VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA

Abstract

Background

The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated.

Aim & Objectives

The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth

Patients & Methods:

This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20.

Results

There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS.

Conclusion

. There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.

Introduction

The most appropriate mode of subsequent delivery of women with prior caesarean birth continues to be a subject of intense research and debate in contemporary obstetric practice1,2,3. This controversy remains a major public health issue because the two options for delivery (planned elective repeat caesarean or planned vaginal birth) in a subsequent pregnancy for these cohort of woman with a previous caesarean birth are associated with both significant maternal and perinatal benefits and risks1,2,4. Vaginal birth after caesarean delivery (VBAC) has long been proposed as a viable measure to reduce overall caesarean delivery rates in both developed and developing countries. It has been found to be safe with careful patient selection and good management of labour with success rates ranging between 60% and 80%5.

Although caesarean rate is rising uncontrollably globally, there remains considerable controversy over what constitute the appropriate caesarean section rate for a given maternal population. In 1985, the World Health Organization quantified that there is no justification for any region of the world to exceed caesarean birth rate of 15%6. The CS rate at Korle Bu Teaching Hospital (KBTH), where the current study was carried out, is high (33%)7 and prior caesarean section is a major contributing factor for a repeat caesarean section8. Recent systematic review concluded that VBAC is a reasonable and safe choice for majority of women with prior caesarean section. However, most of the studies included in the analysis were conducted in the developed countries where there is adequate labour monitoring and ready availability of theatre for immediate delivery in emergency situations9.

However, there exist real practical challenges in low resource settings such as West Africa which might result in severe maternal and perinatal adverse outcomes including deaths in women slated for trial of labour after a prior caesarean delivery (TOLAC). Notwithstanding these inherent unfavourable factors for successful VBAC, TOLAC has been practiced for several decades in these areas with significant success although unacceptable untoward outcomes have been reported8,10,11. The obvious daunting question remains largely unanswered: in West Africa where the luxury of optimal intrapartum maternal and fetal monitoring barely exists coupled with the lack of adequate preparedness for emergency delivery, if urgently indicated, one wonders if it is still ethically acceptable to practice TOLAC in such settings. It is worth remarking that there is no reliable and demonstrable attribute that always correctly identifies and accurately predicts those women with a prior caesarean who will achieve successful VBAC12.

In Ghana, nationwide free delivery services including CS for all pregnant women was introduced in 2008 and such free maternity care has improved the quality of care for most expectant mothers compared to the previous “cash and carry” system which hitherto constituted a physical barrier to skilled birth attendance. We hypothesized that with the possible general improvement in the provision of maternal care in the country due to the free maternal care the management of women with prior caesarean delivery may have changed. The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of TOLAC in the mist of inherent fear and psychological unrest in both the physician and patient undergoing trial of scar. The secondary objective was to relate evidence- based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth.

Patients & Methods

This was a retrospective review conducted at the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana and involving women with a previous caesarean birth who delivered between January 2010 and December 2014. KBTH is the largest tertiary institution in Ghana with total deliveries of approximately 10,000 per year. Generally, it serves as a tertiary hospital within a catchment area of about 50km radius and a population of over 3 million. In KBTH, antenatal clinics are conducted for pregnant women on daily basis and women with a previous caesarean section are considered as high risk obstetric population among others. This cohort of women are usually assessed thoroughly in the antenatal period to determine whether they would benefit from planned or elective repeat CS or planned trial of labour after prior CS (TOLAC) based on their individual characteristics such as the past and present obstetric history.

The data for this review were obtained from the Labour and Recovery wards and the Biostatics unit of the Department of Obstetrics and Gynecology, KBTH. Initially, all the women with a history of a previous caesarean delivery were selected and their hospital identification numbers were recorded in order to trace their medical records. The medical records of this selected group of women were reviewed and two subgroups consisting of those who had definite antenatal delivery plan (either planned repeat caesarean section or trial of labour after previous caesarean section-TOLAC) were finally included in the study. The specific exclusion criteria were women with one previous CS who had either vaginal or caesarean delivery but the plan for delivery was not stated antenatally prior to the onset of labour. These exclusion criteria were critical in this review in order to obtain the true picture of TOLAC and successful vaginal birth after caesarian section (VBAC) based of the adequate pre-labour feto-maternal assessment and subsequent selection for TOLAC by the obstetricians taking care of them. Also excluded from the analysis were women with a previous caesarean birth who had multiple gestations in the index pregnancy to avoid its confounding effect on the mode of delivery.

The data extracted for this review included the maternal age, gravidity, parity, marital status, number of antenatal visits, previous mode of childbirth, gestational age at delivery, mode of delivery, occurrence of uterine rupture and the birth weight as well as the indications for caesarean birth for those who had CS.

In this study, successful VBAC rate was defined as the percentage of women with prior CS who attempted a trial of labour and achieved vaginal birth. Failed TOLAC (failed VBAC) was defined as the proportion of women who attempted trial of labour after previous caesarean section that resulted in a repeat caesarean delivery. Uterine rupture was defined as the disruption or tear of the uterine muscle and visceral peritoneum, or separation of the uterine muscle with extension to the bladder or broad ligament with or without protrusion of fetus/fetal parts outside the uterus5.

In this study informed consent was not obtained because there was no direct contact with the study participants. Approval for the study was obtained from the Ethical and Protocol committee of the University of Ghana School of Medicine and Dentistry. The data obtained were analyzed using SPSS version 20. Descriptive analysis was done and the results were presented in percentages. The independent student t-test was used to compare the means of the continuous variables between those who had elective CS and TOLAC, and also between those who either had successful VBAC or failed VBAC. Multiple logistic regression was used to determine the odds of failed TOLAC based on the birth weight. The test for statistical significance was set at an alpha level of 0.05.

Results

Over the study period spanning from 2010 to 2014, there were a total of 53,581 deliveries at KBTH comprising 31,870 (59.48%) and 21,711 (40.52%) vaginal and caesarean deliveries respectively Table 1.. The average annual delivery was 10,716. Primary caesarean section accounted for 70.8% and 28.7% of the caesarean and the total deliveries respectively. Among the total deliveries, 6,261 (11.7%) had a history of a prior caesarean section out of which 2,119 (33.8%) and 2,472 (39.5%) were scheduled for planned repeat CS and planned TOLAC respectively Table 2. Prior vaginal delivery had been achieved in 42.0% (1,034 women) of those who were slated for TOLAC. Women with incomplete data, no delivery plan and multiple pregnancies were excluded from the final analysis and these constituted 26.7% (1,620) of the one previous caesarean population. Therefore a total of 4,591 with a previous CS were included in the analysis out of which 4,205 (91.6%) and 368 (8.4%) were married and single respectively. Regarding educational background 414 (9.0%) had not received any formal education, 465 (10.1%) had primary, 2005 (43.7%) had junior high school, 1,108 (24.1%) senior high school and 599 (13.0%) had tertiary level education.

Table 1 . Trends in vaginal and caesarean deliveries among pregnant women at KBTH.

Year	Total deliveries	Total vaginal deliveries n (%)	Total CS n (%)	Total primary CS	% of primary CS in caesarean population	% of primary CS in total deliveries
2010	10882	6995 (64.3)	3887 (35.7)	3003	77.2	27.6
2011	10503	6382 (60.8)	4121 (39.2)	3039	73.7	29.6
2012	10278	6154 (59.9)	4124 (40.1)	3145	65.5	30.6
2013	11186	6381 (57.0)	4805 (43.0)	2980	62.0	26.6
2014	10732	5958 (55.5)	4774 (44.5)	3204	67.1	29.9
Total	53581	31870 (59.5)	21711 (40.5)	15371	70.8	28.7

Table 2 . Trends in vaginal birth after previous caesarean section at KBTH.

Year	Total number of 1 previous CS	Scheduled Elective CS n (%)	Exclusiona n (%)	Scheduled for TOLAC, n (%)	Successful VBAC n (%)	Failed VBAC n (%)	% Successful VBAC in 1 previous CS
2010	1036	342 (33.0)	147 (14.2)	547 (52.8)	338 (61.8)	209 (38.2)	32.6
2011	1293	439 (34.0)	366 (28.3)	488 (37.7)	342 (70.1)	146 (29.9)	26.5
2012	1288	384 (29.8)	428 (33.2)	476 (37.0)	303 (63.7)	173 (36.3)	23.5
2013	1316	461 (35.0)	369 (28.0)	486 (37.0)	278 (57.2)	208 (42.8)	21.1
2014	1328	493 (37.1)	360 (27.1)	475 (35.8)	251 (52.8)	224 (47.2)	18.9
Total	6261	2119 (33.8)	1670 (26.7)	2472 (39.5)	1512 (61.2)	960 (38.8)	24.2
a women with a previous CS who had incomplete data, no delivery plan and multiple pregnancies

There was a significant difference between women who had successful and failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min Table 3.. The major indications for emergency repeat CS among women undergoing TOLAC were CPD (17.0%), failure to progress (16.0%), severe preeclampsia/eclampsia (15.4%), fetal macrosomia (13.0%), slow progress of labour (12.5%) and fetal distress (10.8%) as shown in Table 4.. There was a general trend of increasing successful VBAC rate with advancing gestational age from 34 weeks, peaking at 37 weeks, with a successful TOLAC rate of 72.2% as shown in Table 5..

Table 3 . Maternal and neonatal characteristics of TOLAC versus planned repeat caesarean and successful and failed TOLAC.

Variable	TOLAC (mean±SD)	Elective CS (mean±SD)	P value	Successful TOLAC (mean±SD) n=1324	Failed TOLAC (mean±SD) n=3317	P value
Maternal age (years)	30.02 ± 5.03	31.08 ± 4.99	<0.001	29.60 ± 5.03	30.89 ± 4.99	<0.001
Gravidity	3.11 ± 1.33	3.17 ± 1.49	0.124	3.18 ± 1.33	3.13 ± 1.43	0.206
Parity	1.68 ± 1.00	1.63 ± 1.10	0.127	1.78 ± 1.01	1.61 ± 1.07	0.001
Number of ANC visits	6.35 ± 2.71	7.15 ± 2.54	<0.001	6.09 ± 2.69	6.78 ± 2.67	0.072
GA at delivery (weeks)	37.90 ± 2.56	38.74 ± 2.07	<0.001	37.72 ± 2.65	38.51 ± 2.23	<0.001
Birth weight (kg)	3.13 ± 0.66	3.29 ± 0.64	<0.001	3.04 ± 0.56	3.34 ± 0.68	<0.001
Apgar score at 1 min	6.44 ± 1.98	7.17 ± 1.48	<0.001	6.57 ± 1.90	6.33 ± 1.73	<0.026
Apgar score at 5 min	7.69 ± 2.18	8.72 ± 1.48	<0.001	7.81 ± 2.13	7.56 ± 1.80	<0.019

Table 4 . Indications for repeat caesarean section in women with one previous CS .

Planned/Elective repeat CS		Emergency repeat CS (failed TOLAC)
Indication	N (%)	Indications	N (%)
Malpresentation	256 (12.1)	CPD	163 (17.1).
Antepartum hemorrhage	85 (4.0)	Slow progress	120 (12.5)
Preeclampsia/eclampsia	162(7.6)	Failure to progress	154 (16.0)
Fetal macrosomia	348 (16.4)	Fetal distress	104 (10.8)
Bad obstetric history	195 (9.2)	Big baby	125 (13.0)
Previous myomectomy	93 (4.4)	Ruptured uterus*	41 (4.3)
Post date	365 (17.2)	Severe PE/eclampsia	148 (15.4)
Contracted pelvis	148 (7.0)	Malpresentation	28 (2.9)
Maternal request	88 (4.1)	Miscellaneous	77 (8.0)
Prolonged prom	54 (2.5)		-
Retroviral infection	81 (3.8)		-
Sickle cell disease	53 (2.5)		-
GDM	56 (2.6)		-
IUGR	69 (3.2)		-
Miscellaneous	108 (3.1)		-
Total	2119 (100.0)	Total	960 (100.0)
GDM: gestational diabetes mellitus, CPD: cephalo-pelvic disproportion, PE: preeclampsia, CS: caesarean section, IUGR: intrauterine growth restriction, TOLAC: trial of labour after caesarean section*had laparotomy for ruptured uterus*

Table 5 . Successful and failed VBAC rates based on Gestational age at delivery.

Gestational age at delivery in weeks	Successful VBAC n (%)	Failed VBAC n (%)	Total n (%)
<34	84 (62.7)	50 (37.3)	134 (5.4)
34	20 (55.6)	16 (44.4)	36 (1.5)
35	42 (62.7)	25 (37.3)	67 (2.7)
36	84 (60.9)	54 (39.1)	138 (5.6)
37	327 (72.2)	126 (27.8)	453 (18.3)
38	414 (69.6)	181 (30.4)	595 (24.1)
39	207 (48.0)	224 (52.0)	431 (17.4)
40	250 (56.3)	194 (43.7)	444 (18.0)
≥41	84 (48.3)	90 (51.7)	174 (7.0)
Total	1512 (61.2)	960 (38.8)	2472 (100.0)

Birth weights less than 1.5kg or greater than 3.5kg were associated significantly with higher incidence failed TOLAC and emergency repeat CS. Birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS Table 6..

Table 6 . Univariate and multivariate analysis of birth weight and failed VBAC .

Birth weight (kg)	Failed VBAC n (%)	OR	95%CI	P value	Adjusted OR*	95%CI	P value
<1.50 (n=54)	29 (53.7)	1.853	1.078-3.183	0.026	6.813	3.331-13.935	<0.001
1.50-1.99 (n=71)	34 (47.9)	1.464	0.912-2.349	0.114	2.727	0.985-6.827	0.081
2.00-2.49 (n=132)	38 (28.8)	0.622	0.423-0.914	0.016	0.629	0.403-0.982	0.042
2.50-2.99 (n=534)	88 (16.5)	0.241	0.189-0.308	<0.001	0.288	0.223-0.370	<0.001
3.00-3.49 (n=964)	284 (29.5)	0.514	0.433-0.610	<0.001	0.450	0.375-0.541	<0.001
3.50-3.99 (n=545)	361 (66.2)	4.350	3.554-5.324	<0.001	4.025	3.248-4.990	<0.001
≥4.00 (n=172)	126 (73.3)	4.815	3.399-6.820	<0.001	3.898	2.776-5.732	<0.001
*Adjusted for maternal age, gravidity, parity, antenatal visits and gestational age at delivery

Discussion

In this study we found an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for trial of labor after caesarian section (TOLAC). The caesarean rate increased from 35.5% to 44.4% whereas the proportion scheduled for TOLAC decreased from 52% to 37% over the study period. Generally, there was a decreasing trend in VBAC over the last four years of the study period with overall rate of 61.2%. The finding of increasing CS rate may be partly due to the general global increase in CS in contemporary obstetric practice. The overall CS rate determined in this study was 40.5% which is unduly high and most of these were due to high rate of primary CS resulting in large numbers of women with a previous CS. A recent study that validated women’s self-report of emergency CS in KBTH showed that 35% parturients had a history of a previous CS13. The excessively high CS rate determined in the hospital might be partly attributed to the fact that KBTH is a tertiary referral centre for most of the primary and secondary health facilities in Accra and its environs. Most of the complicated labour cases and high risk pregnancies are referred for specialized clinical management at KBTH where consultants’ input to the overall care is readily available. In Ghana, most of the normal and uncomplicated obstetric cases which do not require specialist consultation are managed successfully at the peripheral health institutions whereas the complicated ones are referred to the tertiary hospitals such as KBTH.

Although the overall institutional CS rate in KBTH is high the country-wide rate is about 11% which is within the optimum CS rate of 5-15% specified by WHO6,14. Although the WHO stated that there is no justification for CS rate of greater than 15% in any part of the world, current WHO assessment indicated that CS rate has exceeded the specified maximum limit of 15% in most countries with as high as 45% reported in some countries15. WHO asserts that caesarean section rate is still increasing uncontrollably and is often performed without an absolute medical indication resulting in potential maternal and perinatal short and long term health problems16.

The appropriate choice regarding the mode of delivery for women with a previous CS remains unresolved because the two options (planned repeat CS and TOLAC) for subsequent route of birth are associated with significant maternal and perinatal risks. The most worrying complication of TOLAC is uterine rupture which might result in peripartum hysterectomy with significant blood loss and or maternal and perinatal morbidity and mortality. In the current study 4.3% of women who underwent TOLAC had uterine rupture and this is far higher than the estimated rate of 0.7% for such cohort of women undergoing TOLAC5. The major obstacle in deciding to embark on TOLAC has always been the prediction of the success rate of vaginal delivery as well as knowing accurately when to abandon the trial of labour to avert serious obstetric outcomes. In the developed world it is relatively easy to go around this obstacle but the situation is completely different in low resource settings like Sub-Saharan Africa where myriads of health system challenges as well as clinical management-related problems abound. The major underlying confounder to all these inherent issues revolves around severe poverty, high illiteracy rate and deep rooted cultural practices. Notwithstanding the enumerated challenges TOLAC has been practiced in these regions for ages with significant success rates although there have also been major unacceptable and avoidable perinatal and maternal adverse outcomes including loss of lives10. In all these successes and failures, it is worth remarking that no overwhelming dominance exists from current evidence to recommend a preferred mode of childbirth for expectant mothers with a history of a previous caesarean section. This cohort of women can opt for vaginal birth after caesarian section (VBAC) or elective CS following adequate counselling and discussion with the attending Physician12. The final decision on the mode of birth should be made before the expected delivery date, ideally by 36 weeks of gestation.4 The preference for mode of delivery opted for by the woman following antenatal counselling and provision of sufficient information should be duly respected and documented12.

There have been a lot of models with multiple variables developed to predict the probability of successful VBAC but none of these has gained global popularity in contemporary obstetric practice due to lack of high predictability power and reproducibility17,18,19. In the West African settings where adequate labour monitoring with cardiotocograph and immediate access to theatre in emergency situations are not readily available adequate education and counselling of the mother should be the ultimate in deciding the route of child birth. Although we have recorded some successes, avoidable “near misses” and actual “misses” have occurred in our attempt at achieving VBAC in our sub-region10. The daunting question is whether we should continue to practice TOLAC in the mist of real and potential mishap associated with this option. The other side of the coin is the entrenched perpetuation of poverty and lack of logistics which obviously precludes provision of CS for all women with one previous CS in the mist of the characteristic high fertility rate in our subregion. Other researchers have, therefore, recommended non-practice of TOLAC in such situations20 but the opposite is probably not realistic. Wanyonyi et al recently identified specific concerns related to the conduct of TOLAC in East Africa such as poor maternal education, inefficiencies in healthcare delivery systems, inadequate human resources, lack of unit guidelines, and inadequate fetal monitoring. They recommended that the practice of VBAC should not be encouraged in the region unless these concerns have been resolved20.

In our opinion TOLAC still has a significant place in Sub-Saharan Africa (SSA) following appropriate patient education and counselling to allow informed choice with guidance from the attending physicians, coupled with well dedicated skilled birth attendants for optimum intrapartum monitoring. This is necessary because the merits of VBAC are well documented and these include low incidence of blood loss at delivery and transfusion, thrombo-embolism, puerperal infections, shorter duration of hospitalizations among others. There are, however, well documented factors associated failed TOLAC such as advanced maternal age, gestational age greater than 40 weeks, maternal obesity, preeclampsia, short inter-pregnancy interval and increased neonatal birth weight and recurring indication like cephalopelvic disproportion (CPD)1.

The current study has determined a general downward trend of success rate of TOLAC over the study period with the overall rate of 61.2%, ranging from 52.8 to 70.1%. The high success rate recorded in our study might partly be ascribed to the specific methodology and strict inclusion criteria adopted. In this study, we specifically included women who were slated for TOLAC by the obstetricians during the antenatal period. All other women with a history of a previous caesarean who either delivered vaginally or via CS but were not scheduled for TOLAC antenatally were excluded from the analysis. The idea behind these strict criteria of inclusion was to determine the true proportion of successful VBAC in order to assess the relativity between proper selection protocols and the associated failure rates and complications. This criteria-based inclusion and the subsequent success rate are very vital in the practice of VBAC in low resource settings like West Africa where the luxury of continuous and adequate monitoring of labour in general and specifically in TOLAC population is not readily attainable. In this study as much as 26.7% of the previous CS population did not have any well defined delivery plan stated in their medical records prior to onset of labour (either planned repeat CS or TOLAC). This study has shown that with adequate patient selection based on specific criteria coupled with generous labour monitoring a higher VBAC rate can be achieved even in low resource settings like Ghana. In this regard we recommend careful history taking and physical examination, review of past medical records, discussing the options of delivery with women with a prior CS and indicating the patient preferred choice in her medical notes, bearing in mind that the initial choice of the patient may change in the course of the pregnancy.

The VBAC success rate determined in the current study is higher than rate of 52% previously reported over 10 years ago in the same hospital and this might be attributed to the stricter inclusion criteria used in our methodology in which we included only women with antenatally determined mode of delivery. It may also be due to general improvement in obstetric care in recent times as more women are slated for elective repeat CS with only those with comparatively higher chances of vaginal birth being scheduled for TOLAC. In this study, women who had successful TOLAC were generally younger, with higher parity, lower GA and smaller birth weights. The highest percentages of successful VBAC occurred between the gestational ages of 37 and 38 weeks with a sharp decline at 39 weeks and beyond. We found a gradual improvement in the trends of VBAC rate from a gestational of 34 weeks peaking at 37 weeks with a with a successful TOLAC rate of 72.2%.

In the current study, birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. On the other hand, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and higher chances of successful VBAC. More specifically, birth weights between 2.5 and 2.99kg were associated with the lowest incidence of failed TOLAC and highest chances of successful VBAC. Adanu and McCarthy determined that fetal weight greater than 3.45 kg tripled the odds of having a repeat CS over 10 years ago in the same hospital and this is comparable to the 3.5 kg or greater determined in our study8.

The current study was restricted to TOLAC in women with only one prior CS at KBTH although there have been publications in which successful vaginal deliveries have occurred after more than one prior CS with varying success rates which indirectly correlate with the increasing number of previous CS. In fact other organizations recommend TOLAC in women who have had more than one previous low transverse caesarean deliveries based on the availability of adequate continuous intrapartum fetal monitoring coupled with ready access to theatre for emergency repeat CS when it is urgently needed1,4,21. In KBTH and most West African countries women with a prior history of two or more low transverse CS are considered absolute contraindications to TOLAC based on the principle of significant increase in the risk of uterine rupture and relative lack of optimum intrapartum monitoring. We recommend that two or more previous CS remain absolute contraindication to TOLAC in the developing world where these challenges continue to exist. Other absolute contraindications include previous classical, low vertical T-and J uterine incisions as these are associated with increased risk of intrapartum uterine rupture12.

In the conduct of TOLAC we recommend strict monitoring of patient on the WHO partograph as this has been shown to significantly reduce both maternal and perinatal morbidity and mortality. The use of the WHO partograph results in early detection of deviations from normal labour such as primary dysfunctional labour, secondary arrest of cervical dilatation which might signify early indication of CPD which is a major cause of uterine rupture10. It is important to emphasize that adequately timed intermittent fetal heart auscultation in the conduct of VBAC is acceptable in areas where continuous monitoring is not readily accessible.

Among the women who had failed VBAC, CPD, slow progress and failure to progress constituted 45.4% of the indications for emergency repeat CS. Severe preeclampsia /eclampsia accounted for 15.4% of the indications for CS. In KBTH, preeclampsia/eclampsia constitutes a very prevalent high risk obstetric condition with significant adverse maternal outcomes and it there not surprising that it accounts for a significant proportion of caesarean indications22.

Significant proportion of women had planned repeat CS on account of maternal request and this might be due to fear of childbirth (Tocophobia) which is partly attributed to fear of labour pain, concerns over poor outcome for mother or baby, or previous birth experiences23. In general, the issue of maternal request as an indication for caesarean section is still debatable especially when there is no other obstetric indication. However, maternal request for CS in the background of a previous caesarean section is generally considered as a veritable caesarean indication and should not be misconstrued as controversial. In such cases adequate patient education and counselling should be undertaken to ensure clear patient understanding of the risk-benefit ratio associated with TOLAC recounting that both options are not without maternal and fetal complications. We recommend that patient education and counselling in the process of informed decision making towards TOLAC or otherwise should be initiated early in the antenatal period to enhance adequate comprehension of the realities related to the chosen mode of delivery. It is worth noting that such patient education might have a significant impact if initiated at the time of the primary CS and revisited during the early stages of subsequent pregnancies.

We, also, found that previous adverse pregnancy outcome, commonly designated as bad obstetric history (BOH), constituted 9.2% of women who were excluded from TOLAC and that might have been influenced by maternal desire to avoid vaginal delivery. In this study the major reasons for exclusion from TOLAC were suspected fetal macrosomia, fetal malpresentation, preeclampsia/eclampsia, post date, recurring indication and BOH.

The limitation of the study revolves around the retrospective nature of the design which did not allow for detailed information about the study participants to be obtained. There was no direct contact with the study participants to obtain their views about the quality of care they received in the course of the TOLAC. The strength of our study hinges on the large number of participants included in the study coupled with the stringent inclusion criteria with exclusion of women whose delivery plans were not adequately spelt out during the antenatal period. We recommend a large prospective study in our indigenous women to better understand the relativity of TOLAC and the associated complications and risks. This would inform policy and provide physicians with vital up-to-date information in helping women with one previous caesarean delivery to make informed decision regarding the mode of childbirth in subsequent maternities especially in our subregion. This will result in increased VBAC rates and improved quality of care among women undergoing TOLAC.

Conclusions

There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.