Maternal and perinatal outcomes of delivery after previous one or two cesarean section

Introduction: The prevalence of cesarean deliveries is high in many parts of world. Vaginal birth after cesarean section (VBAC) is a trial of vaginal delivery in selected cases of a previous CS in a well equipped hospital. It offers distinct advantages over a repeat caesarean section, since the operative risks are completely eliminated, the hospital stay is much shorter and expenses involved are much less. Objectives: To study the maternal and perinatal outcomes among women with previous Cesarean section at a tertiary care centre. Materials and Methods: This prospective study was carried out over a period of 12 months. 979 pregnant women with previous caesarean section were recruited in study. A detailed history was taken and mode of delivery decided as per the standard protocol. 636 patients underwent elective repeat LCSC.343 patients were given trial of labour out of which 226 delivered vaginally. Maternal and neonatal outcomes were noted Result: The rate of successful VBAC was 65.89%. Most common indications of repeat caesarean section were fetal distress and failure to progress. Post op maternal and neonatal complications were significantly more in repeat caesarean section group. Incidence of infectious morbidity was also higher in repeat cesarean group than VBAC group. Conclusion: Fetal morbidity and mortality due to trial of labor is comparable with the women laboring without a scar, trial of labour may be encouraged. women given trial of labour with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management of previous one or two


Introduction
The obstetric practice before 1970's was dictated by the phrase, "Once a caesarean always caesarean". Later, because of escalating rate of caesarean section, suggestions were made that vaginal birth after caesarean section might help in reducing caesarean section. VBAC is safe and effective in an appropriate clinical setting and properly selected group of women (Chhabra. S. and Arora G, 2006). 1 Caesarean section is not a simple procedure and needs to be performed only when circumstances distinctly required it (Mukharjee S.N. 2006). 2 In 1916, Cragin 3 introduced the concept of 'once a caesarean always a Caesarean', when referring to a classical uterine incision. The present day dictum revolves around "the optimal management after a previous caesarean delivery" (Krishna Usha et al, 2001). 4 Maternal mortality associated with caesarean section can be 3 times that of vaginal delivery (Esteves-Pereira et al 2016). 5 As pointed out by Emily R. Baker (1994), 6 most common indications for caesarean section are repeat section, dystocia, fetal distress and malpresentation.
The indications of caesarean section can be absolute like severe cephalopelvic disproportion or major degree of placenta previa and relative like accidental hemorrhage, failed induction or malpresentation (Pandey Nagendra Sardesh, 2006). 7 The Robson classification (also known as the 10-group classification) was proposed by the WHO. Later on, a modification to the Robson criteria is proposed. 8 It is used as a global standard for assessing, monitoring and comparing caesarean section rates both within healthcare facilities and between them.
The VBAC recommendations by American College of Obstetrics & Gynaecology, 1998-99, which were renewed in ACOG 2010 9 are as follows: The criteria for selection of cases for VBAC are: A perfect neonatal outcome being every obstetrician's goal, a perinatal loss in caesarean section delivery causes much concern.
2. Aims and Objectives All the cases were analysed prospectively and data was collected in a proforma, meeting the objectives of the study.
Out of 979 cases, 636 cases underwent elective repeat cesarean section, looking into the circumstantial safety of the mother and fetus. 343 were allowed for a trial of labour, out of them women who had failed TOL were taken for emergency LSCS for various indications.
Thus 979 cases included in the study were grouped into: Group 1: Women who were elected for repeat CS without a trial of labour Group 2: Women who were given a trial of labour and delivered vaginally Group 3: Women who were given a trial of labour but due to failed trial, emergency repeat section was performed.
All study subjects were analyzed in thoroughly regarding age, parity, previous obstetric history including number of vaginal or cesarean deliveries and the indication for LSCS. A thorough general, physical, systemic and obstetric examination was done.
Women with gestational age upto 40 weeks were allowed for trial of labour after ruling out contraindication for vaginal delivery and ensuring that there was no obvious feto-pelvic disproportion,. Patients who were allowed for VBAC-TOL, were carefully monitored in intrapartum period for any sign of impending rupture like tachycardia, hypotension, scar tenderness, suprapubic bulge, vaginal bleeding, FHR variability and hematuria, etc.
Induction and augmentation of labour was done in selected cases with oxytocin and/or intracervical prostaglandins where the Bishop's score was poor. Progress of labour was noted with cervical dilatation, effacement, descent of head and uterine contraction. Labour was accelerated with artificial rupture of membrane in active labour wherever required.
In the cases where rupture was suspected TOL was immediately abandoned and taken for emergency laparotomy and necessary steps were taken promptly.
In all the cases that had undergone repeat LSCS, the indication for LSCS, intraopertaive and postoperative details were noted.
In both the group, the perinatal outcome was noted by analyzing the APGAR score, Birth weight, prematurity and neonatal morbidity and mortality.
The data were analyzed using various statistical tests and standard deviation tests.   Table 1 shows that maximum women 842 (86%) were in the age group between 20-30 years followed by 131(12%) above 30 years of age. This is the most fertile period of a woman.

During this study period
This corresponds to the observations made by Minsart et al (2013) 23 which states that maximum number of successful VBAC was associated with those in the age group <35 years.
A bad hypertrophied scar needed excision which increased the duration of surgery. Adhesion between various layers of abdominal wall and abdominal structure, between general and visceral peritoneum needed time consuming adhesionlysis and posed difficulty in opening the abdomen. Adhesiolysis needs surgical skill and experience of an obstetrician.
Extension of uterine incision was more common during emergency LSCS (3.41%) than ERCS (1.26%). M.A. Ramakrishna Rao(2008) 25 found intraperitoneal adhesions of varied types in 73 out of 287 cases (25.43%) in his study. The adhesions in our study were less; the reason may be that most of the primary sections were done in same institute (GMH) either by skilled surgeons or under their supervision by resident doctors.
It is evident from the Table 5 that perinatal morbidity occurred in 67 babies from which perinatal morbidities like birth asphyxia (1.9%) and meconium aspiration syndrome(2.4%) were more common in Elective LSCS than VBAC.
Comparing overall fetal morbidity among 3 groups ERCS (74.62%), VBAC (2.65%), LSCS -TOL (9.40%), fetal morbidity was higher in the ERCS than following VBAC. But this cannot be attributed solely to complications arising out of ERCS as the trial of labour is given only to cases that are uncomplicated or less complicated and the complicated cases were directly taken for LSCS without any trial of labour. This makes the neonates delivered by LSCS more likely to be admitted in NICU.
It is evident from the Table 6 that NICU admission was seen in 27 cases out of which, in 303% elective cases babies were admitted in NICU and in 2.56% cases of emergency LSCS babies got admitted to NICU Loebel et al (2004) 26 also found that the neonatal morbidity and mortality after ERCS was more as compared to VBAC. NICU admission was seen in 2.8% cases in Elective repeat LSCS cases and in 1.1% cases in VBAC. Perinatal death was seen in 2.1% cases in ERCS, while it was seen only in 0.5 % cases of VBAC.
Similar results were obtained by Jinturkar et al (2014) 27 in their study in which NICU admissions were more in repeat LSCS group(2.12%) than the VBAC group (0.3%).
The process of normal vaginal delivery aids the neonate in better initiation of respiration and decreases the chances of birth asphyxia. Birth asphyxia is one of the major causes leading to NICU admission at birth and post delivery.Complicated cases with more chances of perinatal morbidity and mortality like severe oligohydramnios, preeclampsia, APH, etc. are taken for Elective LSCS without trial of labour. Hence, babies delivered by LSCS have a higher chance of NICU admission and perinatal mortality. Table 7 shows that post delivery maternal complications like hospital stay for more than 4 days (9.96%), requirement of post natal IV/IM analgesia (86.85%), paralytic ileus (3.19%) and prolonged catheterization (8.37%) was more in LSCS than VBAC.
Our results were also comparable to those of Yun-Xiu Li et al (2018) 28 in which requirement of post op analgesia was more in the LSCS group (90.4% cases) than the VBAC group (9.6%).
1. Ileus-It occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction. Sepsis, diabetes, hypothyroidism, anaemia, low potassium can be the predisposing factors 2. Post-partum urinary retention leading to prolonged catheterization. 3. Post surgical fatigue and pain-It may affect woman from caring and breastfeeding of the newborn. This is more common in women following delivery by cesarean section and requires IV/IM analgesia for pain relief.

Conclusion
Trial of labour is like a double edged sword, if the woman achieves VBAC, she has the benefits of short hospital stay, decreased morbidity and less expenditure but if TOL fails resulting in LSCS, there is likely to occur maternal and fetal morbidity. Elective repeat cesarean section has its inherent risks of major intra abdominal surgery. Women given trial of labour with careful monitoring and taken for emergency LSCS on minimal indication is the best answer to management of previous one or two CS.

Source of Funding
None.

Conflict of Interest
None.

Parasuram Waddar Post Graduate Student
Cite this article: Vishwakarma K, Yadav G, Waddar P. Maternal and perinatal outcomes of delivery after previous one or two cesarean section. Indian J Obstet Gynecol Res 2020;7(3):308-314.