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F.M.C.O.G. PART II DISSERTATION
PROJECT TITLE:
THE OUTCOME OF VAGINAL BIRTH AFTER
ONE PREVIOUS CAESAREAN SECTION (VBAC)
AT THE UNIVERSITY OF NIGERIA TEACHING HOSPITAL,
ENUGU, SOUTH EAST NIGERIA
NAME OF CANDIDATE:
DR. UGWU GEORGE ONYEMAECHI, MB BS (Nig.) MPH
AF/005/07/004/822
SUPERVISORS:
1. PROF. V. E. EGWUATU [M.B (Lond.) FMCOG, FRCOG, FWACS, FICS]
2. PROF. H. E. ONAH [MBBS, MPHARM, FWACS, FMCOG]
INSTITUTION:
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
UNIVERSITY OF NIGERIA TEACHING HOSPITAL
ITUKU-OZALLA
P.M.B 01129
ENUGU.
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PROJECT TITLE
THE OUTCOME OF VAGINAL BIRTH AFTER
ONE PREVIOUS CAESAREAN SECTION (VBAC)
AT THE UNIVERSITY OF NIGERIA TEACHING HOSPITAL,
ENUGU, SOUTH EAST NIGERIA
Our Ref ............................................................. ………….
UNIVERSITY OF NIGERIA TEACHING HOSPITAL
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CERTIFICATION
We have supervised Dr. Ugwu George Onyemaechi on the writing of this
dissertation, in keeping with the recommendations of the Faculty of
Obstetrics and Gynaecology, National Postgraduate Medical College of
Nigeria.
PROF. V. E. EGWUATU [M.B (Lond.) FMCOG, FRCOG, FWACS, FICS]
Signature/Date
PROF. H. E. ONAH [MBBS, MPHARM, FWACS, FMCOG]
Signature/Date
ITUKU-Ol,ALLA, P.M.B. 01129, ENUGU, NIGERIA. TEL: 042-252022, 252573, 252172, 252134, FAX: 042-252665
E-mail: [email protected]
Prof. O. O. MBONU, MB (Lond.) FRCS(c), FWACS
Chairman, U.N.T.H Management Board Dr. A. U. Mbah, MD (LODZ.,) FNCP, FNIM, (KSJ)
Chief Medical Director
Barr. (Mrs.) M. U. OKONKWO LL.B (HOllS). BL.. MPA, MIHSAN, PMN, FCAI
Director of Administration/Secretary .
U.N.T.H Management Board
Dr. C. C. AMAH, MBBS, FWACS, FICS, MNIM, MNIPR
Chairman, Medical Advisory Committee
Date ………………………………………………
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DECLARATION
It is hereby declared that this work is original. The work has not
been presented to any other College for a Fellowship nor has it been
submitted elsewhere for publication.
Dr. Ugwu George O.
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DEDICATION
To my dear wife Ndidiamaka
Our children Akachukwu and Ebubechukwu
And my mother Janet for their sacrifices, love and encouragement.
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ACKNOWLEDGEMENT
I acknowledge the kindness of Prof. V. E. Egwuatu for graciously
supervising this work from the very beginning even though he is the
teacher of my teachers.
I remain indebted and ever grateful to my mentor and trainer Prof.
H. E. Onah for guiding me step by step through this work.
My special gratitude must go to my supervisory consultants and
friends especially Prof. B. C. Ozumba, Dr(s) H. U. Ezegwui, Umeora, O.
U. J., Dim C. C. for their positive influence at various stages of my
residency training.
I thank Mrs. Ngozi Edeh for secretarial/computer assistance.
And above all, I thank Almighty God for everything.
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TABLE OF CONTENTS
Title Page …. …. i
Project Title …. …. ii
Certification …. …. iii
Declaration …. …. iv
Dedication …. …. v
Acknowledgement …. …. vi
Table of Contents …. …. vii
Abstract …. …. ix
CHAPTER ONE: INTRODUCTION …. …. 1
1.1 Introduction …. …. 1
1.2 Justification of the Study …. …. 3
1.3 Aims and Objectives …. …. 5
CHAPTER TWO: LITERATURE REVIEW ….
2.1 Historical Background …. …. 6
2.2 Feasibility of VBAC …. …. 8
2.3 Candidates for VBAC …. …. 10
2.4 Elective Repeat C/S Versus VBAC …. …. 11
2.5 Preparations for VBAC …. …. 12
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2.6 Induction/Augmentation of Labour in a Previous
Caesarean Delivery …. 14
2.7 Analgesia in VBAC …. 16
2.8 Digital Exploration in VBAC …. 17
2.9 Complications of VBAC …. 17
CHAPTER THREE: PATIENTS AND METHODS …. 20
3.1 Study Centre …. …. 20
3.2 Study Area …. …. 21
3.3 Ethical Clearance …. …. 22
3.4 Patients Selection …. …. 22
3.5 Determination of Sample Size …. …. 23
3.6 Study Design, Data Collection and Analysis …. 24
CHAPTER FOUR: RESULTS …. 27
CHAPTER FIVE: DISCUSSION …. 39
CHAPTER SIX: CONCLUSIONS AND
RECOMMENDATION …. 44
References …. …. 46
Appendix 1: Ethical Clearance Certificate …. 52
Appendix 2: Informed Consent Form …. 53
Appendix 3: Questionnaire …. 54
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ABSTRACT
Background:
Reports from the developing countries on the safety and success
rates of vaginal birth after one previous caesarean delivery are variable.8,24
Although the existing global caesarean section rates are high and rising,
obstetricians are generally reluctant to conduct vaginal delivery in women
with a previous caesarean section because of conceivable complications
and concern for possible litigation.
Objectives:
To determine the prevalence of patients, with one previous
caesarean section at the UNTH. Also to determine and compare the
maternal and fetal outcomes of labour in women who attempted VBAC
successfully or not and those undergoing elective caesarean section.
Design:
It was a prospective cross-sectional study of pregnant women with
one previous caesarean section. It examined the outcome of pregnancy in
such women following attempt at vaginal birth or an elective repeat
caesarean section.
Setting: Department of Obstetrics and Gynaecology, UNTH Ituku –
Ozalla, Enugu.
Subjects: Seventy one (71) consecutive pregnant women with one
previous caesarean section who met the inclusion criteria were recruited.
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Main Outcome Measures:
The main outcome measures for each patient included the mode of
delivery, fetal outcome (including Apgar scores, perinatal death and birth
weight) and maternal outcome (including post partum haemorrhage,
uterine rupture and maternal death).
Results:
The prevalence of one previous caesarean section was found to be
13.6%. Sixty four (90.1%) of the women preferred to have vaginal
delivery despite the one previous caesarean section while 7 (9.9%) opted
for repeat elective caesarean section. Following assessment, 38 (53.5%)
were recruited to have trial of VBAC by the obstetrician, out of whom 19
(50.0%) had successful VBAC. The fetal and maternal outcomes were
generally good with no case of uterine rupture, perinatal or maternal
mortality. Apgar scores of less than 7 in the first minute were significantly
more frequent in those with successful VBAC compared with repeat
elective caesarean section (P = 0.03) but there was no significant different
with those with failed VBAC (P = 0.82). Birth weight of 4.0kg or greater
was significantly more common in those with failed VBAC compared with
successful VBAC (P = 0.03).
Conclusion:
The findings of this study indicate that the maternal and fetal
outcomes of labour in selected women with one previous caesarean
delivery for non-recurrent indications are good, and comparable to those of
women electively delivered by caesarean section.
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CHAPTER ONE
1.1 INTRODUCTION
In the past the dictum “once a caesarean, always a caesarean”
dominated obstetric practice.1 However, in the last few decades the trend
has changed. It is now relatively safer for an attempt at Vaginal Birth
After Caesarean Section (VBAC) as a result of improvement in Obstetric
care, and VBAC is now being recommended as a relatively safe way of
decreasing the ever rising global rate of caesarean delivery.2,3
Vaginal delivery is associated with fewer risks4, requires less
anaesthesia, poses a lower potential for postpartum morbidity, involves a
shorter hospital stay, is more affordable and encourages earlier and better
bonding between mother and infant. These advantages are significant,
especially in a resource poor setting like ours where socio-cultural aversion
to caesarean delivery is common.5
In most published series of women attempting vaginal delivery after
previous caesarean section, 60-80% are reported to achieve successful
vaginal birth6,7,8. Success rate in the developed world is about 80%9, and
in Enugu Nigeria, Egwuatu and colleagues reported successful vaginal
delivery in 71.6% of the patients.10
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The American College of Obstetricians and Gynecologists,
recommends that the selection criteria11 useful in identifying candidates for
VBAC include: one previous low transverse caesarean delivery, clinically
adequate pelvis, no other uterine scars or previous rupture, physicians
immediately available throughout active labour capable of monitoring
labour and performing emergency caesarean section and the availability of
anaesthesia and personnel for emergency caesarean delivery. Although
these conditions are potentially applicable in tertiary centres in the
developing countries there are many inadequacies in meeting them in our
environment.14
Despite its high success rate and relatively few contraindications, the
attitude of many obstetricians especially in our environment towards
VBAC remains guarded. The caesarean section rate of 15-25% has been
reported in many Nigerian Teaching Hospitals12,13,14, and repeat caesarean
section was the leading indication for caesarean delivery in most cases.
These rates are comparable to the National Caesarean section rate of 29%
reported in the United States11,15.
There has been a growing concern over the increasing rate of
caesarean operation worldwide and the need to reduce it. The caesarean
section rate has been significantly linked to the practice of VBAC11,14.
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In Nigeria, where many women are poor and dislike caesarean
delivery and the associated risks are significantly increased due to fragile
health facilities, liberal application of VBAC, where appropriate, should be
recommended in order to reduce the high caesarean section rate. The
provision of accurate information on the outcomes and complications of
VBAC is therefore essential.
1.2 JUSTIFICATION OF THE STUDY
The enthusiasm for VBAC varies greatly amongst patients and
obstetricians. Uterine rupture and the attendant grave complications of
fetal death and life threatening maternal haemorrhage may make
obstetricians reluctant to advocate VBAC when and where it should have
been feasible. This is more likely in the developing countries where the
health facilities are fragile, response to emergencies inadequate and the
availability of wholesome blood for transfusion uncertain.
Several Nigerian women, including the well educated, refuse
caesarean delivery for socio-cultural reasons5. However, the higher
morbidity and mortality associated with caesarean sections in comparison
to vaginal delivery justify the growing concern about unnecessary
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caesarean section worldwide14. In Nigeria, vaginal delivery is always
welcome and preferred by the patient, and is safe and appropriate.
There are currently no randomized trials comparing maternal and
neonatal outcomes for both repeat caesarean section and VBAC11. Instead
VBAC recommendations have been based on data from clinical series
(mainly retrospective) suggesting that the benefits for VBAC outweigh the
risk in most women with one previous low transverse caesarean
delivery3,16. At the UNTH Enugu, there has been no recent prospective
study on the subject of VBAC, its outcome and complications despite its
common application over several years. The various consultant units in
our department of Obstetrics & Gynaecology approach decisions on this
subject differently. The question remains “what is the outcome of labour
in women with one previous caesarean section? Is the outcome different
from those who had repeat elective caesarean section? Is the outcome
different between successful VBAC and failed VBAC?”
A study of the practice, outcome and complications of VBAC is
therefore necessary in order to establish the current practice in our centre
and make appropriate recommendations for its future application.
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1.3 AIMS OF THE STUDY
To determine the outcome of vaginal birth after one previous
caesarean section at the University of Nigeria Teaching Hospital (UNTH),
Enugu South East Nigeria.
SPECIFIC OBJECTIVES
- To determine the prevalence of patients with one previous caesarean
section in UNTH.
- To determine the maternal and fetal outcome of labour in women
undergoing trial of VBAC and those delivered by elective caesarean
section.
- To compare the outcomes from successful VBAC with those with
failed trial of labour.
- To identify factors that may predispose to failed trial of VBAC.
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CHAPTER TWO
LITERATURE REVIEW
2.1 HISTORICAL BACKGROUND OF VAGINAL BIRTH
AFTER CAESAREAN SECTION (VBAC)
The management of a woman with a previous caesarean section has
remained controversial for several decades though with swift changes over
time. In 1916, Craigin made his famous and often quoted assertion “once a
caesarean, always a caesarean.” Then the classical vertical uterine scar
was used almost universally with frequent occurrences of ante - and
intrapartum uterine ruptures. For many decades virtually all women with a
previous caesarean section had elective repeat caesarean section. In 1921,
the Kerr transverse uterine incision was recommended.17
In 1978 a remarkable report was made of 83% successful attempt at
vaginal delivery in patients with prior caesarean section.18 This and
similar reports rekindled interest in attempts at VBAC at a time when only
about 3% of women considered it. This report also came at the heels of an
ever increasing and worrisome caesarean section rate.
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In 1988, the global caesarean section rate was about 25% rising from
a figure of less than 5% in the early 1970(s)19. In England Caesarean
section rate increased from 9% of all deliveries in 1980 to 21% in 200120.
In an effort to curb the escalating caesarean section rate, the American
College of Obstetricians and Gynecologists (1988) recommended that in
the absence of contra-indications, a woman with one previous low
transverse caesarean section be counseled to attempt labour in a subsequent
pregnancy. The recommendation was sustained by accruing evidence that
uterine rupture was infrequent in women undergoing VBAC.11
Although attempt at VBAC has become accepted, it seems to have
decreased in some parts of the world in the last 10 years19. The global
picture is however variable as some reports indicate increasing success of
VBAC. The practice of VBAC may also be affected by the medical
complications and the medico-legal embarrassments experienced by some
practitioners.
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2.2 THE FEASIBILITY OF VAGINAL BIRTH AFTER
CAESAREAN SECTION
Despite the risk of uterine rupture and other complications that may
arise during trial of labour, Vaginal Birth After Caesarean Section (VBAC)
is widely endorsed by obstetricians globally. The American College of
Obstetricians and Gynecologists (ACOG) issued guidelines in favour of
VBAC in 1988 which were updated in 1999 and 2004. In 1997, the Royal
College of Obstetricians and Gynaecologists (RCOG) of England also
recommended consideration of vaginal delivery subsequent to caesarean
section21. These recommendations followed several studies and reports
that documented the feasibility and success of vaginal birth after caesarean
section in both developed and developing countries.2,3,8,10
In a study of 120 women at term pregnancy with one previous
caesarean section, in Ibadan Nigeria, vaginal delivery was successfully
achieved in 86.5% while elective repeat caesarean section was performed
on only 2.5% of the subjects22. There was uterine rupture in 2.5% of the
patients but no maternal mortality was recorded. However, in a similar
study in Pakistan23 only 33.5% of the women had successful vaginal
delivery with a single case of uterine rupture and no maternal mortality.
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In a recent three-year prospective study of women with a previous
caesarean section in a private specialist hospital in Lagos, Nigeria, 29.3%
had elective repeat caesarean section, and 70.7% were allowed trial of
labour. 69.1% of the women who attempted vaginal birth achieved
successful vaginal delivery24. One uterine rupture was recorded; eight
patients had oxytocin augmentation of labour. Several studies have
concluded that vaginal birth after caesarean section is not only feasible but
also reasonably safe8,24,25,26. Overall, the success rates ranges between 52%
and over 80%8,24.
Several earlier Nigerian studies on VBAC documented lower
success rates. For instance, in Enugu Nigeria, Iloabachie in 1989 reported
that 5.1% of the patients with a prior caesarean section delivered
vaginally26 and less than 10% of the patients were allowed VBAC. In
Benin, Okpere in 1982 reported that 54% of women with prior caesarean
delivery were allowed VBAC and 34% of them had successful vaginal
delivery. This rate is similar to a recent report from Pakistan23. The more
recent studies from Ibadan and Lagos reported much higher rates of
successful vaginal delivery in the ranges of 70-80%22,24 which are similar
to other reports from developed countries8.
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2.3 CANDIDATES FOR VBAC
The optimal management for a patient with a prior caesarean section
remains controversial. Careful selection of suitable candidates for VBAC
is important. The patients’ choice and preference must be considered and
emphasis placed on safety. VBAC is associated with a risk of uterine
rupture, with poor outcomes for both mother and baby. The recent
recommendation of the American College of Obstetricians and
Gynaecologists (2004)11 specified that candidates for VBAC should posses
the foll owing characteristics:
- No more than one prior low transverse caesarean delivery.
- Clinically adequate pelvis.
- No other uterine scars or previous rupture
- Physician should be immediately available throughout active
labour who is capable of monitoring labour and performing
emergency caesarean delivery.
- Availability of anaesthesia and personnel for emergency
caesarean delivery.
The society of Obstetricians and Gynaecologists of Canada made similar
recommendations in their guidelines for VBAC.27 The recent guidelines
issued by Royal College of Obstetricians and Gynaecologists of England
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recommend that women with two uncomplicated low transverse caesarean
may be considered suitable for planned VBAC.28
Few reliable data are available to guide clinical decisions regarding
selection of women who are likely to have a successful trial of labour29,30,
and such decisions are frequently individualized.
2.4 ELECTIVE REPEAT CAESAREAN DELIVERY VERSUS
VBAC
When compared with vaginal delivery, Caesarean birth is associated
with increased risks including those of anaesthesia, haemorrhage, damage
to the bladder and other organs, pelvic infection, scarring of uterus and
cost. In spite of these potential concerns, an elective repeat caesarean
delivery is considered by some women to be preferable to attempting a trial
of labour. Reasons for this preference include the convenience of a
scheduled delivery and the possibility of a prolonged and potentially
dangerous labour. In an American study of 312 women, following
extensive counseling, 40% opted for a repeat caesarean section and 39% of
those who had repeat caesarean section reported that they were satisfied
with their choice31.
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However, several studies have shown that expecting mothers still
prefer to deliver vaginally even if the previous delivery was with
instrumentation and complications32. In Enugu and most parts of Nigeria,
the preference women have for vaginal delivery is never in doubt. The
dislike for caesarean delivery often prevents patients from reporting to the
hospital when in labour with attendant fetal and maternal morbidity and
mortality30.
The high cost of caesarean section is another deterring factor in a
resource poor environment. It is noteworthy that the leading indication for
caesarean delivery in Enugu is previous caesarean section14. In 1989,
Iloabachie in Enugu advocated that more women with prior caesarean
section be allowed a trial of vaginal delivery provided safety is ensured26, a
policy that may lower the high rate of caesarean section in our
environment. This study verifies whether that recommendation has
resulted in a higher incidence of VBAC in Enugu.
2.5 PREPARATIONS FOR VBAC
Ideally, the care of women who have uterine scar should begin in the
preconception period. Several reports have indicated the value of
hysterosalpingography, ultrasonography and sonohysterography in the
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assessment of the integrity of uterine scars33. Such early assessment may
inform the decision of the physician in allowing VBAC but its use is
limited. When considering which patients should be offered a trial of
labour after a previous caesarean delivery, compliance with the ACOG
recommendations regarding patients’ selection should be ensured.
Preferably patients should be counseled early in pregnancy regarding the
risks and benefits of VBAC. It is reasonable for women to undergo VBAC
in a safe setting, but the potential complications should be discussed and
documented. If the type of previous uterine incision is in doubt, attempt
should be made to clarify this and obtain the patients’ medical records.
After thorough counseling that weighs the individual benefits and risks of
VBAC, the ultimate decision to attempt this procedure or undertake a
repeat caesarean delivery should be made by the patient and her physician.
In our study area where emergency facilities and appropriate
responses are poor, extra and specific measures are taken to ensure that a
senior obstetrician, anaesthetist and neonatologist are available during
labour and delivery. It is also vital that all arrangements for possible blood
transfusion are completed and intravenous access established at the
commencement of labour in women undergoing VBAC. The labour is
monitored closely with a partograph and cardiotocograph and generally the
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threshold for emergency caesarean section should be lower than for women
who had not undergone a previous caesarean section.
Prediction of VBAC success or failure has not been easy due to
physician bias and dearth of randomized, prospective studies on the best
predicting factors19. Generally predictors of likely success in VBAC may
include – prior vaginal delivery, prior successful VBAC, spontaneous
labour, favourable cervix and preterm delivery.
Maternal obesity, short maternal stature, fetal macrosomia, advanced
maternal age (>35 years), induction of labour, unfavourable cervix,
gestational age > 41 weeks and short interpregnancy interval (less than 6
months) are among the factors that may be associated with failure of
VBAC.8,19
2.6 INDUCTION/AUGMENTATION OF LABOUR IN PATIENTS
WITH PRIOR CAESAREAN DELIVERY:
The use of oxytocin to induce or augment labour has been
implicated in uterine ruptures in women attempting VBAC. In a study of
uterine ruptures after induced or augmented labour, rupture occurred in
2.3% of those in whom labour was induced compared to 1.0% and 0.4% of
those whose labour was augmented or spontaneous respectively34.
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However, many obstetricians now agree that it may be safe to use
oxytocin for the augmentation of labour in patients attempting VBAC35.
Safeguards must, however, be in place to ensure that the augmentation is
carefully controlled and that maternal and fetal well-being are carefully
monitored. Induction of labour is slightly more controversial. It is
sometimes argued that induction of labour in a patient who already has a
uterine scar involves two risk factors, which should lower the threshold for
opting for a repeat caesarean birth.
The use of prostaglandin in women with previous caesarean birth is
still controversial. The risk of uterine rupture in prostaglandin induction in
previous caesarean birth is directly related to the preparation, dose and
regimen. It has been observed that its use in women attempting VBAC
substantially increases the risk of uterine rupture36. The available evidence
however suggests that induction of labour can be carried out safely using
prostaglandins or oxytocin cautiously in carefully selected cases. There
are few reports describing the use of prostaglandin E1 analogue,
misoprostol in women with prior caesarean delivery. Wing and colleagues
prematurely terminated their randomized study of oxytocin versus
misoprostol for labour induction in women with previous caesarean
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delivery after two (2) of the first seventeen (17) women on misoprostol
experienced uterine rupture37.
Despite the perceived risks, a recent survey in England revealed that
89.7% of obstetricians would use oxytocin for augmentation in VBAC
while 75% of those who have been consultants for up to 10 years indicated
that they will not use either oxytocin or prostaglandin in VBAC38. A
review of numerous papers addressing this issue indicates that there is no
absolute contra-indication to the use of oxytocin or prostalandins in
women undergoing VBAC. Greater risk is, however, associated with the
use of prostaglandin. The present study may determine the fetal and
maternal outcomes associated with the use of oxytocin and prostaglandins
in women undergoing VBAC in our centre.
2.7 ANALGESIA IN VBAC
It has been suggested that epidural analgesia could potentially mask
scar rupture because the patient will not be able to feel the pain associated
with the event.19 Abdominal pain is not a reliable feature of scar disruption
and epidural analgesia may not completely block the pain associated with
uterine rupture because the pain often goes above the level of the block.
Epidural analgesia is safe in these women especially where electronic
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monitoring of labour is available, and should not be denied them when it
can be safely administered.
2.8 DIGITAL EXPLORATION
It has been the standard practice to do a digital exploration of the
lower uterine segment after 3rd stage of labour to determine whether scar
disruption had occurred.
Current evidence suggests that the practice confers no benefit and
may even be harmful.8 In asymptomatic patients, digital exploration may
create a rent where there was none or enlarge a small rent and so is now
generally discouraged.
Digital Exploration may be carried out only if there is suprapubic
pain, placental retention or primary postpartum haemorrhage.
2.9 COMPLICATIONS OF VBAC
An attempt at VBAC may fail to achieve vaginal delivery
compelling recourse to a repeat caesarean section. This may be due to fetal
distress, slow progress in labour and/or cephalopelvic disproportion. There
may be a delay in the third stage of labour, and an increase in incidence of
postpartum haemorrhage and of retained placenta39 uterine rupture may
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occur. Other complications include hysterectomy, operative deliveries,
increased maternal infection and need for blood transfusion, neonatal
morbidity/mortality and maternal death.
Uterine rupture during attempted VBAC is a life threatening
complication. In most cases, the cause of uterine rupture is unknown, and
poor obstetric outcome can result even in women who are suitable
candidates for VBAC. The exact incidence of uterine rupture is difficult to
ascertain because reports in the literature sometimes grouped true, uterine
rupture with asymptomatic scar dehiscence8,19. The rate of uterine rupture
is largely dependent on the type and location of the previous incision.
Uterine rupture rates in women with previous classical incision and T-
shaped uterine incisions range between 4% and 9%.11
Documented uterine rupture rates during attempted VBAC are
generally less than 1%.16 Women who attempt VBAC less than 24 months
after their caesarean delivery have a 2-3 fold increased risk of uterine
rupture when compared with women who attempt VBAC more than 24
months after their caesarean section.40
The incidence of maternal death with VBAC is extremely low.
Only 3 maternal deaths were reported among 27,000 women who
attempted VBAC.41
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In summary, current literature supports attempts at VBAC after one
caesarean section in well selected cases. There have been reports of
attempted VBAC after 2 previous caesareans28.
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CHAPTER THREE
PATIENTS AND METHODS
3.1 STUDY CENTRE
The study was carried out in the obstetric unit of the University of
Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu. The new
permanent hospital complex at Ituku-Ozalla is located 21 kilometers from
Enugu City Centre (the capital of Enugu State), along Enugu - Port
Harcourt Expressway.42 It has been recently renovated and equipped
under the Federal Government assisted programme handled by Vamed
Engineering Company. The hospital complex covers an area of about 200
acres and the current bed capacity is 600 with 65 obstetric beds. There are
on-going expansion and development projects in the hospital.
The hospital provides both general and specialist services to the
people of Enugu State and is a referral centre in the south Eastern part of
the country and beyond.
The functions of the obstetric unit are performed in the booking,
antenatal, postnatal and family planning clinics, labour, antenatal lying-in
and special care wards and obstetric theatre. It conducts about 2,200
deliveries annually with a reported caesarean section rare of 25%14.
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3.2 STUDY AREA
Enugu State is one of the five states in the southeast geopolitical
zone of Nigeria. Its capital city is Enugu. It was created in 1991 from the
old Anambra State, and lies partly within the semi-tropical rain forest belt
of the south, and spreads towards the North through a land area of
approximately 8727.1km2,43.
Enugu State shares borders with Abia State to the South, Ebonyi
State to the East, Benue and Kogi States to the Northeast and Northwest
respectively and Anambra State to the West. The State has 17 Local
Government Areas, most of which are predominantly rural except those
within Enugu metropolis, the University town of Nsukka and some parts of
Oji River. The major occupations of the inhabitants range from trading
and the civil service in the urban areas to subsistence farming and animal
pasturing in the rural areas. Its population of about 2.5 million is
predominantly Igbo with pockets of other tribes.43 Other health facilities
within the State include the recently established Enugu State University
Teaching Hospital at Park Lane, G.R.A. Enugu, numerous mission and
private hospitals/clinics, as well as seven District Hospitals at Enugu
Urban, Udi, Nsukka, Agbani, Awgu, Ikem and Enugu-Ezike. Caesarean
section is performed in most of these health facilities, but the personnel
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and facilities needed to appropriately allow attempt at vaginal delivery in
women previously delivered by caesarean section are lacking.
Consequently women with prior caesarean section scars are often referred
to the UNTH, Enugu. Uncertainty about the integrity of the scars may
explain why a previous caesarean section is the commonest indication for
performing caesarean deliveries at the UNTH, Enugu.14
3.3 ETHICAL CLEARANCE
This study has been approved by the University of Nigeria Teaching
Hospital, Ethics Committee. The clearance letter is attached.
3.4 PATIENTS SELECTION
The patients recruited for the study were women attending antenatal
clinic/labour ward of the hospital.
ELIGIBILITY:
The eligibility criteria for the study are:
Pregnant women (second trimester and third trimester) who have had one
previous caesarean section.
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EXCLUSION CRITERIA:
Women who have had two or more caesarean sections.
Women who have had other uterine scars (previous classical caesarean
section/myomectomy), or previous uterine rupture.
Women who declined consent to participate in the study.
3.5 DETERMINATION OF SAMPLE SIZE
In a recent similar Nigerian study,24 the prevalence of previous
Caesarean Section was 11.9%. The minimum sample size (n) for the study
is calculated based on the formula for sample size determination:
n = Z2 P (1 – P)
d2
where Z is the confidence interval, P is the prevalence from a
previous study and d is the level of confidence.
Using a prevalence of 11.9% from previous study, and 5% level of
confidence and confidence interval of 1.96, the minimum sample size n is
= (1.96)2 (0.119) (0.3)
(0.05)2
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= 0.137145
(0.05)2
= 55.0
A minimum sample size of 61 women with one previous caesarean
section was accepted for the study in anticipation of a drop out rate of
about 10%.
3.6 STUDY DESIGN, DATA COLLECTION AND ANALYSIS
The study was a prospective cross-sectional survey of women with
one previous caesarean section. The study commenced after approval by
both the Ethics Committee of the hospital, and National Postgraduate
Medical College of Nigeria. It was carried out from 1st May to 31st
December, 2010.
There was individual counseling of each woman recruited for the
study, after which her consent was obtained. The counseling centred on
the need for research in the health sector so as to improve patient care and
satisfaction and the assurance that information requested will be treated
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35
with utmost confidentiality and used strictly for improvement of maternal
care.
Every woman who presented at the obstetric unit within the study
period, satisfied the inclusion criteria and gave her consent was recruited
for the study. That means consecutive patients who had one previous
caesarean section and were in the second or third trimester of pregnancy.
Recruitment was by the use of a pre-tested, interviewer administered
questionnaire which was administered by the investigator or his trained
assistants (Registrar/House Officer). Each patient recruited was given a
number (or tag) to enable specific follow up.
Information sought included Biodata and socio demographic
characteristics, details of the previous caesarean section, preferred mode of
delivery, and the planned mode of delivery (with her obstetrician). Details
of the mode, outcome and complications of the delivery were documented
at delivery. All patients included in the study were closely followed up
during pregnancy at clinic visits, and hospital admissions especially at 36
weeks gestation or beyond. Suitably qualified patients who presented first
in labour were also included in the study. Some of them were unbooked or
had booked for antenatal care elsewhere.
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36
All patients recruited for the study were seen physically within 48
hours of delivery and their delivery records reviewed to complete the
remaining details on outcome and complications of labour. The
investigator(s) maintained a cordial relationship with the patients selected
for the study and also obtained and recorded their GSM numbers which
were used to trace some of them.
All data collected from the study were keyed into Statistical Package
for Social Sciences (SPSS) computer software version 13.0 for windows.
Such data for each patient included the biodata, indication for previous
caesarean section, mode of delivery, fetal outcome (including Apgar
scores, perinatal death and birth weight) and maternal outcome (including
post partum haemorrhage, uterine rupture and maternal death). After
collection, the data were analyzed by descriptive and inferential statistics at
95% confidence level.
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37
CHAPTER FOUR
RESULTS
The socio-demographic characteristics of the study population
indicate that the average age of the patients was 32.1 + 4.7 years, range:
23-44 years. Most of the patients studied were married (98.6%) while the
remaining 1.4% were separated. Sixty eight women representing 95.8%
were of Christian religion and 70 (98.6%) of them were Igbos. It is note-
worthy that 49 (69.0%) of the patients studied had tertiary education.
Other details of the socio-demographic characteristics are shown in table 1.
During the study period, nine hundred and sixty four deliveries took
place out of which seventy one had one previous caesarean section. The
prevalence of patients with one previous caesarean section in this study is
therefore 13.6%.
The leading indications for the one previous caesarean section
amongst the study group were prolonged labour in 18 women representing
25.4%, preeclampsia 11 (15.5%) and failed induction and abnormal lie (7)
each representing (9.9%) as shown in table 2.
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38
Majority of the women, 64 (90.1%) preferred to have vaginal
delivery despite the one previous caesarean section. Only 7 (9.9%) of
them opted for repeat elective caesarean section as shown in table 3. With
regard to the planned mode of delivery determined by the Obstetrician,
38(53.5%) of the women were assessed to be suitable for vaginal birth,
33(46.5%) for repeat elective caesarean section (table 4). Out of this, 19
(50.0%) of the patients assessed suitable for vaginal birth eventually had
successful VBAC while the remaining 19 (50.0%) had failed VBAC and
were delivered by emergency caesarean section as illustrated in table 5.
The 7 (9.8%) women who had emergency caesarean section for other
obstetric indications were identified.
There was low rate of induction and augmentation of labour in the
study population. Only one patient (1.4%) had induction of labour while
3(4.2%) had augmentation of labour. Cervical ripening was by
intracervical Foley’s Cetheter and only Oxytocin infusion was used for
augmentation of labour. There were no fetal or maternal complications
among the few women who had induction or augmentation of labour.
The fetal and maternal outcome of the study population (tables 6 and
7) was generally good with no case of uterine rupture, neonatal or maternal
deaths recorded in any group. However Agpar Scores of less than 7 in the
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39
first minute was commoner amongst those with vaginal delivery when
compared to those with elective repeat caesarean section (6 vs 0) and the
difference is statistically significant (P = 0.03) as shown in table 9. Apgar
scores less than 7 in the first minute was more in those with failed VBAC
than vaginal delivery (successful VBAC) but the difference was not
statistically significant (P = 0.82) as in table 8. The 5th Minute Apgar
scores were mostly 7 and above in both categories of patients which
underscores the need for a neonatologist at delivery of women with
previous caesarean section.
The birth weight of 4.0kg or greater was more common in those with
elective repeat caesarean section than those who has VBAC (P = 0.221) as
shown in table 9. Among those allowed trial of labour, 6 (31.6%) of those
with failed VBAC had birth weight 4.0kg or greater compared to 0% of
those with successful VBAC (P = 0.03). This difference is statistically
significant (table 8).
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40
Table 1: Socio-demographic Characteristics of the Patients
Characteristics No Percentage
AGE (Years)
Less than 20
20 – 30
31 – 40
Greater than 40
-
31
36
4
-
43.7
50.7
5.6
MARITAL STATUS
Married
Separated
70
1
98.6
1.4
RELIGION
Christianity
Others
68
3
95.8
4.2
TRIBE
Ibo
Others
70
1
98.6
1.4
BOOKING STATUS
Booked
Unbooked
68
3
95.8
4.2
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PREVIOUS DELIVERIES
One (primiparous)
2 - 4
Greater than 4
30
35
6
42.3
49.3
8.4
LEVEL OF EDUCATION
Non-formal
Primary
Secondary
Tertiary
-
7
13
51
-
8.5
15.5
69.0
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Table 2:
Indication for the One Previous Caesarean Section
Indication Frequency Percent
Abnormal Line
Bad Obstetric history
Breech Presentation
Contracted/Inadequate pelvis
Cord Protapse
Failed Induction
Failed Vacuum
Fetal Distress
Fetal Macrosomia
Placenta Praevia
Preventing vertical transmission in HIV
Preeclampsia
Prolonged Labour
Twin Pregnancy
7
1
6
3
1
7
1
3
3
3
3
11
18
4
9.9
1.4
8.5
4.2
1.4
9.9
1.4
4.2
4.2
4.2
4.2
15.5
25.4
5.6
Total 71 100%
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43
Table 3:
Preferred Mode of Delivery by the Patients
Mode of Delivery Frequency Percent
Vaginal delivery
Caesarean Section
64
7
90.1
9.9
Total 71 100%
Table 4:
Planned Mode of Delivery (by the Obstetrician)
Mode of Delivery Frequency Percent
Vaginal birth after caesarean section
Elective Repeat caesarean section
38
33
53.5
46.5
Total 71 100%
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Table 5
Mode of Delivery of the Patients (n = 71)
Mode of Delivery Frequency Percent
Emergency repeat caesarean section
(for failed VBAC)
Emergency repeat caesarean (for other
Obstetric indications)
Elective repeat caesarean section
Vaginal birth after caesarean section
(successful VBAC)
19
7
26
19
26.8
9.8
36.6
26.8
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Table 6:
Fetal outcome from the various modes of delivery
Outcome
Vaginal
Birth
n = 19
Elective
repeat C/S
n = 26
Emergency C/S
(failed VBAC)
n = 19
Emergency C/S
(Other Obstetric
indication)
n = 7
Apgar Scores
At 1 Minute less than 7
At 5 minute less than 7
Apgar Scores:
At 1 Minute 7 and above
At 5 minute 7 and above
Neonatal death
Birth weight (kg):
Less than 2.5
2.6 – 3.9
4.0 and above
6
1
13
18
-
1
18
0
-
-
26
26
-
1
23
2
7
2
12
17
-
1
11
6
2
2
5
5
-
2
2
3
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Table 7:
Maternal outcome from the various modes of delivery
Outcome Complications Vaginal
Birth
n = 19
Elective
repeat C/S
n = 26
Emergency C/S
(failed VBAC)
n = 19
Emergency C/S
(Other Obstetric
indication)
n = 7
Good maternal outcome
(No complications)
Primary Postpartum
haemorrhage (1oPPA)
Secondary Postpartum
haemorrhage (2oPPH)
Puerperal Sepsis
Uterine rupture
Maternal death
18
1
-
-
-
-
24
2
-
-
-
-
16
3
0
-
-
-
7
0
-
-
-
-
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Table 8:
Comparison of Fetal Outcome in women who had vaginal birth and
Emergency caesarean section (failed VBAC)
Outcome
Vaginal
Birth
n = 19
Emergency
C/S
n = 19
X2
P Value
Apgar Scores
At 1 Minute less than 7
At 5 minute less than 7
At 1 Minute 7 and above
At 5 minute 7 and above
Neonatal death
Birth weight (kg):
Less than 2.5
2.6 – 3.9
4.0 and above
6
1
13
18
-
1
18
0
7
2
12
17
-
1
11
6
0.05
0.22
0.12
0.08
-
0.00
1.13
4.5
0.8208
0.6353
0.7276
0.7728
-
1.0
0.2870
0.0339
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Table 9:
Comparison of Fetal Outcome in women who had successful VBAC
and Elective repeat caesarean section
Outcome
Vaginal
Birth
n = 19
Elective repeat
C/S
n = 26
X2
P Value
Apgar Scores
At 1 Minute less than 7
At 5 minute less than 7
At 1 Minute 7 and above
At 5 minute 7 and above
Neonatal death
Birth weight (kg):
Less than 2.5
2.6 – 3.9
4.0 and above
6
1
13
18
-
1
18
0
0
0
26
26
-
1
23
2
4.5
0.75
4.85
1.98
-
0.00
0.41
1.5
0.0339
0.3665
0.0277
0.1590
-
1.00
0.5234
0.2207
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CHAPTER FIVE
DISCUSSION
Findings from this study indicate a high literacy level with majority
(69.0%) having tertiary education. This may be due to enhanced women
education over the years.
The prevalence of one previous caesarean section of 13.6% in this
study is higher but comparable to the 11.9% documented in a similar study
in a Private hospital in Lagos Nigeria.24 This marginally higher prevalence
may be due to the fact that high risk cases including previous caesarean
section are referred to and managed in our teaching hospital. The leading
indications for the one previous caesarean section in the study group were
prolonged labour and preeclampsia. This is different from the overall
leading indication for caesarean section in the hospital which is two or
more previous caesarean section.14
The clear preference for vaginal delivery among the subjects was
expected due to cultural aversion for caesarean delivery. There was 9.9%
of the women who chose repeat caesarean section.
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50
A previous study in this hospital twenty two years ago found a
hundred percent preference for vaginal delivery.10 This suggests enhanced
acceptance of caesarean section as a route of delivery among women with
previous caesarean section. The 9.9% preference for caesarean delivery in
this investigation is in contrast to 40% preference for repeat elective
caesarean section recorded among women with previous caesarean section
in an American study.31
Thirty eight (53.5%) of the patients were allowed to attempt vaginal
delivery. This percentage is high when compared to the figure of less than
10% of women which was recorded in a similar study in Enugu in 1989.26
Our results are similar to the reports from Benin but much lower than the
70.7% who were allowed VBAC in a recent similar study in Lagos.24,25
The lower proportion of women allowed VBAC in this study when
compared to other reports may be due to a combination of reasons.
Medico-legal concerns related to the responsibility of monitoring high risk
labour after a previous caesarean section may be a factor. Moreover, the
necessary conditions including personnel especially anaesthetists,
neonatologist and facilities for emergency caesarean section such as blood
for transfusion may not always be available. The reported decision
delivery interval of 4 hours for emergency caesarean section in our hospital
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51
tends to justify this concern.14 Furthermore, the unavailability of
electronic fetal monitoring facilities in the labour ward and the relocation
of the hospital to its permanent site about 21km from the city where the
senior obstetricians live may contribute. All these may explain why only
about half of the women with one previous caesarean section are allowed
to attempt VBAC despite high caesarean section rate in the hospital.
Out of those allowed attempt at VBAC 19 women (50.0%) achieved
successful vaginal birth while 19 women (50.0%) had failed trial of
VBAC. This finding is higher than the 34% success rate recorded in
Pakistan and Benin Nigeria23, 25 but much lower than the more recent
studies from Ibadan and Lagos that reported successful vaginal deliveries
in the ranges of 70-80%22,24. These higher rates are similar to other
reports from the developed world and a previous report from Enugu8,10.
The lower success rate of VBAC in this study may be due to early and
abrupt recourse to emergency caesarean section occasioned by medico-
legal concern in the face of sub-optimal facilities for intra-partum care.
For instance only a single patient had induction of labour and 3 had
augmentation of labour, all with good outcome. It is possible that more
liberal application of induction and augmentation of labour when indicated
may have increased the rate of successful VBAC in our hospital. A larger
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52
study involving other tertiary hospitals in the region may establish the
overall picture.
A good fetal and maternal outcome of labour was recorded in this
study with no case of uterine rupture, perinatal or maternal death. Previous
studies from Nigeria had recorded 1-5 cases of uterine rupture and 0-
3cases of neonatal death with no maternal death but with higher rates of
successful VBAC.10,24 It remains a challenge to strike a balance between
concern for safety and the need to decrease caesarean section rates.
Findings from this study indicate that in the absence of optimal facilities
most obstetricians are guided by concern for safety, hence only about half
of women with a previous caesarean were allowed attempt at VBAC. This
is in sharp contrast to the new and less restrictive guidelines issued in
August 2010 by American College of Obstetricians and Gynecologists
(ACOG)44. In the revised document ACOG recommended that trial of
labour after previous caesarean delivery (TOLAC) is safe and appropriate
for most women with previous caesarean delivery including women with 2
previous lower segment transverse incisions, twin pregnancy and those
with unknown type of scar. This recommendation may not affect practice
in our environment unless there is improvement in our intrapartum care in
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53
terms of personnel and facilities and our capacity to carry out a timely
emergency caesarean section is guaranteed.
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CHAPTER SIX
CONCLUSIONS AND RECOMMENDATION
The data from this study suggest we are not yet allowing enough
women with one previous caesarean section trial of vaginal delivery. The
rate of induction and augmentation amongst women with one previous
caesarean section is very low and may be contributing to unnecessary
caesarean section.
The fetal and maternal outcome of labour in women with one
previous caesarean section is good and comparable to that of repeat
elective caesarean section.
It is therefore recommended that obstetricians should be more liberal
in allowing trial of vaginal delivery with application of
induction/augmentation (with Oxytocin) as appropriate in women with one
previous caesarean section. This will decrease caesarean section rate
without compromising on safety.
There should be improvement in our intrapatum facilities and
personnel including electronic fetal monitory facilities in labour ward and
reliable blood banking services.
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55
Residential quarters should be provided for Doctors in the new site
of the UNTH at Ituku Ozalla, to enhance availability of senior obstetricians
at emergency.
A larger multicentre study on VBAC may be necessary in our
country to compare outcome and experiences and possibly modify practice
in the wake of the current more liberal guidelines by many other nations
and colleges.
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2. Flamm BL, Newman LA, Thomas St. Fallon D, Yosida MM.
Vaginal Birth after Caesarean Delivery: Result of a 5 year-old
multicenter collaborative study, Obstet Gynecol 1990, 76:750-4.
3. Miker DA, Diaz FG, Paul RH. Vaginal birth after Caesarean: a 10-
year experience. Obstet Gynecol 1994; 84:255-8.
4. Ainbinder SW. Operative Delivery in: Current Obstetric and
Gynaecologic diagnosis and treatment 9th edition. De Cherny AH,
Nathan L (eds) USA: McGraw Hill Companies Inc. 2003; 499-530.
5. Onah HE. Formal education does not improve the acceptance of
caesarean section among pregnant Nigerian women. Int J Gynecol
Obstet, 2002; 76:321-323.
6. Hibbard JU, Ismail MA, Wang Y. Te C, Karrison T. Failed Vaginal
Birth After Caesarean Section: how risky? 1 Maternal Morbidity.
Am J Obstet Gynecol 2001; 184:1365-71.
7. Chauhan SP, Martin J Jr, Henrich Ce Morrison JC, Magann EF.
Maternal and perinatal complications with uterine rupture in 142,
075 patient who attempted vaginal birth after caesarean birth: a
review of literature. Am J Obstet Gynecol 2003; 189:408-17.
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8. Omigbodun AO. Vaginal Birth after Caesarean Section in:
Comprehensive Obstetrics in the Tropics. Kwawukume EY,
Emuveyan EE (eds) Asante & Hittscher Printing Ltd. 2002, 122-
128.
9. Weinstein D, Benshushan A, Tonos V, Zilberstain R, Rojansky N.
Predictive score for vaginal birth after caesarean section. Am J
Obstet Gynecol 1996, 174:192-198.
10. Egwuatu VE, Ezeh IOU. Vaginal delivery in Nigerian women after
a previous caesarean section. Int. J Gynecol Obstet; 1990, 31:1-4.
11. 2006 compendium of selected publications. ACOG Practice
bulletins, number 57, 2004, 1015-1023.
12. Iloabachie GC, Meniru GI. Trends in Caesarean Section. Nig J
Surg Sci, 1992; 2:75-81.
13. Okonofua FE, Makinde OO, Aynagade SO. Yearly trends in a
caesarean section and caesarean mortality at Ile-Ife. Trop J Obstet
Gynaecol, 1988, SE I: 31-35.
14. Nkwo PO, Onah HE, Feasibility of reducing the caesarean section
rate at the University of Nigeria Teaching Hospital, Enugu Nigeria.
Trop J Obstet Gynaecol, 2002; 19 (2): 86-89.
15. Editorial by Resnick Obstet Gynecol 2006, 107:752-4.
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16. Kieser KE, Basekette TF. A 10-year population based study of
uterine rupture. Obstet Gynecol 2002; 100: 749-53.
17. Kerr JMM. The technic of cesarean section, with special reference
to the lower uterine segment incision. Am J Obstet Gynecol 1926;
12: 729-34.
18. Merill BS, Gibbs CE: Planned Vaginal Delivery following caesarean
section. Obstet Gynecol 1978; 52:50.
19. Caughey AB, Spandorfer SD Vaginal birth after caesarean delivery,
e Medicine Updated 2008.
20. NHS 2001 Maternity Statistics 1995/1996 – 1997/1998.
Government Statistical Service London, NHS.
21. Benhow ASD, Meresh M. Effective procedures in maternity care
suitable for audit 1997, London Royal College of Obstetricians and
Gynecologists.
22. Ilesanmi AO, Odukogbe A, Olaleye DO: Vaginal delivery after one
caesarean section in Nigeria women. Journal of Obstetrics and
Gynaecology, 1997; 17(2): 139-142.
23. Nisa M, Hassan L. Trends of Vaginal delivery after one previous
caesarean section in a tertiary care hospital. Parkistan J Med Res,
2004; 43 (2).
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24. Ezechi OC, Kalu EE, Njokanma FO, Ndububa CA, Nwokoro CA,
Okeke GCE Trial of labour after a previous caesarean delivery: A
private hospital experience. Annals of African Medicine 2005; 4(3):
113-117.
25. Okpere EE, Oronsanye AV, Imoedmhe DAG Pregnancy and
delivery after caesarean section: a review of 494 cases. Trop J
Obstet Gynaecol 1981; 3:45-48.
26. Iloabachie GC, Delivery after a previous caesarean section: a review
of 836 cases. Trop J Obstet Gynaecol, 1989; 7:9-10.
27. Society of Obstetricians and Gynaecologists of Canada (SOGC)
clinical practice guidelines, No 155, 2005.
28. Royal College of Obstetricians and Gynaecologists (RCOG)
guidelines, No. 45, 2007.
29. Hashima JN, Eden KB, Oseterwell P, predicting Vaginal Birth after
Caesarean Delivery: A review of Prognostic factors and screening
tools. Am J Obstet Gynecol 2004; 190:547.
30. Guise JM, Berlin M, MC Donagh M, Safety of Vaginal Birth after
Caesarean: A systemic review, Obstet Gynecol 2004, 103:420.
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31. Abitbol MM, Castillo I, Taylor UB, Vaginal Birth after caesarean
section: The patient’s point of view. Am Fam Physician 1993;
47:129.
32. Murphy DJ, Liebling LE Cohort: Study of maternal view on future
mode of delivery after operative delivery in second stage of labour.
Am J Obstet Gynecol 2003; 188 (2): 542-8.
33. Rozenbery P, Goffinet F, Phillippe HJ, Nisand I: Ultrasonographic
measurement of lower uterine segment to assess risk of defects of
scared uterus Lancet, 1996; 347:281-284.
34. Zelop CM, Shipp TD, Repke JT: Uterine rupture during induced or
augmented labour in gravid women with one prior caesarean
delivery. Am J Obstet Gynecol 1999, 181:882.
35. Flamm BL: Vaginal Birth after Caesarean (VBAC) Bailliere’s Best
Pract Rest Clin Obstet Gynecol 2001, 15:81-92.
36. Rovasia DJ, Wood SL, Polland JK Uterine rupture during induced
trial of labour among women with previous caesarean delivery. Am
J Obstet Gynecol 2000, 183:1176.
37. Wing DA, Lovett K, Paul RH: Disruption of prior uterine incision
following misoprostol for labour induction in women with previous
caesarean delivery. Obstet Gynecol, 1998; 91:828-830.
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38. Oladipo A, Syed A; The views of Obstetricians in South West of
England on the use of Prostaglandins and syntocinon in VBAC
Journal of Obstetrics and Gynaecology, 2008, 28: (2) 177-182.
39. Obed JY, Omigbodun AO, Retained Placenta in Patients with
Uterine Scars Nig Med Pract, 1995, 30:36-38.
40. Bujold E, Mehta SH, Bujold C, Gauther RJ. Interdelivery interval
and Uterine rupture. Am J Obstet Gynecol 2002; 187:1199-1202.
41. Mozurkenich EL, Hutton EK, Elective repeat caesarean versus trial
of labour: a meta-analysis of the literature from 1989 to 1999. Am J
Obstet Gynecol 2000; 183:1187-1197.
42. Vamed Engineering Nig. Ltd. Nigerian Teaching Hospitals – A
Federal Government Healthcare Project. Vamed Newsletter: 2007.
43. Enugu State of Nigeria. Available at: hppt//www.ebeano.org/
enugustate2007.
44. American College of Obstetricians and Gynecologists (ACOG)
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APPENDIX 2
INFORMED CONSENT
I humbly request for your consent to participate in a research being carried
out in this hospital to evaluate the Outcome of Vaginal Birth after one
previous caesarean section (VBAC).
A questionnaire will be administered to you during the course of the study
and it will be seeking information on your personal data (names are
optional). Relevant information concerning the current pregnancy, labour
and delivery will be obtained from you.
All information received from your kind person as well as the result of
your investigations will be treated with utmost confidentiality, and with
due regards to the ethical guidelines for conducting medical research.
Thanks for your cooperation.
Dr. Ugwu George O. Department of Obstetrics and Gynaecology
University of Nigeria Teaching Hospital (UNTH), Enugu.
I ………………………..……………………. having read and understood
the above request, hereby consent to participate in the research study.
Signature ……………………….
Date …………………………….
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APPENDIX 3
QUESTIONNAIRE
Dear Madam,
You have been selected to be part of a research in this hospital on
the Outcome of Vaginal birth after One Previous Caesarean Section. The
information you give us will be treated with utmost confidentiality and
used for research purpose only. Your consent and co-operation will be
most appreciated. Thank you.
SECTION ONE:
1. Name/Initials (optional) __________________________________
2. Age in years (as at last birthday) ___________________________
3. Antenatal No. _______________ Hospital No. ________________
4. Marital Status:
(a) Married (b) Single (c) Widowed (d) Divorced
5. Religion/Denomination __________________________________
6. Tribe _________________________________________________
7. Highest level of education:
(a) Non-formal (b) Primary (c) Secondary (d) Tertiary
8. Parity ________________________________________________
9. Booking Status: (a) Booked (b) Unbooked
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65
10. History of previous uterine surgery/evacuation of uterus
______________________________________________________
11. Contact Address/Phone No. _______________________________
12. You had a previous caesarean section, what was the indication?
______________________________________________________
13. What is your preferred mode of delivery in this pregnancy?
(a) Vaginal delivery
(b) Caesarean Section
(c) I don’t know
14. What is the planned mode of delivery (with your Doctor) in this
pregnancy?
(a) Vaginal birth after caesarean section
(b) Repeat Caesarean Section
(c) Not yet decided
15. If labour was allowed or has commenced, how long did it last (in
hours) ________________________________________________
16. Was the labour induced? (a) No (b) Yes
If yes, with what? _______________________________________
17. Was the labour augmented? (a) No (b) Yes
If yes, with what? _______________________________________
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SECTION TWO: FOR RESEARCHER ONLY
1. Mode of delivery
(a) Emergency repeat C/S (for failed VBAC)
(b) Emergency repeat C/S (for other obstetric indications)
(c) Elective repeat C/S
(d) Vaginal delivery (VBAC)
2. Fetal Outcome:
Apgar Scores (1st & 5th Minutes): _____________________
Birth weight/Sex __________________________________
3. Complications:
(a) No complications (good maternal outcome)
(b) Primary post partum haemorrhage (10 PPH)
(c) Secondary post partum haemorrhage (20 PPH)
(d) Puerperal Sepsis
(e) Uterine rupture
(f) Maternal death
(g) Others (specify) __________________________________
