Discussion
The goal of managing an antenatal woman with a scarred uterus is to
provide the woman a well informed choice along with efficient and robust
statistical data of the estimated risks associated with TOLAC and CS and
also to make an individualised prediction of her estimated likelihood to
have a successful VBAC if she wishes to opt for TOLAC. The most common
indication of previous CS in the study population was foetal distress
(25.8%) and the VBAC and CS rates were found to be similar for all
indications of previous CS, comparable to study of Jozwiak et
al9 where 30% population had previous CS done for
foetal distress and the indication of previous CS did not affect the
outcome of TOLAC.
The maximum inter-delivery interval observed in this study was 11 years
and the minimum was 1.5 years (mean 4.63 years). Inter-delivery interval
did not influence the outcome of TOLAC in the present study which was in
sync with the results published by Sinha et al10,
Patel et al11 and Gobillot et al12.
More women had VBAC compared to CS in the spontaneous labour group
(84.2% vs 15.8%) whereas lesser women had VBAC compared to CS in the
induced labour group (42% vs 58%). Sinha et al10demonstrated a similar CS rate of 48% in the induced group compared to
the present study.
Mean cervical dilatation at admission was 1.9 cm and the mean cervical
effacement at admission was 25.4%. The values of both were
significantly higher in women who had VBAC (p=0.001). This was similar
to the study by Landon et al1 where mean dilatation at
admission was 3.3 cm which was significantly higher in VBAC group than
CS group and patients who had dilatation >4 cm had 83.8%
VBAC success.
The mean Bishop’s score at admission was 4.46 for the study population,
100% VBAC success was observed for patients with Bishop’s score
>6 and patients with Bishop’s between 0-3 had only 39.5%
VBAC rate. None of the previously done studies on outcomes following
TOLAC assessed cervical effacement, station of vertex and Bishop’s score
at admission as potential influencing variables for TOLAC success.
VBAC success rate of 42% was observed in induced women in the present
study which was comparable to the results of Atia et al (39.8%)2
Out of the 69.3% induced women, most were induced for Preeclampsia
(16.9%) followed by IUGR (14.9%) and ICP (12.9%). VBAC and CS rates
were similar for all other indications except, ICP in which a
significantly higher CS rate of 81.2% was observed as most of these
women developed foetal distress or MSL intrapartum. Contrary to our
study, maximum proportion of women had IOL for post-dated pregnancy in
all other studies.2,3,12
The present study had caesarean section rate of 45.2% which was similar
to the studies by Jozwiak et al9 and Goel et
al13 but higher than that observed in the studies by
Landon et al, Sinha et al and Patel et al.1,10,11Pathological CTG (21.8%) was the leading indication of CS in the
present study which was in unison with the result of studies by Gobillot
et al12 and Goel et al13 where most
of the caesareans during TOLAC were done for foetal distress.
In the present study, the mean birthweight of the neonates born was 2.3
kg and it was similar among the VBAC and CS groups (2.78 vs 2.66 kg).
Mean birthweight of the neonates had no influence on the outcome of
TOLAC in our study and this was consistent with the results published by
Atia et al and Patel et al.2,11
The mean Apgar scores at 1 min (7.79 vs 7.73) and 5 min (8.84 vs 8.79)
were similar in neonates born by VBAC and CS in the present study which
was consistent with the results of studies done by Atia et al and Shatz
et al.2,3
In the present study, higher rate of neonatal complications were
observed in the women who had failed TOLAC and underwent emergency
repeat CS compared to those who had successful VBAC. Patel et al also
observed similar results in their study cohort. 11
Only one neonatal death occurred during the study which was consistent
with the low rates of neonatal mortality as observed in the study by
Jozwiak et al9 (only 2 neonatal deaths).
Around 27.4% women in the study population had some complication (minor
or major) during labour or in postpartum period. The complication rate
was comparable among women who had VBAC and CS (29.4% vs 25%) in the
present study. Patel et al and Gobillot et al also observed no
significant difference in the complication rates among women who had
VBAC and CS following TOLAC.11,12 Contrary to this,
Shatz et al and observed increased rates of infection, PPH and blood
transfusion in women who had failed TOLAC.3
No case of uterine rupture was observed in the study population despite
a high IOL rate of 69.3%, however 5 out of 124 women did develop scar
dehiscence. The most frequently occurring complication in the study
cohort was PPH (8%) similar to the 12% rate of PPH observed by Jozwiak
et al.9 The rate of occurrence of PPH was similar in
VBAC and CS. Only one woman had massive PPH for which Bakri balloon was
inserted and 5.6% women in the study cohort received blood transfusion.
Around 4% women had cervical tear which is attributable to the 8% rate
of forceps delivery in the study population. Only one woman developed
vulvovaginal hematoma and one developed third degree perineal tear,
consistent with the observations of Patel et al.11
Out of 124 women undergoing TOLAC, 37 (29.8%) accepted contraception.
Around 12.9% women chose tubal ligation, 13.7% chose CuT 380 and 3.2%
chose CuT 375 as the preferred contraceptive method. Contraception rate
was significantly higher in women undergoing CS than in women who had
VBAC (41% vs 20.5%) which reflects the likely ease of getting ligation
done during the surgical procedure of CS itself. None of the previously
published studies have evaluated the contraceptive choice of women
following TOLAC.