CHAPTER I

INTRODUCTION

Caesarean section (CS) rates have risen worldwide. Performance of elective

repeat caesarean is one of the main reasons for the rise in caesarean rates, together
with fetal distress, dystocia and breech presentation. In UK, CS rate in women
with a previous caesarean is 67% as compared The National Sentinel Caesarean
Section Audit. In 2011, one in three women who gave birth in the United States
did so by cesarean delivery. Even though the rates of primary and total cesarean
delivery have plateaued recently, there was a rapid increase in cesarean rates from
1996 to 2011. Efforts to reduce the number of cesarean births, although initially
successful, failed to achieve the United States.1,2
Multiple CS are associated with placental adherence to scar (placenta
increta/praevia) which is a potential surgical challenge and a cause of maternal
morbidity and mortality. A trial of vaginal delivery after previous CS has been
accepted as a way to reduce the overall caesarean rate and also to allow women
choice for mode of delivery. Many studies have supported the efficacy and safety
of vaginal birth after caesarean after one caesarean section (VBAC-1) and reliable
figures of success rate and complications are available for counselling women for
VBAC-1. While clinicians, supported by guidelines from Society of Obstetricians
& Gynaecologists of Canada and American College of Obstetricians &
Gynaecologists, generally recommend or offer a VBAC-1, a trial of vaginal
delivery is generally not offered after two CS (VBAC-2).1,3

Each year in the United States, approximately 60 percent of women with a

prior CS have a VBAC in a subsequent pregnancy. Concern persists that a VBAC
may increase the risk of maternal complications as compared with elective CS.
Such complications include uterine rupture, which is uncommon but serious and
may result in hysterectomy, urologic injury, a need for blood transfusion, maternal
death, and perinatal complications, including neurologic impairment and death.3,4
Population-based studies of the relation between a VBAC and uterine
rupture have had methodological limitations and have produced inconsistent
findings. A study in Nova Scotia, Canada, reported that a VBAC was not
significantly associated with uterine rupture; however, in that study too, few
women had uterine rupture to provide meaningful results. In contrast, studies in
Switzerland and California demonstrated a significantly higher risk of uterine
rupture among women undergoing a VBAC than among women with elective
repeated CS. 1,3,4