A study of the outcome of subsequent pregnancy following previous cesarean section.
Primary CS whether done due to recurrent indication or not, carries risk of abnormal placentation in subsequent pregnancy. Morbid adherence of placenta is a rarer but more severe complication, even more so when number of caesarean delivery increases (2, 3).
Though classical upper segment caesarean section is obsolete now-a-days, even with lower segment caesarean section (LSCS), in a developing country like ours, where malnutrition, frequent conceptions, post-operative infection & subsequent blood transfusion are more common, the wound-healing would not be up to the quality found in developed countries, raising the possibility of scar dehiscence & uterine rupture in next pregnancy.
Now, regarding mode of delivery in women with previous caesarean delivery, primary choice is whether to have elective repeat caesarean section (ERCS) or to attempt vaginal birth after caesarean section (VBAC). Major problem is that lately developed investigational methods like MRI; color Doppler could not assess the scar integrity properly so as to help clinician in decision-making. Therefore, on successful attempt with VBAC in suitable cases makes it "THE CHOICE" but, if failed, it adds up to the significant proportion of maternal and neonatal morbidity, even mortality, as shown by different studies (4,5). On the other hand, ERCS, if selected after 39 weeks of gestation, gives significant good feto-maternal outcome (1). Still about ERCS, major obstetric concern lays in severe adverse outcomes in future pregnancies.
Despite extensive work, clear-cut guideline for exact mode of delivery in post caesarean pregnancy is yet to be decided; and associated risks are still uncertain. Few studies (4, 6-10) in India have dealt with outcome of post-caesarean cases. The current study has been done to review the existing facts with the hope that meticulous individualization in management and modification of certain factors would improve maternal & neonatal outcome.
MATERIALS AND METHODS: The present observational analytical study was carried out over two years (2010-11) taking consecutive 100 post-caesarean cases as admitted on my admission days & delivered in BR Singh Hospital. Third trimester antenatal profile was only included & cases with multiple gestation, prior myomectomy or hysterotomy were excluded from study. Data collection was done by interview technique along with hospital records. Percentage analysis was most often done. Categorical variables were compared with chi-square test; P value was calculated with 2012 Graphpad Software. Relative risk (RR) & Odd ratio (OR) were calculated with 1993-2012 Medcalc Software bvba (Version 12.3.0). All statistical tests were evaluated at the 0.05 significance level.
RESULTS AND ANALYSIS: Amongst a total number of 1276 pregnant women, admitted & delivered in B.R. Singh Hospital, as per Railway Register in my study period (Table 1), 26.02% (4.23+13.87+7.92) cases were post-caesarean. Out of 100 cases under study, maternal morbidity was found in 37 cases & neonatal morbidity in 21 cases. No maternal mortality or stillborn occurred relating to my study cases.
Table 2 clearly tells that among 37 cases with maternal morbidity, operation related morbidity was maximum; intra-operative complications & operative interference, related to ERCS, were responsible for the majority.
Table 3 clearly shows 55% success among TOLAC cases. Morbidity association was significant with mode of delivery (For Maternal Morbidity, [X.sup.2]=13.28, P=0.0013 & for Neonatal Morbidity, [X.sup.2]=6.11, P=0.0471). Comparing with TOLAC cases, ERCS group less likely (RR=0.78) shows maternal morbidity; but in TOLAC group, failed VBAC cases result more significant maternal morbidity (RR=3.97, P=0.0037). Neonatal morbidity was also found highest in failed VBAC cases.
Among cases who had undergone caesarean delivery (table 4), post-partum morbidity was significantly associated ([x.sub.2]=7.7; P=0.0047) with scar condition; more significantly morbidity found (RR=2.47, P=0.0001) when scar integrity was lost, especially in failed VBAC cases.
Most of the cases (table 5), whether prior history of vaginal delivery was present or not, had received caesarean section. But importantly, maternal and neonatal outcomes were poor (85% & 60% respectively) for cases that had history of vaginal delivery & undergone CD, mainly due to failed trial.
Table 6 clarify that maternal and neonatal morbidity outcomes (100% & 75% respectively) were poor when non-admitted cases had undergone caesarean delivery (CD). Even when admitted cases had undergone CD, maternal outcome was not good (39.19% morbidity). Neonatal morbidity was found to be high in first group (40%) as there were cases operative deliveries.
Most of the study cases (table 7) were from 25-30 yrs. age group, where maternal & neonatal morbidity were found in certain range. Importantly, morbidity association with age was found to be highly significant (P=0.0029 & P<0.0001) in both group, specially raised in older age group (>35yrs).
In another scenario (table 8), antenatal status co-relation with outcome was found to be highly significant in both groups. Among post-caesarean cases, who were booked, were found to have less maternal (OR=0.12, RR=0.35) and neonatal outcome (OR=0.12, RR=0.24).
Table 9 shows cases, prior CS which were done due to either CPD or non-progress of labor, mostly received ERCS (86.11 % & 55.56% respectively) & rest those given trial for VBAC, found unsuccessful. With all other indications for prior CS, VBAC success rate was good, except in cases with placenta previa & PROM, where abnormal placentation & dystocia recurred & ERCS (87.5% & 77.78% respectively) performed.
DISCUSSION: National United States CS rate was 4.5% in 1965 when it was first measured. But with 2007 rate of 31.8%, about one mother in three now gives birth by caesarean section in States. CS rate is higher in Latin America, even 40% in different countries of this region (11). The estimate of CS rate in East Asia also is shown to be well above the 15% mark (12).
The estimate of caesarean section (CS) rate in India is 7.1% in the year 1998 and there is 16.7% change in the rate annually (12), which is one of the highest among the countries. Though high values of CS rate found in southern India, West Bengal is the only state from eastern side with high caesarean section rate. A five year audit from a large teaching hospital in Kolkata showed a CS rate of 49.9% (13). Studying in urban referral institution, BR Singh Railway Hospital shows high caesarean section rate of 41.77% in my study period.
Miller et al (14) reported a post caesarean pregnancy rate of 8.1% in 1983 and 14.1% in 1992. Bhat et al al (6) showed a post caesarean pregnancy rate of 8.7%. Agarwal et al (15) study gave 13.7% report whereas in my study period, rate was found to be 26.02%.
Though no maternal or neonatal mortality was found in my study, as compared with Bhat et al study (6), intra-operative complications caused major maternal morbidity.
Vardhan et al (10), Tan et al (16), Shah et al (17), and Dhall et al (18) reported 70 to 80% success in attempts at VBAC. Chhabra et al (4) & Bhat et al (6) gave a 71.2% & 64.6% success report respectively in those who had trial of labor. My study had 55% success rate on attempts of VBAC.
Aisien et al (19) reported a 48.1% incidence of vaginal delivery in previous caesarean section cases, whereas Chhabra et al (4) reported an incidence of 32.4%. Bhat et al (6) & Agarwal et al (15) study reported a 33.3% & 27.7% incidence of vaginal delivery in previous caesarean section cases. In my study, incidence was 22%.
With improved antenatal (clinical & gadgetry) care and institutional confinement, VBAC is considered safer than repeat elective CS in a carefully selected population (20). However in the event of a failed trial, there was a definite increase in neonatal (7) and maternal morbidity (5) which is also reflected in our study.
The most serious adverse outcome of VBAC occurs when uterine scar integrity is lost. In a study of more than 8000 women the rate of scar rupture was 0.5% (21). Locateli et al (22) & Guise et al (23) reported a uterine rupture rate of 0.3% in women with previous caesarean section. Out of 100, one suffered uterine rupture in my study with severe maternal & perinatal morbidity. The incidence of scar dehiscence in my study was 9 in 100 cases.
Any previous vaginal delivery, either before or following a caesarean birth, significantly improves the prognosis for a subsequent vaginal delivery with either spontaneous or induced labour (24). My study also reported that cases with prior history of vaginal delivery delivered vaginally in more occasions (41.18%).
Puja P et al (9) study gave 80.95% success rate in VBAC on admission with Bishop Score >7. My study reported 75% success upon admission in labor with favorable Bishop Score. This statistically significant success was also found in a previous study (7).
Maternal age appears to be an independent risk factor over pregnancy outcome (25), especially in post-CS older women (26). My study found both maternal & neonatal morbidity status to be raised in older age group (>35yrs).
Another statistically significant finding was that cases that were booked, regular in antenatal check-up & aware about the risk got admitted as advised & avoided morbidity in more occasions.
Peaceman and associates (27) found that those with dystocia as the original indication had a significantly lower success rate (54%). In my study, prior CS cases due to either CPD or non-progress of labor, mostly received ERCS (86.11 % & 55.56% respectively), whereas rest those given trial for VBAC, found unsuccessful.
* All cases with post-caesarean pregnancy should have a regular antenatal check-up & mandatory institutional confinement.
* Awareness regarding symptoms of low-lying placenta (especially with previous history of placenta previa), scar tenderness etc. & timely admission would improve perinatal outcome.
* Trial of labor after caesarean (TOLAC) should only be considered in properly selected cases with meticulous labor monitoring & availability of round the clock emergency caesarean facility in the institution.
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(27.) Peaceman AM, Gersnoviez R, Landon MB. The MFMU cesarean registry: Impact of fetal size on trial of labour success for patient with previous caesarean section for dystocia. Am J Obstet Gynecol 2006;195:1127.
Suman Poddar 
PARTICULARS OF CONTRIBUTORS:
[1.] Senior Resident, Department of Obstetrics and Gynaecology, Chitta Ranjan Seva Sadan College of Obstetrics, Gynacology and Child Health, Kolkata.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Suman Poddar, Rama Apartment (2nd Floor), 19, Lal Baba Road, PO+PS: Dankuni, Dist. Hooghly, West Bengal, India, PIN--712311. E-mail: firstname.lastname@example.org
Date of Submission: 11/01/2014.
Date of Peer Review: 12/01/2014.
Date of Acceptance: 24/01/2014.
Date of Publishing: 06/02/2014.
TABLE 1: Delivery statistics from Jan '10 to Dec '11 Type of delivery Total delivery (n = 1276) % VBAC* 54 4.23 VB* other than VBAC 689 54.0 CS* in primi-gravida 255 19.98 CS in single prior CS 177 13.87 CS in >2 prior CS 101 7.92 VBAC*: Vaginal Birth (VB*) After Caesarean Section (CS*) TABLE 2: Analysis of maternal morbidity Causes of morbidity Number of Cases (%) VBAC ERCS * Abnormal placentation 5(13.5) -- 5 Preterm labor 1(2.7) 1 -- Operative interference 10(27.0) -- 6 Intra-operative complication 11(29.7) -- 9 Peripartum hysterectomy 1(2.7) -- 0 Post-partum hemorrhage 3(8.1) 2 0 Post-partum wound sepsis 2(5.4) 0 0 Post-partum thrombosis 2(5.4) 1 0 Puerperal pyrexia 2(5.4) 0 0 Total 37(100) 4 20 Causes of morbidity Failed VBAC Abnormal placentation -- Preterm labor -- Operative interference 4 Intra-operative complication 2 Peripartum hysterectomy 1 Post-partum hemorrhage 1 Post-partum wound sepsis 2 Post-partum thrombosis 1 Puerperal pyrexia 2 Total 13 ERCS *: Elective Repeat Caesarean Section TABLE 3: Mode of delivery co-relating outcome Mode of Number Maternal Neonatal Delivery of cases Morbidity % Morbidity % (n = 100) (n = 37) (n = 21) ERCS 60 20 33.33 8 13.33 VBAC 22 4 18.18 6 27.27 Failed VBAC 18 13 72.22 7 38.89 TABLE 4: Scar integrity & post-operative complications Scar integrity Number of cases Complication % (n = 78) * developed Scar dehiscence 9 7 77.78 Scar rupture 1 1 100 Normal scar 68 22 32.35 (#) * Including those cases undergone caesarean delivery / (#) excluding 3 cases of abnormal placentation with antepartum morbidity TABLE 5: Maternal & neonatal outcome in relation to previous history of vaginal delivery & present mode of delivery Mode of present delivery & Number Maternal % H/O vaginal delivery of cases morbidity VD with (+) history 14 2 14.29 VD with (-) history 8 2 25 CS with (+) history 20 17 85 CS with (-) history 58 16 27.59 Mode of present delivery & Neonatal % H/O vaginal delivery morbidity VD with (+) history 4 28.57 VD with (-) history 2 25 CS with (+) history 12 60 CS with (-) history 3 5.17 TABLE 6: Maternal & neonatal outcome comparing mode of admission & subsequent delivery Mode of admission Number Maternal % Neonatal % & delivery of cases morbidity morbidity Before labor & VD 10 2 20 4 40 Before labor & CS 74 29 39.19 12 16.22 In-labor & VD 12 2 16.67 2 16.67 In-labor & CS 4 4 100 3 75 TABLE 7: Age distribution co-relating outcome Number of cases Maternal Age in years (n = 100) morbidity (n = 37) % < 25 23 2 8.7 25-30 43 16 37.21 31-35 27 14 51.85 > 35 7 5 71.43 Neonatal Age in years morbidity (n = 21) % < 25 0 0 25-30 8 18.6 31-35 7 25.93 > 35 6 85.71 TABLE 8: Antenatal care co-relating morbidity status Case numbers Maternal Antenatal status (n = 100) morbidity (n = 37) % Booked 77 20 25.97 Un-booked 23 17 73.91 Neonatal Antenatal status morbidity (n = 21) % Booked 11 14.29 Un-booked 10 43.48 TABLE 9: Previous caesarean indication co-relating mode of present delivery Previous Number of cases VBAC * % ERCS * indication (n = 100) (n = 22) (n = 60) CPD * 36 0 0 31 Fetal Distress 5 5 100 0 PROM ([double dagger]) 9 0 0 7 Mal-presentation 13 9 69.23 3 Post-dated 5 2 40 0 Placenta previa 8 1 12.5 7 PIH ([section] 8 1 12.5 5 IUGR ([parallel]) 5 3 60 2 Accidental Hge 2 1 50 0 Non-progress 9 0 0 5 Previous % Failed VBAC * % indication (n = 18) CPD * 86.11 5 13.89 Fetal Distress 0 0 0 PROM ([double dagger]) 77.78 2 22.22 Mal-presentation 23.07 1 7.7 Post-dated 0 3 60 Placenta previa 87.5 0 0 PIH ([section] 62.5 2 25 IUGR ([parallel]) 40 0 0 Accidental Hge 0 1 0 Non-progress 55.56 4 44.44 CPD *: Cephalo-pelvic Disproportion, PROM ([double dagger]): Premature Rupture of Membrane, PIH ([section]): Pregnancy Induced Hypertension, IUGR: Intra-uterine Growth Restriction.
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|Title Annotation:||ORIGINAL ARTICLE|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Feb 10, 2014|
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