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CHAPTER III
DISCUSSION

Labor is a physiologic process during which the products of conception (the

fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus.
Delivery is the mode of expulsion of the fetus and placenta. Both are a normal
physiologic process that most women experience without complications. Cesarean
birth is the delivery of a baby through incisions made in the mothers abdomen
and uterus. There was a rapid increase in cesarean rates from 1996 to 2011.1,5,6
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 VBAC1.1,4,10
Some studies show that vaginal birth after two CS (VBAC-2) is associated
with a reasonable success rate (71.7%), although lower than VBAC-1 (76.5%).
The adverse maternal outcomes rates of VBAC-2 are higher than trial of VBAC-1,
but the absolute rates are small. 1,4
The most important issue regarding maternal wellbeing with respect to a
trial of VBAC is whether a catastrophic complication, such as uterine rupture, will
occur and lead to serious morbidity or death. Maternal death during labor and
delivery, regardless of the method of delivery, is uncommon.3

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In Lydon-Rochelles study, the observed rate of uterine rupture of 4.5 per

1000 among women with prior cesarean delivery was consistent with the results
of other studies (range, 3.2 per 1000 to 6.4 per 1000). Uterine rupture rate after
VBAC-2 was reported in all studies except by Flamm. The pooled uterine rupture
rate of 16 studies was 1.36%, ranging 05.4% within studies. Other studies
revealed that uterine rupture rates 0.72% in VBAC-1 versus 1.59% in VBAC-2.
An increased risk of uterine rupture may be attributed to factors other than labor
status at a second delivery among women with prior cesarean delivery, and these
factors may also influence the decision to undertake a trial of labor.1,4,10