Vaginal Birth After One Previous Lower Segment Caesarean Section

From the Department of Obstetrics & Gynecology Christian Medical College & Hospital Ludhiana-141008 Correspondence to : Dr. Puja Puri, 295-Bx, Model Town Extension, Ludhiana-141002 Vaginal Birth after Caesarean Section (VBAC) has always remained a domain of controversies and dilemma in Obstetrics. Nearly 100 years ago it was believed that 'once a C-Section, always a C-Section'. The reasons for increasing C-Section rates are multifactorial but a recent analysis of C-Birth epidemic concluded that a practice of elective repeat C-Section for women with previous C-Section has been the major contributor to the escalation in the total C-Section rate (1). However with improved maternity care, electronic fetal monitoring and institutional delivery for a previous caesarean section, VBAC is considered safer than repeat elective CS in a carefully selected population (2). Patients with successful trial of labor experience fewer blood transfusions, fewer postpartum infections and no increased perinatal mortality as compared to those with planned repeat caesarean delivery (3). However in the event of a failed trial there is a definite increase in perinatal and maternal morbidity and mortality rates (4, 5). The most important risk of vaginal birth after Caesarean is rupture of uterine scar. In a study of more than 8000 women the rate of scar rupture or dehiscence was 0.5% (6). The common factors associated with rupture were excessive use of oxytocics, dysfunctional labour and more than one previous Caesarean section. Material and Methods It was a one year prospective and two year retrospective study carried out on 205 women in the department of Obstetrics & Gynecology, CMC Ludhiana. Sixty women with singleton pregnancy with history of previous one lower segment Caesarean section for nonrecurrent indication were enrolled in the prospective study taking into consideration the ACOG guidelines (7). Exclusion criteria Malpresentations, cephalo pelvic disproportion, multiple pregnancy, IUGR, Placenta Praevia-Major degree, Scar tenderness (on admission), Extension of Previous Uterine Scar. Detailed history of these women was taken with special reference to indication for previous Caesarean section, post operative period and presence of any obstetrical and medical complications. Detailed general physical and abdominal examination was done in all these women. A Pelvic examination was done to know Bishop's Score and adequacy of pelvis. Labor was induced with Cerviprime gel (PGE 2 gel) under close monitoring if women did not go into spontaneous labor at 40 weeks. Oxytocin if indicated was used judiciously for augmentation of labor. Electronic fetal monitoring was done during labor. Pulse, B.P., scar tenderness, bleeding per vaginum was monitored one hourly. Labor progress was charted on a partograph. Second stage of labor was shortened by use of forceps if indicated. All women were Abstract To find out the incidence and factors favorable for vaginal delivery after previous one lower segment CS and to document maternal and fetal complications if any in these women.It was a three year study (two year retrospective and one year prospective) and a total of 205 women with previous one lower segment CS for non recurrent indication were included in the study. Case selection for trial of vaginal delivery was done as per the ACOG guidelines.Out of 205 women who were given trial of labor, 56.1% had a vaginal birth after Caesarean section (VBAC) and 43.9% required emergency repeat CS. There was no maternal or neonatal mortality and also no case of uterine rupture.A trial of vaginal delivery after previous one LSCS in selected patients can eliminate the need for a large proportion of repeat CS. This can significantly decrease the incidence of postpartum morbidity, anesthetic and operative risks and financial liabilities.