Vaginal birth after one previous caesarean section in a tertiary institution in Nigeria

Journal of Obstetrics and Gynaecology (November 2004) Vol. 24, No. 8, 886–890
OBSTETRICS
Vaginal birth after one previous caesarean section in
a tertiary institution in Nigeria
A. O. AISIEN and A. U. ORONSAYE
Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital,
Benin-City, Edo State, Nigeria
Summary
widespread use of repeat elective sections for women who
Vaginal birth after one previous lower segment caesarean section
have had a previous caesarean section (Enkin, 1989;
represents one of the most signi?cant and challenging issues in
Wilkinson et al., 1998).
obstetric practice. A 5-year retrospective study was carried out at
Numerous publications over the years have demonstrated
the University of Benin Teaching Hospital between January 1999
the relative safety and e?cacy of vaginal birth after
and December 2003, to determine the incidence, the maternal and
caesarean section in an attempt to reduce the rising
fetal outcome following vaginal delivery after one previous
caesarean section with a view to evaluating its safety and e?cacy.
caesarean section rate (Enkin, 1989; Paterson and Saunders,
There were 5234 deliveries, with 395 cases of one previous caesarean
1991; Wilkinson et al., 1998; Rageth et al., 1999). The most
section, giving an incidence of 7.5%. The incidences of emergency
feared complications of pregnancy among women with a
caesarean section, elective caesarean section and spontaneous
previous caesarean delivery is rupture of the uterine scar and
vaginal delivery following trial of vaginal delivery were 34.7%,
its accompanying morbidity and mortality for the mother
9.4% and 48.1%, respectively. During the study period there were
and the fetus. Ninety per cent of the caesarean sections are
1317 cases of caesarean section, giving an incidence of 25.2%
now performed through a low transverse uterine incision
caesarean section rate. The incidence of one previous section among
(Dickinson, 1999). In contrast to the past experience with
all caesarean section births was 30%. The major morbidity
classical incision, uterine dehiscence and rupture are
following vaginal delivery was uterine rupture with an incidence
uncommon. Figures of 0.5 – 3.3% have been reported in
of 1.5% and hysterectomy of 0.8%. Three of the uterine ruptures
occurred before admission because the patients laboured at home.
prospective studies of women undergoing a trial of vaginal
One maternal death occurred as a result of uterine rupture and
delivery, similar to the rates of 0.5 – 2% seen among women
postpartum haemorrhage, giving a maternal mortality ratio of 19/
having an elective caesarean section (Enkin, 1989).
100 000 and a case fatality rate of 0.3%. The corrected perinatal
Hospitals in developed countries have accepted vaginal
mortality rate was 15.2/1000, mainly from obstructed labour,
delivery after one previous caesarean section as standard of
abruptio placenta and fetal distress. Both maternal and fetal
care with a high success rate and safety (McGarry, 1969;
mortalities from vaginal birth after one previous section were
Case et al., 1971; American College of Obstetricians and
signi?cantly less than the respective overall maternal and fetal
Gynecologists, 1995).
mortality from the institution. The 1-minute apgar score of babies
In developing countries, an increase in caesarean section
delivered by elective section was signi?cantly (P 5 0.001) higher
has also been documented (Aisien et al., 2002). There is,
than the apgar score of babies delivered by emergency section and
vaginally. There was only one patient with wound dehiscence at
however, a tendency towards larger families perhaps
elective section without associated perinatal death. Vaginal delivery
because of the high perinatal mortality rate (Adeleye,
following caesarean section is relatively safe. However, women in
1982; Harrison et al., 1985; WHO, 1996; Aisien et al.,
developing countries will continue to require counselling to counter
2000). Abdominal delivery is not accepted readily as this is
the myths of aversion to operative delivery even at the expense of
regarded as a failure of womanhood. This results in many
losing their lives. Our hospitals should have adequate monitoring
women both booked and unbooked for antenatal care in
equipment for high-risk pregnancies so that patients and their
hospitals attempting home delivery and only seeking
babies can be assured of survival.
hospital intervention when delivery is not forthcoming and
labour is already complicated by infection. Within this
Introduction
context, studies have assessed policies of vaginal delivery
Over the past 30 years there has been a surge in caesarean
after caesarean section in sub-Saharan Africa (Boulvain et
section rates in developed countries (Notzon et al., 1987;
al., 1997), with the conclusion that vaginal birth after
Government
Statistical
Service,
1997).
The
reasons
caesarean section is feasible and relatively safe. One
advanced are many, including the risk of litigation,
advantage is that women may be more disposed to attend
increased availability of medical technology such as fetal
hospital for supervision of a subsequent pregnancy. The
monitoring neonatal facilities and the patient’s demand for
current retrospective study reviewed the maternal and fetal
caesarean section (Lomas and Enkin, 1989). Maternity unit
outcome following vaginal delivery after previous caesarean
policies to deliver the breech presenting fetus and multiple
section in a tertiary institution to evaluate its safety and
pregnancies by caesarean section and, of course, the
e?cacy with regard to maternal and fetal outcome.
Correspondence to: Dr A. O. Aisien, Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, PMB 1111, Benin
City, Edo State, Nigeria. E-mail: aisienao@uniben.edu/aisienao@yahoo.com
ISSN 0144-3615 print/ISSN 1364-6893 online/04/080886-05 # Taylor & Francis Limited, 2004
DOI: 10.1080/01443610400018742

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Vaginal birth after caesarean section
887
Patients and methods
Table I. Age distribution of patients with one previous
Three hundred and ninety-?ve cases of one previous
caesarean section
caesarean section managed in the institution between
January 1999 and December 2003 were analysed. Data for
Age group (years)
Number
Percentage
the study were retrieved from the patient’s obstetric data
5 20
0
0
sheets, labour ward and theatre records. The exclusion
20 – 24
18
4.6
criteria for vaginal birth after caesarean section in the
25 – 29
101
25.6
institution were classical caesarean section, two or more
30 – 34
171
43.3
previous lower segment caesarean sections and malpresenta-
5 35
105
26.5
tions. A previous history of cephalopelvic disproportion,
Total
395
100
obstructed labour and cervical dystocia were not indications
for repeat caesarean section.
The University of Benin Teaching Hospital operated
an open-door policy where all pregnant patients, booked
Table II. Parity distribution of patients with one
and unbooked, were seen and managed, irrespective of
previous caesarean section
their clinical state. Patients who received antenatal care
and delivered in the hospital are regarded as booked
Parity
Number
Percentage
patients and those who did not receive antenatal care in
1
210
53.2
the
hospital
but
came
to
deliver
are
classi?ed
as
2
80
20.2
unbooked.
All
booked
patients
with
one
previous
3
43
10.9
caesarean
section
were
assessed
thoroughly
in
the
4
37
9.4
antenatal clinic, based on their obstetric history and
5 5
25
6.3
management outcome. They received counselling about
Total
395
100
their management options for their index pregnancy.
Patients admitted in labour for trial of vaginal delivery
were managed using partograph for their progress of
labour and were monitored carefully. Pinard’s stethoscope
Booking status and educational level of the
was used to monitor the fetal heart rate. There was no
women with one previous caesarean section
electronic fetal monitor available in the labour ward.
A total of 84.3% (333) of the patients were booked for
Patients with one previous caesarean section who in
antenatal care and delivered in the hospital, while only
addition have prolonged pregnancy, had cervical ripening
15.7% (62) were unbooked and were admitted as emergency
with a Foley’s catheter and oxytocin infusion following
patients to the labour ward. Of the patients, 99.5% (393)
rupture of membranes. One previous caesarean section
had formal education ranging from primary school to a
was not a contraindication to augmentation, stimulation
tertiary institution.
or induction with oxytocin, but required careful consid-
eration and assessment.
Unbooked cases with one previous caesarean section seen
Indications for elective caesarean section and
for the ?rst time in the labour ward were assessed
emergency section in women with one
individually and managed according to the prevailing
previous caesarean section
circumstances surrounding their admission. Cases of one
Thirty-seven (9.4%) of the patients had an elective
previous caesarean section who required an elective repeat
caesarean section. The main indications were contracted
caesarean section had the operation performed at the end of
pelvis 19% (seven), transverse lie 13.5% (?ve), ‘precious
37 completed weeks of gestation, except those who went
baby’ 13.5% (?ve), breech presentation 10.8% (four) and
into labour earlier.
placenta praevia 10.8% (four) (Table III).
Of the 352 patients with a previous caesarean section
scheduled for trial of vaginal delivery, 162 (41%) had an
Statistical analysis
emergency caesarean section. The main indications were
Statistical analysis of the data generated was with either Z
cephalopelvic disproportion 24.1% (39), fetal distress
or w2 tests where applicable, and the level of signi?cance was
16.0% (26) and obstructed labour 14.8% (24). Of these
set at 5%.
patients, 15.4% (25) had malpresentations and placenta
praevia. They presented in the labour ward as emergency
and had a caesarean section (Table IV).
Results
There were 1317 cases of caesarean section among 5234
deliveries, giving a caesarean section rate of 25.2%. There
Outcome of spontaneous vaginal delivery
were 395 cases with one previous caesarean section, an
One hundred and ninety (48.1%) of the patients with one
incidence of 7.5% and 30% among deliveries and caesarean
previous caesarean section had a spontaneous vaginal
sections, respectively.
delivery. Of the 54 patients with previous history of
cephalopelvic disproportion who had had a trial of vaginal
delivery, only 27.8% (15) had a spontaneous vaginal
Age and parity distribution of patients with
delivery. Also, 50% (17) had a spontaneous vaginal delivery
one previous caesarean section
of the 34 cases with a previous history of obstructed labour.
The age range of the patients was 22 – 43 years with a mean
Two patients diagnosed as cases of cervical dystocia in their
of 31 + 4.3 years. The parity range was 1 – 8 with a mean of
previous pregnancies had a repeat section for a similar
2 + 1.4 (Tables I and II).
indication.

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888
A. O. Aisien and A. U. Oronsaye
Previous history of vaginal delivery by the patient
of labour at home. Three patients ruptured their uterus
signi?cantly (P 5 0.05) increased the spontaneous vaginal
while on the labour ward. Their babies were, however, alive.
birth rate. One hundred and thirty-three of the patients had
Two of the cases had stimulation and augmentation of
augmentation of labour following inadequate uterine
labour with oxytocin. The relative risk of uterine rupture
action, stimulation of labour for spontaneous rupture of
(0.24) was less among those who had stimulation and
membranes or induction of labour with oxytocin, following
augmentation of labour compared with those who did not.
which 61.7% (82) had a spontaneous vaginal delivery
Three of the six cases of uterine rupture required
against 36.8% (49) who required an emergency caesarean
hysterectomy with an incidence of 0.8%. There was one
section.
maternal death due to uterine rupture and postpartum
haemorrhage, giving a maternal mortality ratio of 19/
100 000 and a case fatality rate of 0.3%.
Morbidity and mortality following vaginal birth
During the study period there were 12 cases of uterine
after caesarean section
rupture of an unscarred uterus. One of the patients delivered
There were 6 cases (1.5%) of uterine rupture (three booked
by elective caesarean section was found to have wound
and three unbooked). Three were admitted as cases of
dehiscence at operation, giving an incidence of 2.7%.
uterine rupture with intrauterine fetal death following a trial
Birth weight of babies
Four hundred and ?ve babies were delivered during the
Table III. Indications for elective section in patients
study period, inclusive of 10 twins. Their weights ranged
without one previous caesarean section
from 1.1 to 4.95 kg, with a mean of 3.11 + 0.65 kg. Three
mothers who presented with both twins in cephalic
Indications
Number
Percentage
presentation also delivered vaginally. The birth weight
distribution of the babies is shown in Table V.
Contracted pelvis
7
19.0
Transverse lie
5
13.5
Precious baby
5
13.5
Perinatal mortality and morbidity associated
Breech presentation
4
10.8
with vaginal delivery after previous caesarean
Placenta praevia
4
10.8
section
Twin pregnancy
2
5.4
There were 24 perinatal deaths, 18 of which were
Severe pregnancy-induced
intrauterine fetal deaths before admission. Six perinatal
hypertension
2
5.4
deaths occurred among patients considered for trial of
Bad obstetric history
2
5.4
vaginal delivery. The clinical causes of deaths were
Uterine ?broid
2
5.4
obstructed labour (two), fetal distress (one), abruptio
Unstable lie
1
2.7
placenta (two) and diabetes mellitus in the mother (one)
Previous uterine
giving a corrected perinatal mortality rate of 15.2/10 000,
myomectomy
1
2.7
which was signi?cantly less than the perinatal mortality rate
Previous Manchester repair
1
2.7
for the institution as a whole. None of the patients delivered
Previous repair of vesico-
by elective caesarean section su?ered perinatal death. The
vaginal ?stula
1
2.7
apgar scores of the babies delivered by elective caesarean
Total
37
100
section were signi?cantly higher when compared to babies
delivered either by emergency caesarean section or vaginal
delivery.
Table IV. Indications for emergency section in patients
with one previous caesarean section
Discussion
This study has shown that the caesarean section rate in the
Indications
Number
Percentage
institution was 25%. One previous caesarean section
constituted 30% of all cases of caesarean delivery and
Cephalopelvic disproportion
39
24.1
Fetal distress
26
16.0
Obstructed labour
24
14.8
Severe pregnancy-induced
Table V. Weight of babies with one previous caesarean
hypertension
16
9.9
section
Failure of progress in labour
11
6.8
Weight group (g)
Number
Percentage
Breech presentation
10
6.2
Transverse lie
8
4.9
5 1000
0
0
Placenta praevia
7
4.3
1000 – 1499
9
2.2
Abruptio placenta
6
3.7
1500 – 1999
16
4.0
Failed induction
6
3.7
2000 – 2499
27
6.7
Cord accident
3
1.9
2500 – 2999
73
18.0
Cervical dystocia
3
1.9
3000 – 3499
163
40.2
Eclampsia
2
1.2
3500 – 3999
87
21.5
Twin pregnancy
1
0.6
5 4000
30
7.4
Total
162
100
Total
405
100

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Vaginal birth after caesarean section
889
7.5% of all deliveries. The mean age and parity of the
signs that pointed to rupture of the uterus in these patients.
patients were 31.6 + 4.3 years and 2 + 1.4 respectively. The
Rupture of the unscarred uterus was surprisingly more
booked
patients
were
signi?cantly
higher
than
the
common than rupture of the scarred uterus during the study
unbooked patients and most of them had had a formal
period. Major complications have also been reported
education.
following induction of labour in previous caesarean section,
A high caesarean section rate, as also found in some other
especially with the use of misoprostol (Zelop et al., 1999;
studies (Adeleye, 1981; Okonofua et al., 1988; Aisien et al.,
Lydon-Rochelle et al., 2001).
2002) could be explained by the fact that the institution is a
Even though this study reported two uterine ruptures
referral centre, where many high-risk pregnancies are seen
following augmentation and stimulation of labour with
and managed; 83.5% of the previous caesarean section
oxytocin, the risk of uterine rupture was higher among
patients were allowed a trial of vaginal delivery. Similar high
patients who were not augmented, stimulated or induced.
incidences have also been reported by other authors (Lai
One patient had scar dehiscence noted at elective caesarean
and Sidek, 1993; Van Der Walt et al., 1994; Lovell, 1996;
section. There was one maternal mortality due to uterine
Ola et al., 2001; Abdel Aziz, 2000; Thistle and Chamberlain,
rupture and postpartum haemorrhage, giving a maternal
2002). The vaginal delivery rate was 48.1% lower than the
mortality rate of 19/100 000 and a case fatality rate of 0.3%.
range of 60 – 80% reported in the literature (Van Roosma-
The perinatal mortality rate was 15.2/1000. The maternal
len, 1991; Lai and Sidek, 1993; Lovell, 1996; Al-Chalabi,
and fetal mortalities were signi?cantly less than the overall
1997; Abdel Aziz, 2000; Adjahoto et al., 2001; Ola et al.,
mortalities in the unit for the study period. The apgar score
2001). A similar reduced vaginal delivery rate has also been
of babies delivered by elective caesarean section was higher
published (Van Der Walt et al., 1994; Obara et al., 1998;
than those of emergency caesarean section and spontaneous
Appleton et al., 2000). The reduced vaginal delivery rate in
vaginal delivery. An earlier report (Okpere et al., 1982)
this study could be a re?ection of the high number of cases
published from the hospital had reported higher perinatal
of patients who had emergency caesarean section for
deaths, but no maternal mortality from vaginal birth after
cephalopelvic disproportion, obstructed labour and fetal
caesarean section.
distress. The emergency caesarean section rate was 41%,
In conclusion, this study has shown that vaginal delivery
higher than in other studies of 14% and 12% (Kumar and
after caesarean section is a desirable option as 48% of the
Maouris, 1996; Lovell, 1996). While some other studies
patents had a successful vaginal delivery. The procedure
reported higher rate of elective caesarean section, only 9.4%
gave an option to women who are strongly against operative
of the patients had elective surgery. The lower rate was due
delivery and would risk their life by attempting vaginal
partly to the fact that trial of vaginal delivery was o?ered to
delivery at home. However, vaginal birth after caesarean
patients who met the selection criteria, and partly because
section was not risk free for both mother and fetus. Patients
patients with malpresentations and placenta praevia who
with one previous caesarean section need social and cultural
should have elective surgery presented as an emergency in
counselling regarding aversion to operative delivery, so that
the labour ward, when they could not deliver at home.
they can present early in hospital for delivery. Any
Higher rates of elective sections have been reported in the
institution managing such high-risk pregnancies must also
literature, re?ecting a strict criterion for trial of vaginal
be equipped with adequate maternal and fetal monitoring in
delivery (Lai and Sidek, 1993; Van Der Walt et al., 1994;
labour to detect early complications in order to reduce
Lovell, 1996; Obara et al., 1998).
maternal and fetal morbidity and mortality associated with
Successful vaginal delivery has been found to be
vaginal birth after caesarean section. Better outcome of
in?uenced by previous vaginal delivery (Lai and Sidek,
elective caesarean section should be part of the counselling
1993; Lovell, 1996; Ola et al., 2001; D’Orsi et al., 2001) as
option for women who may choose the option as the ?rst
also seen in this study.
line of management.
The patients with a previous history of cephalopelvic
disproportion and obstructed labour were allowed a trial of
labour, with a success rate of 36%. A large proportion
(64%) still resulted in an emergency caesarean section.
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