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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Dr. Mamta Gupta
Consultant
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Aug 2018




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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2010 | Month : February | Volume : 4 | Issue : 1 | Page : 2005 - 2009 Full Version

Outcome of a Post Caesarean Pregnancy in a Tertiary Center of a Developing Country


Published: February 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.624
BHAT BPR **, SAVANT R *, KAMATH A***

*(D.G.O),** (M.D),*** (M.D) Department of Obstetrics and Gynaecology, Father Muller Medical College, Kankanady,Mangalore - 575 002,Karnataka,(India)

Correspondence Address :
B. Poornima Ramachandra Bhat,
Assistant Professor, Dept of
Obstetrics and Gynecology,Father
Muller Medical College, Kankanady,
Mangalore - 575 002, Karnataka, (India)Fax: 0824-2437402Email:
bprbhat@rediffmail.com,Tel no.:+91
94489 53435

Abstract

Background: An expectant attitude and individualization with respect to the management of pregnancy and labour in patients who had one caesarean section is not only justifiable, but represents sound and conservative obstetrical practice.
Aims:
1. To study the success rate of vaginal birth after caesarean delivery
2. To know the commonest indication for elective and emergency caesarean section
Methods: A total of 219 cases with a history of previous caesarean section beyond 28 weeks of gestation were included in the study. The collected data was analyzed by chi-square test.
Results:The incidence of post caesarean pregnancy cases were 219(8.76%). Out of these, 113 (51.6%) were selected for trial of labour and 106(48.4%) underwent elective repeat caesarean section. Of the 113 women who were allowed for a trial of labour, 73(64.6%) delivered vaginally and 40(35.4%) delivered by emergency repeat caesarean section. Thus, the success rate of VBAC was 64.6%. So a total of 146(66.7%) women underwent repeat caesarean section and 73(33.3%) delivered vaginally. Cephalopelvic disproportion was the most common indication for elective repeat caesarean section and foetal distress for emergency caesarean section.
Conclusion: VBAC should be considered in cases of previous one caesarean delivery for non recurrent indications.

Keywords

Vaginal birth after caesarean section, repeat caesarean section, trial of labour, scar dehiscence, maternal morbidity.

Introduction
For many decades, a scarred uterus was believed to contraindicate labour, out of fear of uterine rupture. In 1916, Craigin pronounced “Once a caesarean always a caesarean”. The year 1978 was a milestone in the history of prior caesarean delivery. Merill and Gibbs (1) reported that subsequent vaginal delivery was safely attempted in 83% of their patients with prior caesarean deliveries. This report served to rekindle interest in vaginal birth after prior caesarean (VBAC). The realization of ever increasing caesarean rates and that a carefully monitored attempt at vaginal delivery in previous caesarean delivery cases is indeed safe has propagated this concept greatly.

There is wide variation in the VBAC rates pronounced by hospitals and physicians. The present study was undertaken to re-ascertain these facts with the hope that more women will be encouraged to avoid an unnecessary repeat caesarean section by opting for vaginal delivery.

VBAC offers distinct advantages over repeat caesarean section, since the operative morbidity and mortality are completely eliminated, the hospital stay is much reduced and the expenses involved are much less. The rate of caesarean section needs to be reduced and this can be achieved to a small extent by avoiding a primary caesarean section done without explicit indications and more importantly, by resorting to a trial of vaginal delivery after previous caesarean section, which is safe for the foetus(2).

Material and Methods

This descriptive study was conducted from 1st January 2007 to 31st January 2008. All patients with a history of previous caesarean section beyond 28 weeks were included. Complete history including indication of previous caesarean section, the details of the present pregnancy, foetal size, amount of liquor, scar tenderness, pelvic adequacy and any other disorders were recorded.

The patients were followed up from admission to discharge from the hospital. The mode of delivery, morbidity (maternal and neonatal) and mortality were noted. Patients with a history of previous caesarean section who were not given the trial of labour underwent elective repeat caesarean section (ERCS). The ERCS group also included those patients who were not allowed the trial of labour (TOL) and had repeat caesarean section, although the caesarean section was done on an emergency basis. Patients who had a failed trial of labour underwent emergency caesarean section. These were included in the emergency section group. This study was approved by the institutional ethical committee. The collected data was analyzed by chi-square test.

Results

During the study period, there were a total of 2498 deliveries out of which 219 women had a previous caesarean section, which constitutes 8.76% of the patients. Of the 219 women with a previous caesarean section, 113(51.6%) were selected for the trial of labour and 106(48.4%) underwent elective repeat caesarean section (p=0.636, not significant).

Of the 113 women who were allowed a trial of labour, 73(64.6%) delivered vaginally and 40(35.4%) delivered by repeat caesarean section. Thus, the success rate of vaginal birth after caesarean section delivery was 64.6% (p=0.002, highly significant). 73(33.3%) women delivered vaginally and 146(66.7%) underwent repeat caesarean section (p=0.000, highly significant) out of the 219 cases with previous caesarean section.

The study shows that 4(5.4%) delivered by vacuum application out of the 73(33.3%) vaginal deliveries. The indication for vacuum application was foetal distress in three cases and the failure of maternal bearing down efforts in one case.

Cephalopelvic disproportion (CPD) was the most important indication for elective repeat caesarean section, accounting for 49% of elective repeat caesarean section, (Table/Fig 1) [Table 1, x2=96.755,p=0.000] , whereas foetal distress (37.5%) was the most common indication in the emergency caesarean section group (Table/Fig 2) [Table 2, x2=23.7, p=0.01].

Of those 12 women whose primary caesarean section was done for CPD, 75% delivered vaginally, whereas 70.5% and 64% of women who underwent primary caesarean section for foetal distress and malpresentation respectively, delivered vaginally (Table/Fig 3) [Table 3, χ2=7.457, p=0.488 not significant].

73% of the women with previous caesarean section, who also had a prior vaginal delivery, delivered vaginally, as compared to 62% of the women who did not undergo prior vaginal delivery. This difference was statistically not significant. Out of the 82 women who were in spontaneous labour, 67% delivered vaginally, where as out of the 20 who were induced with oxytocin, 45% delivered vaginally. This is not statistically significant.

Women who underwent emergency caesarean section had more intra operative complications like bladder injury, extension, haematoma etc. than those who had elective repeat caesarean section. This was statistically significant (p=0.041). 3(2.65%) cases of scar dehiscence were found in 113 patients who were allowed the trial of labour. There were no cases of uterine rupture. Though emergency caesarean section was associated with a 20% maternal morbidity as compared to 9.5% with vaginal delivery and 10.3% with elective repeat caesarean section, this is not a statistically significant difference.

In the majority of the cases where repeat caesarean section was performed, the babies weighed more than 3 kg, whereas in the vaginal delivery cases, the babies weighed less than 3 kg. This was statistically significant (p=0.01).

Emergency caesarean section was associated with 20% perinatal morbidity as compared to 16.4% for vaginal delivery and 1.8% for elective repeat caesarean section. This was statistically significant (p=0.000). There were no perinatal deaths in this study.

Women who had a successful vaginal delivery had a significantly lesser duration of hospital stay as compared to those who had a caesarean section (p=0.0005 highly significant).

Discussion

There has been a steady rise in cases with previous caesarean section over the past few decades. Miller et.al.(3) reported a post caesarean pregnancy rate of 8.1% in 1983 and 14.1% in 1992. Our study showed a post caesarean pregnancy rate of 8.7%. Published literature shows that there has been 70 to 80% success in attempts at VBAC (2),(3),(4),(5),(6),(7). We had a 64.6% success in those who had trial of labour. Aisien et.al.(8) reported a 48.1% incidence of vaginal delivery in previous caesarean section cases, whereas Chabra et.al reported an incidence of 32.4% (9). Our study reported a 33.3% incidence of vaginal delivery in previous caesarean section cases.

Miller et.al. reported a 2.3% incidence of women with multiple caesarean section (3), whereas our study showed the incidence to be 5.6%. Singh et.al reported a 92.8% success rate in vaginal delivery with oxytocin induction (10), whereas our study reported a lower success rate of 58%. The incidence of instrumental delivery in our study was 5.4% as compared to 12.6% and 10.7% reported by Singh et.al (7) and Shah et. al (10), respectively.

Miller et. al. had reported vaginal delivery in 52% of those with CPD, 84% in those with breech presentation and 54% in those with foetal distress as indication of previous caesarean section (3). Our respective figures were 75%, 66.6% and 70.5% in the 3 cases.

In the present study, intraoperative complications like haematoma, bladder injury etc. were found in 57.5% of the cases of the emergency caesarean group as compared to 38.6% of the elective repeat caesarean section group. This was statistically significant (p=0.041). Scar dehiscence was found in 3(2.65%) cases during emergency repeat caesarean section. In all the three cases, oxytocin was not used. There were no cases of scar rupture in our study. Singh et. al. reported a scar dehiscence rate of 1.67%10 .Carolyn et.al in their study of women with previous caesarean section, reported uterine rupture rate of 2.3% in those induced with oxytocin or PGE2 gel as compared to 0.7% among women with spontaneous labour (11). In patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0% as compared to 0.4% in the non- augmented, spontaneously labouring patients. Locateli et.al reported a uterine rupture rate of 0.3% in women with previous caesarean section as compared to 0.03% in the intact uterus group (12). They concluded that induction of labour is not associated with significantly higher rates of uterine rupture among women with previous low transverse caesarean section as compared to women with intact uterus, provided that a consistent protocol with strict intervention criteria is adopted.

In our study, the incidence of febrile morbidity in the emergency caesarean section group was 10%, while that in the elective repeat caesarean section was 1.8%. In another study, the incidences were 5.3% and 6.4% for the respective groups (13). In our study, the incidence of wound infection in the emergency caesarean section group was 5%. There were no cases of wound infection in the elective repeat caesarean section group. McMohan et al (13) reported an incidence of 2.2% in the elective repeat caesarean section group and 1.3% in the emergency caesarean group. In our study, 3.7% of the patients from the elective repeat caesarean section group, 2.7% from the vaginal delivery group and none from the emergency caesarean group required blood transfusion. In the study by McMohan et al (13), 1.1% and 1.3% patients required blood transfusion in the emergency caesarean and elective repeat caesarean section groups, respectively.

Aisien et.al reported one maternal mortality case as a result of uterine rupture and post partum haemorrhage which gave a case fatality rate of 0.3% 8. There was no maternal mortality in our study. Overall, there was no statistically significant difference in the maternal morbidity in the various groups.

The average length of stay was 4 days in the patients who delivered vaginally as compared to 7 days in those who had elective and emergency caesarean section. This was comparable with other studies.

There was no neonatal mortality in our study. When other measures of neonatal outcome were examined in the study, a higher incidence of birth asphyxia was recorded after failed trial of labour than after vaginal delivery. Emergency caesarean section was associated with higher perinatal morbidity than vaginal delivery and ERCS. This was comparable to the study by Brenda et.al (14).The present study shows that neonatal outcome was not adversely affected by VBAC.

Among women with one previous caesarean section and one previous vaginal delivery, those whose most recent delivery was vaginal, had a lower rate of caesarean delivery and shorter duration of labour than those whose most recent delivery was caesarean (15). Our study did not find such a correlation.

To conclude, an expectant attitude and individualization with respect to the management of pregnancy and labour in patients who had one caesarean section is not only justifiable, but represents sound and conservative obstetrical practice. Operative interference will be made in time if complications like foetal or maternal distress or threatened rupture etc. comes into the picture. All women undergoing a trial of labour should be carefully monitored during labour. Substantial reduction in the caesarean rate can be achieved safely and efficiently by encouraging the trial of labour in women with a single previous caesarean delivery.

Key Message

Substantial reduction in the caesarean rate can be achieved safely and efficiently by encouraging trial of labour in women with a single previous caesarean delivery.

References

1.
Merill BS, Gibbs CE. Planed vaginal delivery following caesarean section. Obstet Gynecol. 1978; 52:50-2.
2.
Vardhan S, Behera RC, Sandhu GS, Singh A, Bandhu HC. Vaginal birth after caesarean delivery. J Obstet Gynecol India 2006; 56(4):320-3.
3.
Miller AD, Diaz FG, Paul RH. Vaginal birth after caesarean: A 10 year experience. Obstet Gynecol 1994; 84:255-8.
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Tan PC, Subramaniam RN, Omar SZ. Lab our and perinatal outcome in women at term with one previous lower segment caesarean: A review of 1000 consecutive cases. Aust NZJ Obstet Gynecol 2007; 47(1):31-6
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Ola ER, Imosemi OD, Abudu OO. Vaginal birth after one previous caesarean section- evaluation of predictive factors. Afr J Med Sci 2001; 30(1-2):61-6.
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Martin JN, Perry KG, Robert WE, Megdrech E. The case for trial of labour in the patients with prior low segment vertical caesarean section. Am J Obstet Gynecol, 1997;177:144-8
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Shah JM, Mehta MN, Gokhale AV. Vaginal birth after caesarean delivery. Obs. & Gynae. Today 2007; 12(6):280-1.
8.
Aisien AO, Oronsaye AU. Vaginal birth after one previous caesarean section in a tertiary institute in Nigeria. J Obstet Gynaecol.2004; 24(8):886-90.
9.
Chhabra S, Arora G. Delivery in women with one previous caesarean section. J Obstet Gynecol India 2006; 56(4):304-7.
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Singh VK, Nawani M. Trial of labour in patients with previous caesarean section. J of Obstet Gynaecol of India 1995; 45(5):640-4.
11.
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