Rate, Precautions, and Outcome of Vaginal Birth after Caesarean Section in Beni-Suef Governorate

_______________________________________ Background: Almost a third of all deliveries now involve a caesarean section (CS). Trial of labor after caesarean (TOLAC) followed by vaginal birth after caesarean (VBAC) is crucial for lowering the total caesarean rate since repeat caesarean is the most prevalent single rationale for caesarean. Aim: this study was conducted to assess the incidence, and maternal and neonatal outcomes of vaginal birth after caesarean section. Methods: This retrospective cohort study was conducted at the obstetrics and gynecology department in of Beni-Suef General Hospital. The data was obtained from the files of each patient. The collected data included reported history taking, clinical examinations, preoperative and postoperative investigations, details

Uterine rupture, which includes the incision made into the uterus during the preceding CS, is the most serious complication that may happen to patients having TOLAC (14).Fetal acidosis, neonatal intensive care unit (NICU) admission, and even death may ensue after uterine rupture because blood and oxygen aren't delivered to the infant as they should be (15).This study was conducted to assess the incidence, and maternal and neonatal outcomes of vaginal birth after caesarean section.

Patients and Methods :
This retrospective cohort study assessed the incidence of vaginal birth after caesarean section at Beni-Suef General Hospital from Jan 1, 2016, till Dec 31, 2017.

Technical Design
The data presented in this study were obtained from patients' files at Beni-Suef General Hospital (incomplete files were excluded from the data).

Operational Design
During the preparatory phase, visits to Beni-Suef General Hospital were done to access medical records and test for the available information.The compilation of useful data was aided by a review of relevant literature and expert comments.

Administrative Design
The researcher acquired formal authorization to proceed from the hospital's management.

1-Full history taking for each patient:
A-Personal history as name, age, parity, gravidity, occupation, social class, phone number, address, and special habits.

Ethical consideration
The local IRB of the faculty of Medicine, Beni-Suef University, approved the study protocol with approval number FMBSUREC/03092019/Zahran.All data were anonymous and confidential.

Results:
This study showed that the total deliveries in 2016 and 2017 were 13768.Regarding caesarean delivery, the rate was 38.24%, while in vaginal delivery, the rate was 61.76% (Table 1) The current study demonstrated that 258 cases went for TOLAC, the success of TOLAC was (84.9%).
In contrast (15.1%) failed their TOLAC trial.The rate of VBAC was 1.6% of the total deliveries in 2016 and 2017.Failed TOLAC was due to lack of labor progress (32) and fetal distress (7).

20.5% *P-value is significant
This study showed that there was a statistically significantly higher proportion of elective sections (56.4%), lower duration between the last previous CS and current pregnancy (82.1%), and no previous vaginal delivery (79.5%) in failed cases versus (27.9%, 19.6% and 6.5%) in succeeded cases, respectively (P-value<0.05) (Table 5).

*P-value is significant
This study showed that there was a statistically significantly higher proportion of no ANC follow-up, breech presentation, presence of medical disorders, multiple pregnancies, intact membranes, latent phase of cervical dilatation, and utilization of oxytocin in failed cases than in succeeded cases (Table 6) After adjustment of risk factors that may affect the probability of failure (after exclusion of associated independent variables with each other's and non-clinically significant ones as a residence), the best model with the highest adjusted R square was illustrated in table (7).It was demonstrated that after adjustment for age, previous vaginal delivery, rupture membrane, gestational age, presence of medical disorder, and the previous elective section, it was reported that younger age less than or equal to 20 years, ruptured membranes, presence of medical disorders were associated with increased the probability of failure in the studied cases.In contrast, the presence of previous vaginal delivery and gestational age (37-42) were associated with decreased probability of failure.The significant and the non-significant variables were displayed in the forest plot (figure 1).Table (8) showed that there was a statistically significantly higher proportion of postpartum hemorrhage and uterine rupture in failed cases than in succeeded cases.The perineal tear was present in 7.8% of succeeded cases (P-value<0.05).

Elective previous CS
Table (9) showed that there was a statistically significant lower fetal heart rate and APGAR score at 1 st and 5 th minutes in failed cases than in succeeded cases (P-value<0.01).In agreement with our study, In contrast to us, the study by .

Conclusion and Recommendations:
The TOLAC should be under the supervision of a well-trained team in well-equipped hospitals and meticulous monitoring for both mother and fetus.

Conflicts of interest:
The authors declare that there are no conflicts of interest.

References :
1. Venkatesh KK, Brodney S, Barry MJ, Jackson https://ejmr.journals.ekb.eg/success rate of TOLAC was (84.9%) while the failure rate was (15.1%).Results: The rate of succeeded VBAC was (1.6%) while the rate of CS was (38 %) from all deliveries in 2016 and 2017.There was a difference between succeeded VBAC group and failed group regarding the history of previous vaginal delivery, number, causes, type, indications of prior CS(s), duration between CS and current pregnancy, presentation, medical disorders, fetal heart rate (FHR), Apgar score and need for neonatal intensive care unit (NICU) admission.Conclusion: Regarding VBAC precautions, factors that improve success are previous lower segment CS, previous vaginal delivery, cephalic presentation, a single full-term fetus of average weight, good maternal health (free of medical disorder), the patient is in an active phase of the first stage of labor and previous vaginal delivery.VBAC became one of the solutions to avoid the complications of ERCD as there are fewer complications, shorter hospital stays, faster recovery, avoidance of major surgery, and reduced risk of NICU admission.https://ejmr.journals.ekb.eg/ 1. Introduction: Women who have had a caesarean delivery in the past but choose to have their subsequent child by vaginal delivery are named to have had a vaginal birth after a caesarean section (VBAC).Patients who want to attempt a vaginal birth after caesarean surgery (VBAC) have what is called a "trial of labor" (TOL) (TOLAC) (1).The risks of TOL are low, and the procedure is normally safe.Still, there is a chance of major consequences such as uterine rupture or dehiscence and maternal and/or newborn morbidity (2).The literature showed a large number of pregnant women who have previous CS delivery.Whether it is premeditated or the result of an unexpected labor contraction, patients may have VBAC (3).The percentage of women who had a successful VBAC rose for all gestational ages 38 and above.The VBAC rate rose 7%, from 14.0 to 15.0 percent, at 38 weeks.VBAC births went from 8.0 to 9.0 percent at 39 weeks and from 33.8 to 37.3 percent at 40 weeks, an increase of 13 and 10 percent (4).It should be attempted soon to determine the fetal weight, either physically or by ultrasonographic evaluation.Given that there are no extremely precise techniques for determining fetal birth weight, this information should be taken into account but not utilized exclusively to decide whether or not to do TOL (5).The American College of Obstetrics and Gynecology supports this statement that individuals with up to two previous caesarean births are suitable for TOLAC (ACOG) (6).These situations would also involve past transmyometrial incisions to remove uterine fibroids or to permit open fetal surgery, in addition to prior classical uterine incisions of the "T" or "J" type during caesarean birth (7).Before labor begins at around 36 to 38 6/7 weeks estimated gestational age, scheduled repeat caesarean delivery is advised because patients with a history of uterine rupture also have a higher risk of uterine rupture (8).Facilities that perform TOLAC are needed to be able to carry out an emergency CS.Concern has been expressed that this criterion prevents certain patients, such as those living in remote regions, from having the option of vaginal birth following caesarean section, even if the availability of such services appears reasonable (9).The most recent ACOG Practice Bulletin advised sending such patients to locations that might provide TOLAC as necessary (10).Patients considering TOLAC must get standard prenatal care and extra education about this alternative to a scheduled recurrent caesarean birth (PRCD).If CS is planned, early ultrasound to check gestational age might also be useful (11).In terms of labor management, spontaneous entrance into labor is recommended since it has a better chance of successfully delivering the baby vaginally and a lesser chance of uterine rupture (12).Although studies have shown higher risks of uterine rupture when prostaglandins (such as misoprostol or dinoprostone) are used for cervical ripening, induction of labor (IOL) is still a viable choice when necessary (13).
the first day of last menstrual period (LMP), expected delivery date, duration of labor pains, time of rupture of membranes, and duration between CS and current pregnancy.C-Past history as History of previous CS(s) regarding number, type, and indications, medical disorders or drug intake, history of gynecological and surgical operation or blood transfusion.

B-
Abdominal examination (superficial and deep palpation of fundal level, lateral grips, pelvic grips, fetal heart rate, and scar of previous operations).C-Vaginal examination (state of the cervix, membranes, and presenting part).
examination (gestational age, presentation, number of fetuses, fetal heart rate, and placental site).4-Description of details of vaginal labor: (Catheterization, first stage of labor, episiotomy if needed, intravenous fluids, delivery of the fetus and placenta, hospital stay, etc.).5-Postpartum vital signs and hemoglobin level.6-Postpartum complications such as (perineal tear, postpartum hemorrhage, uterine rupture, and urinary tract injury) 7-Apgar score at first and fifth minutes, neonatal weight, and need for NICU admission.8-Condition of the patients on discharge.9-Return postpartum visit and contraceptive advice.

2. 5 .
Statistical methodology SPSS (Statistical Package for the Social Sciences) version 24 was used for data coding and entry.Independent t-test and chi-squared test were employed to compare the two subgroups regarding numeric and nominal variables, respectively.Binary logistic regression analysis was done to assess the exact risk factors in the best-fit model that explains the probability of failed TOLAC.A P-value less than 0.05 was considered significant.

Figure ( 1 )
Figure (1) Forest plot indicting the odds ratio of the independent variables affecting the probability of failure TOLAC

22 )
Abdulrahman and Ismail wanted to determine the characteristics linked to a successful vaginal birth after CS.Their study included 500 pregnant women with a history of a single lower segment CS were included in the research; 83% (415/500) had a successful vaginal birth following caesarean section, and 17% (85/500) had a failed trial of labor after caesarean surgery (TOLAC).It was shown that 58% of women who attempted VBAC were previous vaginal births.Pregnant women with consistent prenatal care and waited more than two years between deliveries had a greater incidence of vaginal birth after caesarean.(18).In the same line as us, Derebe and coworkers wanted to determine what characteristics are related to a successful VBAC.After having one lower uterine transverse caesarean section delivery, their research found that 35.07 percent of women went on to have successful vaginal births.Out of the failed trial of delivery, fetal distress was seen in 38.9% of the delivered babies, followed by failed progress of labor, which was seen in 32.1% of deliveries.They were the main indications for transformation into an emergency caesarean section.Younger maternal age less than or equal to 30 years, previous successful vaginal delivery after caesarean section, previous vaginal delivery before caesarean section, non-recurrent indication (malpresentation and fetal distress), rupture of membrane, dilatation of cervix for more than or equal 4cm, effacement of the cervix for more than or equal 50%, and low station for more than or equal zero at admission were predictors of successful vaginal delivery after one lower uterine caesarean delivery with transverse section (19).We agreed with Asgarian and colleagues, who researched VBAC's success rate, associated variables, and potential reasons for failure.According to their findings, VBAC has a very high success rate.VBAC was more successful with fewer problems when there was a considerable time gap between pregnancies and births, namely two to four years.Between 2016 and 2018, researchers in Qom surveyed 150 VBAC hopefuls hospitalized for their pregnancies.Vaginal birth after the caesarean reversal (VBAC) was successful in 85.33 percent of cases, but 14.67 percent of women required a second CS due to vaginal delivery complications.Comparing the successful and unsuccessful groups based on the mean time between the prior CS and the current delivery yielded statistically significant results.(t125 = 2.32, p = 0.002).Moreover, the findings indicated that protracted labor and subsequent complications were the leading reasons for VBAC failure [odds ratio was 4.70)], full arrest (odds ratio was 2.70), and decline in the fetal heart (odds ratio was 5.31) (20).We also found that prior vaginal births are strong prognostic predictors of successful VBAC.Trojano and colleagues concurred with us.The success of a VBAC is negatively impacted by maternal obesity and diabetes.(21).We were in the same line with Alkhamis and colleagues who looked at women who had already had one caesarean surgery and tried vaginal birth once the scar healed, as well as women who had already had another caesarean section.Both scheduled and unscheduled csection deliveries (299 women) were included in this retrospective cohort analysis from a hospital setting.A significant association was established between the etiology of a prior caesarean section and the outcome and between VBAC and spontaneous vaginal births.(We agreed with Oboro et al. that labor inducement and a fetal weight of more than 4,000 grams were risk factors for a failed VBAC (23).

Table (
1): Distribution of delivery according to the type of delivery in 2016 and 2017

Table ( 2
): Distribution of the sample according to the success of (TOLAC)

Table ( 5
) Comparison between succeeded TOLAC (VBAC) and failed TOLAC regarding the type of previous CS and duration between CS and current pregnancy

Table ( 6
): Comparison between succeeded TOLAC (VBAC) and failed TOLAC regarding ANC follow-up, gestational age, presence of medical disorders, and other risk factors.

Table ( 7
) Multivariable binary logistic regression analysis for prediction of the risk factors associated with failure of failed TOLAC

Table ( 9) FHR and APGAR score at 1 st and 5 th minutes in succeeded and failed cases:
rate of VBAC was (1.6%) while the rate of