✅ It seems that the overall incidence of obstetric complications in women attempting vaginal birth after cesarean delivery is low and not higher than those with prior vaginal delivery. Therefore, for the achievement of benefits of natural childbirth for both the mother and the fetus, women with a prior cesarean should be offered VBAC.
In recent years, the rate of cesarean delivery has increased significantly (1). In the United States, for example, this rate has risen from 5% of deliveries in 1970 to more than 30% in 2016 (2). Cesarean section has always played an important role in reducing mortality and complications from childbirth in emergencies (1). But its uncontrolled performance as a common method of delivery in non-emergency cases is the main challenge recently (3, 4). The risk of maternal death due to cesarean delivery is three times higher than vaginal delivery. In addition, cesarean delivery has far more complications and risks than normal delivery (5). As with any surgery, cesarean section is associated with both short-term and long-term risks that can affect the health of the mother, child, and future pregnancies in the postpartum years.
According to the World Health Organization (WHO), the expected rate of cesarean section in different countries of the world is 10 to 15% of the total number of deliveries (6). Before the implementation of the Health Transformation Plan (HTP) in Iran, the rate of cesarean section was almost three times the global standard, which of course varies in different parts of the country and between public and private hospitals (7).
One of the indications for repeat cesarean delivery is a history of previous cesarean sections (8). Several national medical associations have provided practical guidelines for vaginal delivery after cesarean section (VBAC) (9). In general, VBAC is relatively safe compared to repeat cesarean section (10). The rate of VBAC has been reported to be 14.40% in the United States (11). Moreover, the success rate of VBAC was reported from 61% to 85% in previous studies (12, 13). Results of the national study in the Qom city showed 85.3% success rate of VBAC, and in this study lower complications were reported when the interval between inter‑deliveries was 2–4 years (14).
With the introduction of this method, mothers with a history of cesarean section will have a new chance to experience natural childbirth to be safe from the complications of cesarean section and surgery. Also, the country's health policies are based on avoiding cesarean section as much as possible and encouraging natural childbirth as much as possible. VBAC is a valuable method because of the many benefits that natural childbirth has for both the mother and the fetus as well as the family and the community economy. Naturally, we know that the delivery process may have complications, and this method is no exception to this rule, so the present study was designed to investigate the possible complications of VBAC compared to the control group.
In this case-control study, 84 women who had undergone a previous cesarean delivery and referred to Baqiyatallah Hospital for VBAC delivery between April to October 2018 were considered as the case group and 84 women with a previous vaginal delivery, who intended to give birth vaginally for the second delivery in the mentioned time period were considered as the control group.
Inclusion criteria were: pregnant women between 15-45 years, gestational age at birth between 24+0 and 41+6 weeks, the birth weight of more than 500 g, who had undergone a previous cesarean delivery for the VBAC group and vaginal delivery for the control group. Exclusion criteria for both groups included more than one previous birth, multiple pregnancies, previous uterine surgery and contraindications for vaginal childbirth such as macrosomia, bleeding, premature birth, preeclampsia and breech presentation.
The ethics committee of the Baqiyatallah University of Medical Sciences approved the study protocol (IR.BMSU.BAQ.REC.1398.033). Demographic (age, education), anthropometric (BMI, hemoglobin level), obstetric and perinatal data (neonate weight) of subjects were collected and registered in a researcher developed form, which was retrieved from their medical records or interview. The investigated outcomes in two groups included urinary and bladder rupture, stool control disorder, uterine rupture, rectal rupture, uterine atony, nephrotic infection, fetal death and the need for maternal hospitalization in the ICU.
For statistical analysis, results were presented as mean ± SD for quantitative variables and were summarized by frequency (percentage) for categorical variables. Continuous variables were compared using the student t-test and qualitative variables were compared using chi-square test or Fisher exact test if appropriate. P values of ≤ 0.05 were considered statistically significant. For the statistical analysis, the statistical software SPSS version 23.0 for windows (IBM, Armonk, New York) was used.
Table 1 shows the baseline and disease history of patients in the two investigated groups. There was no significant difference in the mean age of the patients (P=0.71), BMI (P=0.13), hemoglobin (P=0.54) and neonate weight (P=0.09) between the two groups. Moreover, as shown in Table 1, two groups were homogenous in relation to education (P=0.52). None of the women in the two groups had a history of hypertension or chemotherapy. Two women in the VBAC group and one in the control group had diabetes and the rate of gestational diabetes in the two groups was 3.57% and 4.76%, respectively.
Table 1. Comparison of the baseline characteristics of patients between patients in VBAC and control groups
Variables | VBAC group N = 84 |
Control group N= 84 |
p-value | |
Age (Year) | 30.49±6.83 | 32.08±7.28 | 0.153* | |
Neonate weight (gr) | 3150±215.6 | 3220±313.08 | 0.090* | |
Hemoglobin level | 11.99±0.83 | 12.08±1.04 | 0.541* | |
BMI (Kg/m2) | 26.33±5.25 | 24.98±6.13 | 0.132* | |
Education | Diploma or less | 27 (32.14) | 31 (36.9) | 0.524** |
Academic | 57 (67.85) | 53 (63.09) | ||
Disease history | Hypertension | 0 | 0 | - |
Diabetes | 2 (2.38) | 1 (1.19) | >0.99** | |
Gestational diabetes | 3 (3.57) | 4 (4.76) | >0.99** | |
Chemotherapy | 0 | 0 | - |
*Student t-test, ** Exact fisher test
VBAC: vaginal delivery after cesarean section, BMI: Body mass index
The occurrence of obstetric outcomes, in VBAC and control groups are sown in Table 2. There was no occurrence of urinary rupture, bladder rupture, stool control disorder, uterine rupture, nephrotic infection and ICU hospitalization of the mothers in the two groups. Moreover, in the control group, none of them reported rectal rupture and uterine atony. With regards to puerperal infection (3.57% in VBAC group and 4.76% in control group, P=0.69) and hospitalization of neonates in ICU (9.52% in VBAC group and 5.95% in control group, p=0.39), there was no significant difference between two groups.
Perinatal outcome | VBAC group N = 84 |
Control group N= 84 |
p-value* |
Urinary rupture | 0 | 0 | - |
Bladder rupture | 0 | 0 | - |
Stool control disorder | 0 | 0 | - |
Uterine rupture | 0 | 0 | - |
Rectal rupture | 1 (1.19) | 0 | 0.332 |
Uterine atony | 2 (2.38) | 0 | 0.150 |
Nephrotic infection | 0 | 0 | - |
Puerperal infection | 3 (3.57) | 4 (4.76) | 0.691 |
Fetal death | 0 | 1 (1.19) | 0.333 |
Neonate NICU hospitalization | 8 (9.52) | 5 (5.95) | 0.391 |
Mother ICU hospitalization | 0 | 0 | - |
*Exact Fisher test
VBAC: Vaginal delivery after cesarean section, NICU: Newborn intensive care unit, ICU: Intensive care unit
Discussion
Vaginal delivery is a natural process that usually does not require medical intervention and the country's health policies are based on avoiding cesarean section as much as possible. This study was conducted to investigate the possible complications in women attempting vaginal birth after cesarean delivery. We found that the overall incidence of obstetric complications in those attempting VBAC was low and there was no significant difference between this group compared those with prior vaginal delivery.
In the study of Charitou and colleagues in 2019 (15), severe maternal and fetal complications were very rare. In our study, in line with this study, no severe maternal or fetal complications were observed. Moreover, in another study in Tanzania in 2018 (16), the maternal and neonatal outcomes of the VBAC group were similar to those of women undergoing repeated cesarean section. Takeya et al. in their study only found 0.46% of uterine rupture and no maternal and perinatal death in women who underwent VBAC (17). Moreover, in the multi-center study in Italy on 224 pregnant women that underwent VBAC, there were no report of maternal and neonatal adverse events (18). The results of all the above studies indicate that VBAC is justifiable. However, predictors of success in VBAC should be identified and addressed to eligible women. For example, in Asgarian et al. (14) successful of VBAC was associated with the long interval between inter‑deliveries. In Mizrachi et al. study, previous successful VBAC, lower head station on decision at previous cesarean delivery, the lower newborn weight at previous cesarean delivery and larger cervical effacement on admission at delivery were the predictors of successful VBAC (19). In the Lazarou et al. study high BMI, no previous spontaneous delivery, and fetal distress as a cesarean indication were negatively correlated with a successful VBAC (20). In Li et al. study, gestational age, history of vaginal delivery, birth weight, BMI, spontaneous onset of labour, and rupture of membranes were independently associated with VBAC (21). Clinical judgment is important in deciding whether to have a vaginal delivery after a cesarean or a repeat cesarean section. It seems that most women who have already had a cesarean section can give birth vaginally if the patient is carefully selected and the delivery is well supervised.
However, this study had some limitations, due to the small sample size of the study and the low occurrence of complications, we could not have a strong statistical inference and enough power to distinguishing possible differences. Secondly, due to the retrospective nature of the study, we could not include data on neonatal outcomes. Finally, due to low resource we could not include a third group including those who had an elective repeated cesarean delivery and compared their complications with these two investigated groups to determine the safest mode of delivery.
Conclusion
It seems that the overall incidence of obstetric complications in women attempting vaginal birth after cesarean delivery is low and not higher than those with prior vaginal delivery. Therefore, for the achievement of benefits of natural childbirth for both the mother and the fetus, women with a prior cesarean should be offered VBAC.
Funding
This study was funded by the Baqiyatallah University of Medical Sciences, I.R. Iran.
Authors' contributions
ZS, and AJ developed the idea and the proposal, abstracted, and prepared the manuscript. ZS, AS and AJ participated in the study design and analyzed the data. AJ contributed to the data gathering. All authors read and approved the final manuscript.
Acknowledgements
None.
Conflicts of Interest
The authors declare that they have no competing interests.
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