Vol 39 # 2 June 2007 - Kma.org.kw

June 2007KUWAIT MEDICAL JOURNALOriginal ArticleDelivery after Prior Cesarean Section in KuwaitAlexander Omu 1,2 , Majedah Al-Azemi 1,2, Jehad Al-Harmi 1,2, Huda Abdul Azeem 2 , Hanan N Al-Salem 21Department of Obstetrics and Gynecology, Faculty of Medicine and 2 Maternity Hospital, KuwaitABSTRACTIntroduction: There has been a dramatic increase in ratesof cesarean section (CS) worldwide. Vaginal deliveryafter prior CS is one of the strategies to reduce the highCS rate.Objective: To evaluate the mode of delivery after priorCS over a 14 year period from 1992 to 2005Study Design: Retrospective Clinical StudySetting: Maternity Hospital, KuwaitSubjects and Methods: The socio-demographiccharacteristics and the mode of delivery after prior CS of12,725 eligible women were extracted from the annualreports, perinatal and maternal committee re c o rd s ,patient files and the central CS registers for validation.Results: Out of 12,725 women with prior CS, 7655 (60%)achieved vaginal delivery (spontaneous vaginal delivery86% and instrumental vaginal delivery 14%). In 8%INTRODUCTIONThere has been a marked increase in the rate ofcesarean section (CS) worldwide [1,2] . To lessen thishigh rate and decrease the health care costsassociated with CS, deliberate efforts were made tore-examine the practice of elective CS [3-5] . Routineelective CS for a second delivery for women withprior lower segment CS results in an excess ofmaternal morbidity and mortality and a high costto medical re s o u rces and the medical team [ 6 - 8 ] .Complications related to further cesare a ndeliveries include placenta previa, accreta andhysterectomies. There are now many reports ofsignificant reduction of CS rates, while maintainingor even improving perinatal outcome [9] . Vaginalbirth after cesarean delivery has therefore beenadvocated as a safe and practical means ofreducing the overall CS rate. However, thep roportion of women who attempt vaginaldelivery after prior CS has decreased larg e l ybecause of concern about increased maternal andperinatal morbidity [10] . In some centers, only onet h i rd of patients with lower segment CS willrequire the procedure again if allowed a trial oflabor [11] .Kuwait Medical Journal 2007, 39 (2):157-161KEYWORDS: indications, prior CS, vaginal deliverywomen, elective CS was carried out mainly for abnormalp resentation, medical disorders, macrosomia andmultiple pregnancies. There was a downward trend inthe vaginal delivery rate from 65.7% in 1992 to 51.3% in2005. Infertility / IVF and multiple pregnancies increasedt h ree-fold as indications for repeat emergency CSbetween 1992-1995 and 2000-2005 periods. CS rate afterinduction of labor was 52% whereas 48% had vaginaldelivery.C o n c l u s i o n : After a prior CS, vaginal delivery wasachieved in 60% of the women with few complications.With appropriate selection of patients, vaginal delivery issafe. Active management of labor and involvement ofsenior staff in the decision to perform repeat CS isadvocated.Concerns have been raised by many about theoverall risk of uterine rupture for women with aprior cesarean delivery undergoing a subsequenttrial of labor. The risk has been estimated to bebetween 0.2 and 1.0 percent [12,13] . McMahon et al [14]d i rectly addressed the issue of maternal andperinatal morbidity and mortality associated withtrial of labor in 3249 women with previous CS ascompared to 2889 women who chose to have arepeat CS. There were no differences in perinataloutcomes, number of maternal deaths nor mildmaternal morbidity and mortality. The likelihoodof major complications however, was almostdouble in women undergoing trial with a scar.T h e re have also been strong arguments thatelective CS will prevent long term consequences ofpregnancy, labor and delivery such as urinary andanal incontinence and utero-vaginal prolapse as aresult of vaginal birth [6] . A contrary view suggeststhat the etiology of incontinence is multi-factorialwith many risk factors other than vaginald e l i v e r y [ 7 ] . The re p roductive consequences ofmultiple CSs should always be considered whenmaking policy decisions re g a rding risk-benefit(This article was presented at the 12 th International Conference of the Kuwait Medical Association, April 1-4, 2007)Address correspondence to:Dr. Alexander E. Omu, Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait.Fax: 00965 5338906, E-mail: omu @hsc.edu.kw