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

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June 2007KUWAIT MEDICAL JOURNAL 159Table 2: Mode of vaginal delivery after prior CSTable 3: Indications of CS after prior CS1980-84 1985-89 1992-95 1996-99 Totaln (%) n (%) n (%) n (%)Previous CS 3996 (68.9) 4302 (65.2) 2151 (60.3)2276 (55.1)* 12725Vaginal delivery* 2625 (65.7) 2633 (61.2) 1229 (54.6) 1168 (51.3) 7655 (60.2)Spontaneous vaginaldelivery 2256 (86.0) 2262 (85.9) 1045 (85.0) 1016 (87) 6579 (85.9)Vacuum extraction 273 (10.4) 276 (10.5) 133 (10.8) 113 (9.7) 795 (10.4)Forceps delivery 87 (3.3) 90 (3.4) 47 (3.9) 39 (3.3) 263 (3.4)Breech delivery 9 (0.3) 5 (0.2) 47 (3.9) - 18 (0.2)* Significant decrease between 1980 and 1999: p < 0.01Table 4: Effects of the indications of prior CS on mode of deliveryduring current pregnancyIndications for Vaginal delivery Emergency CS Elective CS Totalprior CS after prior CS after prior CS after prior CSn (%) n (%) n (%)Failure to progress in labor 2311(74.4) 536 (17.3) 258 (8.3) 3105 (24.4)Cephalo-pelvic Disproportion 616 (20.5) 2087 (69.4) 302 (10.1) 3003 (23.6)Fetal distress 2014 (81.6) 279 (11.3) 176 (7.1) 2469 (19.4)Abnormal presentation 1447 (60.8) 888 (38.4) 158 (7.1) 2379 (18.7)Failed induction 152 (47.8) 148 (46.7) 17 (5.3) 318 (2.5)Others 965 (65.5) 488 (43.3) 98 (8.7) 1451 (11.4)Total 7655 (60.2 ) 4047 (31.8 ) 1023 (8.0 ) 12,725three-fold increase in the second half of the study.These include infertility/IVF-ET (p < 0.001) andmultiple pregnancies (p < 0.001). These two factorscannot fully account for the downward trends invaginal delivery rates.Effects of the indications in patients with priorCS:Analysis of the indications in patients with priorCS is shown in Table 4. The odds ratio of achievingvaginal delivery after prior CS was highest for fetaldistress (OR = 4.8, 95% CI 3.4, 6.2), failure toprogress (OR = 3.8, 95% CI 3.0, 5.6) and abnormalpresentation (OR = 3.2, 95% CI 2.2, 2.6) whereas itwas lowest for cephalo - pelvic disproportion (OR =0.8, 95% CI - 0.4,1.2) and was associated with thelowest vaginal delivery rate of 20.5 percent.Effects of the mode of delivery on perinatal andmaternal outcome:T h e re were significantly more pre t e r mdeliveries by elective CS and emergency CS than byvaginal delivery (15.3% and 12.4% versus 6.5%; p
160Delivery after Prior Cesarean Section in Kuwait June 2007Table 5: Outcome of delivery after prior CS according tothe mode of deliveryVaginal delivery % Emergency CS % Elective CSn = 7655 n = 4047 % n = 1023Gestational age at delivery40 weeks 5.8 14.6 2.8Birthweight< 2.5 Kg 7.2 13.2 15.32.5-4.0 Kg 87.2 75.2 73.1>4.0 kg 5.6 11.6 11.6Perinatal mortality 97 (1.3%) 69 (1.7%) 19 (1.8%)Maternal Morbidity 11(1.4 per 1000) 8 (2.0 per 1000) 4 (3.9 per 1000)Postpartum hemorrhageRuptured uterus 5 (0.7 per 1000) 4 (1.0 per 1000) -Retained placenta 7 - -Placenta accreta 2 (0.3 per 1000) 3 (0.74 per1000) 3 (2.9 per 1000)per 1000 in women delivered by emergency CS.Suspicion or impending rupture of the uterus wasusually an indication for emergency CS. Ruptureduterus had no effect on perinatal mortality (noperinatal death) but in three women, cesare a nhysterectomy was carried out because of severepostpartum hemorrhage from major placentaprevia and placenta accreta.DISCUSSIONThe present study has demonstrated that a trialof labor after prior CS is safe in about 60 percent ofwomen in Kuwait but only 48 percent afterinduction of labor. The crude perinatal mortality inthe present study was 14.5 per 1000. If the extremep reterm births and congenital anomaliesincompatible with life were excluded, the perinatalmortality among women with vaginal deliveryafter prior cesarean section could be comparablewith the general maternity population perinatalmortality rate of 9 -10 per 1000. The outcome of thepresent study is similar to the outcomes of previousstudies in which vaginal delivery occurred in 50 -80 percent cases following a prior CS [5,14,16] . In arecent study in which a trial of labor was carriedout in 17, 613 women with previous CS, the successrate was 73.7% (65.6% after induction of labor) [17] .Like in the present study, there were fewcomplications. The downward trend of vaginaldelivery after prior CS with decline of 22 percent(65% in 1980 - 84 to 51% in 1995 - 99) is of greatconcern. This is due to the three main indications,viz antepartum haemorrhage, successful infertilitymanagement with in-vitro fertilization andconsequent multiple pregnancies. This was theo fficial policy of the Assisted Repro d u c t i v eTechnology team then and the anxiety of thepatients. These factors cannot fully account for thedrop in vaginal delivery rates. The present studyhas also shown that history of previous CS is animportant factor in the outcome in a subsequentpregnancy. This is consistent with a recent report byBujold et al [18] . When the indication for a prior CSwas cephalo-pelvic disproportion, the rate ofvaginal delivery was lower than when theindication was not a recurrent cause. The mainconcern for vaginal delivery after prior CS is that ofuterine ru p t u re [ 19 ] . In the present study, theincidence of uterine rupture was 0.7 per 1000 forvaginal delivery and 1.0 per 1000 for emergency CS.This is much lower than an overall risk of uterinerupture for women with a prior cesarean deliveryu n d e rgoing subsequent trial labor which isreported to be between 0.2 and 1 percent [20] and 0.4to 8.0 percent in patients undergoing oxytocinaugmentation [21,22] . This risk can be further reducedby appropriate selection of patients, method ofinduction and adequate monitoring during labor. Itmust be pointed out however that a symptomaticuterine dehiscence of 0.5 to 2% after vaginaldelivery is associated with minimal morbidity andit is hardly identified.Socol et al [ 3 ] have successfully intro d u c e dguidelines promoting vaginal birth after CSt h rough active management of labor andcirculation of CS rates of attending obstetricians.This has significantly led to reduction of CS rates.Myers and Gleischer [ 5 ] took similar steps, formanagement of fetal distress and bre e c hpresentation, in which it was mandatory to take asecond opinion before performing a nonemergencyCS.As part of the decision making pro c e s s ,information and counseling should aim to estimatespecific risks and probability of successful vaginaldelivery or risk factors for failure of trial of laborafter prior CS [23,24] . Every hospital should thereforeestablish practice guidelines on the management ofpatients with prior CS. For example, after Medlinedatabase analysis of articles published fro mJanuary 1, 1995 to February 28, 2004, on vaginaldelivery after CS, a Canadian group developedguidelines on the management of delivery afterprior CS [ 25 ] . The highlight of these guidelinesincluded the need for informed consent,conducting the delivery in a hospital with resourcesand availability of operating-room staff andcontinuous electronic monitoring.CONCLUSIONIn well selected women, vaginal delivery afterprior CS carries a low risk. There is a need to reviewthe liberal policy of operative delivery followingsuccessful assisted reproductive technology. Thetrend towards fewer vaginal deliveries after priorCS can be halted and reduced through active
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