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 Table of Contents  
Year : 2016  |  Volume : 15  |  Issue : 2  |  Page : 97-99

Vaginal delivery after three previous caesarean sections: A report of two cases

Obstetrics and Gynaecology Department, University of Abuja Teaching Hospital, Gwagwalada, FCT-Abuja, Nigeria

Date of Web Publication13-Jan-2017

Correspondence Address:
Olatunde Onafowokan
Obstetrics and Gynaecology Department, University of Abuja Teaching Hospital, Gwagwalada, FCT-Abuja
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2384-5589.198318

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Vaginal birth after one caesarean section (CS) is considered safe in selected women. However, women with more than one CS in low-income settings are at higher risk of complications with vaginal birth. Thus, abdominal delivery is recommended for women with more than one CS in low-income countries unlike in high-income countries. This study was designed to raise awareness on the remote possibility of safe vaginal delivery after three CS in low-income countries. The records of two women who had vaginal deliveries after three previous CS were retrieved and reviewed. Both women presented in advanced labour and had unplanned but successful vaginal deliveries. There was no uterine rupture. The risks and consequences of uterine rupture may outweigh the benefits of unplanned vaginal birth after more than one CS. These unusual cases suggest the remote possibility of success and the need for further studies on defining safety guidelines for low-resource settings.

Keywords: Birth, caesarean, previous, sections, three, vaginal

How to cite this article:
Onafowokan O, Akaba GO, Adebayo F. Vaginal delivery after three previous caesarean sections: A report of two cases. Afr J Med Health Sci 2016;15:97-9

How to cite this URL:
Onafowokan O, Akaba GO, Adebayo F. Vaginal delivery after three previous caesarean sections: A report of two cases. Afr J Med Health Sci [serial online] 2016 [cited 2021 Apr 19];15:97-9. Available from: http://www.ajmhs.org/text.asp?2016/15/2/97/198318

  Introduction Top

Delivery after a caesarean section (CS) is associated with increased risk of uterine rupture. However, recent evidence has not shown any significant difference in outcomes between planned Vaginal Birth After Caesarean section (VBAC) and elective repeat CS (ERCS).[1] Failed VBAC has been shown to have a poorer outcome than ERCS.[2] With proper guidelines, the risk of rupture can be minimized. This led to high success rates being reported for VBAC after one previous CS (VBAC-1) and its global recommendation.[3],[4]

Similarly, there are reports of successes with planned vaginal delivery after two and three CSs (VBAC-2 and VBAC-3).[3],[4],[5] Cahill et al.[6] also reported that there was no significant difference in success rates between VBAC-1 and VBAC-3. Hence, VBAC-3 and its benefits are not new to high-income countries.[3],[4],[5] These benefits include avoidance of surgery and its complications, reduced hospital stay and hospital cost, early ambulation and higher chances at subsequent VBAC.[3],[4],5]

However, in low-resource settings wherein aversion to surgery, high parities and low contraceptive uptakes prevail, VBAC after multiple CSs is considered dangerous because of limitations in equipment, monitoring and early intervention.[2],[7],[8] Hence, ERCS is inevitable in such settings. Unfortunately, ERCS is also associated with higher risks as the order of CSs increases,[5] thus, posing a major challenge for obstetricians practicing in such settings. The two cases reported may suggest the need for further research into identifying safety guidelines for VBAC after more than one CS.

  Case History Top

Case no. 1

Mrs. O.V. was a 36-year-old gravida 4 para 3+0 woman with three living children. She was 1.58 m tall. Her three previous deliveries in 2004, 2007 and 2009 were by CS. The indications for CS in the previous deliveries were foetal distress, placenta praevia and two previous CS, respectively. The birth weights were between 3.0 and 3.4 kg.

In 2012, she was booked at 36 weeks gestation and was counselled for ERCS at 38 weeks. She, however, defaulted the admission only to present in spontaneous labour 5 days after the planned ERCS. At presentation she was clinically stable and had active uterine contractions. The foetus was in longitudinal lie, cephalic presenting and the head was engaged. Vaginal examination revealed clear liquor, cervical dilation of 8 cm and the presenting part was vertex at station +2. She subsequently had a spontaneous vaginal delivery (SVD) 30 min later while arrangements for CS were just being concluded. The foetal outcome was a 3.5 kg neonate with Apgar scores of 8 and 9 at the 1st and 5th min, respectively.

She had primary postpartum haemorrhage from cervical lacerations. The estimated blood loss (EBL) was 650 ml. Her lacerations were repaired and she was discharged home on the 3rd day with haematinics and prophylactic antibiotics. Her puerperium was eventful.

Case no. 2

Mrs. G.E.C. was a 32-year-old gravida 4 para 3+1 woman with three living children. She was 1.53 m tall. She had a CS for obstructed labour in 2004. The baby weighed 2.85 kg and had good Apgar scores. Her second CS was in 2006 at a Mission hospital, but she was not aware of the indication or baby’s birth weight. She had a miscarriage in 2008 and an ERCS in 2009 for a 2.5 kg baby. She did not experience any postoperative complications.

In 2012, after unremarkable antenatal care, she and her husband consented to ERCS and bilateral tubal ligation. However, she presented with ’head on perineum’ at 36 weeks gestation and had an SVD while still being admitted. The foetal outcome was a 2.2 kg neonate with APGAR scores of 9 and 10 at 1 and 5 min, respectively. The EBL was 200 ml. The tubal ligation was declined but she chose another form of contraception. Her puerperium was unremarkable.

The lower uterine segment was not explored in both women.

  Discussion Top

The aforementioned two women had unplanned but successful vaginal birth after three CSs in a hospital wherein the policy for such women is ERCS based on constraints in meeting the recommendations for VBAC after high-order CSs.[9] The deliveries could easily have ended in severe morbidity or mortality. Therefore, the success of VBAC-3 in the two women was unusual and unexpected in this clime. Only one case report from Nigeria was found in literature.[10]

The unusual success may be attributed to the favourable maternal ages, good inter-pregnancy intervals, absence of complicated scars, cephalic presenting average-sized babies, spontaneous labour and good labour progress as reported by several workers.[3],[4],[7],[9] The absence of ‘classical scars’ and other absolute contraindications to vaginal delivery such as major praevia could also have favoured the successful outcome in both women. Studies have also shown that high-order CSs for lower segment scars were not absolute contraindications to VBAC as was seen in these two women.[3],[4],[9] However, isolated cases of success with VBAC after one ‘classical’ scar have been reported.[10],[11]

Ironically, both women never had previous vaginal deliveries, a major predictor of successful VBAC.[3],[4] The genital laceration sustained by Mrs. O.V. suggest that she may have hurriedly pushed out the baby to avoid a repeat CS section to which she had earlier consented. This attitude and the late presentation in labour by both women are in agreement with the suggestions by Ugwu et al.[8] that there is a strong aversion to caesarean delivery among women in Nigeria. Mrs. G.E.C. had her first CS for obstructed labour, which is a recurrent indication, thereby making vaginal delivery a dangerous decision. Her unusual success in vaginal delivery may also have been due to prematurity and lower birth weight, which have been reported to favour vaginal delivery.[3],[5]

  Conclusion Top

The risks and consequences of uterine rupture may outweigh the benefits of unplanned VBAC after more than one CS. Unusual cases like these suggest the remote possibility of success and the need for further studies on defining safety guidelines for low-resource settings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database Syst Rev 2013. Art. No.: CD004224. doi: 10.1002/14651858.CD004224.pub3.  Back to cited text no. 1
Wanyonyi SZ, Ngichabe SK. Safety concerns for planned vaginal birth after caesarean section in sub-Saharan Africa. BJOG 2014;121:141–4.  Back to cited text no. 2
Royal College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Birth. Green-top Guideline No. 45. London: RCOG; 2015.  Back to cited text no. 3
American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010;116:450–63.  Back to cited text no. 4
Cook J, Jarvis S, Knight M, Dhanjal M. Multiple repeat caesarean section in the UK: Incidence and consequences to mother and child. A national, prospective, cohort study. BJOG 2013;120:85–91.  Back to cited text no. 5
Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones G. Vaginal birth after caesarean for women with three or more prior caesareans: Assessing safety and success. BJOG 2010;117:422–7.  Back to cited text no. 6
Gupta P, Jahan I, Jograjiya GR. Is vaginal delivery safe after previous lower segment caesarean section in developing country? Niger Med J 2014;55:260–5.  Back to cited text no. 7
  Medknow Journal  
Ugwu GO, Iyoke CA, Onah HE, Egwuatu VE, Ezugwu FO. Maternal and perinatal outcomes of delivery after a previous Cesarean section in Enugu, Southeast Nigeria: A prospective observational study. Int J Womens Health 2014;6:301–5. doi: 10.2147/IJWH. S56147.  Back to cited text no. 8
Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2) − A systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010;117:5–19.  Back to cited text no. 9
Ojule J, Anyanwuocha K. Vaginal birth after three previous caesarean sections: A case report. webmed central. Obstet and Gynecol 2010;1:WMC00918.  Back to cited text no. 10
Ande AB, Onafowokan O, Njoku GC. Two vaginal deliveries after 10 a classical caesarean section: Case reports. Niger Postgrad Med J 2003;10:110–2.  Back to cited text no. 11
  Medknow Journal  


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