as also found in some other
studies (Adeleye, 1981; Okonofua et al., 1988; Aisien et al.,
2002) could be explained by the fact that the institution is a
referral centre, where many high-risk pregnancies are seen
and managed; 83.5% of the previous caesarean section
patients were allowed a trial of vaginal delivery. Similar high
incidences have also been reported by other authors (Lai
and Sidek, 1993; Van Der Walt et al., 1994; Lovell, 1996;
Ola et al., 2001; Abdel Aziz, 2000; Thistle and Chamberlain,
2002). The vaginal delivery rate was 48.1% lower than the
range of 60 – 80% reported in the literature (Van Roosma-
len, 1991; Lai and Sidek, 1993; Lovell, 1996; Al-Chalabi,
1997; Abdel Aziz, 2000; Adjahoto et al., 2001; Ola et al.,
2001). A similar reduced vaginal delivery rate has also been
published (Van Der Walt et al., 1994; Obara et al., 1998;
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Appleton et al., 2000). The reduced vaginal delivery rate in
this study could be a reflection of the high number of cases
of patients who had emergency caesarean section for
cephalopelvic disproportion, obstructed labour and fetal
distress. The emergency caesarean section rate was 41%,
higher than in other studies of 14% and 12% (Kumar and
Maouris, 1996; Lovell, 1996). While some other studies
reported higher rate of elective caesarean section, only 9.4%
of the patients had elective surgery. The lower rate was due
partly to the fact that trial of vaginal delivery was offered to
patients who met the selection criteria, and partly because
patients with malpresentations and placenta praevia who
should have elective surgery presented as an emergency in
the labour ward, when they could not deliver at home.
Higher rates of elective sections have been reported in the
literature, reflecting a strict criterion for trial of vaginal
delivery (Lai and Sidek, 1993; Van Der Walt et al., 1994;
Lovell, 1996; Obara et al., 1998).
Successful vaginal delivery has been found to be
influenced by previous vaginal delivery (Lai and Sidek,
1993; Lovell, 1996; Ola et al., 2001; D’Orsi et al., 2001) as
also seen in this study.
The patients with a previous history of cephalopelvic
disproportion and obstructed labour were allowed a trial of
labour, with a success rate of 36%. A large proportion
(64%) still resulted in an emergency caesarean section.
Patients should therefore be selected on individual merit for
trial of vaginal birth. Other studies have shown higher
vaginal delivery rates for these groups of patients (Perveen
and Shah, 1997; Ola et al., 2001).
Reports in the literature (Farmer et al., 1991; Jones et al.,
1991; Leung et al., 1993; McMahon et al., 1996) have
suggested a significant risk of uterine rupture with poor
outcome for both the woman and her infant following
vaginal delivery. Unfortunately, there are no reliable ways
to predict the trial of labour that will result in vaginal birth
or emergency caesarean section (Scott, 1991; Pickhardt et
al., 1992; Leung et al., 1993). In this study there were six
cases of uterine rupture, three of which were managed by
hysterectomy. There was 100% salvage rate for babies
whose mothers ruptured their uterus in the labour ward
compared with mothers who ruptured before admission,
because they chose to labour at home. Abnormality of the
fetal heart rate coupled with vaginal bleeding in a woman
who had not previously bled during the labour were early
Vaginal birth after caesarean section 889
signs that pointed to rupture of the uterus in these patients.
Rupture of the unscarred uterus was surprisingly more
common than rupture of the scarred uterus during the study
period. Major complications have also been reported
following induction of labour in previous caesarean section,
especially with the use of misoprostol (Zelop et al., 1999;
Lydon-Rochelle et al., 2001).
Even though this study reported two uterine ruptures
following augmentation and stimulation of labour with
oxytocin, the risk of uterine rupture was higher among
patients who were not augmented, stimulated or induced.
One patient had scar dehiscence noted at elective caesarean
section. There was one maternal mortality due to uterine
rupture and postpartum haemorrhage, giving a maternal
mortality rate of 19/100 000 and a case fatality rate of 0.3%.
The perinatal mortality rate was 15.2/1000. The maternal
and fetal mortalities were significantly less than the overall
mortalities in the unit for the study period. The apgar score
of babies delivered by elective caesarean section was higher
than those of emergency caesarean section and spontaneous
vaginal delivery. An earlier report (Okpere et al., 1982)
published from the hospital had reported higher perinatal
deaths, but no maternal mortality from vaginal birth after
caesarean section.
In conclusion, this study has shown that vaginal delivery
after caesarean section is a desirable option as 48% of the
patents had a successful vaginal delivery. The procedure
gave an option to women who are strongly against operative
delivery and would risk their life by attempting vaginal
delivery at home. However, vaginal birth after caesarean
section was not risk free for both mother and fetus. Patients
with one previous caesarean section need social and cultural
counselling regarding aversion to operative delivery, so that
they can present early in hospital for delivery. Any
institution managing such high-risk pregnancies must also
be equipped with adequate maternal and fetal monitoring in
labour to detect early complications in order to reduce
maternal and fetal morbidity and mortality associated with
vaginal birth after caesarean section. Better outcome of
elective caesarean section should be part of the counselling
option for women who may choose the option as the first
line of management.
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