الفهرس 
Aim of the workOnly 14 pages are availabe for public view
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Abstract
Summary, Conclusions and Recommendations
During the past two decades, there has been a dramatic increase in the cesarean birth rate within a generation, cesarean delivery rate had been increased from a rate of (1 in 50 births in 1970) to nearly (1 in 4 births today) (Hamilton et al., 1993).
“Once a cesarean section, always a cesarean section” was first; proposed as clinical dictum by Cragin (1916). This dictum dates back to an era when most cesarean sections involved classical uterine incisions, and when antibiotics and transfusion were unknown (Acher et al., 1999).
Now due to changes in the type of uterine incision, being mostly lower segment transverse incision, combined with the advantages in technology which allows continuous and accurate monitoring of the mother as well as the fetus, it is widely accepted that an attempt of vaginal delivery should be made unless there are other indications for abdominal delivery (Bivins and Galiup, 2000).
The aim of the study was:
- To review the trends in the frequency of CS births.
- To review the trends in the trial of labor (TOL) as an alternative to repeat CS.
- To do retrospective study among those females underwent trial of labor after previous one CS aiming to evaluate TOL.
This study included all parturient with a history of previous one cesarean section who were admitted and delivered at Benha University Hospital, Maternity Department (n = 832), as a retrospective study through the period from the first of January 2002, till the end of December 2004.
Only 745 (89.5%) of 832 pregnant women with previous history of one CS had satisfied all the inclusion and exclusion criteria and represent the study group under TOL.
Study group was subdivided into two groups:
Group A: included 496 cases with successful TOL and delivered vaginally.
Group B: included 249 cases with failure TOL and had repeat cesarean section.
Factors which were found to be significantly affecting the success of trial of labor included maternal age, history of prior vaginal delivery, the indication of previous cesarean section, birth weight, the degree of cervical dilatation at admission on labor and gestational age.
The best chance of successful vaginal delivery was obtained by those patients who had prior vaginal delivery (75.6% success rate) especially when it occurred after the previous cesarean section as compared with 60.2% success rate in those without a history of prior vaginal delivery.
In this study, the highest significant success rate of TOL was present when the previous CS was done for non-persistant cause as PIH 96.2%, Twins 93.2%, Malpresentation 81.5% and APH 60% also, parturients with prior cesarean section for cephalopelvic disproportion / failure to progress were less likely for vaginal delivery 40% success rate than those who had their primary CS for non-persistant cause.
The success rate of TOL was significantly high when the birth weight was less than 4000gm i.e., 69.1%, 71.2%, 61.8% of those with birth weight 3500-4000gm, 2500-3499gm and < 2500gm respectively. No success of TOL was achieved when the birth weight was more than 4000gm.
The degree of cervical dilatation on admission in labor was found to be a significant prognostic factor with regard to successful vaginal delivery after trial labor. The success rate was 28.7% when the cervix was <4cm dilated, which is significantly lower than 91.2% success rate when the cervix was equal to or higher than 4cm dilated.
Furthermore, regarding complications of delivery, the incidence of uterine scar separation was 3.7% (n = 28) among all patients with previous one cesarean section (n = 745).
Also, as evidenced from the available records, there was no single maternal mortality among all patients included in this study (n = 832).
There was 38 cases of perinatal mortality (5.1%) from 745 mothers with previous one cesarean section which was dependant on the birth weight as it was significantly higher when the birth weight was < 2500gm.
from the results obtained in this study, it could be concluded that: trial of vaginal delivery is relatively safe and not associated with increased maternal or fetal risks as long as both are under close observation with the availability of ready surgical theatre and a continuous blood banking.
Patients fulfilling the following criteria can be selected for the trial of labor:
- A history of only one lower segment transverse cesarean section.
- Vertex presentation.
- Adequate bony pelvis.
- No other contraindications for vaginal delivery.
Factors associated with enhanced probability of successful trial of labor included, non recurrent indication of the primary cesarean section, history of prior vaginal delivery especially when it occurred after the primary cesarean section, more dilated cervix at admission in labor and birth weight less than 4000 gms, maternal age 20-29 years and gestational age 37-40 weeks.
The clinical dictum “once a cesarean section, always a cesarean section” is an outmoded dictum and can be replaced by the clinical dictum “once a cesarean section, always a hospital delivery”.
Conclusion and Recommendations:
from the results of the study, we concluded that to decrease cesarean section rate and to increase the successful TOL rate without association of maternal or fetal complications, we must fulfill the following points:
1- Accurate decision of CS according to the indication.
2- Good performing of lower segment transverse CS.
3- Better antenatal care.
4- Good selection of patients for TOL.
5- Better monitoring during labor.
During ANC, we must detect the following:
1- Type of previous scar.
2- Indication of previous CS.
3- Intervention of vaginal deliveries.
4- Occurrence of any complications.
5- Take a decision of we will allow TOL or not.
Better monitoring during labor by the application of an intra-uterine pressure catheter and fetal scalp electrode as soon after admission as possible for measuring the intra-uterine pressure and continuous fetal monitoring.
The allowance of all these facilities give better outcome by more neonatal support by the allowance of good neonatal intensive care unit.
from the results of the study, we recommend that hospital with appropriate facilities, service and staff for prompt emergency cesarean birth in a proper selection of cases should permit a safe trial of labor and vaginal delivery for women who had a previous lower segment cesarean section, the allowance of all these facilities associated by high successful rate of TOL that can be taken as a guideline in future studies.
Also, we recommend to adjust and re-evaluate files registration system of medical statistical department at Benha University Hospital as there were many registration defects, loss data that affected outcome of the results of this study that may be more accurate if we achieved full data about indications of primary CS, conditions associated with perinatal mortality and maternal morbidity as ruptured uterine scar.