Successful experience of spontaneous labor after a single cesarean section

doi:10.21203/rs.3.rs-5084181/v1

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Successful experience of spontaneous labor after a single cesarean section

https://doi.org/10.21203/rs.3.rs-5084181/v1

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Introduction

The birth plan for pregnant women with a history of cesarean delivery is controversial nowadays, as many pregnant women want to repeat cesarean delivery instead of vaginal delivery, and fears of complications make some obstetricians avoid vaginal delivery.

Methods

A cross-sectional study was conducted at Al-Zahrawi Hospital in Damascus, during the period 20/12/2023 to 10/7/2024. The patients' files at the hospital were studied, and their number was 306 patients after applying the inclusion and exclusion criteria.

Results

The data of 306 pregnant women were studied, where 264 of them underwent a trial of labor and 42 underwent an elective cesarean section. The success rate of the trial of labor was (82.2%), compared to the failure rate of the trial of labor (17.8%). The majority of pregnant women in both groups had a body mass index of 25–29 kg/m2. Failure to complete vaginal delivery accounted for 61.7% of previous cesarean section indications in the group with current failed labor versus 34.6% in the group with successful labor. In the group with current failed labor, previous cesarean section indications such as elderly or high-risk pregnancy were higher than in the group with successful labor.

Conclusion

In this study, we found that the success rate of labor was 82.2%, with good cesarean scar in 64.5%.

Obstetrics & Gynecology

Cesarean section

labor

TOLAC

complications

The management of women with a previous cesarean has been controversial for the past 100 years. In 1916, Cragin made his famous statement: “once a cesarean always a cesarean.”.

The fear of uterine rupture was because the classical cesarean was the prevailing method at that time until 1921, when Kerr introduced the cesarean through an incision in the lower segment of the uterus. With the encouragement and support of the American College of Obstetricians and Gynecologists, several encouraging attempts were made to increase the rate of vaginal birth after cesarean (VBAC). These attempts were crowned with success, as the rate of vaginal birth after cesarean (VBAC) increased from 3.4% in 1980 to a peak of 28.3% in 1996 in the United States.

However, over the past 20 years, the rate of vaginal birth after cesarean (VBAC) has continued to decline. The rate of attempted vaginal birth after cesarean section in the United States has declined from about 28% in 1996 to 8% in 2006. ^[1]

In 2010, the American College of Obstetricians and Gynecologists published recommendations for vaginal birth after cesarean (VBAC) offering a trial of labor after cesarean (TOLAC) to most women with a single symptomatic cesarean.

However, barriers to offering a trial of labor and acceptance of TOLAC include patient preference, lack of facilities that offer TOLAC, and physicians' unwillingness to offer TOLAC due to concerns about liability.^[2]

In 2013, the success rate of a trial of labor in the United States for women who attempted TOLAC after one prior cesarean delivery was 70.4 percent, and for those with two or more prior cesarean deliveries, it was 51.4 percent.^[3]

In a 2010 analysis, the two factors that increased the odds of VBAC by at least threefold were having a prior VBAC and having a prior vaginal delivery.^[4] The most significant factor associated with TOLAC failure (i.e., cesarean delivery during labor) was having a prior cesarean delivery due to failure to progress after repeated induction.

Other factors that played a role, but were not strongly associated with TOLAC failure, included increased body mass index and older mothers. Induction of labor significantly reduced the odds of a successful trial of labor after a prior cesarean compared with having spontaneous labor. Unlike most medical decisions, where patients weigh the risks and benefits for themselves, pregnant women must weigh the risks and benefits for both themselves and their fetus. Most pregnant women are willing to accept a high degree of risk to themselves for zero or near-zero risk to their babies ^[5], although the desire to achieve a vaginal birth can sometimes lead to increased risk to the newborn, as in out-of-hospital TOLAC ^[6].

Aim of the study

Evaluation of spontaneous labor after single cesarean section and obstetric complications.

Cross-sectional study, conducted at Al-Zahrawi Hospital in Damascus, during the period 12/20/2023 to 7/10/2024. The patients' files in the hospital were studied and their number reached 306 patients after applying the inclusion and exclusion criteria. This was done through a form designed with the help of the research supervisor (included in the appendix), which contains a set of questions that serve the research objective. The approval of the Syrian Private University and the approval of Al-Zahrawi Hospital was obtained to enter and review the patients’ files.

Statistical analysis: Patients' data were tabulated and entered into the computer, and then the Statistical Package for the Social Sciences (SPSS) program, version (26), was used to analyze this data. The following statistical methods were used in the analysis: Descriptive analysis: This involves finding the relative frequency distributions of the categorical study variables. Inferential analysis: This part of the analysis aims to present and interpret the results and infer from them in order to reach the study's goal, by conducting the Chi Square test of independence to study whether there is a relationship between two descriptive variables by applying the Chi Square statistic.

We studied the data of 306 pregnant women, 264 of whom underwent a labor trial and 42 underwent an elective caesarean section. By studying this data statistically, we reached the following results

The research sample was divided into two main groups: the labor trial group and the direct (elective) caesarean section group without a labor trial. The labor trial group was divided according to the result into a group with a successful labor trial and thus completing the vaginal delivery, and a group with a failed labor trial and thus converting the birth to a caesarean section. The success rate of the labor trial was 217 (82.2%), compared to a failure rate of the labor trial of 47 (17.8%). (Table 1)

Table 1
		N	%	Total
labor experience	Success = vaginal birth	217	82.2	264/86.3%
labor experience	Failure = cesarean section	47	17.8	264/86.3%
elective caesarean section		42	13.7	42/13.7%
Total		306	100

Study of the relationship between different variables and the outcome of the labor experience

In this section, we studied the relationship between different variables and the outcome of the labor experience (success, failure and conversion to cesarean section), and we reached the following results

(Table 2) shows that the average age of the pregnant woman and the gestational age were greater in the group with a successful labor experience, but the difference was not statistically significant. The average period between the current birth and the previous cesarean section was greater in the group with a successful labor experience, and by a statistically significant difference.

Table 2
	Successful labor experience		Failed labor trial		P-Value
	Mean	St.D	Mean	St.D	P-Value
Age (years)	27.7	6.7	26.5	6.7	0.294
Gestational age (weeks)	37.9	1.4	37.5	2.1	0.064
The period between the previous cesarean section and the current pregnancy	4.1	3.1	2.6	1.5	0.002

From (Table 3) we note that the majority of pregnant women in both groups had a body mass index of 25–29 kg/m2 and represented the largest category in both the failed and successful labor trial groups, while a body mass index of less than 25 kg/m2 represented 0.5% of the successful labor trial group and 2.1% of the failed labor trial group, but the difference between the two groups was not statistically significant.

Table 3
	Successful labor experience		Failed labor trial		P-Value	Failed labor trial	Successful labor experience
	N	%	N	%	P-Value	Failed labor trial	Successful labor experience
< 25 Kg/m²	1	0.50%	1	2.10%	0.378	50%	50%
25–29 Kg/m²	214	98.60%	45	95.70%		17.40%	82.60%
≥ 30 Kg/m²²	2	0.90%	1	2.10%		33.30%	66.70%

From (Table 4) we note the following: The percentage of pregnant women who had a history of vaginal birth before or after cesarean section was greater in the group with a successful trial of labor and by a statistically significant difference, and the percentage of successful trial of labor was greater in the case of a vaginal birth after cesarean section. The average number of previous vaginal births was generally close between the two groups, and the average number of previous vaginal births after cesarean section was greater in the group with a successful trial of labor, but the differences were not statistically significant.

Table 4
	Successful labor experience		Failed labor trial		P-Value	Failed labor trial	Successful labor experience
	N	%	N	%	P-Value	Failed labor trial	Successful labor experience
Previous vaginal birth	137	63.10%	12	25.50%	< 0.001	8.10%	91.90%
Vaginal birth before cesarean section	91	41.90%	12	25.50%	0.037	11.70%	88.30%
Vaginal birth after cesarean section	73	53.30%	3	6.40%	< 0.001	3.90%	96.10%
	Mean	St. D	Mean	St. D	P-Value
Number of vaginal deliveries	2.9	1.9	2.9	2	0.965
Number of previous vaginal births before cesarean section	2.8	1.8	2.7	2.1	0.884
Number of vaginal births after previous cesarean section	2.1	1.4	1	0	0.172

From (Table 5) we note the following: Labor disorders (failure to progress, cessation of descent, cessation of dilation) constituted 61.7% of the indications for previous cesarean section in the group in which the current trial of labor had failed, compared to 34.6% in the group in which the trial of labor had succeeded. In the group in which the trial of labor had succeeded, previous cesarean section with relative indications such as: eclampsia, hydrocephalus, umbilical prolapse, genital warts, multiple pregnancy, abnormal placenta, in addition to cesarean section of unknown cause were higher than in the group in which the trial of labor had failed.

Table 5
	Successful labor experience		Failed labor trial		P-Value	Failed labor trial	Successful labor experience
	N	%	N	%	P-Value	Failed labor trial	Successful labor experience
Eclampsia	1	0.50%	0	0%	0.018	0%	100%
Hydrocephalus	1	0.50%	0	0%		0%	100%
Elective	7	3.20%	0	0%		0%	100%
Umbilical cord prolapse	4	1.80%	0	0%		0%	100%
fetal pain	13	6%	2	4.30%		13.30%	86.70%
genital warts	1	0.50%	0	0%		0%	100%
Dear Pregnant	2	0.90%	1	2.10%		33.30%	66.70%
Multiple pregnancy	21	9.70%	1	2.10%		4.50%	95.50%
long term pregnancy	1	0.50%	0	0%		0%	100%
Labor disorders	75	34.60%	29	61.70%		27.90%	72.10%
old woman	0	0%	2	4.30%		100%	0%
Placenta accreta	69	31.80%	9	19.10%		11.50%	88.50%
Placental abruption	1	0.50%	0	0%		0%	100%
unknown	21	9.70%	3	6.40%		12.50%	87.50%

From (Table 6) we note the following: The average weight of the newborn was close between the two groups and the difference was not statistically significant. The proportion of newborns weighing less than 2500 g or more than 3500 g was greater in the group with a successful trial of labor, while the proportion of newborns weighing 2500–3500 g was greater in the group with a failed trial of labor, but without statistical significance for the difference.

Table 6
	Successful labor experience		Failed labor trial		P	Failed labor trial	Successful labor experience
	Mean	St.D	Mean	St.D	P	Failed labor trial	Successful labor experience
newborn weight	3156.8	378.1	3221.3	271.8	0.269	-	-
	N	%	N	%	P
< 2500 g	4	1.80%	0	0%	0.525	0%	100%
2500–3500 g	188	86.60%	43	91.50%		18.60%	81.40%
> 3500 g	25	11.50%	4	8.50%		13.80%	86.20%

From (Table 7), we note that the most common cause of cesarean section and failure of the labor trial was: labor disorders, followed by severe pain at the scar site, then fetal pain. Uterine rupture occurred in one case, and there was suspicion of placental abruption in one case as well.

Table 7
	N	%
Severe pain at the site of the scar	5	10.6%
fetal pain	3	6.4%
uterine rupture	1	2.1%
Placental abruption suspected	1	2.1%
Labor disorders	37	78.7%

Study of the relationship between the studied variables and the labor experience

In this section, we studied the relationship between the different variables and the labor experience with the aim of determining their impact on the choice of the labor experience in the entire research sample, and we reached the following results

From (Table 8), we note the following: The average age of the pregnant woman is greater in the labor experience group, while the average gestational age is greater in the elective cesarean section group, but the difference was not statistically significant. The average period between the previous cesarean section and the current birth is greater in the labor experience group, with a statistically significant difference.

Table 8
	labor experience		electoral caesarean		P-Value
	Mean	St.D	Mean	St.D	P-Value
Age (years)	27.4	6.7	26.6	8.1	0.486
Gestational age (weeks)	37.9	1.5	38.1	1.7	0.358
The period between the previous cesarean section and the current pregnancy	3.8	2.9	2.8	2.4	0.049

From (Table 9) we note that the percentage of pregnant women with a body mass index between 25–29 kg/m2 was greater in the labor experience group, while the percentage of pregnant women with a body mass index < 25 or ≥ 30 kg/m2 was greater in the elective cesarean section group, but the difference was not statistically significant.

Table 9
	labor experience		electoral caesarean		P-Value
	N	%	N	%	P-Value
< 25 Kg/m²	2	0.80%	2	4.80%	0.083
25–29 Kg/m²	259	98.10%	39	92.90%
≥ 30 Kg/m²	3	1.10%	1	2.40%

From (Table 10) we note the following: The percentage of having a previous vaginal birth in general, as well as a vaginal birth after a previous caesarean section, is greater in the experience group with a statistically significant difference. The percentage of having a history of vaginal birth before a previous caesarean section is greater in the elective caesarean section group, but without statistical significance for the difference.

Table 10
	labor experience		electoral caesarean		P-Value
	N	%	N	%	P-Value
Previous vaginal birth	149	56.40%	8	19%	< 0.001
Vaginal birth before cesarean section	103	69.10%	8	100%	0.062
Vaginal birth after cesarean section	76	51%	0	0%	0.005

This study included a group of pregnant women with a history of one cesarean delivery who underwent a labor trial and studied the relationship of different variables with the success or failure of the labor trial. There was also a group of pregnant women who underwent an elective cesarean section to compare the variables with them as well as to explore the rates of complications in it.

The success rate of the labor trial and completion of vaginal delivery in the current study was 82.2%, which is a good rate compared to comparative studies in which the success rate of the labor trial was 33.9–87.2%, indicating a good chance of completing vaginal delivery after a history of cesarean delivery.

By studying the relationship between the success of the labor experience and the age of the pregnant woman and the gestational age, this relationship was not statistically significant, as it was close between the two groups, and this is consistent with comparative studies with the exception of the study by Xing ^[7], which found that the average age of pregnant women was younger in the vaginal delivery group and by a statistically significant difference. As a result, it can be said that the age of the pregnant woman and the gestational age are not associated with the success of the labor experience in most studies, with the possibility of difficulty in completing vaginal delivery in older pregnant women according to the study by Xing ^[7]. In the current study, the average period between the previous cesarean section and the current birth was greater in the case of a successful labor experience and by a statistically significant difference.

This can be explained by the fact that increasing the period between pregnancies reduces pregnancy complications that may be a reason for switching to a cesarean section, the most important of which is pain at the site of the scar, as the longer period between pregnancies improves the organization of the previous cesarean scar, which results in the possibility of less pain. The body mass index of the majority of pregnant women in the current study was between 25–29 kg/m2 and represented the largest category in both the failed and successful labor group, while the body mass index less than 25 kg/m2 represented 0.5% of the successful labor group and 2.1% of the failed labor group, but the relationship between body mass index and successful labor was not statistically significant. In the study of Xing ^[7], who studied the relationship between weight gained during pregnancy and successful labor, he found that gaining 15–20 kg during pregnancy was associated with an increased rate of successful labor with a statistically significant difference. In the study of Patel ^[8], he studied the relationship between the average body mass index and successful labor and found that it was close between the two groups and the difference was not statistically significant. As a result, it can be said that the relationship between body mass index and successful labor needs more research and investigation, but with a tendency towards successful labor in cases of average body mass index. The success of the labor experience was accompanied by a high rate of vaginal birth history before or after a previous cesarean section, with a statistically significant difference, which was consistent with the results of most comparative studies. As a result, a previous vaginal birth increases the chances of a successful labor experience, and this may be related to the absence of some factors that increase the likelihood of the need for a cesarean section. Also, a pregnant woman undergoing a vaginal birth increases her ability to tolerate labor in subsequent births and reduces the fear of pain associated with vaginal birth in many pregnant women. The relationship between the success of the labor experience and the indication for a previous cesarean section was statistically significant. The rate of each of the previous labor disorders, multiple pregnancy, and elderly pregnant women was higher in the case of labor disorders, but the difference was clear in the case of labor disorders, which indicates the presence of factors that hinder or weaken the chances of completing a vaginal birth that were previously present or repeated in the current pregnancy.

The relationship between the weight of the newborn and the success of the trial of labor was not statistically significant, similar to the results of the Eleje study ^[9], while in the Xing study ^[7], the average weight of the newborns was greater in the case of failed trial of labor by a statistically significant difference, which may be due to the presence of macrosomia in some newborns in this study, which led to difficulty in completing vaginal delivery, so the relationship between the weight of the newborn and the success of the trial of labor needs further research.

Failure to complete vaginal delivery was the most common indication for caesarean section and failed trial of labor, followed by severe pain at the scar site and fetal pain, and there was one case of uterine rupture and one case of suspected placental abruption.

The differences between the trial of labor group and the elective caesarean group were studied to reveal the relationship of these variables with the choice to undergo the trial of labor, as well as to study the differences in outcomes between the two groups.

The mean age of the pregnant woman, the gestational age, and the distribution of pregnant women according to body mass index were close between the two groups, while the mean interval between the current pregnancy and the previous cesarean section was greater in the labor experience group by a statistically significant difference, and as a result, spacing pregnancies increases the pregnant woman's ability to undergo labor experience.

The percentage of having a history of vaginal birth was greater in the labor experience group by a statistically significant difference, and as a result, previous vaginal birth increases the pregnant woman's ability to undergo labor experience.

In this study, we found that the success rate of the labor trial was 82.2%.

Declarations Ethical statement:

The ethical consent was obtained from Syrian private university ethical committee Competing Interest: the authors declare no competing of interests.

Availability of data and materials:

All data are available from the corresponding author on reasonable request.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Appendix is not available with this version.

The authors declare no competing interests.

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Successful experience of spontaneous labor after a single cesarean section

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Abstract

Background

Methods

Results

Discussion

Conclusion

Declarations

References

Appendix

Additional Declarations

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