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Table of Content - Volume 16 Issue 3 - December 2020
Study of TOLAC (trial of labour after caesarean) at a tertiary hospital
Kusum Kumari1, Reena Kumari2*
1Senior Resident, 2Associate Professor, Department of Obstetrics & Gynaecology, Anugrah Narayan Magadh Medical College (ANMMCH), Gaya, Bihar, INDIA. Email: drkusum74@gmail.com
Abstract Background: Cesarean section (CS) is one of most common major surgical procedures, life-saving both for the mother and the newborn when medically indicated. Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. Assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Present study was focused towards maternal and early neonatal outcome in patients underwent at our tertiary health care center. Material and Methods: Present study was a prospective, observational study conducted in patients who underwent TOLAC. Labour was monitored as per standard protocols with the help of WHO partograph. All the cases were provisionally prepared for emergency LSCS. Augmentation of labour was done with artificial rupture of membranes/ oxytocin infusion when indicated. Ventouse/ forceps were used in second stage of labour. Ante partum, intra partum and post-partum complications were noted in all patients whether delivered vaginally or abdominally. Maternal and early neonatal outcome were collected. Results: Out of total 171 cases, 67 (39%) patients had successful VBAC (vaginal birth after caesarean delivery) while 104 (61%) patients required emergency caesarean section. Most common maternal age group for present study was 25- 29 years (42 %) followed by 19- 24 years age group (35 %). Most patient in present study were of parity 2 (52%), underwent emergency LSCS in previous pregnancy (64%). Successful TOLAC was most common in patients with <2500 gm fetal birth weight in last pregnancy (46 %). In patients kept for TOLAC most common indications of previous caesarean section was fetal distress (22%), cephalo-pelvic disproportion (19%), mal-presentation (16%) and non-progress of labour (13%). Among patients kept for TOLAC 55% had spontaneous delivery while 33% required augmentation with ARM and/or oxytocin and 12% had instrumental vaginal delivery. Conclusion: TOLAC is a safe alternative to repeat an elective caesarean. Majority of the cases of previous caesarean section done for non-recurrent indication can be delivered safely by the vaginal route, without any major complication to the mother and the newborn, in an institution having facilities for emergency caesarean. Key Words: Post Caesarean Pregnancy, TOLAC, VBAC, Maternal Outcome, early neonatal Outcome.
INTRODUCTION Cesarean section (CS) is one of most common major surgical procedures, life-saving both for the mother and the newborn when medically indicated.1 Women undergoing cesarean section have a higher morbidity and mortality rate than those having vaginal birth, such as massive postpartum hemorrhage, need for blood transfusion, anesthesia-associated complications, surgical risks (intestinal obstruction, wound dehiscence, wound scars, infection, etc.), and obstetric complications in subsequent pregnancies.2 Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (i.e., VBAC) and elective repeat cesarean delivery.3 For women with more than one previous cesarean delivery, TOLAC is likely to be successful, but with an estimated higher risk of uterine rupture (0.2 to 1.5% with a transverse uterine incision, 1.0 to 1.6% with a low-vertical uterine incision).4 While vaginal delivery has less chances of infection, can be performed without general or spinal anaesthesia, provide early ambulation and early discharge, results in better bonding and early breast feeding.5 Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Present study was focused towards maternal and early neonatal outcome in patients underwent at our tertiary health care center.
MATERIAL AND METHODS Present study was a prospective, observational study of the patients who underwent TOLAC from December 2016 to December 2019 at ,anugrah narayan magadh medical college, Gaya. Study was conducted at department of obstetrics and gynaecology, done after institutional ethical approval. Inclusion criteria – patients fulfilling all below mentioned criteria
Exclusion criteria
Study was explained to patients in local language and written consent was taken for participation. Final inclusion was done by senior obstetrician. Demographic details ( age, address, educational and socioeconomic status) and clinical history (obstetric, menstrual, Relevant past, personal and family history) were noted. General examination and obstetrical examination and relevant investigations are noted from the case sheets. Special attention was paid to the details of the previous caesarean section such as indication, elective/emergency surgery, complications encountered during and after delivery, gestational age, baby weight, fetal outcome, any surgical abortions after LSCS. Labour was monitored as per standard protocols with the help of WHO partograph. All the cases were provisionally prepared for emergency LSCS. Augmentation of labour was done with artificial rupture of membranes/ oxytocin infusion when indicated. Ventouse/ forceps were used in second stage of labour. Ante partum, intra partum and post-partum complications were noted in all patients whether delivered vaginally or abdominally. Maternal and early neonatal outcome were collected. For statistical analysis continuous variables (age, birth weight) were presented as Mean + SD. Categorical variables were expressed in percentages. Chi square test was used for comparison. Statistical analysis was done using descriptive statistics.
RESULTS In the present study, total 171 cases satisfying study criteria were included for trial of labour after caesarean delivery. Out of these 67 (39%) patients had successful VBAC (vaginal birth after caesarean delivery ) while 104 (61%) patients required emergency caesarean section. Table 1: Mode of delivery in TOLAC patients
Most common maternal age group for present study was 25- 29 years (42 %) followed by 19- 24 years age group (35 %). Successful TOLAC was most common in 19- 24 years (51 %) followed by 25- 29 years age group (37 %). Emergency LSCS was most common in 25- 29 years (44 %) followed by 19- 24 years age group (25 %). Most patient in present study were of parity 2 (52%), underwent emergency LSCS in previous pregnancy (64%). Successful TOLAC was most common in patients with <2500 gm fetal birth weight in last pregnancy (46 %). Emergency LSCS was most common in patients with 3000-3499 gm fetal birth weight in last pregnancy (35 %). Table 2: Characteristics of pregnant women undergoing trial of labor after caesarean section.
In patients kept for TOLAC most common indications of previous caesarean section was fetal distress (22%), cephalo-pelvic disproportion (19%), mal-presentation (16%) and non-progress of labour (13%).
Table 3: Indications of Previous CS
Among patients kept for TOLAC 55% had spontaneous delivery while 33% required augmentation with ARM and/or oxytocin and 12% had instrumental vaginal delivery.
Table 4: mode of delivery in VBAC
Among patients kept for TOLAC who required repeat emergency caesarean section, in cases of failed trial of labor, fetal distress (44%), nonprogress of labour (31%) and maternal request (9%) were most common indications.
Table 5: Indication of repeat emergency caesarean in cases of failed trial of labor
In present study 39% success rate was noted in patients with or without history of prior vaginal delivery. Table 6: Prior Vaginal Delivery
We noted only one case of atonic PPH in VBAC patients. In emergency LSCS group 1 atonic PPH, 2 traumatic PPH (1 due to dense adhesions, 1 due to extension of uterine incision), 3 scar dehiscence were noted. Postoperative SSI and fever were also noted in emergency LSCS group. We did not noticed any case of uterine rupture in present study.
Table 7: Maternal complications
13% and 11% neonates from VBAC and emergency LSCS group required NICU admission respectively. No stillbirth or neonatal death was noted in present study.
Table 8: Neonatal complications in vaginal deliveries (n=15) and repeat cesarean group (n=85)
DISCUSSION Rise in rate of caesarean deliveries is noted in every part of world. Most researchers believe that the main causes of this rise are the continuous monitoring of the fetal heart during labour , the lack of experience in dealing with instrumental delivery or vaginal breech delivery, and maternal request.6 Repeat caesarean section after a previous one is also a major contributing factor, accounting for more than one-third of all caesarean deliveries in the United States.7 TOLAC is an alternative to reduce rate and morbidities associated with caesarean delivery. The success rate of vaginal delivery after trial of labor (TOLAC) is dependent on several factors, which includes cervical Bishop score at admission, spontaneous onset of labor, and epidural analgesia.8 In present study VBAC was noted in 39% patients kept for TOLAC. other Indian studies reported different incidence of VBAC such as Najma KP et al.9 (11.87%), Sharma A et al.10 (27.45%), Manikya Rao11 (48%). 73% patients with birth weight of ≤ 3.0 kg had successful vaginal delivery, similar results were noted by Mugdha L Jungari et al.12 and Balachandran L et al.13. In a study by Iyer et al..,14 on 318 women noted that there are more chances of VBAC (84.8%) in women with history of previous vaginal delivery compared to ones without (62.7%). In the present study the most common indication for repeat LSCS were fetal distress and Nonprogress of labour. Other studies from India reported similar findings.11,15,16 Factors associated with decreased VBAC success were labor induction, labor augmentation, short inter-pregnancy interval, birth weight >4000 gm, gestational age 41 weeks or greater, excess maternal weight gain, maternal obesity, recurrent indication for initial cesarean delivery and unfavorable cervical status at admission.17,18 Uterine rupture or dehiscence associated with TOLAC results in the most significant increase in the likelihood of additional maternal and neonatal morbidity. Uterine rupture is associated with an increased risk of severe maternal complications, such as hysterectomy, hemorrhage, as well as severe fetal complications, such as hypoxic ischemic encephalopathy and perinatal death. Because of concerns about this complication, the rate of attempted TOLAC continues to fall all over the world.19,20 In emergency LSCS group we noted 3% PPH, 2% SSI and 1% post-op fever. Comparing with other studies, Uma Pandey et al.15 reported pyrexia 7.1%, blood transfusion done for 7.1%, urinary tract infection (UTI) 7.1%, episiotomy infection in 7.1%, while Manikya Rao et al.11 reported 23.07% overall morbidity. Goel SS et al. also reported significantly more maternal complications in the form of PPH and need of blood transfusion in cases undergoing repeat CS whether emergency or elective than delivered vaginally.21 The age‑old dictum from Cragin ER (1916), “Once caesarean is always caesarean” has completely lost its relevance and finally given way to another statement: “if a strong uterine scar is indicated and there are no other indications for CD, preference should be given to spontaneous delivery”.22 According to the American College of Obstetricians and Gynecologists (ACOG), most women with one previous cesarean delivery and a low-transverse incision are candidates of TOLAC and should be counseled about TOLAC and offered a trial of labor.3 However, TOLAC should only be attempted in centre well equipped with comprehensive emergency obstetric care and with facilities for emergency 24-hour caesarean section, due to the catastrophic nature of uterine rupture.23
CONCLUSION TOLAC is a safe alternative to repeat an elective caesarean. Majority of the cases of previous caesarean section done for non-recurrent indication can be delivered safely by the vaginal route, without any major complication to the mother and the newborn, in an institution having facilities for emergency caesarean.
REFERENCES
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