Vol 43 # 3 September 2011 - Kma.org.kw

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190 Re-appraisal of Vaginal Delivery after Previous Two Cesarean Sections September 2011 during a trial of labor [19,26] . There is increasing evidence that VBAC is safe and successful, and the dictum of once a CS, always a CS is no longer applicable [27] . Evidence is accumulating in western countries with regard to the safety and success of VBAC after multiple previous incisions in the lower segment [28] . Therefore, women in our community with two previous CS should at least be assessed individually, counseled and offered VBAC attempts. The objective of this study is to present evidence that trial of labor can be accomplished safely in women with two previous cesarean births. The obstetric and neonatal outcome of forty women with previous two CS with different indications and of unknown scars, and who, after counseling, preferred to have vaginal birth is presented. SUBJECTS AND METHODS This retrospective study included forty women with two previous CS, and who delivered vaginally at the Obstetric Unit of King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, over a period of seven years (1993 - 1999). The study group was selected for trial of labor despite having two previous CS, based on criteria such as the request of the couple during antenatal counseling for vaginal delivery, the estimated fetal size of less than 3.8 kg by ultrasound scan and spontaneous onset of labor. Data was retrieved from medical records on maternal characteristics of nationality, age, height, parity, primary and repeat CS, previous vaginal delivery, and the indications for CS in the two previous cesarean deliveries. The primary CS is defined as delivery of a neonate by CS in mothers with no previous history of a CS and repeat CS is delivery of a neonate by CS following a previous CS. Other data included presentation of the fetus in labor, the use of analgesia and syntocinon during labor, gestational age at delivery, duration of labor and type of vaginal delivery. Neonatal characteristics such as baby weight, Apgar score at 1 and 5 minutes, admission to neonatal intensive care unit (NICU) and baby outcome were also retrieved. Statistical Analysis Data was analyzed using STATPAC Gold statistical analysis package and is presented as percentages and means ( ± SD). RESULTS During the study period, a total of 30,378 deliveries were conducted at KKUH, including 3877 (12.8 %) by CS. Primary CS comprised of 1959 cases (6.5%), and repeat CS (> 2 CS) comprised of 1918 (6.3%) cases out of the total deliveries. Repeat CS included 498 women (1.6%) who had two CS. Of the 498 women with Table 1: Demographic and obstetric characteristics of 40 women with history of previous CSs delivered vaginally in the index pregnancy Characteristics Nationality Saudi Non-Saudi Age (yrs) < 35 >35 Height (cms) 150 Primary CS Repeat cesarean in 2nd pregnancy History of vaginal delivery Intervening vaginal delivery Spontaneous onset of labour Epidural analgesia Syntocinon augmentation Gestation at delivery (weeks) 40 Type of delivery SVD Assisted breech Age (years) Parity Height (cms) Gestation at delivery (weeks) Duration of labor (hours and minutes) First stage Second stage No. two CS, forty women (8 %) underwent a voluntary trial of labor after obtaining informed consent. The characteristics of this cohort of women are presented in Table 1. All women were Saudi except one who was a Pakistani. 40% out of these were > 35 years and parity ranged from 2 to 9, were short statured (< 150 cm), half of them had CS in their first pregnancy (primary CS) and 25% had a repeat CS in their second pregnancy. More than two third (80%) had a history of vaginal delivery and 40% had had intervening vaginal delivery (vaginal delivery between the 2 CS). Thirty eight women (95%) went into labor spontaneously at a mean gestational age of 37 + 4.0 weeks (range 26 - 42 weeks) and labor was induced in two women who had midtrimester intrauterine fetal deaths with prostaglandin intravenous (IV) Nalador infusion. Forty-fivepercentof the women needed labor augmentation by syntocinon infusion and epidural analgesia. Thirty-four (85%) of the laboring women had spontaneous vaginal deliveries and the remaining were assisted breech. Regarding mean duration of labor, the first stage was 6.1 + 4.01 hrs (range 1.15 - 19.21) and the second stage was 0.15 + 0.12 hrs (range 0.03 - 0.47). 39 1 24 16 12 28 20 10 32 16 38 9 18 7 30 3 34 6 Mean ± SD 33.6 ± 4.26 4.6 ± 1.95 151.9 ± 5.34 37 ± 4.0 6.1 ± 4.01 0.15 ± 0.12 % 97.5 2.5 60 40 30 70 50 25 80 40 95 22.5 45 17.5 75 7.5 85 15 Range 24 - 42 2 - 9 140 - 165 26 - 42 1.15 - 19.21 0.03 - 0.47
September 2011 KUWAIT MEDICAL JOURNAL 191 Table 2: Neonatal characteristics of babies born to 40 women with history of previous 2 CSs delivered vaginally Characteristics Presentation of fetus Breech Cephalic Neonatal weight (gms) < 2500 2500 - 3500 > 3500 NICU admission Neonatal outcome Alive IUFD Apgar score (n = 35) At 1 min 4 - 6 7 - 9 At 5 min 5 - 7 8 - 10 Neonatal characteristics depicted in Table 2 shows that four babies weighed more than 3.5 kg and the mean birth weight was 2590 + 737.31 gm (range 950 - 3650 gm). Out of the 40 women, five had intrauterine fetal deaths (IUFD), four were diagnosed prior to labor and one presented with an abruptio placenta at 37 weeks. Only two (5.7%) babies had low Apgar scores at 1 and 5 minutes. In six women (15%) the presentation of fetus was breech in labor (Table 3). Four of them were preterm (gestational age 26 - 27 weeks), one had IUFD at 37 weeks gestation, and the sixth one was 38 weeks pregnant. All the six had assisted vaginal breech deliveries. There were six (15%) admissions to the NICU in the entire study group (Table 4). Four out of these admissions were breech deliveries, admitted mainly due to prematurity. The other two cephalic presentations delivered at 35 and 36 weeks of gestation with birth weights of 2130 and 2600 grams respectively and were admitted for grunting. The two grunting babies were kept under observation for n 6 34 14 22 4 6 35 5 2 33 2 33 % 15 85 35 55 10 15 87.5 12.5 5.7 94.3 5.7 94.3 NICU = Neonatal intensive care unit, IUFD = Intrauterine fetal death two days while the four premature babies delivered by assisted breech were in the NICU for an average period of four weeks. The indications for the two previous CS in the study group are depicted as pie diagrams in Fig. 1 and 2. Five cases of special interest have been presented in detail, in which vaginal delivery was accomplished after two prior CS in spite of the presence of such features as cephalo-pelvic disproportion (CPD), breech presentation, big baby, short stature, obesity, diabetes, unknown scar and high blood pressure. Case I: A 32-year-old woman who had two previous CS for CPD was booked at 19 weeks in her third pregnancy. Lateral pelvimetry revealed a pelvic inlet of 8.3 cm and an outlet of 9.5 cm. At 37 weeks, she presented in labor with lack of fetal movements for one day. The fundal height corresponded to 32 weeks, with breech presentation. There was no fetal heart activity. On pelvic examination, the cervix was soft, fully effaced and 6 cm dilated with intact membranes and a frank breech at minus-2 station. Ultrasound fetal weight was estimated to be 1.9 kg. Four hours later she progressed to spontaneous delivery of the breech following an episiotomy. The outcome was a male fresh still-born, normal macroscopically and weighing 1.7 kg. The post-partum period was uneventful. Case II: This was a 28-year-old woman, para 2 + 0, who had had two CS previously at different hospitals for failure to progress. She was booked in this hospital for the current pregnancy. Her height was 148 cm but the radiological pelvimetry was adequate. At 39 weeks of gestation she presented in labor, the fundal height corresponding with her weeks of gestation, and the fetus was a cephalic presentation and the head was 2/5 th palpable per abdomen. Clinical examination was normal and the cervix was found to be 6 cm dilated. The membranes ruptured spontaneously, and following an episiotomy she had spontaneous vertex delivery of a normal healthy baby boy weighing 3.6 kilogram. The third stage was uneventful. Case III: A 34-year-old woman, para 4 + 0, with two previous CS for breech presentation and with Table 3: Characteristics of fetuses presenting as breech in six women with history of previous two CS who delivered vaginally Table 4: Characteristics of babies admitted in NICU of six women with history of previous two CS who delivered vaginally Fetus no. Gestational age in weeks Weight in grams Apgar score NICU admission Baby no. Gestational age in weeks Weight in grams Mode of delivery Apgar score 1 2 3 4 5 6 26 26+ 27 27 37 38 950 950 1440 1310 1700 3060 4 - 7 5 - 7 7 - 9 7 - 9 0 - 0 7 - 9 Yes Yes Yes Yes - No 1 2 3 4 5 6 26 26+ 27 27 35 36 950 950 1440 1310 2130 2600 Assisted breech. Assisted breech. Assisted breech. Assisted breech. Vertex Vertex 4 - 7 5 - 7 7 - 9 7 - 9 7 - 8 7 - 9
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