Optimization of clinical outcome of women with previous one lower segment cesarean section

doi:10.4236/ojog.2012.23055

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Open Journal of Obstetrics and Gynecology, 2012, 2, 265-269 OJOG

http://dx.doi.org/10.4236/ojog.2012.23055 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

Optimization of clinical outcome of women with previous

one lower segment cesarean section

Mamdoh Eskandar1*, Jameelah Aboud2, Majed Alshahrani2, Mervat Hassanein3, Azza Alyamani1

1Department of Ob s tetrics and Gynecology and Reproductive Medicine, College of Medicine, King Khalid University, Abha, KSA

2Department of Ob s tetrics and Gynecology, Abha General Hospital, Abha, KSA

3Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha, KSA

Email: *[email protected]

Received 16 May 2012; revised 17 June 2012; accepted 29 June 2012

ABSTRACT

Background and Objectives: To investigate the out-

come in women with planned Vaginal Birth After

Cesarean (VBAC) in comparison to Repeat Cesarean

Section (RCS) and to those undergoing vaginal birth.

Des ign and Settings: Retrospective study, women with

a history of one lower segment cesarean section

(LSCS) admitted to Abha General Hospital for deliv-

ery from September, 2010 to February, 2011. Sub-

jects and Methods: The demographic maternal and

neonatal data and data concerning the course of de-

livery were reviewed in 418 women underwent trial of

labor (TOL) and subjected to statistical analysis to

study the predictive factors and outcome. All cases

were divided into 3 groups, VBAC group (212 women),

RCS group (206 women) and the neonates of the

VBAC group were compared to those of a control

group consists of 287 neonates who were delivered

vaginally. Results: The success rate of VBAC was

50.72%, with no uterine rupture or wound dehiscence.

Failure to progress was the most common (40.2%)

indication of RCS followed by fetal distress (29.9%).

Young maternal age (P < 0.05), previous vaginal de-

liveries after CS (P < 0.05) and occiput anterior posi-

tion (P < 0.01) were significantly associated with suc-

cessful VBAC. Neonatal Intensive Care Unit (NICU)

admission was significantly higher in the RCS group

(P < 0.001), while no significant difference was found

between NICU admission in the VBAC and the con-

trol groups. Conclusion: VBAC should remain an

available option. Informed consent, good reporting

and thorough documentation of the VBAC decision

are crucial. During TOL, continuous fetal monitoring

and, ultrasound evaluation of the previous scar are

recommended. Emergency CS should be considered if

duration of the TOL is prolonged with non reassuring

CTG.

Keywords: VBAC; TOL; RCS; Pregnancy Outcome

1. INTRODUCTION

Quality improvement efforts, practice management skills,

in addition to safe, ethical practices and the need for a

focus on preven tion are all necessary to optimize clinical

outcomes. Change based on adoption of national standards

derived from Evidence-Based practice and randomized

controlled trials (RCTs) alone may not always establish

how diagnostic and therapeu tic procedures actually work

in clinical practice. For this reason, health care organiza-

tions must develop the tools to identify and adopt best

practice and improve clinical outcomes locally [1].

Previous studies assessing the safety of VBAC have

compared VBAC to Elective Repeat Cesarean Section

(ERCS) despite the fact that the risks posed by each are

considerably different. Explaining the complications of

VBAC in a way that is meaningful to women can be

challenging and thus a comparison to a similar group of

women who have undergone normal vaginal delivery

may be a more relevant comparison [2].

Benefits of VBAC may outweigh the risks in most

women with one previous low transverse cesarean, but

even with good facilities and personnel, numerous fac-

tors warrant special caution. Therefore, the aim of this

study was to investigate the outcome in women with

planned Vaginal Birth After Caesarean (VBAC) in com-

parison to Repeat Cesarean Section (RCS) and also to

those undergoing vaginal birth, in attempt to build up a

safer clinical pathway for management and improve the

health-care delivery system in Abha General Hospital in

the coming years.

2. SUBJECTS AND METHODS

This retrospective study was conducted on a total of 418

women with a history of one lower segment cesarean

section (LSCS) and had delivered at Abha General Hos-

pital from September, 2010 to February, 2011.

The demographic maternal and neonatal data as well

*Corresponding a uthor.

OPEN ACCESS

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269

266

as data concerning the course of the trial of labor of all

cases were reviewed using especially designed data

collecting tables, which then subjected to statistical ana-

lysis. Accordingly; all cases were divided into 3 groups;

VBAC group consists of 212 women, RCS group con-

sists of 206 women, (50/212 in the V BAC and 84/206 in

the RCS groups respectively were of high parity and

analyzed separately) and a control group consists of 287

neonates who were delivered by spontaneous vaginal

delivery. The neonates of the VBAC group were com-

pared to those of the control group who their mothers

delivered vaginally matched for age and parity. Descrip-

tive statistics included mean and stan dar d deviation. t test

as well as Chi Square test were the significance tests th at

used. P value < 0.05 indicated significance.

3. RESULTS

The demographic maternal data of all women participat-

ing in the study we re presented in Table 1.

212/418 (50.72%) delivered by VBAC while 206/418

(49.28%) delivered by RCS after a failed trial of labor,

with no uterine rupture or wound dehiscence. Maternal

age was significantly older in RCS group with significant

higher percentage of obstetric complications (P < 0.05).

Failure to progress was the most common (40.2%) in-

dication of RCS followed by fetal distress (29.9%), re-

f usal of th e pa tie nts to co n t inu e the tria l (2. 5%), i mpending

rupture of the uterus and intrapartum spotting (2.1%),

while other indications as abnormal head position, IUGR,

prolonged ROM, accounted for about fourth of the cases

(25.3%).

Significant higher percentage (35.19% vs. 17.21%) of

successful VBAC was found in women of low parity

who had previous vaginal deliveries after CS (Ta b l e 2 ).

In all women either of low or high parity postpartum

complications were highly significant in those delivered

by RCS (Tables 3 and 4).

The occiput anterior was highly significant position in

women who delivered vaginally by successful VBAC

than RCS (98.15% vs. 87.70% respectively). Apgar score

< 5 at one minute was significantly (P < 0.001) more

among the neonates of women who delivered by RCS

(17.36% vs. 1.25% respectively) Table 5.

The comparison between the percentages of NICU

admission in VBAC and RCS gr oups (5.56% vs. 19.67%

respectively) being higher in the RCS group was pre-

sented in Table 5 while no significant difference was

found between the percentages of NICU admission in the

VBAC and the control groups.

4. DISCUSSION

Based on current evidence, the success rates for VBAC

Table 1. Demographic maternal data.

VBAC Group N = 212 RCS Group N = 206 P Value

Age (Years) Mean (SD)a 29.65 (5.584) 31.35 (6.507) P < 0.05

Parity Mean (SD)

1 - 3

1.584 (0.755)

5.400 (1.818)

1.344 (0.627)

5.918 (1.910) P > 0. 05

Social Class

Number (Percent)b

Low

Moderate

N = 207c

42 (19.81%)

165 (77.83%)

N = 203d

44 (21.67%)

159 (78.33%)

P > 0.05

Previous History of Associated Medical Disorders

Number (Percent) 5 (2.02%) 9 (2.90%) P > 0.05

Associated Obstetric Complications

Number (Percent) 37 (13.03%) 62 (29.95%) P < 0.05

aValues are mean age (standard deviation); bNumber (percent); c5 cases were missed; d3 cases were missed.

Table 2. Clinical characteristics of the previous CS in women of low parity.

VBAC Group N = 162 RCS Group N = 122 P Value

Interval since PCSe (Months) Mean (SD) 38.674 (25.856) 40.818 (30.531) P > 0.05

Previous vaginal delivery after PCS Number (Percent ) 57 (35.19%) 21 (17.21%) P < 0.05

Postoperative Complications after PCS None None -

Hospital Stay after PCS (Days) Mean (SD) 3.476 (0.859) ( R a ng e 2 - 4) 3.458 (0.798) ( R a ng e 3 - 5) P > 0.05

ePrevious cesarean section.

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269 267

Table 3. Cours e of delivery in the VBAC and RCS groups in women of low parity.

VBAC Group N = 162 RCS Group N = 122 P Value

Gestational Age (Weeks) Mean (SD) 39.287 (1.393) 38.964 (2.427) P > 0.05

Attendant Number (Percent)

Resident

Specialist

146 (90.12%)

16 (9.88%)

61 (50%)

61 (50%) P < 0.001

Oxytocin Units Number (Percent) 2 Units+ 12 (7.41%) 14 (11.48%) P > 0.05

Duration of Labor (Hours) Mean (SD) 7.531 (6.479) 9.346 (7.969) P > 0.05

Maternal Postpartum Complicationsf Number (Percent) 2 (0.94%) 19 (9.22%) P < 0.001

fPostpartum complications include; h emorrhage, maternal ICU adm i s si on and emergency blood transfusion.

Table 4. Course of delivery in the VBAC and RCS groups in women with high parity.

VBAC Group N = 50 RCS Group N = 84 P Value

Gestational Age (Weeks) Mean (SD) 39.519 (1.221) 38.741 (2.123) P > 0.05

Attendant Number (Percent)

Resident

Specialist

43 (86%)

7 (14%)

31 (37.65%)

53 (62.35%) P < 0.05

Oxytocin Units Number (Percent) 2 Units+ 3 (6%) 4 (4.76%) P > 0.05

Duration of Labor (Hours) Mean (SD) 7.25 (7.30 2) 11.919 (8.949) P < 0.05

Maternal Postpartum Complications Number (Percent) 1 (0.47%) 4 (1.94%) P < 0.001

Table 5. Clinical data of the neonates in the VBAC and RCS groups in women of low parity.

VBAC Group N = 162 RCS Group N =122 P Value

Gender Number (Percent)

Males

Females

74 (45.68%)

88 (54.34%)

68 (55.74%)

54 (44.26%) P < 0.001

Birth Weight (Grams) Mean (SD) 2996 (0.452) 3011 (0.432) P > 0.05

Placental Weight (Grams) Mean (SD) 561.132 (116.327) 623.623 (155.077) P < 0.01

Presentation Number (Percent)

Occiput Anterior

Occiput Posterior

159 (98, 15%)

3 (1.85%)

107 (87.70%)

15 (12.30%) P < 0. 01

Apgar Score at 1 Minute Number (Pe rcent)

N = 160g

2 (1.25%)

158g (98.75%)

N = 121h

21 (17.36%)

100h (82.64%) P < 0. 001

NICU Admission Number (Percent) 9 (5.56%) 24 (19.67%) P < 0. 001

g2 cases were misse d ; h1 case was missed.

range f rom 60% - 80% (Ameri can Colleg e of Obstet ri ci ans

and Gynecologists (ACOG) VBAC Guidelines) [3]. De-

cision analysis concluded that VBAC is a reasonable

option when the chance of success exceeds 50% [4].

Failure to progress was the most common (40.2%) in-

dication of RCS in this study, followed by fetal distress

(29.9%). This is in contradictory to Finley and Gibbs

who found that true fetal distress only occurs in 1.5% of

all VBAC attempts [5]. This is may be due to misinter-

pretation of CTG traces, therefore, further evaluation of

the relationship between fetal tracing abnormalities and

uterine rupture is important as a nonreassuring fetal heart

rate is the most frequent sign [6].

Uterine rupture is more likely during trial of labor but

the rate is usually <1% (0.4% - 0.9%). It is more likely

with shorter interval between pregnancies < 18 months

[7], with labor induction or oxytocin augmentation [8],

macrocosmic babies [9] and postdates pregnancies [10].

In the present study, no uterine rupture or wound de-

hiscence were reported in the studied sample. This

agreed with one study reported 0.0% rupture range

without use of oxytocin [11] and other study reported

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269

268

rare uterine rupture (0.15%) when labor was spontaneous

without augmentation [12]. The reasonable explanation

is that the interval since the Previous Cesarean Section

(PCS) in the present study was long (Tabl e 2 ), our pa-

tients came in spontaneous labor and augmentation with

Oxytocin was used in small dose only in 7.4% - 11.5% of

patients (Ta b l e 3 ). Also we have no postdates (Ta bl e 4)

or macrosomia (Table 5).

Studying the course of delivery in the previous CS in

VBAC group compared to RCS group, results revealed

significant higher percentage of vaginal deliveries after

the PCS in the VBAC compared to RCS group (Table 2).

This is in agreement of previous studies which proved

that women who have delivered vaginally are more

likely to succeed at VBAC by factor of 9 to 28 than those

who have not [ 13,14].

Despite thousands of citations in the world’s literature

there are currently no randomized trials comparing ma-

ternal or neonatal outcomes for both RCS and VBAC. In

the current study maternal complications (postpartum

hemorrhage, emergency blood transfusion and maternal

Intensive Care Unit admissions) were significantly higher

among RCS group compared to VBAC group (Ta b le s 3

and 4). Author et al. and authors [15,16] showed lower

maternal morbidity after a trial of labor than after RCS.

The same was found in the present research where

maternal complications in all women were significantly

higher among RCS group compared to VBAC group.

With repeat cesarean section the risk of placental pro-

blems is increased and infants are affected. In the present

study, no perinatal deaths were recorded in the studied

sample, in absolute terms, the risk of perinatal death as-

sociated a trial of labor and uterine rupture was low 1 in

2200 [17]. In the present study, we have no perinatal

deaths because we have no uterine ruptures. This is sup-

ported by the finding of Lydon-Rochelle et al. [8] who

found the rate of infant mortality was 5.5% in cases in-

volving uterine rupture, compared with 0.5% without

rupture.

As found in one study that the rate of infant mortality

was 5.5% in cases involving uterine rupture.

Comparing the neonatal morbidity in VBAC, RCS and

control groups, the present study revealed that there was

a highly significant difference between percentages of

NICU admission in both studied groups; being more in

RCS group (Table 5), while no significant difference was

found between the VBAC and the control groups. This

disagrees with a study which recorded hypoxic-ischemic

encephalopathy occurred in no infants in ERCS and in 12

infants in TOL group [18]. This contradiction can be ex-

plained by that our women did RCS after failed VBAC

thus more exhausted infants needed NICU admission

while cesarean sections in their study were planned

ERCS.

Based on the results of this research, we conclude that

when women are carefully selected in situation with op-

timal facilities and personnel, VBAC should remain an

available option. Informed consent, good reporting and

thorough documentation of the VBAC decision are cru-

cial to reduce the medico legal risk. Every woman with

history of one LSCS in spontaneous labor, providing

there was no clear indication of RECS, should be care-

fully evaluated by individualized assessment before a

management plan is made and documented. All women

with full term, singleton, normal pregn an cy, with average

fetal weight, vertex presentation should have an attempt

of VBAC especially in young women with low parity

and history of previous vaginal deliveries after their pre-

vious CS.

During the Trial of Labor, continuous fetal monitoring

is mandatory, ultrasound evaluation of the previous scar

is recommended both intrapartum and postpartum to

confirm scar integrity and detect asymptomatic income-

plete uterine rupture. Emergency CS should be con-

sidered if the duration of the TOL is prolonged with non

reassuring CTG. The attending doctor should be fully

aware of these General Guidelines for VBAC.

Active role should be played in educating both women

and practitioners about healthy childbirth practices that

not only encourage VBAC but also discourage the over-

use of primary CS. This is of prime importance espe-

cially among Saudi women who usually plan for big

families.

Further studies are needed to investigate safety of

VBAC with twins, suspected macrosomia and unknown

uterine scars. Also, to identify the possible hidden

perinatal mortality if VBAC is compared to RECS at 37 -

38 weeks.

REFERENCES

[1] Hobel, C.J., Lu, M.C. and Gambone, J.C. (2010) A

life-course perspective for women’s health care. Safe,

ethical and effective practice. In: Gambone, J.C. and

Hobel, C.J., Eds., Essentials of obstetrics and gynecology,

5th Edition, Elsevier, Philadelphia, 3-11.

[2] Rozen, G., Ugoni, A.M. and Sheehan, P.M. (2010) A new

perspective on VBAC: A retrospective cohort study.

WWW.PubMed.com

[3] American College of Obstetricians and Gynecologists

(2010). VBAC guidelines published in August.

http://www.acog.org/

[4] Mankuta, D.D., Leshno, M.M., Menasche, M.M. and

Brezis, M.M. (2003) Vaginal birth after CS: Trial of labor

or repeat CS. A decision analysis. American Journal of

Obstetrics & Gynecology, 189, 714-719.

doi:10.1067/S0002-9378(03)00833-0

[5] Finley, B.E. and Gibbs, C.E. (1986) Emergent cesarean

delivery in patients undergoing a trial of labor with a

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269

269

OPEN ACCESS

transverse lower segment scar. American Journal of Ob-

stetrics & Gynecology, 155, 936-939.

[6] American College of Obstetricians and Gynecologists

(2004) Practice bulletin 54: VBAC. Washington DC.

[7] Shipp, T.D., Zelop, C.M., Repke, J.T., Cohen, A., Lie-

berman, E. (2001) Interdelivery interval and risk of

symptomatic uterine rupture. Obstetrics & Gynecology,

97, 175-177. doi:10.1016/S0029-7844(00)01129-7

[8] Lydon-Rochelle, M., Holt, V.L., Easterling, T.R. and

Martin, D.P. (2001) Risk of uterine rupture during labor

among women with a prior cesarean delivery. The New

England Journal of Medicine, 345, 3-8.

doi:10.1056/NEJM200107053450101

[9] Elkousy, M.A., Sammel, M., Stevens, E., Peipert, J.F. and

Macones, G. (2003) The effect of birth weight on vaginal

bir th after cesarean delivery success rates. American Jour-

nal of Obstetrics & Gynecology, 188, 824-830.

doi:10.1067/mob.2003.186

[10] Zelop, C.M., Shipp, T.D., Cohen, A., Repke, J.T. and

Lieberman, E. (2001) Trial of labor after 40 weeks gesta-

tion in women with prior cesarean. Obstetrics & Gyne-

cology, 97, 391-393.

doi:10.1016/S0029-7844(00)01175-3

[11] Chattopadhyay, S.K., et al. (1994) Planned vaginal deli-

very after two previous cesarean sections. British Journal

of Obstetrics and Gynaecology, 101, 498-500.

[12] Dekker, G.A., Chan, A., Luke, C.G., Priest, K., Ri ley, M.,

Halliday, J., King, J.F., Gee, V., O’Neill, M., Snell, M.,

Cull, V. and Cornes, S. (2010) Risk of uterine rupture in

Australian wome n attempti ng vaginal birth after one prior

caesarean section: A retrospective population-based co-

hort study. An International Journal of Obstetrics & Gy-

naecology, 11 7, 1358-1365.

doi:10.1111/j.1471-0528.2010.02688.x

[13] Flamm, B.L. (1997) Once a cesarean always a contro-

versy. Obstetrics & Gynecology, 90, 312-315.

doi:10.1016/S0029-7844(97)00263-9

[14] McNally, O.M. and Tumer, M.J. (1999) Induction of la-

bor after one previous cesarean section. Australian and

New Zealand Journal of Obstetrics and Gynaecology, 39,

425-429. doi:10.1111/j.1479-828X.1999.tb03126.x

[15] Rosen, M.G., Dickinson, J.C. and Westhoff, C.L. (1991)

Vaginal birth after cesarean: A meta-analysis of mortality

and mortality. Obstetrics & Gynecology, 77, 465-470.

[16] O’Brien, J.M., Barton, J.R. and Donaldson, E.S. (1996)

The management of placenta percreta conservative and

operative strategies. American Journal of Obstetrics &

Gynecology, 175, 1632-1638.

[17] Smith, G.C., Pell, J.P., Cameron, A.D. and Dobbie, R.

(2002) Risk of perinatal death associated with labor after

previous cesarean delivery in uncomplicated term preg-

nancies. The Journal of the American Medical Associa-

tion, 287, 2684-2690. doi:10.1001/jama.287.20.2684

[18] Mark, B., Landon, M.D., John, C., Hauth, M.D., Kenneth,

J., et al. (2004) Maternal and perinatal outcomes associ-

ated with a trial of labor after cesarean delivery. The New

England Journal of Medicine, 351, 2581-2589.

doi:10.1056/NEJMoa040405