VAGINAL BIRTH AFTER CAESAREAN SECTION

Abstract

Nobody can deny the fact that caesarean section is a lifesaving obstetrical procedure for both mother and thebaby. Decision for caesarean section should be made byexperienced and qualified obstetricians. The well knownprinciples of ethics like: autonomy, beneficence, nonmaleficence, and justice should be followed by theattending doctors. Based upon their knowledge, skills,and experience, decision of the obstetrician should bedeemed ethical without suspecting their motives.Pre-requisites for VBAC:1. Previous caesarean section performed for nonrepetitive causes like, breech presentation placentaprevia, and foetal distress etc.12. Time interval between previous caesarean section andcurrent pregnancy should be minimal 2 years. Weekscars will rupture easily if time interval betweenprevious caesarean section and present pregnancy isless than 2 years. In Pakistan 80% pregnancies areunplanned and many patients report in labour within 9months of previous c-section. Measurement of uterinescar thickness by ultrasound scan is not so far a goodpredictor of scar integrity and is still in experimentalstages.23. In current pregnancy patient should be booked with aqualified obstetrician from the beginning of thepregnancy.4. Pregnancy is uncomplicated and low risk, if there isany added problem like abnormal foetal presentation,twin pregnancy, IUGR, macrosomic babyhypertension, uncontrolled diabetes, and badobstetrical history when caesarean section is preferredover VBAC.5. All patients with previous c-section should be assessedby a qualified Obstetrician in last month ofpregnancy.36. It should preferably be spontaneous labour. Inductionwith oxytocin and prostaglandin should be avoideddue to increased risk of scar rupture leading to highperinatal and maternal mortality.4,57. Patients should take labour in hospital that is wellequipped having facilities of continuous foetalmonitoring, cardiotocography (CTG), and continuousCTG monitoring —a mandatory requirement for thepatient on trial of VBAC. Only signs of impendingscar rupture are CTG abnormities (sudden onset of latedeceleration).6 Labour wards of tertiary care hospitalsin Pakistan are over worked where high risk andcritical patients are referred. It is not possible to applycontinues CTG on 50–60 labouring patients. Presently2–3 CTG machines are available in some hospitals.Caesarean section on demand:Caesarean section on demand is on the rise for socialreasons. Obstetricians cannot reject the demand of thepatient for elective caesarean section. Patients should bethoroughly counselled about the pros and cons ofvaginal delivery vs caesarean section.7 After thoroughcounselling final decision about the mode of deliveryhas to be the choice of the patient. With everything finestill there are 10–15% chances of caesarean section inpatients who are in labour (Vagina delivery cannot beguaranteed!).Moreover, incidence of prenatal mortality is 2–3 fold higher in emergency caesarean section comparedto elective caesarean section, and maternal mortality is1.5–2 folds higher in emergency caesarean section.8–10Vaginal delivery is a retrospective diagnosis and nobodycan guarantee, normal delivery before hand. In modernobstetrics there is no place for difficult vaginaldelivery.11 With improvement of surgical techniques,better anaesthesia, blood transfusion services, and use ofantibiotics, caesarean section is considered safe for bothmother and baby over difficult vaginal delivery. Withrising caesarean section rates, prenatal mortality/maternal morality, cerebral palsy, and rate of vesicovaginal fistula have been reduced. Chronic pelvic floorproblems like utero-vaginal prolapse, urinary stressincontinence and anal sphincter damage, and flatus andstools incontinence are less common in patients whohad caesarean section deliveries.12Caesarean section rate can be reduced by:1. Having planned pregnancies2. Proper booking in antenatal clinics3. Advice about diet and regular exercise duringpregnancy to avoid foetal macrosomia4. External cephalic version (ECV) for uncomplicatedbreech presentation at 36–37 weeks as success rate ofECV is 50%. Such patients should be referred toconsultants for ECV in time.5. Strict control of diabetes with insulin, diet and exercise6. Proper treatment and control of hypertension and preeclampsia to avoid iatrogenic premature delivery bycaesarean section.7. Encouragement of spontaneous labour, avoidinginduction of labour with prostaglandins and oxytocics.Injudicious use of oxytocics causes foetal distresswhich usually needs delivery by caesarean section.8. Avoiding post-maturity as delivery beyond 41 weeksof gestation would increase the incidence of caesareansection and instrumental delivery.J Ayub Med Coll Abbottabad 2012;24(3-4)2 http://www.ayubmed.edu.pk/JAMC/24-3/Editorial.pdfIncidence of scar rupture for lower segmentcaesarean section is 1–1.5% and for classical caesareansection it is 5%. It means among 100 patients, onepatient can have ruptured uterus. To save that oneprecious maternal life we have to manage those 100patients with extreme care.