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Dr Ibrahim Ayyad ,Dep
of obgyn, Royal Jordanian medical
Services
Correspondance should
be sent to Dr. Ibrahim at the address:
Ayyad ayyadibrahim@hotmail.com, Jordan
Ramtha P. O. Box 559
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Objective:
To determinethe success rate for trial
of vaginal birth in women with one
prior caesarean delivery.
Materials
and methods:
Two hundred and sixty eight pregnant
women who had one prior caesarean
delivery were given a trial of vaginal
birth spontaneously or after induction
by oxytocin when indicated. The umber
of vaginal deliveries, caesarean births,
and maternal and perinatal outcomes
was recorded.
Results:
One hundred and ninety two women (70%)
had a successful vaginal birth and
forty-nine women (30%) had a repeat
caesarean delivery. Repeat caesarean
deliveries were performed dur to failed
progress and fetal distress in most
of the caesarean births.
Conclusion:
Our study indicated that vaginal birth
after caesarean birth is safe if properly
monitored.
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Key words:
Antibiotic, girls, cystitis, E.coli, efficacy
It has been found that repeat
caesarean births had a higher rate of early
gestational age and respiratory complications.
(1)
Because of the increased number
of women with elective repeat caesarean
delivery, a trial of labor was tried.
According to the American
College of Obstetricians and Gynecologists
Practice Bulletin in 1998, elective repeat
caesarean delivery now accounts for approximately
one third of all caesarean deliveries in
the United States. The same applies for
our department. The rate of vaginal birth
after caesarean in USA in 1990 was 19.5%
while in Norway it was 56.9%. (2).
Many studies have indicated
the safety of vaginal birth after caesarean
delivery. (3-6) But still there is much
to be searched for to define this.
.
This prospective trial was undertaken to
define the success rate of vaginal deliveries
and the maternal and perinatal outcomes.
Between September 2003 and
September 2004, two hundred and sixty two
pregnant women who were followed up at our
antenatal clinic at Prince Rushed Bin Al-Hasan
Hospital were enrolled in the study. All
of them had prior lower segment caesarean
delivery for non-recurrent causes and had
no high-risk pregnancy other than a caesarean
scar. All of them were of the same ethnic
group, aged between 20 and 30 years and
parity of one to three and pregnant with
an average size baby.
Twenty seven cases were excluded
from the study because they had malpresentation
(14cases), placenta previa (5 cases) and
contracted pelvis (8 cases). Once in labour,
they were admitted to the labour room and
offered a trial of vaginal birth after written
consent and after being monitored carefully
to avoid rupture of the uterus by monitoring
the following signs: vital signs, suprapubic
tenderness, fetal distress by electronic
continuous fetal heart rate monitoring and
the development of vaginal bleeding.
Seventy-two cases required oxytocin augmentation
because of inefficient uterine contractions.
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Out of
two hundred and sixty eight cases, twenty-seven
cases (10%) were excluded from the trial
of vaginal delivery because they had caesarean
section for the indications mentioned in
Table
1.
Two hundred and forty one cases were given
a trial of vaginal delivery, out of whom
one hundred and ninety two cases (80%) had
successful vaginal delivery and in forty-nine
cases (20%) the trial was discontinued because
an emergency caesarean section was performed
for the indications mentioned in Table
2.
One hundred
and sixty nine cases (70%) delivered spontaneously
without oxytocin induction, while seventy-two
cases (30%) required oxytocin for induction
of labor, out of whom forty seven cases
(65%) had successful vaginal birth while
twenty five cases (35%) required caesarean
birth for failed progress.
Our findings of an 80% successful
rate for vaginal birth are consistent with
those of Loebel G et al (2004) who reported
81% successful vaginal birth after a prior
Cesarean delivery (1). Several other studies
indicated similar successful vaginal birth
rate. (6-10)
Burrows LJ et al (2004) studied
32834 cases and found that 5656 cases required
repeat caesarean section, which means a
repeat caesarean section rate of 19%, findings
similar to ours (20%). (11)
Tongsong T and Jitawong C found a nearly
similar repeat caesarean birth rate.(12)
Caesarean section was performed
for the following indications in decreasing
order of frequency: 25% for failed induction,
20% for fetal distress and 4% for impending
uterine rupture.
Due to the proper monitoring
of patients no single case of uterine rupture
was observed, similar to what Tongsong T
(2003) obtained in his study.(12)
Comparatively, Durnwald C and Mercer B (2004)
showed that uterine rupture occurred in
0.8% of his study group.(13)
In their study ,Lin C and
Raynor BD showed that the rate of uterine
rupture was increased in all inductions
compared with that of the spontaneous labor
group. They found that among patients with
1 prior caesarean, rupture rates with misoprostol
and oxytocin induction were 0.8% and 1.1%,
respectively.(114)
No maternal or neonatal mortality
or significant morbidity were found in our
study, findings in accordance to Dizdarevic
J et al (2004).(3,15)
Our study showed a good success
rate of vaginal birth after one prior caesarean
section, where 80% of cases in the trial
had successful vaginal birth. Most of the
cases, which failed to have vaginal birth,
were due to failure to progress when given
oxytocin, and fetal distress and these are
non-recurrent causes of caesarean section.
This shows that we should encourage the
policy of vaginal birth after previous caesarean
birth for non-recurrent causes. This can
prevent the postoperative maternal mortality
and morbidity.
Future research should focus
on an evaluation of both short-term and
long-term consequences of vaginal birth
after cesarean delivery compared with elective
repeat cesarean section
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- Loebel G, Zelop CM, Egan
JF, Wax J. Maternal and neonatal morbidity
after elective repeat Cesarean delivery
versus a trial of labor after previous
Cesarean delivery in a community teaching
hospital . J Matern Fetal Neonatal Med.
2004 Apr;15(4):243
- Chua S, Arulkumaran S:
Trial of scar. Aust N Z Obstet Gynaecol
37:6, 1997
- American College of Obstetricians
and Gynecologists: Vaginal Birth After
Previous Cesarean Delivery. Washington,
DC, American College of Obstetricians
and Gynecologists, 1998. ACOG Practice
Bulletin #2
- Flamm BL, Goings JR, Liu
Y, et al: Elective repeat cesarean delivery
versus trial of labor: A prospective multicenter
study. Obstet Gynecol 83:927, 1994
- Miller DA, Diaz FG, Paul
RH: Vaginal birth after cesarean: A 10-year
experience. Obstet Gynecol 84:255, 1994
- Phelan JP, Clark SL, Diaz
F, et al: Vaginal birth after cesarean.
Am J Obstet Gynecol 157:1510, 1987
- Hendler I, Bujold E. Effect
of prior vaginal delivery or prior vaginal
birth after cesarean delivery on obstetric
outcomes in women undergoing trial of
labor . Gynecol. 2004 Aug;104(2):273-7
- Dizdarevic J, Abadzic N,
Begic K, Nikulin B, Mulalic L, Dekovic
S, Gavrankapeta-novic F, Beganovic N,
Stojkanovic G. Trial of labor after previous
cesarean section.
- Sepou A, Nguembi E, Yanza
MC, Penguele A, Ngbale R, Kouabosso A,
Domande-Modanga Z, Gaunefet C, Nali MN.
Uterine scars and subsequent vaginal birth:
follow-up of 73 parturients in the Central
Maternity Hospital of Bangui (Central
African Republic). Sante. 2003 Oct-Dec;13(4):231-3.
- Grinstead J, Grobman WA.
Induction of labor after one prior cesarean:
predictors of vaginal delivery. Gynecol.
2004 Mar;103(3):534-8
- Guise JM, Berlin M, McDonagh
M, Osterweil P, Chan B, Helfand M. Safety
of vaginal birth after cesarean: a systematic
review. Obstet Gynecol. 2004 Mar;103(3):420-9.
- Burrows LJ, Meyn LA, Weber
AM. Maternal morbidity associated with
vaginal versus cesarean delivery. Obstet
Gynecol. 2004 May;103(5 Pt 1):907-12
- Tongsong T, Jitawong C.
Success rate of vaginal birth after cesarean
delivery at Maharaj Nakorn Chiang Mai
Hospital. J Med Assoc Thai. 2003 Sep;86(9):829-35
- Durnwald C, Mercer B. Vaginal
birth after Cesarean delivery: predicting
success, risks of failure. J Matern Fetal
Neonatal Med. 2004;15(6):388-393
- Lin C, Raynor BD. Risk
of uterine rupture in labor induction
of patients with prior cesarean section:
an inner city hospital experience. Am
J Obstet Gynecol. 2004 May;190(5):1476-8.
- Dec;15(6):479 Odibo AO,
Macones GA. Current concepts regarding
vaginal birth after cesarean delivery.
Curr Opin Obstet Gynecol. 2003 -82.
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