Trial of Labor after Cesarean (TOLAC) for Vaginal Birth after Previous Cesarean Section (VBAC) versus repeat cesarean section

Abstract

Background: Allowing a woman with a previous cesarean birth a trial of labour is a controversial area. In 1916, Cragin popularized the dictum, "once a caesarean section, always a caesarean section [1] because of prevailing use of classical CS at that time. Now due to lower segment caesarean section (LSCS), cesarean-related morbidity and mortality are significantly reduced. The dictum now is "once a caesarean section, can be given trial of labour in a wellequipped hospital", The reasons which led to the reversal of the old dictum are based upon the newer concepts of the assessment of scar integrity, fetal well-being, and improved facilities of emergency CS [2] . Nevertheless, a previous CS does cast a shadow over the outcome of future pregnancies [3] . With present techniques and skill, the incidence of cesarean scar rupture in subsequent pregnancies is very low. The strength of the uterine scar and its capacity to with stand the stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in advance. These cases require the assessment and supervision of a senior obstetrician during labor [4,14] . Hence, the present study was undertaken to assess the success and safety of VBAC in selected cases of one previous LSCS and to evaluate the maternal and fetal outcome in these cases. Material & Methods: This was a prospective observational study carried out in a tertiary care teaching institute Mahila Chikitsalya, J.L.N. Medical College, Ajmer during the period July 2019 to October 2019. The trial of vaginal delivery was continued till there was satisfactory progress. The trial was terminated by emergency repeat CS, when there was evidence of unsatisfactory progress, scar tenderness or fetal distress Results: In the present study, 27 (54%) subjects underwent successful VBAC while 23 (46%) subjects had to undergo repeat LSCS due to failed vaginal trial of labour. The success of VBAC in the present study was 54%. This result was comparable with the results of other studies reported by Phelan et al., [7] In our study, the rate of a repeat CS was 46% and commonest indication for that was fetal distress. Limitations: The limitation of the study lies in the fact that the study was carried out in a tertiary care centre, where there is adequate manpower to supervise each delivery, reducing complication rates of VBAC. Similar results may not be replicated at centers other than tertiary care centers. Conclusion:The old dictum" Once a caesarean always a caesarean" should be changed to "Once a caesarean always an institutional delivery". Majority of the cases of previous CS done for non-recurrent indication can be delivered safely by the vaginal route, without any major complication to the mother and the newborn, in an institution having facilities for emergency CSs. It has been proved to be a safe alternative to repeat an elective CS in selected cases.