Vaginal birth after classical Caesarean section.

Current belief in obstetric practice is that the scar of a classical Caesarean section is more prone to rupture than that of a lower segment Caesarean section and that for this reason elective repeat Caesarean should always be undertaken in subsequent pregnancies. This review of the history of management of women after a previous classical Caesarean section was prompted by the presentation of a 30-year-old woman who, in her eighth pregnancy, was admitted in established labour and with a moderate degree of intrapartum haemorrhage. She was unbooked and had received no antenatal care. A rapid consultation revealed the following obstetric history: 1 1990 – normal vaginal delivery; 2 1991 – miscarriage; 3 1994 – classical Caesarean section at 27 weeks for fetal distress in premature labour, performed in our hospital. Well documented operative details: Pfannenstiel skin incision, midline incision in upper uterine segment, repair of uterus in three layers with polyglactin 910 (Vicryl, Ethicon), no postoperative pyrexia or other apparent complication. 4 1996–2001 – four normal vaginal deliveries in a country hospital; no booking or antenatal care in any pregnancy; on each occasion presented in labour; largest baby weight 4100 g; no complications with any delivery. Staff at the country hospital had believed her Caesarean section had been a lower segment procedure, an impression reinforced by her Pfannenstiel scar. On examination, she was haemodynamically stable and cardiotocography was satisfactory. A portable ultrasound scan showed a posterior placenta but it was impossible to see the lower edge owing to body habitus; her weight was greater than 130 kg. In the operating theatre a vaginal examination showed the cervix to be thin and 7 cm dilated, the placenta was not praevia, the fetal head was well down in the pelvis and vaginal bleeding slight. Labour was allowed to continue under the direct view of a senior obstetrician, and within 1 h a normal vaginal delivery of a male infant, 3460 g, occurred. Total blood loss was 700 mL and the woman was clinically well postpartum. Six weeks later she had open tubal ligation performed – the scar of the classical Caesarean section was barely visible on inspection. Historical literature review