211
Int. J. Gynecol. Obstet., 1991, 34: 211-215 International Federation of Gynecology and Obstetrics
Vaginal birth after cesarean section in rural Tanzania J. van Roosmalen Department
of Obstetrics
and Gynaecology,
Leiden State University
Hospital,
P.O. Box 9600, 2300 RC LAden (The Netherlands)
(Received November 2nd, 1989) (Revised and accepted December 20th, 1989)
Abstract
Eighty-seven of 134 women with a history of previous cesarean section in two rural hospitals in Tanzania had a vaginal delivery after a trial of labor. The incidence of scar-rupture was high; in 9 of 134 cases (6.7%). Maternal death, however, dia’not occur. It is concluded that a trial of labor is justified, and that the risk of scarrupture should be balanced with the risk of repeat operations.
reports from Western Europe. In two recent studies in The Netherlands, for instance, three out of four women with a previous operation were allowed a trial of labor [9,17]. An important factor which contributed to the rise of cesarean births, is the relative safety of the operation for the mother, although maternal morbidity after cesarean section is much higher than after vaginal delivery. Maternal mortality after cesarean section in the United States is reported to be as low as 0.02-0.07%
VIKeywords: Cesarean section; Previous cesarean
section; Trial of labor; Uterine scar rupture; Tanzania. Introduction
Cesarean section has become the most frequently performed major operation in the United States, and an elective repeat-operation is the most common indication for cesarean section [4]. This largely results from adhering to Craigin’s dictum: “Once a cesarean section, always a cesarean section” [3]. Although reports have been published which advocate this policy to be abandoned [4,13], only 8% of all women with a history of a previous cesarean section in America were allowed a trial of labor in 1984 [18]. This is in sharp contrast with 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Maternal mortality after cesarean section in African countries, especially in rural hospitals where most cesareans are performed by generalist doctors or even by medical auxiliaries, is high with a range of 0.6-5.0% in a recent review [16]. Maternal mortality studies from Africa often do not refer specifically to this point [6,11]. In this article, data are presented on the outcome of labor in women with a history of a previous cesarean section. The issue whether a trial of labor is justified in the circumstances of rural hospitals in African countries, will be addressed. Materials and methods
All 134 women with a history of a previous cesarean section, who delivered in two rural Clinical and Clinical Research
212
van Roosmalen
hospitals in the South Western Highlands of Tanzania between June 1976 and May 1983, are included in the study. This group consisted of 1.8% of all 7511 women who delivered in the two hospitals during the study period. The characteristics of both hospitals have been described in detail elsewhere [ 161. Data on maternal and perinatal outcome were related to the indication of the previous cesarean section, a history of a previous vaginal delivery and the number of previous operations. Differences between groups were statistically tested using the chi-square test at a 5% level. Generally, cesarean section was only performed after the onset of labor. In women needing a repeat operation, this was done to prevent iatrogenic preterm birth as the exact dates were frequently unknown. This policy also better fitted in the sociocultural setting of a rural community. Rl?SUltS Eighty-seven of 134 women (65%) had a vaginal delivery after a previous cesarean section (Table I). There were five scar-ruptures (5.7%), but no maternal deaths occurred. Two of the five newborns of women with scar-
Table I.
Mode of delivery in women with a previous cesarean birth.
Mode of delivery
V&d
rupture survived. Spontaneous vertex delivery (SVD) occurred in 52 women with good results (mean birthweight 2840 g). Delivery by vacuum extraction (VE) in 27 women was related to a significantly higher mean birthweight (3205 g). Repeat cesarean section was performed in 43 women (32%). In only 8 of these women, was the reason for repeat operation not CPD/FTP. Placenta previa (2), breech position (3) and transverse lie (3) were the indications for these repeat operations. There was no maternal death, but in three women serious complications occurred, which resulted in “near-deaths”. There were a further four abdominal deliveries for ruptured scars (3%). In two of these four cases a breech presentation was accepted for vaginal delivery. During these labors, signs of uterine rupture and secondary fetal death prompted emergency abdominal delivery. The lowest rate of vaginal delivery was observed in those women who had undergone either a previous cesarean birth for CPD (44%) or more than one previous operation (30%). Nonrecurrent indications were mainly transverse lie and placenta previa: 82% of those women had a vaginal delivery. Not surprisingly, in 25 women the indication for the previous operation was unknown: these women behav-
Number (%)
Scar-rupture
Perinatal mortality on admission alive + dead = total
52 (39) 27 (20) 4 (3) 4 (3)
2 0 2 1
Id 0 1 0
43 (32)
0
1 +0=1/43
4 (3)
4
2 + 2 = 414
delivery
Spontaneous vertexs Vacuum extractionb Breech delivery Destructive operation
+ 1 = z54 + 1 = l/27 +0=1/5 + 4 = 414
Abdominal delivery
Repeat CS’ (3 breech incl.) Laparotomy scar-rupture (2 breech incl.) BMean birthweight: 2840 g (SD 560). bMean birthweight: 3205 g (SD 410). cMean birthweight: 2914 g (SD 455). dPreterm birth of 1160 g. Inr J Gynecol Obsrel 34
Vaginal birth after cesarean section
Ta& II. Outcome of labor in women with previous cesarean birth in relation to the indication of previous operation, a history of previous vaginal delivery and the number of previous operations. Outcome of index labor (%) Vaginal delivery Illdkatlon
Table III. Perinatal mortality and scar-rupture in women with a previous cesarean birth in relation to the indication of the previous operation, a history of previous vaginal delivery and the number of previous operations. Chi-square: no statistically significant differences. Outcome of index labor (%)
Abdominal delivery
Perinatal mortality
previous cesuean seetlon~
CPD Nonrecurrent indication Unknown indication
213
28 (44) 31 (82) 22 (88)
36 (56) 8 (18) 3 (12)
hdlcdon prevhs eesarean seetloo CPD (n = 64) 9 (14) Nonrecurrent (II = 45) 4 (9) Unknown (a = 25) 0
23 (53) 64 (70)
20 (47) 27 (30)
Previous v8gld
81 (71)
33 (29)
6 (30)
14 (70)
No. of prwiom operatiom One previous cesarean section (n = 114) More than one previous operation (n = 20)
Scar-rupture
5 (8) 4 (9) 0
F%ViOUSV8gfdbid
No previous vaginal birth Previous vaginal birth No. of previous cesue8ndC One previous cesarean section More than one previous operation
=QLqtare: 24.36; df = 2; P < 0.001. bChi-square: 3.64; df = 1; P = 0.06 (ns). cChi-square: 12.59; df = 1; P < 0.001. Included in the group of more than one operation: three women with one previous cesaman birth and one previous symphyseotomy and two women with one previous cesarean birth and one previous scar-rupture.
ed like the group with a nonrecurrent indication and 88% delivered vaginally (Table II). The rate of vaginal birth in women who had previously only experienced a cesarean section, but never a vaginal delivery was 53%. This increased to 70% in women who had a previous vaginal delivery. This trend, however, was not statistically significant (Table II). There were no significant differences in perinatal mortality and in the incidence of scarrupture between (Table III): (1) groups with different indications for the previous cesarean birth; (2) women who had experienced prior vaginal delivery and those who had not; (3) women with a different number of previous cesarean sections.
hlrth
No (n = 43) Yes (n = 91)
3 (7) 10 (11)
2 (5) 7 (8)
10 (9)
8 (7)
3 (14)
1 (5)
cases, rupture had already occurred before admission to hospital; another two occurred when vaginal delivery was deliberately aimed at, after the fetus had died due to cord prolapse. In eight cases of uterine scar-rupture hysterorraphy was performed by continuous one layer suturing of the uterine rupture, often the quickest possible operation to achieve hemostasis and thereby controlling shock [7]. One woman needed hysterectomy because of severe extension of the tear. In four women, tubal ligation was performed additionally. In the other four, cultural reasons (the women only having one or even no children) prevented this. There were no maternal deaths related to uterine scar-rupture. This was in contrast with the high maternal death rate after spontaneous uterine rupture: live maternal deaths took place in 21 such cases (24%) during the study period 1161. Discussion
Scar-rupture
Uterine scar-rupture occurred with a high frequency in 9 of 134 women (6.7%). In three
A rate of 65% vaginal deliveries after a previous cesarean birth compares favorably Clinical and Clinical Research
214
van Roosmalen
Talk IV. Maternal outcome of labor in women with a previous cesarean birth in different regions of the world. Scarrupture (%)
Region
Women with previous cesarean section
Repeat cesarean birth (%)
United States of America Europe Africa Asia
3603
1930 (54)
17 (0.5)
9827 7018 1759
4981 (51) 3740 (53) 809 (46)
77 (0.8) 271 (3.9) 64 (3.6)
Source: Van Roosmalen [ 161.
with rates reported from all over the world (Table IV). Especially when the presentation was vertex (79 women), results were good with no maternal and perinatal deaths attributable to the trial of labor in hospital. In the small group with breech presentation (9 women), however, results were disastrous: four scar-ruptures occurred in hospital and three perinatal deaths were attributable to this complication. One may question the acceptance of these cases for a trial of vaginal delivery. Had these nine breech infants been delivered by repeat operation, the vaginal delivery rate would have been lowered from 65 to 62%, while the perinatal mortality would probably have been much less and the incidence of scarrupture halved in the whole series of 134 women with a previous cesarean birth. Scar-rupture
Uterine scar-rupture occurred with a high frequency (6.7%). This was the most striking difference between the series reported from Western and from African and Asian countries (Table IV). The observed difference may be related to the different circumstances in Africa, preventing women with a history of a previous cesarean birth reporting to hospital early in labor. In Zaria (Nigeria), 24% of women with a previous cesarean birth were unbooked emergency admissions in a subsequent labor [5]. In Machakos (Kenya), 86% of these women inIn1 J Gynecol Obster 34
tended to deliver in hospital; only 73% actually did so [19]. A higher frequency of scar-rupture in African than in industrialized societies is not necessarily an argument against a trial of labor. It stresses the point, however, that one should be very careful in taking the decision whether to perform the first cesarean section or not and it may be put forward as a reason to practice alternative methods like symphyseotomy [ 151. It is clear from the above, that Craigin’s dictum “once a cesarean, always a cesarean” is outdated. The dictum could be changed into “once a cesarean, always hospital delivery”. “Twice a cesarean” is often followed by repeat operation, although some authors even question this rationale [2]. Criteria for allowing a trial of labor after a prior cesarean birth have become more liberal at present. In earlier times, women with an unknown type of cesarean section scar, and with febrile or septic morbidity after the previous operation were generally excluded from a trial and exposed to elective repeat section. Applying similar criteria to a population in rural hospitals in African countries, would considerably reduce the number of vaginal deliveries after a previous operation as often the type of uterine scar is unknown, cephalopelvic disproportion (CPD) has a high prevalence and the postoperative course has often been febrile with septic complications. Allowing a trial of labor is only safe in circumstances with suitable facilities to perform a repeat operation instantly should complications arise. Breech presentation may be such a complication. The incidence of scar-rupture should be balanced against the risk of repeat cesarean birth. When repeat cesarean sections would be performed as a routine, a low rate of complications after so many operations could well produce overall results which are not better than those obtained with a high rate of complications after scar-rupture in few women. The total number of complications could well be higher with so many repeat operations [lo].
Vaginal birth after cesarean section
The significantly higher vaginal birth rate when the indication for the previous operation was a nonrecurrent one, is in agreement with most studies in the literature [8,12]. Yet, almost half of women with a prior operation for a recurrent reason, i.e. CPD, delivered vaginally. One may assume that at least some cases of diagnosed CPD were in fact labors with inefficient uterine action, and this is especially so when oxytocin is not used to augment prolonged labor in primigravidae. The risk of scar-rupture and perinatal death did not significantly alter for different indications of previous cesarean birth. Neither did it relate to the presence or absence of a previous vaginal birth in the obstetric history. These facts endorse the dictum “once a cesarean, always hospital delivery”. This was contrary to what rural health workers in Tanzania thought: 26 of 49 did not consider a woman with one previous cesarean birth and four normal deliveries thereafter to be at risk [ 141. This indicates the need for close supervision of these workers, who are the first to meet women with a previous cesarean birth in their rural antenatal clinics. Given the evidence provided in this article, we conclude that a trial of labor in hospital is justified in most women with a history of a previous cesarean birth.
Bottoms SF. Rosen MG. Sokol RJ: The increase in the caesarean birth rate. N Engl J Med 302: 559, 1980. Camilleri AP, Busutttil T: “Twice a Caesarean ...“. J Obstet Gynaecol Br Commonw 75: 1305, 1968. Craigin
5
Harrison KA. Rossiter CE, Chong H et al: Antenatal care, formal education and childbearing. Br J Obstet Gynaecol suppr 5: 14, 1985.
6
Harrison KA. Rossiter CE: Maternal mortality. Br J Obstet Gynaecol Suppl5: 100, 1985. Haspels AA: Uterine rupture in central Java. Thesis, Amsterdam, 1961.
7 8 9
10
11 12
13 14
15 16 17
I8
19
References
EB: Conservatism
in obstetrics.
215
Horowitz BJ, Edelstein SW, always a cesarean. Obstet Jansen FW, Van Roosmalen Gravenhorst J: Vaginal birth
Lippman L: Once a cesarean Gynecol Surv 36: 592, 1981. J, Keirse MJNC. Bennebroek after caesarean section. Ned
Tijdschr Geneeskd 133: 666, 1989. Kirchhoff H: Birgt die berechtigte lntensivierung der prospektiven Geburtsleitung zum Nutzen des Kindes fur die Mutter eine erhohte Gefahr? Fruh-und Spatkomplikationen nach Kaiserschnittoperationen. Geburtsh Frauenheilk 37: 103. 1977. Kwast BE: Maternal mortality in Addis Ababa, Ethiopia. Thesis, Wales, 1985. Lavin JP. Stephens RJ, Miodovnik M, Barden TP: Vaginal delivery in patients with a prior cesarean section. Obstet Gynecol 59: 135. 1982. Phelan JP, Clark SL, Diaz F, Paul EN: Vaginal birth after cesarean. Am J Obstet Gynecol 157: 1510, 1987. Roosmalen J van, Roosmalen-Wiebenga MW van: Effectiveness of seminars in training rural health workers. Trop Dot 16: 90, 1986. Van Roosmalen J: Symphyseotomy as an alternative to cesarean section. Int J Gynecol Obstet 25: 451, 1987. Van Roosmalen J: Maternal health care in the South Western Highlands of Tanzania. PhD Thesis, Leiden, 1988. Roumen FJME, Janssen AAJM, Vrouenraets FPJM: Outcome of delivery after previous cesarean section. Ned Tijdschr Geneeskd 133: 672, 1989. Shiono PH, Fielden JG, McNellis D, Rhoads GG, Pearse WH: Recent trends in cesarean birth and trial of labor rates in the United States. J Am Med Assoc 257: 494, 1987. Voorhoeve AM, Kars C, Ginneken JK van: Modern and traditional antenatal and delivery care. In: Maternal and Child Health in Rural Kenya, an Epidemiological Study (eds JK van Ginneken, AS Muller) pp 309-322. Croom Helm. Kent,
1984.
Address for reprints:
NY Med J 104: I.
1916. Flamm BL. Lim OW, Jones C, Fallon D, Newman LA, Mantis JK: Vaginal birth after cesarean section: results of a multicenter study. Am J Obstet Gynecol 158; 1079, 1988.
J. van Roosmnlen Bloemendanlseweg 244, 2051 GN Overveen, The Netherlands
Clinical and Clinical Research
Int. J. Gynecol. Obstet., 1991, 34: 211-215 International Federation of Gynecology and Obstetrics
Vaginal birth after cesarean section in rural Tanzania J. van Roosmalen Department
of Obstetrics
and Gynaecology,
Leiden State University
Hospital,
P.O. Box 9600, 2300 RC LAden (The Netherlands)
(Received November 2nd, 1989) (Revised and accepted December 20th, 1989)
Abstract
Eighty-seven of 134 women with a history of previous cesarean section in two rural hospitals in Tanzania had a vaginal delivery after a trial of labor. The incidence of scar-rupture was high; in 9 of 134 cases (6.7%). Maternal death, however, dia’not occur. It is concluded that a trial of labor is justified, and that the risk of scarrupture should be balanced with the risk of repeat operations.
reports from Western Europe. In two recent studies in The Netherlands, for instance, three out of four women with a previous operation were allowed a trial of labor [9,17]. An important factor which contributed to the rise of cesarean births, is the relative safety of the operation for the mother, although maternal morbidity after cesarean section is much higher than after vaginal delivery. Maternal mortality after cesarean section in the United States is reported to be as low as 0.02-0.07%
VIKeywords: Cesarean section; Previous cesarean
section; Trial of labor; Uterine scar rupture; Tanzania. Introduction
Cesarean section has become the most frequently performed major operation in the United States, and an elective repeat-operation is the most common indication for cesarean section [4]. This largely results from adhering to Craigin’s dictum: “Once a cesarean section, always a cesarean section” [3]. Although reports have been published which advocate this policy to be abandoned [4,13], only 8% of all women with a history of a previous cesarean section in America were allowed a trial of labor in 1984 [18]. This is in sharp contrast with 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Maternal mortality after cesarean section in African countries, especially in rural hospitals where most cesareans are performed by generalist doctors or even by medical auxiliaries, is high with a range of 0.6-5.0% in a recent review [16]. Maternal mortality studies from Africa often do not refer specifically to this point [6,11]. In this article, data are presented on the outcome of labor in women with a history of a previous cesarean section. The issue whether a trial of labor is justified in the circumstances of rural hospitals in African countries, will be addressed. Materials and methods
All 134 women with a history of a previous cesarean section, who delivered in two rural Clinical and Clinical Research
212
van Roosmalen
hospitals in the South Western Highlands of Tanzania between June 1976 and May 1983, are included in the study. This group consisted of 1.8% of all 7511 women who delivered in the two hospitals during the study period. The characteristics of both hospitals have been described in detail elsewhere [ 161. Data on maternal and perinatal outcome were related to the indication of the previous cesarean section, a history of a previous vaginal delivery and the number of previous operations. Differences between groups were statistically tested using the chi-square test at a 5% level. Generally, cesarean section was only performed after the onset of labor. In women needing a repeat operation, this was done to prevent iatrogenic preterm birth as the exact dates were frequently unknown. This policy also better fitted in the sociocultural setting of a rural community. Rl?SUltS Eighty-seven of 134 women (65%) had a vaginal delivery after a previous cesarean section (Table I). There were five scar-ruptures (5.7%), but no maternal deaths occurred. Two of the five newborns of women with scar-
Table I.
Mode of delivery in women with a previous cesarean birth.
Mode of delivery
V&d
rupture survived. Spontaneous vertex delivery (SVD) occurred in 52 women with good results (mean birthweight 2840 g). Delivery by vacuum extraction (VE) in 27 women was related to a significantly higher mean birthweight (3205 g). Repeat cesarean section was performed in 43 women (32%). In only 8 of these women, was the reason for repeat operation not CPD/FTP. Placenta previa (2), breech position (3) and transverse lie (3) were the indications for these repeat operations. There was no maternal death, but in three women serious complications occurred, which resulted in “near-deaths”. There were a further four abdominal deliveries for ruptured scars (3%). In two of these four cases a breech presentation was accepted for vaginal delivery. During these labors, signs of uterine rupture and secondary fetal death prompted emergency abdominal delivery. The lowest rate of vaginal delivery was observed in those women who had undergone either a previous cesarean birth for CPD (44%) or more than one previous operation (30%). Nonrecurrent indications were mainly transverse lie and placenta previa: 82% of those women had a vaginal delivery. Not surprisingly, in 25 women the indication for the previous operation was unknown: these women behav-
Number (%)
Scar-rupture
Perinatal mortality on admission alive + dead = total
52 (39) 27 (20) 4 (3) 4 (3)
2 0 2 1
Id 0 1 0
43 (32)
0
1 +0=1/43
4 (3)
4
2 + 2 = 414
delivery
Spontaneous vertexs Vacuum extractionb Breech delivery Destructive operation
+ 1 = z54 + 1 = l/27 +0=1/5 + 4 = 414
Abdominal delivery
Repeat CS’ (3 breech incl.) Laparotomy scar-rupture (2 breech incl.) BMean birthweight: 2840 g (SD 560). bMean birthweight: 3205 g (SD 410). cMean birthweight: 2914 g (SD 455). dPreterm birth of 1160 g. Inr J Gynecol Obsrel 34
Vaginal birth after cesarean section
Ta& II. Outcome of labor in women with previous cesarean birth in relation to the indication of previous operation, a history of previous vaginal delivery and the number of previous operations. Outcome of index labor (%) Vaginal delivery Illdkatlon
Table III. Perinatal mortality and scar-rupture in women with a previous cesarean birth in relation to the indication of the previous operation, a history of previous vaginal delivery and the number of previous operations. Chi-square: no statistically significant differences. Outcome of index labor (%)
Abdominal delivery
Perinatal mortality
previous cesuean seetlon~
CPD Nonrecurrent indication Unknown indication
213
28 (44) 31 (82) 22 (88)
36 (56) 8 (18) 3 (12)
hdlcdon prevhs eesarean seetloo CPD (n = 64) 9 (14) Nonrecurrent (II = 45) 4 (9) Unknown (a = 25) 0
23 (53) 64 (70)
20 (47) 27 (30)
Previous v8gld
81 (71)
33 (29)
6 (30)
14 (70)
No. of prwiom operatiom One previous cesarean section (n = 114) More than one previous operation (n = 20)
Scar-rupture
5 (8) 4 (9) 0
F%ViOUSV8gfdbid
No previous vaginal birth Previous vaginal birth No. of previous cesue8ndC One previous cesarean section More than one previous operation
=QLqtare: 24.36; df = 2; P < 0.001. bChi-square: 3.64; df = 1; P = 0.06 (ns). cChi-square: 12.59; df = 1; P < 0.001. Included in the group of more than one operation: three women with one previous cesaman birth and one previous symphyseotomy and two women with one previous cesarean birth and one previous scar-rupture.
ed like the group with a nonrecurrent indication and 88% delivered vaginally (Table II). The rate of vaginal birth in women who had previously only experienced a cesarean section, but never a vaginal delivery was 53%. This increased to 70% in women who had a previous vaginal delivery. This trend, however, was not statistically significant (Table II). There were no significant differences in perinatal mortality and in the incidence of scarrupture between (Table III): (1) groups with different indications for the previous cesarean birth; (2) women who had experienced prior vaginal delivery and those who had not; (3) women with a different number of previous cesarean sections.
hlrth
No (n = 43) Yes (n = 91)
3 (7) 10 (11)
2 (5) 7 (8)
10 (9)
8 (7)
3 (14)
1 (5)
cases, rupture had already occurred before admission to hospital; another two occurred when vaginal delivery was deliberately aimed at, after the fetus had died due to cord prolapse. In eight cases of uterine scar-rupture hysterorraphy was performed by continuous one layer suturing of the uterine rupture, often the quickest possible operation to achieve hemostasis and thereby controlling shock [7]. One woman needed hysterectomy because of severe extension of the tear. In four women, tubal ligation was performed additionally. In the other four, cultural reasons (the women only having one or even no children) prevented this. There were no maternal deaths related to uterine scar-rupture. This was in contrast with the high maternal death rate after spontaneous uterine rupture: live maternal deaths took place in 21 such cases (24%) during the study period 1161. Discussion
Scar-rupture
Uterine scar-rupture occurred with a high frequency in 9 of 134 women (6.7%). In three
A rate of 65% vaginal deliveries after a previous cesarean birth compares favorably Clinical and Clinical Research
214
van Roosmalen
Talk IV. Maternal outcome of labor in women with a previous cesarean birth in different regions of the world. Scarrupture (%)
Region
Women with previous cesarean section
Repeat cesarean birth (%)
United States of America Europe Africa Asia
3603
1930 (54)
17 (0.5)
9827 7018 1759
4981 (51) 3740 (53) 809 (46)
77 (0.8) 271 (3.9) 64 (3.6)
Source: Van Roosmalen [ 161.
with rates reported from all over the world (Table IV). Especially when the presentation was vertex (79 women), results were good with no maternal and perinatal deaths attributable to the trial of labor in hospital. In the small group with breech presentation (9 women), however, results were disastrous: four scar-ruptures occurred in hospital and three perinatal deaths were attributable to this complication. One may question the acceptance of these cases for a trial of vaginal delivery. Had these nine breech infants been delivered by repeat operation, the vaginal delivery rate would have been lowered from 65 to 62%, while the perinatal mortality would probably have been much less and the incidence of scarrupture halved in the whole series of 134 women with a previous cesarean birth. Scar-rupture
Uterine scar-rupture occurred with a high frequency (6.7%). This was the most striking difference between the series reported from Western and from African and Asian countries (Table IV). The observed difference may be related to the different circumstances in Africa, preventing women with a history of a previous cesarean birth reporting to hospital early in labor. In Zaria (Nigeria), 24% of women with a previous cesarean birth were unbooked emergency admissions in a subsequent labor [5]. In Machakos (Kenya), 86% of these women inIn1 J Gynecol Obster 34
tended to deliver in hospital; only 73% actually did so [19]. A higher frequency of scar-rupture in African than in industrialized societies is not necessarily an argument against a trial of labor. It stresses the point, however, that one should be very careful in taking the decision whether to perform the first cesarean section or not and it may be put forward as a reason to practice alternative methods like symphyseotomy [ 151. It is clear from the above, that Craigin’s dictum “once a cesarean, always a cesarean” is outdated. The dictum could be changed into “once a cesarean, always hospital delivery”. “Twice a cesarean” is often followed by repeat operation, although some authors even question this rationale [2]. Criteria for allowing a trial of labor after a prior cesarean birth have become more liberal at present. In earlier times, women with an unknown type of cesarean section scar, and with febrile or septic morbidity after the previous operation were generally excluded from a trial and exposed to elective repeat section. Applying similar criteria to a population in rural hospitals in African countries, would considerably reduce the number of vaginal deliveries after a previous operation as often the type of uterine scar is unknown, cephalopelvic disproportion (CPD) has a high prevalence and the postoperative course has often been febrile with septic complications. Allowing a trial of labor is only safe in circumstances with suitable facilities to perform a repeat operation instantly should complications arise. Breech presentation may be such a complication. The incidence of scar-rupture should be balanced against the risk of repeat cesarean birth. When repeat cesarean sections would be performed as a routine, a low rate of complications after so many operations could well produce overall results which are not better than those obtained with a high rate of complications after scar-rupture in few women. The total number of complications could well be higher with so many repeat operations [lo].
Vaginal birth after cesarean section
The significantly higher vaginal birth rate when the indication for the previous operation was a nonrecurrent one, is in agreement with most studies in the literature [8,12]. Yet, almost half of women with a prior operation for a recurrent reason, i.e. CPD, delivered vaginally. One may assume that at least some cases of diagnosed CPD were in fact labors with inefficient uterine action, and this is especially so when oxytocin is not used to augment prolonged labor in primigravidae. The risk of scar-rupture and perinatal death did not significantly alter for different indications of previous cesarean birth. Neither did it relate to the presence or absence of a previous vaginal birth in the obstetric history. These facts endorse the dictum “once a cesarean, always hospital delivery”. This was contrary to what rural health workers in Tanzania thought: 26 of 49 did not consider a woman with one previous cesarean birth and four normal deliveries thereafter to be at risk [ 141. This indicates the need for close supervision of these workers, who are the first to meet women with a previous cesarean birth in their rural antenatal clinics. Given the evidence provided in this article, we conclude that a trial of labor in hospital is justified in most women with a history of a previous cesarean birth.
Bottoms SF. Rosen MG. Sokol RJ: The increase in the caesarean birth rate. N Engl J Med 302: 559, 1980. Camilleri AP, Busutttil T: “Twice a Caesarean ...“. J Obstet Gynaecol Br Commonw 75: 1305, 1968. Craigin
5
Harrison KA. Rossiter CE, Chong H et al: Antenatal care, formal education and childbearing. Br J Obstet Gynaecol suppr 5: 14, 1985.
6
Harrison KA. Rossiter CE: Maternal mortality. Br J Obstet Gynaecol Suppl5: 100, 1985. Haspels AA: Uterine rupture in central Java. Thesis, Amsterdam, 1961.
7 8 9
10
11 12
13 14
15 16 17
I8
19
References
EB: Conservatism
in obstetrics.
215
Horowitz BJ, Edelstein SW, always a cesarean. Obstet Jansen FW, Van Roosmalen Gravenhorst J: Vaginal birth
Lippman L: Once a cesarean Gynecol Surv 36: 592, 1981. J, Keirse MJNC. Bennebroek after caesarean section. Ned
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