The outcome of Trial of Labour After Cesarean (TOLAC) in a Sri Lankan tertiary care center
and development of a risk-prediction model.
Dr. V.J. Meegoda1, Dr. K.G. Hewawitharana2, Dr. W.D.T.A. Mahathanthila1, Dr. M.A.N.P. Dilruvan2, Dr. D. Samaranayake3
1Faculty of Medicine, University of Colombo, Sri Lanka. 2Department of Gynaecology and Obstetrics, De Soyza Maternity Hospital, Colombo, Sri Lanka. 3Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
INTRODUCTION
•Rising Caesarean Sections(CS) rate is a major challenge for obstetricians & to the local health system.
•Previous CS being the commonest indication for CS; TOLAC becomes an important alternative.
•However, TOLAC is known to be associated with complications.
•A scoring system to identify women who can achieve Vaginal Birth After Cesarean (VBAC) following TOLAC is a timely need.
METHODOLOGY
•Study was conducted as a retrospective cohort study based of secondary data from DeSoyza hospital, which is the premier maternity hospital in the country.
•Data was extracted from health records of 328 mothers who had presented for delivery with previous one CS, and no contraindication for vaginal delivery (VD).
•Factors associated with VBAC were analyzed using Chi-square followed by binary logistic regression at significance of P<0.05.
•Variables significantly associated with VBAC were assigned points based on strength of association and a scoring system was developed.
RESULTS
•Mean age of the mothers were 31.2 years and 9.1% had parity >3.
•While 17.4% had a history of VD, 9.8% had already undergone VBAC.
•Majority of previous CS (63.1%) were done as emergencies with the commonest (43.9%) indication being fetal distress (FD).
•Majority had normal CTG (91.5%) and Modified Bishops Score (MBS)<7 (70.9%) on admission.
•In the index pregnancy, 125 (38.1%) underwent TOLAC of which 81 (24.7%) succeeded while 44 (13.4%) failed, leading to emergency CS.
•Majority of 51.8% had undergone elective CS, and 10.1% had emergency CS for other reasons.
•Mothers who had undergone TOLAC (n=125) were selected for model development, of whom 64.8% (n=81) had achieved VBAC.
•Previous VD (p=0.053), previous VBAC (p=0.025), FD not contributing for preceding CS (p=0.010), MBS on admission >7 (p=0.003), higher cervical effacement on admission (p=0.008), maternal age <30 years (p=0.066) showed significant associations with VBAC.
•Binary logistic regression revealed following as determinants of VBAC: history of VBAC (OR=11.4, p=0.05), FD not being an indication for previous CS (OR=5.5, p=0.003), MBS >7 on admission (OR=14.4, p=0.048) and maternal age <30 (OR=3.5, p=0.027).
CONCLUSION
This scoring system can be utilized to predict the success of TOLAC and thereby reduce the rate of unwarranted CS.
