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Vaginal birth after cesarean section
(VBAC)
Presenter
Dr. Hem Nath Subedi
Resident, OBGYN
COMS-TH, Bharatpur
• Few issues in modern obstetrics have been as controversial
as management of the woman who has had a prior cesarean
deliv...
• In 1920s the technique of low transverse uterine incision was
introduced by Kerr.1
• A large number of women may have su...
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth ...
Pregnant women with a previous cesarean section
can deliver in one of the following ways.2
• Trial of labour after previou...
Maternal risk of TOLAC
Risk of uterine rupture.
• One of the major determinants of severe adverse outcome
associated with ...
Maternal risk of TOLAC
Risk associated with failed TOLAC.
• The major determinant of morbidity associated with a decision ...
Risk of TOLAC to fetus/neonate
• The risk of perinatal death associated with TOLAC is
comparable to that of nulliparas in ...
9
Candidate for a TOLAC
Some Factors for Consideration in Selection of Candidates for
Vaginal Birth after Cesarean Delivery ...
Contraindication to TOLAC
• Due to higher absolute risks of uterine rupture or unknown
risks planned TOLAC is contraindica...
12
Factors influencing success of VBAC
• Type of prior uterine incision
• Prior uterine rupture
• Closure of prior incision
•...
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth ...
Prior uterine rupture
• Women who have previously sustained a uterine rupture are at
increased risk for recurrence during ...
Closure of prior incision
• Chapman (1997) and Tucker (1993) and their associates found
no relationship between a one- and...
Interdelivery interval
• Having at least 24 months between the date of the last cesarean
birth and the due date for this p...
Number of prior cesarean incisions
• It also seems logical that the risk of uterine rupture would
increase with the number...
Prior vaginal delivery
• Previous vaginal birth, particularly previous VBAC , Is The
Single Best Predictor For Successful ...
Indication for prior cesarean delivery
• The success rate for a trial of labor depends to some extent on
the indication fo...
Fetal size
• It has not been conclusively proven that increasing fetal size
increases the risk for uterine rupture with VB...
Multifetal gestation
• Twin pregnancy does not appear to increase the risk of uterine
rupture with VBAC.1
• Ford and assoc...
Maternal obesity
• Obesity decreases the success of VBAC.1
• Hibbard and colleagues (2006) reported the following vaginal
...
Antenatal care
• Counseling regarding mode of delivery should ideally start at
the time of the sentinel cesarean .2
• Wome...
Factors to note at booking visit include
• Number and type of previous uterine scars, indications for
prior cesarean secti...
Antenatal counseling
• Women with a prior history of one uncomplicated LSCS , in an
otherwise uncomplicated pregnancy at t...
If decision is made for TOLAC ,the woman
should be advised:
• To present to the obstetric unit early in labour or if there...
Intrapartum Management
• Women who have had a previous cesarean section should
be offered care during labour in a unit whe...
Continuous fetal monitoring
• Continuous electronic fetal monitoring is recommended
following the onset of uterine contrac...
Partogram for progress of labour
• Partographic progress of labour enhances safety. A partogram,
in addition to monitoring...
Analgesia
• Epidural analgesia for labour may be used as part of TOLAC ,
and adequate pain relief may encourage women to c...
Early diagnosis of uterine rupture
• Early diagnosis of uterine scar rupture followed by expeditious
laparotomy and resusc...
Delivery
• The length of the second stage should not exceed 2 hrs. one
hour to allow passive descent, but no more than one...
Role of induction and augmentation of labour in
VBAC
• Women with a previous cesarean should be informed of the
two to thr...
Thank you
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Vaginal birth after cesarean section

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Vaginal birth after cesarean section

  1. 1. Vaginal birth after cesarean section (VBAC) Presenter Dr. Hem Nath Subedi Resident, OBGYN COMS-TH, Bharatpur
  2. 2. • Few issues in modern obstetrics have been as controversial as management of the woman who has had a prior cesarean delivery.1 • For many decades, a scarred uterus was believed by most to contraindicate labor out of fear of uterine rupture.1 • In 1916 Cragnin made his famous oft-quoted and now seemingly excessive pronouncement, “Once a cesarean always a cesarean.”1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 2
  3. 3. • In 1920s the technique of low transverse uterine incision was introduced by Kerr.1 • A large number of women may have successful and safe vaginal birth after cesarean (VBAC) with reported figures of 70% to 80% (Flamm etal 1990).2 • American College of Obstetricians and Gynecologist concurs and states , ‘Most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered Trial of Labour after Cesarean (TOLAC) (ACOG 2010).2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 3
  4. 4. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 4
  5. 5. Pregnant women with a previous cesarean section can deliver in one of the following ways.2 • Trial of labour after previous cesarean delivery ending in vaginal birth. • Trial of labour after previous cesarean delivery ending in emergency cesarean section. • Planned elective repeat cesarean section(ERCS). TOLAC should be undertaken in facilities with staff immediately available to provide emergencycare.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 5
  6. 6. Maternal risk of TOLAC Risk of uterine rupture. • One of the major determinants of severe adverse outcome associated with VBAC is whether uterine rupture occurs.2 • The incidence of this is generally estimated to be in region of 0.5% to 1.0%.2 • Considering all gestational ages, uterine rupture occurs in approximately 325 per 1,00,000 women undergoing trial of labour.2 • Maternal death from uterine rupture in planned VBAC occurs in less than 1/1,00,000 cases in the developed countries. There may be much higher in developing countries (Farmer et al ).2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266- 276 6
  7. 7. Maternal risk of TOLAC Risk associated with failed TOLAC. • The major determinant of morbidity associated with a decision for TOLAC is whether the attempt is successful.2 • In a study from Nigeria, failed VBAC was associated with higher incidence of chorioamnionitis, PPH, Blood transfusion, uterine rupture, hysterectomy and composite major neonatal morbidities.2 • The risk factors which predicted failure were (obri et al 2010).2 – Younger age – Lack of previous vaginal delivery – Induction of labour – Fetal weight>4kg 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 7
  8. 8. Risk of TOLAC to fetus/neonate • The risk of perinatal death associated with TOLAC is comparable to that of nulliparas in labour.2 • TOLAC carries a 2-3/10000 additional risk of birth related perinatal death when compared with elective repeat cesarean section (ERCS).2 • The rate of hypoxic-ischemic encephalopathy can increase significantly with uterine rupture. However, it is important to remember that this complication is also extremely rare.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 8
  9. 9. 9
  10. 10. Candidate for a TOLAC Some Factors for Consideration in Selection of Candidates for Vaginal Birth after Cesarean Delivery (VBAC) – One previous prior low-transverse cesarean delivery – Clinically adequate pelvis – No other uterine scars or previous rupture – Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery – Availability of anesthesia and personnel for emergency cesarean delivery Reprinted, with permission, from American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin 54. Washington, DC: ACOG; 2004. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 10
  11. 11. Contraindication to TOLAC • Due to higher absolute risks of uterine rupture or unknown risks planned TOLAC is contraindicated in women with: 1 – Previous uterine rupture; risk of recurrent rupture is unknown – Previous high vertical classical cesarean section where the uterine incision has involved the whole length of the uterine corpus (200-900/10000) risk of uterine rupture. – Three or more previous cesarean deliveries. – Where the women herself refuses. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 11
  12. 12. 12
  13. 13. Factors influencing success of VBAC • Type of prior uterine incision • Prior uterine rupture • Closure of prior incision • Interdelivery interval • Number of prior cesarean incisions • Prior vaginal delivery • Indication for prior cesarean delivery • Fetal size • Multifetal gestation • Maternal obesity 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 13
  14. 14. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 14
  15. 15. Prior uterine rupture • Women who have previously sustained a uterine rupture are at increased risk for recurrence during a subsequent attempted VBAC. • Women with prior uterine rupture or classical or T-shaped incision ideally should undergo repeat cesarean delivery when fetal pulmonary maturity is assured, and preferably prior to the onset of labour. • Counseling regarding the hazards of unattended labor and signs of possible uterine rupture. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 15
  16. 16. Closure of prior incision • Chapman (1997) and Tucker (1993) and their associates found no relationship between a one- and two-layer closure and the risk of subsequent uterine rupture.1 • Durnwald and Mercer (2003) also found no increased risk of rupture, they reported that uterine dehiscence was more common after single-layer closure.1 • Bujold and co-workers (2002) found that a single-layer closure was associated with nearly a fourfold increased risk of rupture compared with a double-layer closure.1,2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 16
  17. 17. Interdelivery interval • Having at least 24 months between the date of the last cesarean birth and the due date for this pregnancy increases the chance of successful VBAC and decreases the risk of uterine rupture.2 • Shipp and associates (2001) examined the relationship between interdelivery interval and uterine rupture in 2409 women who had one prior cesarean delivery. Uterine rupture developed in 29 women—1.4 percent. Interdelivery intervals of 18 months or less were associated with a threefold increased risk of symptomatic rupture during a subsequent trial of labor compared with intervals greater than 18 months.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 17
  18. 18. Number of prior cesarean incisions • It also seems logical that the risk of uterine rupture would increase with the number of previous cesarean deliveries.1 • Miller and colleagues (1994) studied 12,707 such women undergoing a trial of labor. They reported rupture rates of 0.6 percent following one cesarean delivery and 1.8 percent for women with two prior cesarean deliveries.1 • Macones and associates (2005a) reported a twofold increase in the rate of uterine rupture among women attempting trial of labor after two prior cesarean deliveries—1.8 percent— compared with those with one—0.9 percent.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 18
  19. 19. Prior vaginal delivery • Previous vaginal birth, particularly previous VBAC , Is The Single Best Predictor For Successful VBAC.2 • It is associated with an approximately 87% to 90% success rate for planned VBAC.2 • The rate of rupture increases with each successive labour , but a prior vaginal delivery also increases the chance of a successful VBAC attempt.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 19
  20. 20. Indication for prior cesarean delivery • The success rate for a trial of labor depends to some extent on the indication for the previous cesarean delivery. 1 • In a large series reported by Wing and Paul (1999), 91 percent of women whose first cesarean delivery was for breech presentation subsequently delivered vaginally.1 • If fetal distress was the original indication, the success rate was 84 percent.1 • Prior dystocia is an important predictor of vaginal delivery after prior cesarean. In more than 1900 women, Peaceman and associates (2006) found that those with dystocia as the original indication had a significantly lower success rate compared with those with other indications—54 versus 67 percent, respectively.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 20
  21. 21. Fetal size • It has not been conclusively proven that increasing fetal size increases the risk for uterine rupture with VBAC.1 • Zelop and associates (2001) compared the outcomes of almost 2750 women undergoing a trial of labor of whom 1.1 percent had a uterine rupture. The rate increased—albeit not significantly—with increasing fetal weight—1.0 percent for <4000 g, 1.6 percent for >4000 g, and 2.4 percent for >4250 g.1 • Elkousy and colleagues (2003) reported that for women attempting VBAC who had no previous vaginal deliveries, the relative risk of rupture doubled if birth weight was >4000 g.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 21
  22. 22. Multifetal gestation • Twin pregnancy does not appear to increase the risk of uterine rupture with VBAC.1 • Ford and associates (2006) analyzed the outcomes of 1850 such women with a prior cesarean delivery who attempted a trial of labor. The uterine rupture rate was 0.9 percent, and the rate of successful vaginal delivery was 45 percent.1 • Cahill (2005) and Varner (2007) and their colleagues reported rupture rates of 0.7 to 1.1 percent and vaginal delivery rates of 75 to 85 percent.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 22
  23. 23. Maternal obesity • Obesity decreases the success of VBAC.1 • Hibbard and colleagues (2006) reported the following vaginal delivery rates: 85 percent with a normal body mass index (BMI), 78 percent with a BMI between 25 and 30, 70 percent with a BMI between 30 and 40, and 61 percent with a BMI of 40 or more.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 23
  24. 24. Antenatal care • Counseling regarding mode of delivery should ideally start at the time of the sentinel cesarean .2 • Women should be offered information regarding the need for the first cesarean and implication it may have for future pregnancies and deliveries.2 • Identify ,at the first antenatal visit all women who have had a previous cesarean section or have a uterine scar, a senior consultant should assess them.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 24
  25. 25. Factors to note at booking visit include • Number and type of previous uterine scars, indications for prior cesarean section, there any puerperal complications, gestation at time of prior cesarean section, interconception interval and other associated medical problem.2 • Anticipated family size: this is important as the longer term risks related to further repeat cesarean section scars med be taken into consideration ( placenta previa, placenta accreta, blood loss , transfusion, hysterectomy and mortality).2 • History of a successful vaginal delivery and whether this was before or after the uterine scar. The rupture rate rises with each successive labour but a prior vaginal delivery also increases the chance of a successful VBAC attempt. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 25
  26. 26. Antenatal counseling • Women with a prior history of one uncomplicated LSCS , in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative on an elective repeat cesarean.2 • The antenatal counseling of women with a prior cesarean birth should be documented in the notes . A patient information leaflet should be provide with the consultation.2 • A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/planned delivery date, ideally by 36weeks of gestation (flamm et al 1990).2 • Placenta previa/accreta should be excluded with USG. Identifying and treating anemia early on is important in these women. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 26
  27. 27. If decision is made for TOLAC ,the woman should be advised: • To present to the obstetric unit early in labour or if there is SROM occurs.2 • That the decision made in the antenatal clinic is not binding .2 • To have a clear understanding with the obstetric team which states the boundaries of safe practice to which they have agreed and indicate the circumstances under which they would request that a repeat cesarean section be carried out.2 • Te decision should be clearly documented in the antenatal records 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 27
  28. 28. Intrapartum Management • Women who have had a previous cesarean section should be offered care during labour in a unit where: – There is immediate access to cesarean section. – There are on site blood transfusion services or blood can be obtained with in a reasonable amount of time. – Facilities for continuous fetal heart monitoring are available, preferably electronic fetal heart monitoring. – Specialist obstetricians, anesthetists and pediatrician are available round the clock 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 28
  29. 29. Continuous fetal monitoring • Continuous electronic fetal monitoring is recommended following the onset of uterine contractions for the duration of TOLAC.2 • An abnormal CTG is the most consistent finding in uterine rupture and is present in 55% to 87% of these events(guise et al 2004).2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 29
  30. 30. Partogram for progress of labour • Partographic progress of labour enhances safety. A partogram, in addition to monitoring progress of labour , enables effective monitoring of maternal parameters like blood pressure and pulse rate.2 • The duration of labour should be closely monitored with special reference to alert and action line on partogram. Prolongation of labour is an important sign of dystocia.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 30
  31. 31. Analgesia • Epidural analgesia for labour may be used as part of TOLAC , and adequate pain relief may encourage women to choose TOLAC (sakala et al 1990, flamm et al 1998).2 • In addition effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is FHR tracing abnormalities.2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 31
  32. 32. Early diagnosis of uterine rupture • Early diagnosis of uterine scar rupture followed by expeditious laparotomy and resuscitations essential to reduce associated morbidity and mortality and infants. • There is no single pathognomonic clinical feature that is indicative of uterine rupture but the presence of any of the following peripartum signs and symptoms should raise the concern of the possibilities of uterine rupture (turner 2002) – Abnormal CTG tracing, severe abdominal pain persisting in between contractions, chest pain or shoulder tip pain, acute onset scar tenderness, abnormal vaginal bleeding and hematuria, cessation of previously efficient uterine activity, maternal tachycardia, hypotension or shock, loss of station of the presenting part. 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266- 276 32
  33. 33. Delivery • The length of the second stage should not exceed 2 hrs. one hour to allow passive descent, but no more than one hour for active pushing (or 30 minutes if the woman has had a prior vaginal delivery).2 • Assisted delivery ,in the presence of a prior uterine scar, should ideally only be performed by an experienced consultant. This should be in the operating theatre with provision for immediate cesarean section.2 • Excessive vaginal bleeding or signs of hypovolemia are potential signs of uterine rupture and should prompt complete evaluation of the genital tract (cahill etal 2005).2 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 33
  34. 34. Role of induction and augmentation of labour in VBAC • Women with a previous cesarean should be informed of the two to three fold increased risk of uterine rupture and around 1.5 fold increased risk of cesarean section in induced labours compared with spontaneous labour.2 • Lydon-Rochelle and associates (2001) performed a retrospective population-based study. They found that induction of labor with prostaglandins for VBAC increased the uterine rupture risk more than 15-fold compared with elective repeat cesarean delivery.1 1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 34
  35. 35. Thank you 35

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