Open Journal of Obstetrics and Gynecology, 2012, 2, 265-269 OJOG
http://dx.doi.org/10.4236/ojog.2012.23055 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)
Optimization of clinical outcome of women with previous
one lower segment cesarean section
Mamdoh Eskandar1*, Jameelah Aboud2, Majed Alshahrani2, Mervat Hassanein3, Azza Alyamani1
1Department of Ob s tetrics and Gynecology and Reproductive Medicine, College of Medicine, King Khalid University, Abha, KSA
2Department of Ob s tetrics and Gynecology, Abha General Hospital, Abha, KSA
3Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha, KSA
Received 16 May 2012; revised 17 June 2012; accepted 29 June 2012
ABSTRACT
Background and Objectives: To investigate the out-
come in women with planned Vaginal Birth After
Cesarean (VBAC) in comparison to Repeat Cesarean
Section (RCS) and to those undergoing vaginal birth.
Des ign and Settings: Retrospective study, women with
a history of one lower segment cesarean section
(LSCS) admitted to Abha General Hospital for deliv-
ery from September, 2010 to February, 2011. Sub-
jects and Methods: The demographic maternal and
neonatal data and data concerning the course of de-
livery were reviewed in 418 women underwent trial of
labor (TOL) and subjected to statistical analysis to
study the predictive factors and outcome. All cases
were divided into 3 groups, VBAC group (212 women),
RCS group (206 women) and the neonates of the
VBAC group were compared to those of a control
group consists of 287 neonates who were delivered
vaginally. Results: The success rate of VBAC was
50.72%, with no uterine rupture or wound dehiscence.
Failure to progress was the most common (40.2%)
indication of RCS followed by fetal distress (29.9%).
Young maternal age (P < 0.05), previous vaginal de-
liveries after CS (P < 0.05) and occiput anterior posi-
tion (P < 0.01) were significantly associated with suc-
cessful VBAC. Neonatal Intensive Care Unit (NICU)
admission was significantly higher in the RCS group
(P < 0.001), while no significant difference was found
between NICU admission in the VBAC and the con-
trol groups. Conclusion: VBAC should remain an
available option. Informed consent, good reporting
and thorough documentation of the VBAC decision
are crucial. During TOL, continuous fetal monitoring
and, ultrasound evaluation of the previous scar are
recommended. Emergency CS should be considered if
duration of the TOL is prolonged with non reassuring
CTG.
Keywords: VBAC; TOL; RCS; Pregnancy Outcome
1. INTRODUCTION
Quality improvement efforts, practice management skills,
in addition to safe, ethical practices and the need for a
focus on preven tion are all necessary to optimize clinical
outcomes. Change based on adoption of national standards
derived from Evidence-Based practice and randomized
controlled trials (RCTs) alone may not always establish
how diagnostic and therapeu tic procedures actually work
in clinical practice. For this reason, health care organiza-
tions must develop the tools to identify and adopt best
practice and improve clinical outcomes locally [1].
Previous studies assessing the safety of VBAC have
compared VBAC to Elective Repeat Cesarean Section
(ERCS) despite the fact that the risks posed by each are
considerably different. Explaining the complications of
VBAC in a way that is meaningful to women can be
challenging and thus a comparison to a similar group of
women who have undergone normal vaginal delivery
may be a more relevant comparison [2].
Benefits of VBAC may outweigh the risks in most
women with one previous low transverse cesarean, but
even with good facilities and personnel, numerous fac-
tors warrant special caution. Therefore, the aim of this
study was to investigate the outcome in women with
planned Vaginal Birth After Caesarean (VBAC) in com-
parison to Repeat Cesarean Section (RCS) and also to
those undergoing vaginal birth, in attempt to build up a
safer clinical pathway for management and improve the
health-care delivery system in Abha General Hospital in
the coming years.
2. SUBJECTS AND METHODS
This retrospective study was conducted on a total of 418
women with a history of one lower segment cesarean
section (LSCS) and had delivered at Abha General Hos-
pital from September, 2010 to February, 2011.
The demographic maternal and neonatal data as well
*Corresponding a uthor.

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269 266
as data concerning the course of the trial of labor of all
cases were reviewed using especially designed data
collecting tables, which then subjected to statistical ana-
lysis. Accordingly; all cases were divided into 3 groups;
VBAC group consists of 212 women, RCS group con-
sists of 206 women, (50/212 in the V BAC and 84/206 in
the RCS groups respectively were of high parity and
analyzed separately) and a control group consists of 287
neonates who were delivered by spontaneous vaginal
delivery. The neonates of the VBAC group were com-
pared to those of the control group who their mothers
delivered vaginally matched for age and parity. Descrip-
tive statistics included mean and stan dar d deviation. t test
as well as Chi Square test were the significance tests th at
used. P value < 0.05 indicated significance.
3. RESULTS
The demographic maternal data of all women participat-
ing in the study we re presented in Table 1.
212/418 (50.72%) delivered by VBAC while 206/418
(49.28%) delivered by RCS after a failed trial of labor,
with no uterine rupture or wound dehiscence. Maternal
age was significantly older in RCS group with significant
higher percentage of obstetric complications (P < 0.05).
Failure to progress was the most common (40.2%) in-
dication of RCS followed by fetal distress (29.9%), re-
f usal of th e pa tie nts to co n t inu e the tria l (2. 5%), i mpending
rupture of the uterus and intrapartum spotting (2.1%),
while other indications as abnormal head position, IUGR,
prolonged ROM, accounted for about fourth of the cases
(25.3%).
Significant higher percentage (35.19% vs. 17.21%) of
successful VBAC was found in women of low parity
who had previous vaginal deliveries after CS (Ta b l e 2 ).
In all women either of low or high parity postpartum
complications were highly significant in those delivered
by RCS (Tables 3 and 4).
The occiput anterior was highly significant position in
women who delivered vaginally by successful VBAC
than RCS (98.15% vs. 87.70% respectively). Apgar score
< 5 at one minute was significantly (P < 0.001) more
among the neonates of women who delivered by RCS
(17.36% vs. 1.25% respectively) Table 5.
The comparison between the percentages of NICU
admission in VBAC and RCS gr oups (5.56% vs. 19.67%
respectively) being higher in the RCS group was pre-
sented in Table 5 while no significant difference was
found between the percentages of NICU admission in the
VBAC and the control groups.
4. DISCUSSION
Based on current evidence, the success rates for VBAC
Table 1. Demographic maternal data.
VBAC Group N = 212 RCS Group N = 206 P Value
Age (Years) Mean (SD)a 29.65 (5.584) 31.35 (6.507) P < 0.05
Parity Mean (SD)
1 - 3
>3
1.584 (0.755)
5.400 (1.818)
1.344 (0.627)
5.918 (1.910) P > 0. 05
Social Class
Number (Percent)b
Low
Moderate
N = 207c
42 (19.81%)
165 (77.83%)
N = 203d
44 (21.67%)
159 (78.33%)
P > 0.05
Previous History of Associated Medical Disorders
Number (Percent) 5 (2.02%) 9 (2.90%) P > 0.05
Associated Obstetric Complications
Number (Percent) 37 (13.03%) 62 (29.95%) P < 0.05
aValues are mean age (standard deviation); bNumber (percent); c5 cases were missed; d3 cases were missed.
Table 2. Clinical characteristics of the previous CS in women of low parity.
VBAC Group N = 162 RCS Group N = 122 P Value
Interval since PCSe (Months) Mean (SD) 38.674 (25.856) 40.818 (30.531) P > 0.05
Previous vaginal delivery after PCS Number (Percent ) 57 (35.19%) 21 (17.21%) P < 0.05
Postoperative Complications after PCS None None -
Hospital Stay after PCS (Days) Mean (SD) 3.476 (0.859) ( R a ng e 2 - 4) 3.458 (0.798) ( R a ng e 3 - 5) P > 0.05
ePrevious cesarean section.

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269 267
Table 3. Cours e of delivery in the VBAC and RCS groups in women of low parity.
VBAC Group N = 162 RCS Group N = 122 P Value
Gestational Age (Weeks) Mean (SD) 39.287 (1.393) 38.964 (2.427) P > 0.05
Attendant Number (Percent)
Resident
Specialist
146 (90.12%)
16 (9.88%)
61 (50%)
61 (50%) P < 0.001
Oxytocin Units Number (Percent) 2 Units+ 12 (7.41%) 14 (11.48%) P > 0.05
Duration of Labor (Hours) Mean (SD) 7.531 (6.479) 9.346 (7.969) P > 0.05
Maternal Postpartum Complicationsf Number (Percent) 2 (0.94%) 19 (9.22%) P < 0.001
fPostpartum complications include; h emorrhage, maternal ICU adm i s si on and emergency blood transfusion.
Table 4. Course of delivery in the VBAC and RCS groups in women with high parity.
VBAC Group N = 50 RCS Group N = 84 P Value
Gestational Age (Weeks) Mean (SD) 39.519 (1.221) 38.741 (2.123) P > 0.05
Attendant Number (Percent)
Resident
Specialist
43 (86%)
7 (14%)
31 (37.65%)
53 (62.35%) P < 0.05
Oxytocin Units Number (Percent) 2 Units+ 3 (6%) 4 (4.76%) P > 0.05
Duration of Labor (Hours) Mean (SD) 7.25 (7.30 2) 11.919 (8.949) P < 0.05
Maternal Postpartum Complications Number (Percent) 1 (0.47%) 4 (1.94%) P < 0.001
Table 5. Clinical data of the neonates in the VBAC and RCS groups in women of low parity.
VBAC Group N = 162 RCS Group N =122 P Value
Gender Number (Percent)
Males
Females
74 (45.68%)
88 (54.34%)
68 (55.74%)
54 (44.26%) P < 0.001
Birth Weight (Grams) Mean (SD) 2996 (0.452) 3011 (0.432) P > 0.05
Placental Weight (Grams) Mean (SD) 561.132 (116.327) 623.623 (155.077) P < 0.01
Presentation Number (Percent)
Occiput Anterior
Occiput Posterior
159 (98, 15%)
3 (1.85%)
107 (87.70%)
15 (12.30%) P < 0. 01
Apgar Score at 1 Minute Number (Pe rcent)
<5
5+
N = 160g
2 (1.25%)
158g (98.75%)
N = 121h
21 (17.36%)
100h (82.64%) P < 0. 001
NICU Admission Number (Percent) 9 (5.56%) 24 (19.67%) P < 0. 001
g2 cases were misse d ; h1 case was missed.
range f rom 60% - 80% (Ameri can Colleg e of Obstet ri ci ans
and Gynecologists (ACOG) VBAC Guidelines) [3]. De-
cision analysis concluded that VBAC is a reasonable
option when the chance of success exceeds 50% [4].
Failure to progress was the most common (40.2%) in-
dication of RCS in this study, followed by fetal distress
(29.9%). This is in contradictory to Finley and Gibbs
who found that true fetal distress only occurs in 1.5% of
all VBAC attempts [5]. This is may be due to misinter-
pretation of CTG traces, therefore, further evaluation of
the relationship between fetal tracing abnormalities and
uterine rupture is important as a nonreassuring fetal heart
rate is the most frequent sign [6].
Uterine rupture is more likely during trial of labor but
the rate is usually <1% (0.4% - 0.9%). It is more likely
with shorter interval between pregnancies < 18 months
[7], with labor induction or oxytocin augmentation [8],
macrocosmic babies [9] and postdates pregnancies [10].
In the present study, no uterine rupture or wound de-
hiscence were reported in the studied sample. This
agreed with one study reported 0.0% rupture range
without use of oxytocin [11] and other study reported

M. Eskandar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 265-269 268
rare uterine rupture (0.15%) when labor was spontaneous
without augmentation [12]. The reasonable explanation
is that the interval since the Previous Cesarean Section
(PCS) in the present study was long (Tabl e 2 ), our pa-
tients came in spontaneous labor and augmentation with
Oxytocin was used in small dose only in 7.4% - 11.5% of
patients (Ta b l e 3 ). Also we have no postdates (Ta bl e 4)
or macrosomia (Table 5).
Studying the course of delivery in the previous CS in
VBAC group compared to RCS group, results revealed
significant higher percentage of vaginal deliveries after
the PCS in the VBAC compared to RCS group (Table 2).
This is in agreement of previous studies which proved
that women who have delivered vaginally are more
likely to succeed at VBAC by factor of 9 to 28 than those
who have not [ 13,14].
Despite thousands of citations in the world’s literature
there are currently no randomized trials comparing ma-
ternal or neonatal outcomes for both RCS and VBAC. In
the current study maternal complications (postpartum
hemorrhage, emergency blood transfusion and maternal
Intensive Care Unit admissions) were significantly higher
among RCS group compared to VBAC group (Ta b le s 3
and 4). Author et al. and authors [15,16] showed lower
maternal morbidity after a trial of labor than after RCS.
The same was found in the present research where
maternal complications in all women were significantly
higher among RCS group compared to VBAC group.
With repeat cesarean section the risk of placental pro-
blems is increased and infants are affected. In the present
study, no perinatal deaths were recorded in the studied
sample, in absolute terms, the risk of perinatal death as-
sociated a trial of labor and uterine rupture was low 1 in
2200 [17]. In the present study, we have no perinatal
deaths because we have no uterine ruptures. This is sup-
ported by the finding of Lydon-Rochelle et al. [8] who
found the rate of infant mortality was 5.5% in cases in-
volving uterine rupture, compared with 0.5% without
rupture.
As found in one study that the rate of infant mortality
was 5.5% in cases involving uterine rupture.
Comparing the neonatal morbidity in VBAC, RCS and
control groups, the present study revealed that there was
a highly significant difference between percentages of
NICU admission in both studied groups; being more in
RCS group (Table 5), while no significant difference was
found between the VBAC and the control groups. This
disagrees with a study which recorded hypoxic-ischemic
encephalopathy occurred in no infants in ERCS and in 12
infants in TOL group [18]. This contradiction can be ex-
plained by that our women did RCS after failed VBAC
thus more exhausted infants needed NICU admission
while cesarean sections in their study were planned
ERCS.
Based on the results of this research, we conclude that
when women are carefully selected in situation with op-
timal facilities and personnel, VBAC should remain an
available option. Informed consent, good reporting and
thorough documentation of the VBAC decision are cru-
cial to reduce the medico legal risk. Every woman with
history of one LSCS in spontaneous labor, providing
there was no clear indication of RECS, should be care-
fully evaluated by individualized assessment before a
management plan is made and documented. All women
with full term, singleton, normal pregn an cy, with average
fetal weight, vertex presentation should have an attempt
of VBAC especially in young women with low parity
and history of previous vaginal deliveries after their pre-
vious CS.
During the Trial of Labor, continuous fetal monitoring
is mandatory, ultrasound evaluation of the previous scar
is recommended both intrapartum and postpartum to
confirm scar integrity and detect asymptomatic income-
plete uterine rupture. Emergency CS should be con-
sidered if the duration of the TOL is prolonged with non
reassuring CTG. The attending doctor should be fully
aware of these General Guidelines for VBAC.
Active role should be played in educating both women
and practitioners about healthy childbirth practices that
not only encourage VBAC but also discourage the over-
use of primary CS. This is of prime importance espe-
cially among Saudi women who usually plan for big
families.
Further studies are needed to investigate safety of
VBAC with twins, suspected macrosomia and unknown
uterine scars. Also, to identify the possible hidden
perinatal mortality if VBAC is compared to RECS at 37 -
38 weeks.
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