Keywords : lower segment cesarean section ● vaginal birth after cesarean internal podalic version
Cesarean delivery rates are rising. In cases of previous cesarean delivery the absolute and relative risks associated with a trial of labor as compared with elective repeated cesarean are uncertain. Asakura and Myers 1 reported wound separations in 2.0% with two or more prior cesareans, compared to 1.1% with one prior cesarean and stated that overall important adverse outcomes were infrequent and not related to the number of previous cesareans. Martel and MacKinnon 2 searched MEDLINE database from January 1995 to February 2004 and suggested that a trial of labor in women with more than one previous cesarean section is likely to be successful but is associated with a higher risk of uterine rupture.
An unbooked 26 year old G4 P3 L2 A0 uneducated housewife from rural area was admitted on 21st March, 2005 with 7 months amenorrhea and pain in abdomen for one day. All her three deliveries were by cesarean section the last one being 2 years back. Her first cesarean section was an emergency operation for prolonged second stage and the baby died in the nursery. The subsequent cesarean sections were for previous cesarean section.
Her general condition was fair, build and nutrition average, temperature normal, pulse 88/minute and regular, and blood pressure 110/80 mmHg. Cardiovascular and respiratory systems were normal. She was mildly pale and had nontender midline abdominal scars of previous cesarean sections. Uterus was 30 weeks, size and the lie was transverse with head in the right lumbar region. Fetal heart rate was 142/minute and regular. She had strong uterine contractions. On vaginal examination cervix was 4.5 cm dilated and 50% effaced. Bag of membranes was elongated and the presenting part high up. Her hemoglobin was 9 g/dL and blood group O +ve. She was taken up for emergency cesarean section. In the operation theater vaginal examination was repeated. As the cervix was fully dilated and fully effaced the membranes were ruptured under general anesthesia and internal podalic version followed by breech extraction was carried out. She stood the procedure well. The premature male baby weighing1.5 kg and having apgar score of 8 was shifted to nursery. The mother was observed for 24 hours. Postpartum stay was uneventful and she was discharged on 5th day with a healthy baby. She underwent laparoscopic sterilization 3 months later.
Many women had successful vaginal births after two or more prior cesarean sections3. Bowyer and Chapman 4 reported a case of vaginal birth following three previous sections. The average success rate of vaginal birth after two or more previous cesareans is about 71- 72% 5. The available data show that the rate of uterine dehiscence is slightly high 6.
Spaans et al 7 after studying 246 women with a history of more than one previous cesarean section reported that 76% delivered by elective cesarean section and 24% had a trial of labor of whom 83% had a vaginal birth. Maternal morbidity and perinatal mortality did not differ in the two groups. Emembolu 8 showed that the risk of fetal outcome related to labor in patients with multiple cesarean sections was low and could be eliminated by careful patient selection and close intrapartum care.
We had no plans of delivering our patient vaginally. In fact she was taken to the operation theater for a planned repeat cesarean section. The finding in the operation theater that the cervix was fully dilated and that the fetus was premature tempted us to undertake internal podalic version and breech extraction.
