VAGINAL DELIVERY AFTER CAESAREAN SECTION
AbstractThe trend to deliver with caesarean section has increased in the recent years. The factors affecting thistrend need re-consideration. Most of the women would deliver normally after a trial of labour afterprevious caesarean section. The obstetricians should abide by ethics in clinical practice, carefullyevaluate the indication before every caesarean section, and take an unbiased decision before performinga caesarean section.Trend to deliver with caesarean section (CS) hasincreased recently. The underlying factors are increasedknowledge, availability of facilities and patients’ fear ofvaginal birth. Many women are now opting for acaesarean delivery, even when it is not absolutelyrequired. Moreover, some obstetricians find it easy toperform a CS rather than to wait longer in trial of labour.On the basis of the available evidence the concept of aprophylactic caesarean section being outrageous hasbeen shattered by the fact that almost a third of femaleobstetricians would choose it for themselves.1 Increasedrate of primary caesarean delivery in the United Statesin recent years, and a declining vaginal birth aftercaesarean (VBAC) rate has increased the overall rate ofcaesarean deliveries.2 Recent increases in the proportionof US women with a prior caesarean delivery mean thatan increasing number of women are faced with thechoice and associated risks of either VBAC or repeatcaesarean delivery.3A prior caesarean birth increases the risk ofboth elective and emergency caesarean births anduterine rupture in a subsequent pregnancy.4 A trial oflabour after prior caesarean delivery is associated with agreater perinatal risk than is elective repeated caesareandelivery without labour, although absolute risks are low.This information is relevant for counselling womenabout their choices after a caesarean section.5 Womenwith a history of a prior caesarean birth may receiveconflicting information regarding options in futurepregnancies related to the choice of a trial of labour aftera caesarean (TOLAC) or having an elective repeatcaesarean delivery (ERCD).6 Need for induction andaugmentation of labour are both factors associated withan increased likelihood of unsuccessful vaginal birthand risk of uterine rupture.4Trial of labour after caesarean (TOLAC)delivery is currently a hot obstetrical topic owing to theacute rise in the rate of caesarean deliveries, bothprimary and repeat.7 Certain labour managementpractices increase the risk for uterine rupture 2–3 times,although the absolute increase is small from a baselineuterine rupture rate.8 After accounting for labourduration, induction is not associated with an increasedrisk of uterine rupture in women undergoing TOLAC.9Ultrasonography can be a useful tool forevaluation of the uterus in planning a normal deliveryafter previous CS. Ultrasound measurements of the CSscar expressed as residual myometrial thickness (RMT)and the change in RMT between the first and the secondtrimester of pregnancy, can accurately predict asuccessful trial of labour in patients with one previousCS.10To meet patient expectations for a safe andsuccessful outcome with a trial of labour after caesareandelivery (TOLAC), specific management plans,checklists, practical coverage arrangements, andsimulation drills are necessary.11The reports Health Committee MaternityServices and Changing Childbirth suggested thatwomen should have a pivotal role in their obstetric care.On the basis of the available evidence the concept of aprophylactic caesarean section being outrageous hasbeen shattered by the fact that almost a third of femaleobstetricians would choose it for themselves.1 A motherto-be must be explained in detail the benefits and risksof a CS before she opts for or is made to accept the CSfor delivery of her child. The obstetrician must neithersimply be a technician to receive dictation from herpatient, nor should be deciding herself alone about themode of delivery. The option of CS should be left onlyfor a really deserving case with genuine reasons for aprimary or a subsequent CS, and not only because of aprevious caesarean section. Excluding a small numberof cases who require an elective CS, labour may safelybe permitted in women who have had one previouscaesarean section, and most will deliver vaginally.12Induction of labour does not increase the riskof repeat caesarean section or uterine rupture. Thoughoxytocin may be administered to augment inefficientlabour, the combined use of oxytocin to acceleratelabour and analgesia significantly increases the risk ofuterine rupture.12Obstetricians should abide by ethics in clinicalpractice and carefully evaluate the indication in everyCS and take an unbiased decision before performing CSon demand/request. Although the debate will continueregarding the appropriateness of CS on demand, anydiscussion of risks and benefits must include theJ Ayub Med Coll Abbottabad 2012;24(1)2 http://www.ayubmed.edu.pk/JAMC/24-1/Editorial.pdfpotential for long term risks of repeated CS, includinghysterectomy and maternal and foetal death.13
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