VAGINAL BIRTH AFTER CAESAREAN SECTION

Abstract

Nobody can deny the fact that caesarean section is a life
saving obstetrical procedure for both mother and the
baby. Decision for caesarean section should be made by
experienced and qualified obstetricians. The well known
principles of ethics like: autonomy, beneficence, nonmaleficence, and justice should be followed by the
attending doctors. Based upon their knowledge, skills,
and experience, decision of the obstetrician should be
deemed ethical without suspecting their motives.
Pre-requisites for VBAC:
1. Previous caesarean section performed for nonrepetitive causes like, breech presentation placenta
previa, and foetal distress etc.1
2. Time interval between previous caesarean section and
current pregnancy should be minimal 2 years. Week
scars will rupture easily if time interval between
previous caesarean section and present pregnancy is
less than 2 years. In Pakistan 80% pregnancies are
unplanned and many patients report in labour within 9
months of previous c-section. Measurement of uterine
scar thickness by ultrasound scan is not so far a good
predictor of scar integrity and is still in experimental
stages.2
3. In current pregnancy patient should be booked with a
qualified obstetrician from the beginning of the
pregnancy.
4. Pregnancy is uncomplicated and low risk, if there is
any added problem like abnormal foetal presentation,
twin pregnancy, IUGR, macrosomic baby
hypertension, uncontrolled diabetes, and bad
obstetrical history when caesarean section is preferred
over VBAC.
5. All patients with previous c-section should be assessed
by a qualified Obstetrician in last month of
pregnancy.3
6. It should preferably be spontaneous labour. Induction
with oxytocin and prostaglandin should be avoided
due to increased risk of scar rupture leading to high
perinatal and maternal mortality.4,5
7. Patients should take labour in hospital that is well
equipped having facilities of continuous foetal
monitoring, cardiotocography (CTG), and continuous
CTG monitoring -a mandatory requirement for the
patient on trial of VBAC. Only signs of impending
scar rupture are CTG abnormities (sudden onset of late
deceleration).6 Labour wards of tertiary care hospitals
in Pakistan are over worked where high risk and
critical patients are referred. It is not possible to apply
continues CTG on 50-60 labouring patients. Presently
2-3 CTG machines are available in some hospitals.
Caesarean section on demand:
Caesarean section on demand is on the rise for social
reasons. Obstetricians cannot reject the demand of the
patient for elective caesarean section. Patients should be
thoroughly counselled about the pros and cons of
vaginal delivery vs caesarean section.7 After thorough
counselling final decision about the mode of delivery
has to be the choice of the patient. With everything fine
still there are 10-15% chances of caesarean section in
patients who are in labour (Vagina delivery cannot be
guaranteed!).
Moreover, incidence of prenatal mortality is 2-
3 fold higher in emergency caesarean section compared
to elective caesarean section, and maternal mortality is
1.5-2 folds higher in emergency caesarean section.8-10
Vaginal delivery is a retrospective diagnosis and nobody
can guarantee, normal delivery before hand. In modern
obstetrics there is no place for difficult vaginal
delivery.11 With improvement of surgical techniques,
better anaesthesia, blood transfusion services, and use of
antibiotics, caesarean section is considered safe for both
mother and baby over difficult vaginal delivery. With
rising caesarean section rates, prenatal mortality/
maternal morality, cerebral palsy, and rate of vesicovaginal fistula have been reduced. Chronic pelvic floor
problems like utero-vaginal prolapse, urinary stress
incontinence and anal sphincter damage, and flatus and
stools incontinence are less common in patients who
had caesarean section deliveries.12
Caesarean section rate can be reduced by:
1. Having planned pregnancies
2. Proper booking in antenatal clinics
3. Advice about diet and regular exercise during
pregnancy to avoid foetal macrosomia
4. External cephalic version (ECV) for uncomplicated
breech presentation at 36-37 weeks as success rate of
ECV is 50%. Such patients should be referred to
consultants for ECV in time.
5. Strict control of diabetes with insulin, diet and exercise
6. Proper treatment and control of hypertension and preeclampsia to avoid iatrogenic premature delivery by
caesarean section.
7. Encouragement of spontaneous labour, avoiding
induction of labour with prostaglandins and oxytocics.
Injudicious use of oxytocics causes foetal distress
which usually needs delivery by caesarean section.
8. Avoiding post-maturity as delivery beyond 41 weeks
of gestation would increase the incidence of caesarean
section and instrumental delivery.
J Ayub Med Coll Abbottabad 2012;24(3-4)
2 http://www.ayubmed.edu.pk/JAMC/24-3/Editorial.pdf
Incidence of scar rupture for lower segment
caesarean section is 1-1.5% and for classical caesarean
section it is 5%. It means among 100 patients, one
patient can have ruptured uterus. To save that one
precious maternal life we have to manage those 100
patients with extreme care.