A study of the maternal and fetal outcome in vaginal birth after previous one caesarean section

Pradeep Patil^1*, Rajiv Dabade²

Abstract               Background: Vaginal Birth After Caesaerean Section (VBAC) is an important dilemma on obstetric practice. Caesaerean section has its complications. Proper monitoring of mother and baby during labour can increase the chances of VBAC and reduces post operative complication of caesaerean section. Aim and objective: To study the maternal and fetal outcome in vaginal birth after previous caesarean section Methodology: Present study was a prospective study carried out in 261 patients. Trial of labour was given in labour rooms to those who have undergone spontaneous labour or who have been induced. Careful monitoring of labour was done by recording maternal pulse, Blood Pressure and plotting the partogram and fetal Heart monitoring. Patients requiring LSCS were shifted to operation theatre. Remaining delivered by normal vaginal delivery or assisted delivery. Data was collected with pretested questionnaire. It included sociodemographic data. Outcome of the delivery noted. Perinatal death rate, birth weight of baby, APGAR score at 1 min and 5 min were noted. Results: The overall success rate of VBAC in our study was 74%. The perinatal Death rate in present study was 1.5%. Birth weight and mode of delivery were significantly associated. Bad APGAR scores were not much associated with the mode of delivery at the end of 5 minutes.

Key Word: maternal and fetal outcome, vaginal birth, caesarean section

INTRODUCTION

The indications for cesarean delivery have been undergoing a gradual change over the last few decades. This change has been in the form of an increase in the number of indications rather than anything else, as caesarean births have become safer. This is not to imply that they have become safer than normal uncomplicated vaginal deliveries but that they have become safer than they used to be. The major contributors to making caesarean delivery safer were improvement in techniques of anesthesia, advent of powerful and effective antibiotics, availability of blood transfusion and last but not the least, improvement in surgical techniques and operative skills. The initial list of indications for caesarean delivery included conditions where it was done mainly for maternal interest when a further trial of labor was considered hazardous. More recently, however, the health of the fetus has played a significant role in making the decision for a caesarean birth. This has become increasingly pronounced after the advent of high-resolution ultrasound, Doppler ultrasound and electronic fetal monitoring. What contributed to the increasing list of indications for caesarean section was the safety of caesarean birth in certain high-risk pregnancies. There also has been a definite trend in some centers towards a planned caesarean birth for women who have conceived following assisted reproductive techniques. Of late, the safety of an elective caesarean birth has prompted some obstetricians in the developed world to consider and allow for the feasibility of an elective caesarean section based on maternal request. Caesarean birth has been definitely instrumental in decreasing the maternal and perinatal morbidity and mortality. Even though caesarean birth has become safer than it used to be, still it is not without morbidity. Therefore, the decision for the mode of delivery must be made with judicious caution. Repeat caesarean sections account for the major share of the present day indications for caesarean sections. ln lndia, it ranges from 8.48% to 41.9 % ^1,2 A study³ reveals that repeat cesarean sections account for 35% of all cesarean sections in u.s.A, 23%in Nonvay and 8% in Hungary. In the past decade there has been much focus on the issue of vaginal birth after caesarean section. lt has been argued," The most remarkable change in obstetric practice over the past decade was management of the woman with a prior caesarean delivery." Schmitza reported 62 out of 448 women with a history of previous caesarean section, who undenvent vaginal delivery at Lewis Memorial lVlaternity Hospital. Schmitz reasoned that if the risk of uterine rupture was 4o/o and the maternal mortality from rupture was 11%lhen the maternal mortalily (0.44%) is less with trial of Labor.

Though the practice of VBAC increased significantly, there have been several reports ^4-8 published that suggest that VBAC may be riskier than anticipated. Such reports raised concern about the safety of VBAC and have contributed to heightened controversy. world wide success rate of trial of labor after cesarean is about 7580%; while risk of uterine rupture in such trial is o.5-1% the current study is also an endeavor with the objective in mind of estimating risks and trends in VBAC.

Aim and objective: To study the maternal and fetal outcome in vaginal birth after previous caesarean section

MATERIAL AND METHODS

Present study is a prospective study carried out in government medical college Nagpur. Total 261 patients underwent the study in the labor room of department of obstetric and gynecology. Study was conducted for one year from August 2005 t0 July 2006. The cohort for this study was formed by total number of patients delivering at Government Medical College and Hospital Nagpur during the study period. Total 12,591 women delivered during this period. The total caesarean section rate for this was found to be 23.74 within this period.

lnclusion criteria: 1. Patients with only one previous caesarean 2. All vertex presentations 3. Singleton gestations

Exclusion criteria: 1. Patients with known classical or inverted T incision during previous caesarean section. 2. Any uterine incision with extension into body (upper uterine segment) of uterus in prior section. 3. Lower vertical scar in previous section 4. Patients with presentations/lie apart from vertex i.e. patients with transverse lie/oblique lie, breech, face, brow presentation. 5. Patients with twin pregnancy/multiple gestation 6. Patients having upper segment hysterotomy scar 7. Patients having previous scar of myomectomy. Study was approved by ethical committee of the institute. A valid written consent was taken from the patients after explaining study to them. Subjects were the patients admitted in labour rooms for trial of labour. These consisted both those booked cases who have visited before in the antenatal clinics and those who have visited directly in emergency. Lower uterine segment thickness was measured by ultrasound examination in patients after they have completed 36 weeks of gestation. But lower uterine segment thickness was not done in those patients who were in labour though have passed their 36 weeks of gestation. Pelvic Assessment was done to assess the adequacy of pelvis. Emergency preparedness measures like availability of surgeon, anaesthesia provider, operating room personnel and sufficient blood was always ensured. Trial of labour was given in labour rooms to those who have undergone spontaneous labour or who have been induced and labour augmentations by Pitocin in lV drip was done in those who required. Careful monitoring of labour was done by recording maternal pulse, Blood Pressure and plotting the partogram for each patient over INDIAN NOMOGRAM FOR CERVICAL DILATATION and fetal Heart monitoring by intermittent auscultation by stethoscope and Doppler.

Vigilant watch was kept for symptoms and signs of scar dehiscence such as maternal and fetal tachycardia, hypotension, fetal bradycardia, per vaginal bleeding; lower uterine segment tenderness or change in uterine contour especially when labour was induced or augmented. Patients who developed fetal distress, who crossed the action line on partogram, who developed signs and symptoms of scar dehiscence were shifted for emergency LSCS.  Data was collected with pretested questionnaire. It included sociodemographic data. Outcome of the delivery noted. Perinatal death rate, birth weight of baby, APGAR score at 1 min and 5 min were noted Data analysed with appropriate statistical tests.

RESULTS

Table 1: Distribution of patients according to Age grouped mother and type of delivery

P=0.0045 RR = 0.76(0.68-0.84)

Table 2: Distribution of patients according to birth weight of baby and type of delivery

P<0.05 RR= 0.78 (0.65-0.83)

Table 3: Distribution of patients according to APGAR score in baby and type of delivery

DISCUSSION

In our study Total 261 patients were given trial of labour. Out of those 193 ( 74%) delivered vaginally without assistance while only 5 (1.9%) required assistance with forceps. About 63 (24.2%) patients required repeat caesarean section due to various reasons. Bujold et al. ⁹ found that advanced age was associated a higher rate of failed TOL in patients with a prior caesarean section. ln addition, older patients were more likely to have had a prior successful vaginal delivery .the rate of successful VBAC in these patients is more than 80%.However,he found no association between the maternal age at the time of prior C.S.and risk of uterine rupture. Shipp et al. (2002) ¹⁰ addressed these issues by including only women having one prior cesarean delivery and no prior vaginal deliveries, and also have shown that maternal age has a statistically significant independent association with symptomatic uterine rupture. Uterine incisions after cesarean delivery appear to heal by scar formation as opposed to myometrial regeneration as has been previously suggested. lncreasing age is a critical factor in the risk for abdominal wound dehiscence. Although it is possible that factors related to healing could contribute to the increase in uterine rupture, the specific factors responsible for the higher rate of uterine rupture with increasing maternal age remain to be elucidated. Patients having birth weight more than 3.5 kg were 3. All needed repeat C.S. (100%). When compared to older studies, in study done by Elkousy ¹¹ in 2003 success rate with no previous vaginal births and EFW of > 4,000 gms was <50o/o, while the uterine rupture rate in this group with infants > 4,000 gms was 3.6%. ln a record review of women at term with one PCS Zelop et al. ¹² in 2001 repeat C.S. rate was 40 % for infants larger than 4000 grams.

In our study we observed High APGAR score in 1.1% babies. Similar findings were seen in Jarrell et al. where they observed 1.3% depressed babies. Lieberman et al. ¹³ also observed 1.03% depressed babies. In studies like Saldana et al. ¹⁴ (3.2%) and Rosen et al. ¹⁵ (3.8%) this percentage was more than our study.  The percentage of babies being depressed at birth was more, probably because of the absence of foetal monitoring devices for early diagnosis during labour. The overall success rate of VBAC in our study was 74%. Various other study shows comparable results like Rageth et al. ¹⁶ 73.3%, Sims et al. ¹⁷ 77%, Elkousy et al. ¹¹ 74% and Bujold et al. ⁹ 78 %. The success or failure, as in the cases of the present study, cannot be, thereby, attributed to the presence of a scar alone, but to the labour various maternal characteristics collectively, which precedes the repeat C.S. The repeat C.S. results due to failure of this labour. The perinatal Death rate in present study was 1.5%. Saldana et al. ¹⁴ observed perinatal death rate of 0.7%. Jarrell et al. ¹⁸ and Rosen et al. ¹⁵ had not recorded any death in their study. Stone et al. ¹⁹ and Rageth et al. ¹⁶ found perinatal death rate of 0.4% and 0.6% respectively. Out of the 4 babies that died, only 2 deaths could be attributed to factors relating to a trial and failure of vaginal labor i.e. only 0.75%. Deaths were due to foetal distress. ln spite of over judicious care in the absence of monitoring facilities, 4 babies were lost, implicating that the facilities are a 'must as advised by ACOG guidelines for high risk patients like the present study group.

CONCLUSION

Use of fetal monitoring techniques along with more liberal use of induction methods would help to achieve greater number of successful VBAC trials without increasing maternal or fetal morbidity.

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