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A study of vaginal birth after caesarean.

INTRODUCTION: Present day obstetric practice demand an ideal uncomplicated antenatal period, labour and post-partum period blessed with a healthy mother and newborn baby. In this day of small family norms, the baby's right of survival is increasingly recognized and consequently majority of the indications for the operation are solely in the interest of the baby. Practicing obstetricians encounter increasing number of post caesarean pregnancies because the number of primary caesarean section from non-recurrent causes is rapidly rising. There is a growing concern by the obstetricians managing these cases since there are medical as well as legal problems involved. All post caesarean pregnancies do not require repeat caesarean and a majority of them may have uncomplicated vaginal delivery. With the escalating rate of caesarean section suggestions were made that vaginal birth after caesarean section might help in reducing the rate of caesarean section. A trial of labor in cases of previous caesarean section has been accepted as a way to reduce the overall caesarean section rate. There is evidence of safety of trial of labor with or without induction of labor, with reduction in iatrogenic prematurity, and maternal morbidity and mortality.

METHODS: A prospective study is carried out on women with one previous lower segment caesarean section(LSCS) for a non-recurrent cause, attending the Antenatal clinic and labour room of Regional Institute of Medical Sciences, Manipur, for a period of 2(two) years from 1st Aug., 2007 to 31st July, 2009.

Exclusion Criteria for the study will be:

1. Two previous caesarean sections.

2. Previous caesarean section with other obstetric complications like breech presentation, transverse lie, twin pregnancy, major degree placenta previa, cephalopelvic disproportion, lethal foetal anomalies.

3. History of post-operative wound infection following previous LSCS.

4. Estimated fetal weight > 4 Kg.

5. Associated anaemia (Hb<10g%), pregnancy induced hypertension, diabetes, heart disease and renal disease.

6. Previous vertical uterine scar and scar of other uterine surgery.

Plans of management, waiting for spontaneous onset or induction after looking into the indication of previous caesarean section, eventful/uneventful previous caesarean section, thinning of the uterine scar on ultrasonography, fetopelvic disproportion in the present pregnancy and other contra indications to induction and vaginal delivery will be recorded for all the study subjects. Trial of labour and vaginal delivery with induction or augmentation of labour was done whenever necessary.

During the period of trial each case was put in the observation bed attached to the labour room under strict monitoring of the foeto-maternal wellbeing and progress of labour. Oxytocin infusion drip was used whenever indicated either for induction or augmentation of labour. Prostaglandin E2 gel was applied in selected cases for cervical ripening or induction of labour.

Whether the labour was spontaneous or induced, it will be monitored with:

1. Hourly recording of vital parameters--temperature, pulse, respiration and blood pressure.

2. Foetal heart rate monitoring.

3. Monitoring of uterine contractions.

4. Partograph.

5. A close watch for the early recognition of scar dehiscence by identifying maternal tachycardia, vaginal bleeding, scar tenderness and foetal heart rate alterations.

RESULTS: During the period there were a total of 18858 deliveries with a caesarean rate of 25%. Post caesarean pregnancies were 7.5% making an overall 1414 pregnancies with two previous CS of 96 patients. 928 post caesarean cases were with recurrent indications and 390 patients were of non-recurrent indications. After screening the 390 patients with exclusion criteria and counseling for undergoing vaginal birth following lower segment caesarean section (VBAC), only 100 of the eligible agreed to undergo trial of labour. Of these patients 50 delivered vaginally and the remaining 50 patients had to undergo emergency repeat caesarean section (CS). The indications of the emergency CS were mostly of fetal distress, scar tenderness or non- progress in labour. There was only 50 VBAC.

The outcome of vaginal birth after caesarean (VBAC), repeat caesarean due to failed trial of labour and normal vaginal delivery (NVD) are compared for test of significance. Average age of NVD women was 29.5 [+ or -] 5.555 years, VBAC -29.6 [+ or -] 5.07 years and 30.9 [+ or -] 4.91 years for repeat caesarean women. The duration of marriage ranges within 5-6 years. The mean period of gestation for VBAC was 37.86 [+ or -] 5.89 weeks, 39.10 [+ or -] 0.81 weeks for repeat caesarean women and 39.46 [+ or -] 1.37 weeks for NVD women.

Table 1 shows that duration of last child birth and duration of hospital stay for NVD are significantly lower than that for VBAC group. But amount of blood transfusion and weight of baby of both the groups do not differ significantly at 0.05 probability level.

DISCUSSION: Obstetrical practice today has liberalized vaginal birth after caesarean section (VBAC) in appropriately selected women with a previous caesarean pregnancy. This is done without compromising with the foeto maternal safety margins either in a vaginal birth or in a repeat caesarean section. The selection of women for VBAC is mainly influenced by women's desire and conditions favorable for vaginal delivery. The objective of this study is to evaluate the efficacy and safety of attempted VBAC with a view to decrease the caesarean rate.

The Regional Institute of Medical Sciences Hospital is the top ranked referral centre of Manipur where disproportionate mixtures of complicated and uncomplicated cases are dealt with. Therefore, variability of data on either side may be seen swinging from national and international scale of research and studies.

Lahousen M and Burmucic R (1) reported a VBAC rate of 55.3%, Mor- Yosef S. et al (2) had 55.1% and Matias JP et al (3) had 58.1%. Shakti V et al (4) and Tan PC et al (5) reported higher rates of 72.1% and 71.2% respectively. The present study reports a VBAC rate of 50%. Placek PA6 found the VBAC rate to be 4.9% in the US in 1980-85. European countries have adopted VBAC demonstrated by rates of 43% in Norway and 39% in Scotland. Tripathi JB et al (7) had a higher success rate of VBAC at 73% and Smith GCS8 with 74.2%.

The decision for a VBAC delivery is more influenced by traditional medical practice and the patient reluctance to consider VBAC, viewing labour pain as more severe than the pain of surgery (Placek PJ et al, 1988). To reduce the caesarean delivery rate, the number of trial of labour should be increased among women who have had caesarean section (Chuang JH et al (9)). Leeman LM et al (10) reflected patient choice caesarean delivery is increasing in the US citing ethical premises of autonomy and informed consent, despite a lack of evidence of its safety. Goldman G et al (11) found the VBAC rate depend on the caesarean rate of the attending obstetrician.

But pregnancy after the age of 35 years is very much prevalent in our present day society and improved obstetrical care has made advanced maternal age compatible with successful pregnancy for such women, especially in the absence of pre-existing medical or obstetrical disorders. Matias JP et al (2007) found an association of older age with increasing repeat CS rate.

The mean weight of the babies born NVD was 3.18 [+ or -] 0.48kg, that of VBAC was 3.09 [+ or -] 0.409kg and that of repeat caesarean section was 3.36 [+ or -] 0.304kg. A lighter baby in the current pregnancy favors a successful vaginal delivery and with heavier babies the vaginal rate is reduced.

Maximum number of patients had previous caesarean section for breech presentation of which 58.6% delivered vaginally. Proper selection of cases for trial of labour, including clinical examination of the patients, induction or augmentation in selected cases with proper monitoring of labour may bring about a good number of vaginal deliveries in the cases where the previous caesarean section was done even for CPD. A non-recurrent indication for previous CS such as breech presentation or foetal distress is associated with high successful VBAC rate than recurrent indications such as cephalo-pelvic disproportion (Brill Y and Windrim R. (12) Shakti V et al (2006) and Tripathi JB et al (2006) studied on women with one prior lower segment caesarean section for a non-recurrent indication to confirm the efficacy and safety of trial of labour. Lahousen M and Burmucic R (1986) found higher VBAC rate in breech presentation or foetal distress. The probable reason for a higher success rate of trial of labour seen in western countries may be due to the fact that the cases were screened properly. Caesarean section rates in many countries have risen 5-10 fold driven in part by a reliance on electronic foetal monitoring, pressure from health consumers to salvage small babies, fear of litigation, decreasing expertise in operative vaginal deliveries and in lifestyle choices (Ugwumadu A). (13)

Zweefler J et al (14) found a decrease in the VBAC rate after the American College of Obstetricians and Gynaecologists (ACOG) revised the guidelines to allow VBAC to be attempted in institutions equipped to respond to emergency with physicians immediately available to provide emergency care. Iglesias S. et al (15) recommended that hospitals providing obstetric care have units of blood, operating rooms, neonatal resuscitation equipment and nursing, anaesthetic and surgical personnel available so that, if necessary, a VBAC can be performed within 30 minutes for any women including those undergoing VBAC.

In the present study, there is no routine exploration of the scar or uterus following vaginal delivery and placental expulsion in haemodynamically stable patients. So dehiscence was not seen in those patients who delivered vaginally. There was no associated neo natal or maternal morbidity and mortality.

15 cases underwent repeat CS due to scar tenderness and found 4 cases to be having scar dehiscence during operation and needed just simple repair. This shows that only scar tenderness does not give a final diagnostic point of scar rupture, but it is an important sign to be observed in all the patients. Smith GCS et al (2004) obtained an overall proportion of 74.2% vaginal birth and a uterine rupture rate of 0.35%.

In our study maternal mortality is zero. The maternal morbidity after vaginal delivery is definitely low in comparison to that after repeat caesarean. The VBAC group showed more postpartum hemorrhage (6%) than the repeat CS group (4%). The normal delivery group did not show any postpartum haemorrhage. The maternal morbidity is shown by the number of days in hospital admission. It was 3.08 [+ or -] 0.98 days in NVD, 3.74 [+ or -] 1.849 days in VBAC and 6.06 [+ or -] 1.038 days in the case of repeat caesarean. This shows the maternal morbidity to be more in the case of those undergoing repeat caesarean section. The mean length of hospital stay was similar to the findings of Placek PJ et al (1988). Iglesias S et al (1991) and Tan PC et al (2007) found the increased rate of VBAC accompanied by a tendency towards an overall decrease in the maternal length of hospital stay.

There was no perinatal mortality in the present study. And the perinatal morbidity was similar in all the cases, with neonatal intensive care unit (NICU) admission at 12% in normal cases, 12% in VBAC cases and 14% in repeat CS cases. Resuscitation was necessitated in 26% of the NVD cases but only 12% needed NICU admission, 16% of VBAC cases were resuscitated with 12% NICU admission and 24% of repeat CS were resuscitated with 14% NICU admission. Therefore, slightly increased percentage of NICU admission is seen in the case of repeat CS group. Shakti V et al (2006) found the perinatal morbidity of VBAC cases and repeat CS cases comparable to that for other normal deliveries. Smith GCS et al (2004) viewed that the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year than in hospitals with [greater than or equal to] 3000 births a year. The neonatal and maternal mortality rates did not improve despite increasing rates of repeat CS during the years after the AICOG, 1999 VBAC guideline revision (John Zweefler, 2006). The strongest prediction for neonatal admission was emergency caesarean delivery, further emphasizing the need of careful case selection in a trial of labour to minimize the risk of failure (Tan PC16).

CONCLUSION: Practicing obstetricians encounter increasing number of post caesarean pregnancies because the number of primary caesarean section from non-recurrent causes is rapidly rising. A trial of labor in cases of previous caesarean section is the way to reduce the overall caesarean section rate. Physicians need to discuss the risks and benefits of VBAC following trial of labour or elective repeat caesarean section with patients and patients' choices must be considered. Intensive study and research is deemed necessary to outline the optimum management of post caesarean pregnancies and make an endeavour to decrease the overall caesarean rate.

DOI: 10.14260/jemds/2015/1264

BIBLIOGRAPHY:

(1.) Lahousen M and Burmucic R: Labor management following previous caesarean section, Geburtshilfe Frauenheilkd; 46(3): 170-3, 1986.

(2.) Mor--Yosef S, Zeevi D, Samueloff A, Donhin M, Frankfurter H and Schenker JG: Vaginal delivery following one previous ceasarean birth: nationwide survey, Asia Oceania J Obstet Gynaecol; 16(1): 33-7, 1990.

(3.) Matias JP, Parpinelli MA and Cecatti JG: Factors associated with mode of delivery among primipara women with one previous ceasarean section and undergoing a trial of labor, Rev Assoc Med Bras; 53(2): 109-15, 2007.

(4.) Shakti V, Behera RC, Sandhu GS, Singh A and Bandhu HC: Vaginal birth after caesarean delivery, J obstet Gynecol India; 56(4): 320-323, 2006.

(5.) Tan PC, Subramaniam RN and Omar SZ: Labour and perinatal outcome in women at term with one previous lower segment Caesarean: A review of 1000 consecutive cases, Australian and New Zealand Journal of Obstetrics and Gynaecology; 47: 31-36, 2007.

(6.) Placek PA and Taffel SM: Vaginal birth after caesarean (VBAC) in the 1980s, American Journal of Public Health; 78(5): 512-515, 1988.

(7.) Tripathi JB, Doshi HU and Kotdawala PJ: Vaginal birth after one caesarean section: analysis of indicators of success, J Indian Med Assoc; 104(3): 113-5, 2006.

(8.) Smith GCS, White IR, Pell JP and Dobbie R: Predicting caesarean section and uterine rupture among women attempting vaginal birth after prior caesarean section, PLOS Medicine; 2(9): 0871-0878, 2005.

(9.) Chuang JH and Jenders RA: Trial of labour versus elective repeat caesarean section for the women with a previous caesarean section: a decision analysis, Proceedings AMIA Symposium: 226-230, 1999.

(10.) Leeman LM and Plante LA: Patient choice vaginal delivery? Annals of Family Medicine; 4(3): 265-268, 2006.

(11.) Goldman G, Pieault R, Bilodeau H and Blais R: Effects of patient, physician and hospital characteristics on the likelihood of vaginal birth after previous caesarean section in Quebec, Can Med Assoc J; 143(10): 1017-1024, 1990.

(12.) Brill Y and Windrim R: Vaginal birth after caesarean section: review of antenatal predictors of success, J Obstet Gynaecol Can; 25(4): 275-86, 2003.

(13.) Ugwumadu A: Does the maxim"once a caesarean, always a caesarean" still hold true? PLOS Medicine; 2(9): 0837-0838, 2005.

(14.) Zweefler J, Garza A, Hughes S, Stanich MA, Hierholzer A and Lau M: Vaginal birth after caesarean in California: before and after a change in guidelines, Annals of Family Medicine; 4(3): 228-234, 2006.

(15.) Iglesias S, Burn R and Saunders LD: Reducing the caesarean section rate in a rural community hospital, Can Med Assoc J; 145(11): 1459-1464, 1991.

(16.) Tan P C, Subramaniam R N and Omar S Z: Predictors for caesarean delivery and neonatal admission after trial of labour in women with one previous lower segment caesarean scar, Singapore Med J; 49(3): 188-192,2008.

AUTHORS:

Ratana Usham [1], Helen Kamei [2], Th. Digel Singh [3], Y. Ajitkumar [4], N. Nabakishore [5]

[1.] Ratana Usham

[2.] Helen Kamei

[3.] Th. Digel Singh

[4.] Y. Ajitkumar

[5.] N. Nabakishore

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Obstetrics & Gynaecology, JNIMS.

[2.] Assistant Professor, Department of Obstetrics & Gynaecology, JNIMS.

[3.] Assistant Professor, Department of Obstetrics & Gynaecology, JNIMS.

[4.] Registrar, Department of Obstetrics & Gynaecology, RIMS.

[5.] Professor & HOD, Department of Obstetrics & Gynaecology, RIMS

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Ratana Usham, Assistant Professor, Department of Obstetrics & Gynaecology, JINMS, Porompat, Imphal-795005, Manipur.

E-mail: ratana.usham@gmail.com

Date of Submission: 28/05/2015. Date of Peer Review: 29/05/2015. Date of Acceptance: 13/06/2015. Date of Publishing: 20/06/2015.
Table 1: Comparison of Mean [+ or -] SD of parameters between NVD and
VBAC

                                         NVD

Parameter               No. of        Mean [+ or -] SD
                         cases

Last child birth          50      2.5680 [+ or -] 1.01528
  (duration in yr.)
Blood T ransfusion        50      0.0400 [+ or -] 0.19795
Weight of baby in Kg      50      3.1820 [+ or -] 0.48136
Duration of hospital      50      3.0800 [+ or -] 0.98644
  stay in days

                                          VBAC

Parameter               No. of        Mean [+ or -] SD
                         cases

Last child birth          50      3.1800 [+ or -] 1.38932
  (duration in yr.)
Blood T ransfusion        50      0.2000 [+ or -] 0.69985
Weight of baby in Kg      50      3.0980 [+ or -] 0.40982
Duration of hospital      50      3.7400 [+ or -] 1.84954
  stay in days

                          t-               P-
Parameter               value    d.f.    value

Last child birth        2.515     98     0.014
  (duration in yr.)
Blood T ransfusion      1.556     98     0.123
Weight of baby in Kg    0.940     98     0.350
Duration of hospital    2.226     98     0.028
  stay in days

Table 2: Comparison of Mean [+ or -] SD of parameters between
VBAC and Repeat CS

Parameter                               VBAC

                        No. of        Mean [+ or -] SD
                         cases

Last child birth          50      3.1800 [+ or -] 1.38932
  (Duration in yr.)
Blood Transfusion         50      0.2000 [+ or -] 0.69985
Weight of baby in Kg      50      3.0980 [+ or -] 0.40982
Duration of hospital      50      3.7400 [+ or -] 1.84954
  stay in days

Parameter                             Repeat CS

                        No. of        Mean [+ or -] SD
                         cases

Last child birth          50      3.5320 [+ or -] 1.87469
  (Duration in yr.)
Blood Transfusion         50      0.1600 [+ or -] 0.46773
Weight of baby in Kg      50      3.3640 [+ or -] 0.30423
Duration of hospital      50      6.0600 [+ or -] 1.03825
  stay in days

Parameter               t-value    d.f.    P- value

Last child birth         1.067      98       0.289
  (Duration in yr.)
Blood Transfusion        0.336      98       0.738
Weight of baby in Kg     3.685      98       0.000
Duration of hospital     7.734      98       0.000
  stay in days

Table 3: Comparison of cases between NVD and VBAC according parameters

Parameters                                 Type of groups

                                            NVD    VBAC

Parity                         P0            1       0
                               P1           36      39
                               P2           12       8
                               P3            1       3
Admission                    Routine        21      16
                            Emergency       29      34
Labor                      Spontaneous      33      35
                             Induced        17      15
Mode of delivery               NVD          38      21
                            Ventouse        12      28
                             Forceps         0       1
Complication              Perineal tear      0       1
                          Cervical tear      1       2
                         Fetal distress      0       5
                               PPH           0       3
                            Hematoma         1       0
                               Nil          48      39
Sex of baby                   Male          29      27
                             Female         21      23
A/S                            >7           38      43
                               <7           12       7
Resuscitation of baby        Absent         37      42
                             Present        13       8
Neonatal ICU                 Absent         44      44
                             Present         6       6

Parameters                                   [chi     d.f.    P-value
                                           square]

Parity                         P0            2.92       3       0.50
                               P1
                               P2
                               P3
Admission                    Routine        1.073       1      0.300
                            Emergency
Labor                      Spontaneous      0.184       1      0.668
                             Induced
Mode of delivery               NVD          12.298      2      0.002
                            Ventouse
                             Forceps
Complication              Perineal tear     11.264      5      0.046
                          Cervical tear
                         Fetal distress
                               PPH
                            Hematoma
                               Nil
Sex of baby                   Male          0.162       1      0.687
                             Female
A/S                            >7           1.624       1      0.202
                               <7
Resuscitation of baby        Absent         1.507       1      0.220
                             Present
Neonatal ICU                 Absent         0.000       1      1.000
                             Present

Table 4: Comparison of cases between VBAC and Repeat CS according
parameters

Parameters                                   Type of group

                                           VBAC   Repeat CS

Parity                         P1           39       44
                               P2           8         5
                               P3           3         1
CS done before /after        Before         27       27
  labor                       After         23       23
Admission                    Routine        16       30
                            Emergency       34       20
Labor                      Spontaneous      35       32
                             Induced        15       18
Complication              Perineal tear     1         0
                          Cervical tear     2         0
                         Fetal distress     5         0
                               PPH          3         2
                               Nil          39       48
Sex of baby                   Male          27       29
                             Female         23       21
A/S                            >7           43       40
                               <7           7        10
Resuscitation of baby        Absent         42       38
                             Present        8        12
Neonatal ICU                 Absent         44       43
                             Present        6         7
Placenta                    Adherent        2         3
                             Normal         48       47

Parameters
                                            [chi      d.f.    P-value
                                           square]

Parity                         P1           4.231      5       0.517
                               P2
                               P3
CS done before /after        Before         0.000      1       1.000
  labor                       After
Admission                    Routine        7.890      1       0.005
                            Emergency
Labor                      Spontaneous      0.407      1       0.523
                             Induced
Complication              Perineal tear     9.131      4       0.058
                          Cervical tear
                         Fetal distress
                               PPH
                               Nil
Sex of baby                   Male          0.162      1       0.687
                             Female
A/S                            >7           0.638      1       0.424
                               <7
Resuscitation of baby        Absent         1.000      1       0.317
                             Present
Neonatal ICU                 Absent         0.088      1       0.766
                             Present
Placenta                    Adherent        0.211      1       0.646
                             Normal
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Title Annotation:ORIGINAL ARTICLE
Author:Usham, Ratana; Kamei, Helen; Singh, Th. Digel; Ajitkumar, Y.; Nabakishore, N.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Jun 22, 2015
Words:3491
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