Vol 43 # 3 September 2011 - Kma.org.kw
Vol 43 # 3 September 2011 - Kma.org.kw
Vol 43 # 3 September 2011 - Kma.org.kw
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>September</strong> <strong>2011</strong><br />
KUWAIT MEDICAL JOURNAL 189<br />
Original Article<br />
Re-appraisal of Vaginal Delivery after<br />
Previous Two Cesarean Sections<br />
Lulu Abdullah Al Nuaim<br />
Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh, Saudi Arabia<br />
Kuwait Medical Journal <strong>2011</strong>; <strong>43</strong> (3): 189 -195<br />
ABSTRACT<br />
Objective: To study the outcome of offering a trial of labor<br />
to women with history of two previous cesarean sections<br />
(CS) after appropriate counseling<br />
Design: Retrospective<br />
Setting: Obstetric Unit at King Khalid University Hospital,<br />
Riyadh, Saudi Arabia, over a period of seven years (1993<br />
– 1999)<br />
Subjects: A total of 40 women with two previous CS<br />
requested a trial of labor<br />
Intervention: Trial of labor despite having two previous CS<br />
based on specific predetermined criteria<br />
Main Outcome Measure(s): (1) The rate of vaginal delivery,<br />
(2) The rate of repeat CS and (3) Neonatal outcome<br />
Results: This group represents 8% of women with a history<br />
of two previous CS out of which 50% had primary CS<br />
and 25% had repeated CS in their previous pregnancies.<br />
Spontaneous labor occurred in 95% and augmentation<br />
in 45%. There was no uterine dehiscence or rupture in<br />
this study. There were five intrauterine deaths, six babies<br />
admitted to the NICU; four for prematurity and breech<br />
delivery and two for grunting. There was no birth asphyxia<br />
or neonatal death. Five of these cases are presented in<br />
detail.<br />
Conclusion: The favorable outcome in this study shows<br />
that trial of labor can be safely offered to a selected group of<br />
women with two previous CS after proper counseling. This<br />
goal can be achieved without limiting childbirth options<br />
for women who sincerely wish to avoid multiple cesarean<br />
deliveries. Larger trials are needed in our community to<br />
support finding in this study.<br />
KEY WORDS: pregnancy outcome, repeat CS, vaginal birth after cesarean<br />
INTRODUCTION<br />
The rate of cesarean delivery has increased steadily<br />
over the past 30 years world wide, with current rates<br />
of > 25% [1-4] and the repeat cesarean section (CS) rate<br />
for low risk women of all ages and racial groups is<br />
now 88.7% [5] . Studies conducted in 1980’s have shown<br />
that the primary reason for the continuing escalation<br />
of cesarean delivery rate is the performance of elective<br />
repeat CS [6] , since the relative safety of cesarean delivery<br />
had promoted a more liberal approach to its use [7] .<br />
However, this has resulted in considerable concern<br />
as a public health issue. Studies conducted later have<br />
reported that the procedure though common, presents<br />
a high maternal morbidity and mortality [8-10] . Attention<br />
had been focused on the alternative to cesarean birth<br />
for some time [11] . Several studies performed in the<br />
1970’s and 1980’s confirmed the safety of vaginal birth<br />
after a CS (VBAC) [12-13] .<br />
In addition, studies in the 1990’s have supported that<br />
VBAC is an acceptable option to routine elective repeat<br />
surgery [14-16] . This has been approved by the American<br />
College of Obstetricians and Gynecologists, provided<br />
certain criteria are fulfilled [3] . Most authorities now<br />
agree that VBAC should be encouraged, in order to<br />
reduce the rising cesarean delivery rate [6] . The success<br />
rate for VBAC is up to 79% [17] . The benefits of VBAC,<br />
in terms of reduced costs and maternal morbidity,<br />
without jeopardizing fetal outcome have been welldocumented<br />
[18] . Women with previous cesarean<br />
births now represent a relatively large proportion of<br />
the obstetric population and this is likely to increase<br />
even more, if the present cesarean birth rate continues.<br />
Since women’s and physicians’ interest in VBAC is<br />
increasing, the obvious question of whether such<br />
management alternative should be extended to women<br />
with two previous cesarean deliveries is being raised<br />
more frequently [19,20] , especially for women whose<br />
initial CS were performed for clearly non-repetitive<br />
indications.<br />
Data is now accumulating on vaginal birth after<br />
two CS [19-25] . Uterine scar separation does not appear to<br />
be affected by the number of previous uterine incisions<br />
Address correspondence to:<br />
Dr. Lulu A. Al Nuaim, MRCOG, MSc, Associate Professor and Consultant, Department of Obstetrics and Gynecology, College of Medicine &<br />
King Khalid University Hospital, King Saud University, P O Box 2925, Riyadh, 11461, KSA. Tel: + 966 (1) 4920260, Fax: + 966 (1) 4920520<br />
E-mail: lulu.alnuaim@gmail.com
Change language