Printer Friendly

A prospective comparative study of a trial of labor after cesarean vs. elective repeat cesarean section (ERCS) in view of maternal outcomes.

Introduction

Uterine rupture is an unusual problem of pregnancy possibly resulting in extreme maternal and fetal morbidity and mortality. [1] In India, it is responsible for 5%-10% cases of all maternal deaths even now. [2] With an increasing era of cesarean section (CS), it poses some documented risk to the mother in subsequent pregnancy such as placenta praevia and accrete or rupture of previous scar.

There are two types of uterine rupture, complete and incomplete, distinguished by whether or not the serous coat of the uterus is involved [3] In the former, the uterine content including fetus and, occasionally, placenta may be discharged into the peritoneal cavity; whereas in the latter, the serous coat is intact, and the fetus and the placenta are inside the uterine cavity. [4] The complete variety is more dangerous of the two varieties. [5,6] Rupture of uterus during labor is more threatening than that occurring in pregnancy, because shock is greater, and infection cannot be avoided. [7,8] The damage to the uterus is sometimes beyond repair, and a hysterectomy is required.

In a WHO systematic review of uterine rupture worldwide, the median incidence was 5.3 per 10,000 births. [9] The majority of cesarean uterine incisions are low-transverse, and this type of incision presents the lowest risk for rupture in subsequent pregnancies. [10]

Materials and Methods

This prospective observational study was carried out in the Department of Obstetrics and Gynecology, PDU Medical College, Rajkot, Gujarat, India, from January 1, 2014 to June 30, 2015.

During this study, the patients (booked or unbooked) who had undergone a previous CS (irrespective of numbers) either with labor pain or posted for elective repeat cesarean section (ERCS) attending the labor room of the Department of Obstetrics and Gynecology, PDU Medical College, Rajkot, were selected.

Detail history of each patient was recorded. Special attentions on observations such as age, parity, no previous CS, indications of previous CS, and any vaginal deliveries were noted. In both emergency and ERCS, intraoperative and postoperative findings and complications were noted.

This is an observational study that included data collection from patients received in this institute. It does not pose any risk to the patients and does not pass any cost to the institute.

Result

During the study period, 10,315 deliveries were noted, of which patients who had undergone a previous CS were 1,082. Among the previous cesarean cases, trial of labor was given for 222 cases, of which successful vaginal birth after cesarean (VBAC) was found in 136 cases (61.26%), while in 86 (38.74%) cases emergency cesarean was performed. In 860 cases, ERCS was done.

Of the 1,082 patients, the common age group was 21-30 years (77.17%). Of the 1,082 cases, 93 (8.5%) were preterm, while 989 (91.5%) were term having term pregnancy. No rupture or dehiscence was noted in preterm patients.

Incidence of rupture and dehiscence in trial of labor group was 4.5% (10 cases) and 2.7% (6 cases) respectively, while no rupture was noted in the ERCS group. Scar dehiscence was found in 8 cases (0.93%) in the ERCS group.

In 2 cases, among the trial of labor group, obstetric hysterectomy was performed for rupture, while in 2 cases, bladder injury was noted. No maternal morbidities have been noted in ERCS group. No mortality has been recorded in study period.

Discussion

There are numerous reasons that influence the decision to proceed with either a trial of labor after previous cesarean delivery or ERCS delivery. For the majority of women with a previous cesarean delivery, a trial of labor should be encouraged. There are few absolute contraindications. [11]

Uterine rupture is called as a disarray of the uterine muscle continuing to and including the uterine serosa or disarray of the uterine muscle with extension to the bladder or broad ligament. Uterine dehiscence is defined as disruption of the uterine muscle with intact uterine serosa. [12]

In our study, the success rate of VBAC is 61.26%. Nielsen et al., [13] in their study for 10 years, reported the delivery of 24,644 patients. Of these women, 2036 (8.3%) had previously undergone CS. A trial of labor was allowed in 1,008 of these patients and 92.2% delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%.

In 1996, a study of 6,138 women from Nova Scotia with a previous CS was published reporting that the major maternal complications, including uterine rupture were almost doubled (1.6% vs. 0.8%) in the trial of labor after cesarean group when compared with the group of women who underwent an ERCS. [14] In our study, incidence of rupture and dehiscence in trial of labor group was 4.5% (10 cases) and 2.7% (6 cases), respectively, while no rupture was noted in the ERCS group. Scar dehiscence was found in 8 cases (0.93%) in the ERCS group. So, we also found a higher rate of rupture or dehiscence in trial of labor group when compared with the ERCS group.

Conclusion

In our study, the success rate of VBAC is 61.26%; incidence of rupture and dehiscence in trial of labor group was 4.5% (10 cases) and 2.7% (6 cases), respectively, while no rupture was noted in the ERCS group. Scar dehiscence was found in 8 cases (0.93%) in the ERCS group. So, we also found a higher rate of rupture or dehiscence in trial of labor group when compared with the ERCS group.

So, decision for trial of labor or ERCS should be made by patient's choice, through detailed history and examination. Even though many studies showing success rate of VBAC higher (around 92%), [13] maternal morbidities associated complications of trial of labor are life threatening, and we conclude ERCS is safer when compared with VBAC in view of maternal outcome.

DOI: 10.5455/ijmsph.2016.14102015130

References

[1.] Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 2004; 329:19-25.

[2.] Bhaskar Rao K. Obstructed labor. In: Obstetrics and Gynecology for Postgraduates, Vol 1. 1st edn, Ratnam SS, Bhasker Rao K, Arulkumaran S (Eds.). Madras: Orient Longman, 1992. pp. 130-2.

[3.] Rana S. Obstetrics trauma. In: Obstetrics and Perinatal Care for Developing Countries, 1st edn. Pakistan: SAF Publications, 1998. pp. 1308-15.

[4.] Donald I. Maternal injuries. In: Practical Obstetrics Problems, 5th edn. Hong Kong: PG Publishing (Pvt.) Ltd, 1983. pp. 795-803.

[5.] Ames RPM. Rupture of uterus. Am J Obstet Gynecol 1981; 14:361-95.

[6.] Miller DA, Diaz FG, Paul RH. Rupture of unscarred uterus. Am J Obstet Gynecol 1996; 174:345.

[7.] Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture of the unscarred uterus. Obstet Gynecol 1997; 671-3.

[8.] Fedorkow DM, Nimrod CA, Taylor PJ. Rupture uterus in pregnancy: a Canadian hospital's experience. CMAJ 1987; 137(1):27-9.

[9.] Hofmeyr GJ, Say L, Gulmezoglu AM. WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. BJOG 2005; 112(9):1221-8.

[10.] Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 2010; 32(4):321-7.

[11.] McMahon MJ. Vaginal birth after cesarean. Clin Obstet Gynecol 1998; 41(2):369-81.

[12.] Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351(25):2581-9.

[13.] Nielsen TF, Ljungblad U, Hagberg H. Rupture and dehiscence of cesarean section scar during pregnancy and delivery. Am J Obstet Gynecol 1989; 160(3):569-73.

[14.] McMahon MJ, Luther ER, Bowes WA, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996; 335:689-95.

Kamal D Goswami, Kavita M Dudhrejia, Prakash H Parmar, Nayana Baldha

Department of Obstetrics and Gynecology, PDU Medical College, Rajkot, Gujarat, India.

Correspondence to: Prakash H Parmar, E-mail: drparmarobgy@gmail.com

Received October 14, 2015. Accepted October 24, 2015
COPYRIGHT 2016 Association of Physiologists, Pharmacists and Pharmacologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2016 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Research Article
Author:Goswami, Kamal D.; Dudhrejia, Kavita M.; Parmar, Prakash H.; Baldha, Nayana
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Feb 1, 2016
Words:1369
Previous Article:Storage, handling, and potential health risks of household cleaning substances in Sulaimani City, Iraq.
Next Article:Rising challenge of multiple morbidities among the rural poor in India--a case of the Sundarbans in West Bengal.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters