VAGINAL DELIVERY AFTER CAESAREAN SECTION

Abstract

The trend to deliver with caesarean section has increased in the recent years. The factors affecting this
trend need re-consideration. Most of the women would deliver normally after a trial of labour after
previous caesarean section. The obstetricians should abide by ethics in clinical practice, carefully
evaluate the indication before every caesarean section, and take an unbiased decision before performing
a caesarean section.
Trend to deliver with caesarean section (CS) has
increased recently. The underlying factors are increased
knowledge, availability of facilities and patients' fear of
vaginal birth. Many women are now opting for a
caesarean delivery, even when it is not absolutely
required. Moreover, some obstetricians find it easy to
perform a CS rather than to wait longer in trial of labour.
On the basis of the available evidence the concept of a
prophylactic caesarean section being outrageous has
been shattered by the fact that almost a third of female
obstetricians would choose it for themselves.1 Increased
rate of primary caesarean delivery in the United States
in recent years, and a declining vaginal birth after
caesarean (VBAC) rate has increased the overall rate of
caesarean deliveries.2 Recent increases in the proportion
of US women with a prior caesarean delivery mean that
an increasing number of women are faced with the
choice and associated risks of either VBAC or repeat
caesarean delivery.3
A prior caesarean birth increases the risk of
both elective and emergency caesarean births and
uterine rupture in a subsequent pregnancy.4 A trial of
labour after prior caesarean delivery is associated with a
greater perinatal risk than is elective repeated caesarean
delivery without labour, although absolute risks are low.
This information is relevant for counselling women
about their choices after a caesarean section.5 Women
with a history of a prior caesarean birth may receive
conflicting information regarding options in future
pregnancies related to the choice of a trial of labour after
a caesarean (TOLAC) or having an elective repeat
caesarean delivery (ERCD).6 Need for induction and
augmentation of labour are both factors associated with
an increased likelihood of unsuccessful vaginal birth
and risk of uterine rupture.4
Trial of labour after caesarean (TOLAC)
delivery is currently a hot obstetrical topic owing to the
acute rise in the rate of caesarean deliveries, both
primary and repeat.7 Certain labour management
practices increase the risk for uterine rupture 2-3 times,
although the absolute increase is small from a baseline
uterine rupture rate.8 After accounting for labour
duration, induction is not associated with an increased
risk of uterine rupture in women undergoing TOLAC.9
Ultrasonography can be a useful tool for
evaluation of the uterus in planning a normal delivery
after previous CS. Ultrasound measurements of the CS
scar expressed as residual myometrial thickness (RMT)
and the change in RMT between the first and the second
trimester of pregnancy, can accurately predict a
successful trial of labour in patients with one previous
CS.10
To meet patient expectations for a safe and
successful outcome with a trial of labour after caesarean
delivery (TOLAC), specific management plans,
checklists, practical coverage arrangements, and
simulation drills are necessary.11
The reports Health Committee Maternity
Services and Changing Childbirth suggested that
women should have a pivotal role in their obstetric care.
On the basis of the available evidence the concept of a
prophylactic caesarean section being outrageous has
been shattered by the fact that almost a third of female
obstetricians would choose it for themselves.1 A motherto-be must be explained in detail the benefits and risks
of a CS before she opts for or is made to accept the CS
for delivery of her child. The obstetrician must neither
simply be a technician to receive dictation from her
patient, nor should be deciding herself alone about the
mode of delivery. The option of CS should be left only
for a really deserving case with genuine reasons for a
primary or a subsequent CS, and not only because of a
previous caesarean section. Excluding a small number
of cases who require an elective CS, labour may safely
be permitted in women who have had one previous
caesarean section, and most will deliver vaginally.12
Induction of labour does not increase the risk
of repeat caesarean section or uterine rupture. Though
oxytocin may be administered to augment inefficient
labour, the combined use of oxytocin to accelerate
labour and analgesia significantly increases the risk of
uterine rupture.12
Obstetricians should abide by ethics in clinical
practice and carefully evaluate the indication in every
CS and take an unbiased decision before performing CS
on demand/request. Although the debate will continue
regarding the appropriateness of CS on demand, any
discussion of risks and benefits must include the
J Ayub Med Coll Abbottabad 2012;24(1)
2 http://www.ayubmed.edu.pk/JAMC/24-1/Editorial.pdf
potential for long term risks of repeated CS, including
hysterectomy and maternal and foetal death.13