Induction of Labour for Trial of Vaginal Birth After Caesarean Section in a Remote District Hospital

EDITORIAL COMMENT: We accepted this paper because it expresses an obstetric philosophy evolved in the circumstance of obstetrics practice in a hospital 1,800 km from a State capital city with patients whose homes may be hundreds of km from the ‘local’ hospital. In this setting induction of labour is more than a social convenience. This paper explores the hypothesis that it is reasonable to practise this finesse even when the woman has had a Caesarean section and wishes to achieve a vaginal delivery. This series is, as the authors indicate, very small ‐ absence of perinatal mortality or uterine rupture in 33 cases of trial of vaginal delivery after Caesarean section, with induction of labour in 26 of them, does not prove that the procedure is safe even if the obstetrician has the experience necessary to perform Caesarean hysterectomy should uterine rupture occur. Targett (A) reviewed a series of 1,577 patients having trial of vaginal delivery after Caesarean section and reported an incidence of uterine rupture of 0.8%. He concluded that to ensure the greatest chance of vaginal delivery with optimum safety, the onset of labour should be spontaneous. It is against this background that the excellent results in this small special series from Port Hedland should be viewed. Our statistician commented that with 33 cases and given a 0.8% chance of scar rupture, the study would have a 77% probability of finding no cases of uterine rupture just by chance. However, it does say with 80% certainty that the rupture rate is not more than 5%! The takeaway message from this report seems to be that induction of labour was favoured, not to increase the success rate of vaginal delivery after Caesarean section, but to satisfy the problems of planning the time of delivery within hours in women who had a previous Caesarean section and were living remote from a hospital with staff not routinely available to monitor labour and deal with any complications. Summary: In a retrospective review of 79 women with 1 or more previous Caesarean section, 33 (41.8%) women agreed to a trial of vaginal birth. Twenty nine women had labour induced and 26 (89.7%) of them had a successful vaginal delivery. Four women laboured spontaneously and 1 of them needed an emergency Caesarean section for failure to progress. The overall vaginal delivery rate for women selected to undergo a trial of vaginal birth after Caesarean was 87.9%. The overall emergency Caesarean section rate was 4 of 33 (12.1%). During the study period the Caesarean section rate for the hospital fell from 32.2% to 11%. This study suggests that induction of labour in women with a previous Caesarean section is very successful in achieving vaginal delivery and has a role to play in remote and rural hospitals.