Risks of Vaginal Delivery Following Caesarean Section

This paper conducts a systematic review on the risks involved in a vaginal delivery after a C-section. The research methodology involves collecting secondary data from relevant sources and using the GRADE method for data analysis. The findings will help in designing better intervention strategies to promote maternal and fetal health.

Running head: EVIDENCE BASED NURSING RESEARCH
EVIDENCE BASED NURSING RESEARCH: RISKS OF VAGINAL DELIVERY
FOLLOWING CAESEREAN SECTION
Name of the Student:
Name of the University:
Author note:

1EVIDENCE BASED NURSING RESEARCH
Executive Summary:
A common myth about caesarean delivery states that a woman who had previously
underwent a C-section must undergo caesarean delivery in subsequent pregnancies. However,
the findings of the research studies have rendered the myth completely obsolete. It has been
reported that women who had previously underwent a C-section could attempt for a safe vaginal
delivery in the subsequent pregnancies. It should also be mentioned in this regard that a vaginal
delivery after C-section is accompanied with a significant number of risk factors, that include,
uterine rupture, surgical cite infection and poor maternal and fetal health outcome. This paper
intends to conduct an exhaustive systematic review on the available literatures that assesses the
risks involved in a vaginal delivery after a C-section.

2EVIDENCE BASED NURSING RESEARCH
Table of Contents
Chapter 1..............................................................................................................................4
Introduction:........................................................................................................................4
Background:.....................................................................................................................5
Problem Statement:..........................................................................................................6
Research Aims and Objectives........................................................................................7
Aim..................................................................................................................................7
Research Question...........................................................................................................7
Objectives........................................................................................................................7
Research Rationale:.........................................................................................................9
Research Methodology..................................................................................................10
Chapter 2............................................................................................................................11
Methodology:.....................................................................................................................11
Justification:...................................................................................................................12
Literature Search:...........................................................................................................12
Key words:.....................................................................................................................12
Chapter 3............................................................................................................................20
Literature Review:.............................................................................................................20
Chapter 4............................................................................................................................26

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Analysis:........................................................................................................................26
GRADE Assessment:.....................................................................................................26
Chapter 5............................................................................................................................39
Conclusion:........................................................................................................................39
Recommendations:............................................................................................................42
References:........................................................................................................................43
Grade Adapted Grade Approach Table:............................................................................48

4EVIDENCE BASED NURSING RESEARCH
Chapter 1
Introduction:
While the deliverance of a baby is greeted with excitement and positivity from the
concerned family, the process itself can be rather cumbersome and complicated for the mother. A
number of infant delivery options are available at present. While each procedure brings with
itself, a unique set of advantages and complications, the health and safety of the baby and the
mother, must always be priorities during the final confirmation of the chosen method. While
there may be specific preferences presented by the parents for the delivery of the baby, it is
however, always advised to opt for procedures suggested by the associated medical professional.
The types of delivery methods which are available nowadays include: vaginal delivery, forceps
delivery, caesarean section, vacuum extraction and vaginal birth after caesarean (VBAC) (Chu et
al. 2017).
This research will aim to focus on the risks and complications associated with vaginal
birth after extraction as the chosen method for delivery of the infant. At present, a number of
women are opting for VBAC and it has been documented that women undertaking vaginal
delivery after C-section have a success rate of 60 to 80%, due to the onset of advancements in
medical science and technology in obstetrics (Sabol, Denman and GUISE 2015.). In comparison
to a caesarean mode of infant delivery, a vaginal delivery brings forth a number of advantages
such as lack of surgery or the complications of the placenta associated with surgery, a hospital
stay of short duration and a faster recovery rate of undertaking daily life activities (Regan et al.
2015).

5EVIDENCE BASED NURSING RESEARCH
However, it is worthwhile to note that after a C-section, the possibilities of a undertaking
a vaginal delivery by the mother decreases due to the susceptibilities of complications. An
unsuccessful vaginal labour after caesarean section may often lead to complications such as
rupturing of the uterus which is characterized by the uterus tearing (Tilden et al. 2017). This not
only leads to fatal complications in the delivery of the baby but also presents a life threatening
complicating in the mother, who may suffer from excessive bleeding. To prevent the bleeding, a
caesarean section may be performed as an emergency (Mone et al. 2014). Likewise, there may
be requirement of a hysterectomy, further ending the future possibilities of the mother to undergo
conception. Hence, prior to undertaking a second vaginal delivery, the associated health
professional must thoroughly evaluate the medical history of the mother and the possible risks
(Dhillon et al. 2017).
Background:
Vaginal Delivery:
The process of vaginal delivery can be explained as the medium of giving birth to babies
through the vagina. The method is common in all mammals except in monotremes that lay eggs
within the external environment. In case of humans, this method is commonly used for the
delivery of the baby. It should be noted here that the length of hospital stay for a normal vaginal
delivery is in between 36 to 48 hours. On the other hand, the length of hospital stay with an
epistomy (a surgical incision to widen vaginal opening) is generally in between 48 to 60 hours
and for a C-section it is in between 72 to 108 hours. Vaginal delivery can be of various kinds
depending upon the type of labor pain and are known with different terms that include,
spontaneous vaginal delivery, assisted vaginal delivery, induced vaginal delivery and normal
vaginal delivery.

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C-section:
C-section or Caesarean section can be defined as the use of surgery to facilitate delivery.
It should be mentioned that a caesarean section is usually performed on sensing a risk with the
normal delivery method. In general, caesarean section is devised in complex situations such as
twin pregnancy, obstructed labor, breech-birth, higher blood pressure of the mother or
complications with the umbilical cord. C-section is generally performed on the basis of the
mother’s pelvis structure or a prior C-section history. It should be noted that a trial period post
C-section is possible, however it is laden with critical complications. Research studies
recommend that C-section should only be performed under medical emergencies. However, the
method in modern times has become popular and is performed upon request by expecting
mothers and their families. The process is performed within an hour and is usually performed
with the spinal block. The patient is anaesthetized and a urinary catheter is utilized in order to
drain the content of the bladder. The abdominal skin is then cleaned with an antiseptic and an
incision is then made. The length is generally about 12 cm in length and after the delivery of the
baby, the incision is stitched. The patient can start breastfeeding on recovering her senses and
can be discharged from the hospital after some days.
Problem Statement:
A normal established notion believes that mothers who had once been subjected to a C-
section would have to undergo the same procedure during their second pregnancy. However,
recent findings have stated that women who had previously undergone caesarean delivery could
safely opt for a trial of labor in order to have normal vaginal deliveries in the next phase of
pregnancy. Studies have identified a number of benefits associated with the trail of labor post C-
section. The benefits incorporate a shorter duration of hospital stay along with postpartum

7EVIDENCE BASED NURSING RESEARCH
recovery. In addition to this, fewer incidences of complications such as postpartum fever, uterine
infection and thromboembolism within the lungs and the leg has also been identified that require
frequent blood transfusion. Also, vaginal birth after C-section has been identified to cause fewer
breathing problems within babies. It should also be stated here that vaginal delivery has also
been identified with a number of risks that include risk of fetal death and a ruptured uterus
resulting in a critical condition. The fetal death rate through vaginal delivery after a successful C-
section has been reported to be higher which indicates the need to investigate and evaluate the
risks associated with vaginal delivery post C-section. It should be mentioned here that the
research study and the findings would help in designing the best intervention strategies and
practices so as to foster effective maternal and fetal health outcome.
Research Aims and Objectives
Aim
The aim of the following research is to determine the risks associated with vaginal
delivery as second procedure in pregnant mothers who have undertaken caesarean section
previously for the implementation of safe infant delivery practices at the local level.
Research Question
What are the risks of a subsequent vaginal delivery following a caesarean section?
Objectives
As per the aim of the research, the objectives of the following research are the following:
 To critical examine and analyze the risk factors which militate vaginal delivery as second
procedure after previous caesarean section.

8EVIDENCE BASED NURSING RESEARCH
 To evaluate the presence of factors which could reduce the conductance of back to back
caesarean section, that is the performance of caesarean section as a second mode of infant
delivery after a caesarean section conducted previously.
 To make recommendations which will improve outcomes associated with infant delivery
services.
 To evaluate the effectiveness of local policies and programs on infant delivery services
(in this case, back to back caesarean sections).

9EVIDENCE BASED NURSING RESEARCH
Research Rationale:
The rationale for conducting the research can be explained as collecting information
about the risk factors that might manifest itself post vaginal delivery attempt followed by a
caesarean section. It should be noted that the delivery of a baby is directly connected with
emotions of euphoria and positivity for both the expecting mother as well as other family
members. Also, after the process of delivery, it is important to ensure that the maternal health as
well as the fetal health is appropriately maintained so as to avoid any chances of loss of life,
injury or increased medical expenditure. Therefore, it can be said that the research would focus
on investigating and analyzing the possible risks of opting vaginal delivery post C-section on the
basis of the published literary evidences. Also, the findings would help in designing better
intervention strategies so as to reduce associated medical cost and at the same time promote
maternal as well as fetal health.

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Research Methodology
The methodology of the research will involve a critical review of the available evidence
concerning the risks associated with VBAC by undergoing an extensive search and evaluation of
available scientific evidence and evidence based research practice. The required literature search
strategy will be conducted as per the PICO framework, that is:
P (Population): Pregnant women aged 17 to 40 years
I (Intervention): Second vaginal delivery and associated risks
after previous caesarean section
C (Comparison): Back to back caesarean sections
(Outcome): Maternal and Neonatal safety at birth
Fig: Table 1
Hence, the search strategy will include researches with relevance to the PICO framework
as well as keywords such as ‘caesarean section’, ‘vaginal delivery’, ‘vaginal birth after
caesarean’, ‘maternal health’, ‘neonatal health and safety’ and ‘risks’, along with Boolean
operators. Studies which will be irrelevant to the keywords and PICO framework will be
excluded. Research studies which will focus on modes of delivery different those of vaginal or
C-section will also be excluded. It will be ensured that the selected research papers should be
within the timeframe of 2013 to 2018.

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Chapter 2
Methodology:
Methodology can be defined as an integral chapter of a dissertation or thesis. As
mentioned by Neuman (2013), it clearly outlines the best strategy that could be adopted for data
collection on order to address the research objectives. In addition to this, it should also be noted
that the methodology section clearly helps in the process of adapting an appropriate research
study design to address the research question. The systematic review for this research study
would include the relevant qualitative and quantitative literatures retrieved from the electronic
databases. Papers included would predominately comprise of meta-analysis reviews and high
standard research papers published in reputed academic journals. Further, the papers would be
selected on the basis of the inclusion criteria and critically appraised. It should be noted here that
review papers that focus on childbearing and include the target age between 17 to 40 years would
be considered. Further, the quality of the retrieved papers would be assessed using the GRADE
(Grading of Recommendations Assessment Development and Evaluation). The PICO table
would be used for data collection and data analysis.
The GRADE method would be used to collect the research data in order to assess the
overall patient outcome and estimate the optimal factors that are suitable for a safe vaginal
delivery. The PICO questions would be used in order to retrieve relevant papers (Refer. Table 1).
Further, on the basis of the exclusion criteria (Refer. Table 2) and Inclusion criteria (Refer. Table
3), an adapted GRADE evaluation table (Refer. Table 4) would be used for data analysis.

12EVIDENCE BASED NURSING RESEARCH
Justification:
The rationale for choosing a qualitative study design is to investigate and analyze the
previously existing research studies that focus on the risks pertaining to a subsequent vaginal
delivery after a C-section. Further, the research methodology of conducting a systematic review
characteristically includes the appropriate procedure of collecting secondary data from relevant
research papers and critically appraising the research studies to synthesize findings. Also, the
research method would help in the process of accumulating current evidence and at the same
time identify existing research gaps so as to strategically enhance the standard of evidence-based
practice to ensure effective care.
Literature Search:
In order to conduct a systematic review, the initial procedure would involve conducting a
thorough research on the popular databases in order to retrieve relevant information (Taylor et
al., 2015). The process of literature search would facilitate identification of relevant research
studies that match the critical key-terms in order to shortlist authentic research articles to validate
the systematic review.
Key words:
As mentioned by Pannerselvam (2014), prior to conducting a systematic review of the
literatures, it is vital to identify proper key-terms. This is because, proper key terms help in
covering the basic concepts of the research topic. In this context, the key terms that were used to
conduct the search on the electronic databases included the following:
Vaginal delivery, C-section, risk, delivery, pregnancy, negative implication, maternal health,
fetal health, morbidity, post-delivery care

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Bibliographic Aids:
In order to develop an in-depth access to relevant information, it is important to conduct
an exhaustive research online. Online databases comprise a record of published research studies
that serve as important resources to gather information (Etikan et al. 2016). In this case, it should
be mentioned that the online databases that were accessed for the collection of information
included Google Scholar, PubMed, Medline and Cochrane Library. Further, before proceeding
with the research study a number of published systematic review were read in order to develop
unique objectives and prevent the chances of drafting a duplicate work. This was done with the
use of the mentioned key-words in the Cochrane library database, however the search yielded
negative results that validates the fact that the research idea was not a duplicated one. Also, the
search helped in identifying existing literature gaps that helped in devising clear research
objectives.
Search Strategy:
The search strategy includes a set of search protocol that focuses on the research aim and
ensures that the research is focused on the correct direction (Emerson 2015). It should further be
noted in this regard the search strategy stringently involves the consideration of the inclusion and
exclusion criteria for shortlisting relevant studies. The inclusion and exclusion criteria thus acts
as filters that help in retrieving appropriate research articles and excluding irrelevant articles. In
this regard, it should be mentioned that, inclusion and exclusion criteria help in setting specific
boundaries that determine the structure of the research study (Moher et al. 2015).

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PRISMA 2009 Flow Diagram
Papers identified through database
search n=20
Additional records
identified through other sources
n=2
Records after duplicates removed
n=18
(n = )
Records screened
n=18
(n = )
Records excluded
n=1
(n = )
Full-text articles
assessed for eligibility
(n = 17 )
Full-text articles
excluded, (do not meet
inclusion) n=10
Studies included in
literature review
(n = 7 )

15EVIDENCE BASED NURSING RESEARCH
Exclusion Criteria:
The exclusion criteria can be defined as characteristics that are used for the elimination of
irrelevant and duplicate research studies. In relation to this research study, the exclusion criteria
comprises the following considerations:
 Research studies published prior to 2013
 Research articles that build on case-studies, animal-trials, doctoral dissertation and
clinical guidelines
 Research papers published in any other foreign language except English
Fig: Table 2
Inclusion Criteria:
On the other hand, inclusion criteria comprises the consideration of the factors that testify
the validity of a research article to be included in a research study. In this context, the inclusion
criteria comprised of the following characteristics:
 Primary and secondary research articles
 Critically analyzed review papers that propose relevant recommendations on child-
bearing (targeted age group: 17-40 years)
 Research articles that were published in English language
 Research papers published in between 2013 to 2018
 Research papers that were peer-reviewed
 Research methods that were based on a qualitative or quantitative research design
Fig: Table 3
Search Outcome:
The initial step involved the use of Google Scholar to obtain relevant research articles.
The search was conducted after applying appropriate filters. The search-filters included selecting

16EVIDENCE BASED NURSING RESEARCH
the year of publishing between the year 2013 to 2018. The total results that were obtained
included approximately 14,250 for community care and 12,150 for in-patient care. The huge
number of search results indicated the presence of a large number of relevant research articles on
the research topic. However, it is important to refine the search results in order to extract
appropriate information. As stated by Johnson (2014), the use of Boolean operators help in
drawing a relationship between the key words so as to retrieve refined results. In this case, two
Boolean operators AND/OR were used to obtain relevant results. The use of the two Boolean
terms helped in retrieving a combination of results which subsequently helped in saving a lot of
time and returned relevant results. The results were then examined after reading the title and
abstracts. Further, after removing the duplicates the papers were thoroughly read to collect
important information.
Key words in combination with Boolean operators:
Key word 1 Boolean Operator Key word 2
Vaginal delivery Or/And pregnancy
C-section Or/And Negative implication
Maternal health Or/And Fetal health
risk Or/And Delivery
morbidity Or/And Post-delivery care

17EVIDENCE BASED NURSING RESEARCH
Fig: Search results from Google Scholar
Fig: Search results from Google Scholar

18EVIDENCE BASED NURSING RESEARCH
Snowball Technique:
Retrieving information from the electronic database is feasible as it helps in retrieving
important information, however, it is also important to utilize alternative methods for conducting
a thorough search. Researchers have mentioned that relying solely upon the information
collected from electronic databases might lead to skipping on important information that are vital
to address the research objective (Johnson 2014). Therefore, in order to avoid such
circumstances, the reference list of the short-listed literatures were thoroughly scrutinized and
included within the research study to make the review more authentic. This method is popularly
known as the snowball technique and it helps in avoiding key word bias. It should further be
noted that the search was stopped on reaching the data saturation point. This point was
characterized by obtaining redundant search results and it helped in the development of a
rounded perspective. A total of 50 articles were further analyzed for the review process. The
further procedure included performing a quality assessment on the short-listed 50 articles. The
abstract was read and linked to the research objectives. A total of 35 articles were excluded on
the basis of abstract analysis. Further, the articles were analyzed for full-text and this resulted in
the exclusion of 7 more articles that involved a reduced sample-size. It should be mentioned that
a poor sample size increases the possibility of generating biased results. Finally, 7 articles were
chosen for the literature review.
Research Approach:
According to Taylor et al. (2015), it has been said that research approach can be of two
types that include inductive approach and deductive approach. In this case, the research approach

19EVIDENCE BASED NURSING RESEARCH
is inductive as the research study would help in generating new ideas from already existing
information. The inductive approach would thus be used to access risks related to a subsequent
vaginal delivery after a C-section.
Research Philosophy:
Research philosophy is of three types and includes three philosophies that is, positivism,
realism and Interpretivism (Panneerselvam 2014). In this research, the research philosophy
would be interpretivisim. The rationale behind the choice of this particular research philosophy is
the effectiveness of the interpretivism philosophy in conducting qualitative research and
performing an in-depth analysis of small scale data.
Research Design:
As stated by Neuman (2013), research design can be of various types that include
exploratory, explanatory and descriptive type. This research study would be based upon the
descriptive type of research design. This study design helps in identifying emerging themes and
establishing a relationship between the identified themes.
Conclusion:
Therefore, to conclude it can be said that the researcher would conduct a qualitative
research study with interpretive research philosophy, inductive research approach and a
descriptive research style. Further, the literature review would include 7 research articles that
were retrieved after conducting a search on the electronic databases.

20EVIDENCE BASED NURSING RESEARCH
Chapter 3
Literature Review:
In order to investigate and understand the risks involved with the process of subsequent
vaginal delivery after a C-section, an exhaustive literature review was conducted. The
significance of conducting the literature review majorly included accumulation of recent
evidences in relation to research topic and identifying the existing research gap in order to
promote scope for future research studies. According to Shorten, Shorten and Kennedy (2014), it
has been mentioned that prior C-section mode adopted for the delivery often creates an
emotional dilemma in subsequent deliveries. The research study considered a sample size of 187
women with their expression about making a decision about the method of delivery at 36-38
weeks. The findings prove that decision making about vaginal delivery after a prior C-section
was exceedingly complex as it involve emotional insecurities about the safety of the baby and
anxiety.
Typically, a major percentage of the women preferred to undergo vaginal delivery in
comparison to a recurrent C-section for an accelerated recovery. It should also be mentioned in
this context, that the findings of the research study significantly pointed out that the clinical
counselling provided by the care professionals deeply affected the decision making process of
the patients. As mentioned by Cristopher (2018), it has been stated that the rate of vaginal
delivery or normal delivery is significantly declining with the advancing years with reference to
Canada and other developed nations. The major cause attributes for the above stated reason
includes the complex nature of subsequent pregnancies and associated labor pain. However, the
use of vaccum and forceps in the recent times, have popularized the concept of operative vaginal

21EVIDENCE BASED NURSING RESEARCH
delivery. However, operative vaginal delivery has also been associated with a number of risks
that include, trauma within the mid-pelvic region and high rates of severe perineal trauma
resulting in high rates of morbidity. Another study conducted by Carmen et al. (2018),
investigated the maternal and fetal outcome of vaginal delivery after a C-section. The researchers
considered the data collected from the District Abstract Database that comprises delivery data in
relation to all the hospital deliveries across Canada.
The collected data was inclusive of singleton deliveries of women between 37 and 43
weeks of gestation who had undergone a prior C-section in between April 2003 to March 2015.
The findings revealed serious cases of maternal and neonatal morbidity and mortality. The
researchers used the logistic regression model to estimate the 95% confidence intervals and the
adjusted rate ratios. Interestingly, the results proved that the rate of maternal and mortality were
lower in case of elective caesarean delivery in relation to opting for vaginal delivery after a C-
section. The analyzed results revealed 5.65 v/s 10.7 per 1000 deliveries with adjusted RR 1.96
and 95% CI 2.19 TO 1.76). In addition to this, the differences in rate in case of severe maternal
and neonatal morbidity and mortality were significantly small (5.42 AND 7.09 per 1000
deliveries). Further, the association between vaginal birth after caesarean delivery and neonatal
morbidity and mortality reflected temporal worsening with adjusted RR 0.94, 95% CI 0.77 to
1.15 in 2003-2005 and adjusted RR 2.07, 95% CI 1.83 to 2.35 in 2012-2014. Therefore, it can be
said that the vaginal delivery after C-section is associated with significant higher rates of
morbidity and mortality for both mothers and infants and temporal worsening of infant outcomes
indicate the need to foster careful monitoring during labor and delivery.
As stated by Shrestha et al. (2014), vaginal delivery post C-section is invariably
associated with surgical cite infections. Surgical cite infections after a C-section has been

22EVIDENCE BASED NURSING RESEARCH
reported to cause maternal morbidity which leads to a prolong hospital stay and increased
medical expenditure. The researchers considered a sample size of 648 women who had
undergone a surgical procedure for the delivery process. The calculated mean age of the subjects
was 24 +/- 4.18. The prevalence rate of surgical infection was found within 82 subjects (12.6%).
Further, the incidence of surgical site infection was common in patients who had encountered
rupture of membrane prior to surgery (p=0.020), who had underwent emergency surgery
(p=0.004), who had vertical skin incision (p=0.0001) and interrupted skin suturing (p=0.0001)
during the surgical process. Opting for vaginal delivery in the subsequent pregnancy after a C-
section involved high risks of encountering recurring surgical cite infections.
A research study by Smith et al. (2015), investigated the risks involved in mothers opting
for a vaginal delivery after a C-section procedure. The study revealed the incidences of Uterine
rupture and previous incision types which was earlier unidentified among the women who had
attempted a trial of labor post a cesarean delivery. The researchers conducted a secondary
analysis of a prospective multicenter observational study that comprised 15,519 singletons who
had attempted a trial of labor after a previous history of one caesarean delivery. The researchers
further estimated the odds ratio in order to understand the existing connection between uterine
incision location and uterine rupture. The multivariate logistic regression model was used in
order to analyze the findings. Interestingly, the findings revealed that in between the years 1999
to 2002, 99 out of 15,519 women that accounts for a total of (0.64%) experienced uterine rupture
during a trial of labor and had previously undergone a caesarean delivery. On the other hand,
pregnant women who were affected with an unknown scar showed lower odds in relation to
uterine rupture with the adjusted odds ratio, 0.71; 95% CI 0,37-1.37). The findings suggested
that women unaware of a uterine incision were at a lower risk of developing uterine rupture in

23EVIDENCE BASED NURSING RESEARCH
comparison to women who were aware about a uterine transverse incision. Chao et al. (2018) has
supported the increased probability of uterine rupture in women opting for a vaginal delivery
who have a medical history of C-section.
The research study conducted by Chao et al. (2018), focused on the incidence of uterine
rupture through previous C-sections and its subsequent traumatizing impact on the surrounding
myometrium. The researchers conducted a retrospective clinical review to analyze the cases of
uterine rupture that had occurred over a period of 15 years within a Taiwanese obstetric center.
The rate of accessed uterine rupture was equivalent to 3.8 per 10,000 deliveries. A total of 22
cases of uterine rupture had been accessed in 20 women, with two of them experiencing double
episodes of rupture. Further, the results suggested that 7 uterine ruptures had occurred through
previous C-sections, 13 through non CS-ruptures and two in women who had no medical record
of any possible surgery. The findings proved that C-sections could invariably lead to uterine
ruptures or uterine scars with the highest probability in patients who had previously undergone
endoscopic uterine surgery. Another research study conducted by Regan et al. (2015)
investigated the risks involved in opting for vaginal delivery after a previous record of C-section
in patients. The researchers adapted a cohort research study design and considered the total
number of births in Ohio during the years 2006 to 2007. The study critically categorized high
risk patients as women with singleton gestations who had at least one of the following risk
factors. The risk factors included higher body mass index greater than 30, hypertension or
diabetes. The accumulated data was analyzed with the help of the logistic regression model that
evaluated the influence of the mentioned risk factors on successful subsequent vaginal delivery
post C-section. The findings revealed a connection between several factors and the success rate
of VBAC. The factors included the consideration of a prior vaginal delivery, weight gain during

24EVIDENCE BASED NURSING RESEARCH
pregnancy, Caucasian race and labor augmentation. Interesting, it was found that out of 280882
births, 68.0% of the patients had a successful VBAC against 32% who experienced critical
complications. Out of the total participants considered, 79084 that accounts of 27.1% were high-
risk pregnancies and 8658 that accounts for 10.09% were patients who had undergone one
previous C-section. 1433 patients which accounted for 16.6% women underwent TOLAC (a
trial of labor after caesarean). It was estimated from the findings that high-risk patients with a
prior history of C-section were not likely to undergo TOLAC but showed a high rate of VBAC.
Another research study conducted by O’Neill et al. (2014), investigated the negative
health outcome associated with vaginal delivery post C-section. The negative health outcomes
included incidences of subsequent stillbirth, miscarriages and ectopic pregnancy after primary C-
section. The research study was based on a population cohort design. The sample size included
women with live births between the years 1982 to 2010 with a subsequent follow-up. The cox
regression model was used in order to analyze the C-section types, and sub-group analysis was
performed on the basis of the caesarean type in order to comprehend the cause for stillbirths was
performed. The results showed a stark increase in the number of stillbirths in women with
caesarean delivery in comparison to women who had undergone a vaginal delivery. The results
showed hazard ratio [HR] 1.14, 95% CU 1.01, 1.28 in women with C-section compared to
spontaneous vaginal delivery. The results indicated an absolute theoretical risk increase of 0.03%
for stillbirth. The findings further stated that C-section was associated with an increased
probability of increased stillbirth and ectopic pregnancy.
Research Gap:

25EVIDENCE BASED NURSING RESEARCH
On the basis of the exhaustive literature review, it can be said that the papers included
majorly talked about the risks involved in subsequent vaginal delivery after a C-section. The
papers did not propose or highlight the recommendations that could ensure a safer vaginal
delivery after a previous medical history of C-section. At the same time, it was found that the
papers did not discuss about the complications that might affect a subsequent pregnancy after a
successful C-section delivery. The papers only focused on conditions such as uterine rupture and
an increase in the probability of still birth or miscarriages after a C-section. Therefore, it can be
said that an existing research gap can be identified in terms of devising strategic
recommendations so as to render successful vaginal delivery outcomes after a C-section.

26EVIDENCE BASED NURSING RESEARCH
Chapter 4
Analysis:
This chapter contains a description of the findings obtained from the scholarly articles
extracted from the electronic databases, in the form of GRADE approach table. Patterns are
examined and recorded within the data presented in all the extracted articles, followed by their
marking according to GRADE assessment.
GRADE Assessment:
Article Number: 01
Author: Shrestha et al. 2014
Year: 2014
The Aim of the evidence/ article: Incidence and risk factors of surgical site infection following
caesarean section at Dhulikhel Hospital
Population: 648 women who underwent surgical procedure for delivery
Intervention: As it was an observational study, no interventions had been administered by the
researchers
Methods used in the evidence: Prospective and descriptive study
Outcomes: Incidence rate of surgical infection after first delivery was found equivalent to 12.6%
(82 out of 648 cases). Women who had undergone caesarean sections for the first time also
reported rupture of their membrane, prior to the surgical procedure, which in turn increased their

27EVIDENCE BASED NURSING RESEARCH
chances of suffering from surgical site infections (p=0.020). Risks of these infections during the
first caesarean section were also common amid females who had vertical skin incision
(p=0.0001), were subjected to emergency surgery (p=0.0004), and reported intermittent
membrane suturing (p=0.0001) during the surgery.
Comment: GRADE: High impact. The findings of the study helped in establishing the fact that
postpartum surgical site infection and wound infection increase the length of hospitalisation of
the women and also poses a burden to their overall health, thereby increasing risks of vaginal
delivery. The sample size considered was effective for generalizing results.
Article Number: 02
Author: Knight et al. 2014
Year: 2014
The Aim of the evidence/ article: Vaginal birth after caesarean section: a cohort study
investigating factors associated with its uptake and success
Population: Women who had a singleton delivery by C-section between 1April 2004 to 31 March
2011 and second birth on March 31 2012
Intervention: Successfully attempted VBAC
Methods used in the evidence: Cohort study
Outcomes: Following implementation of a logistic regression model, 75,086 women were found
to attempt a VBAC for second delivery that accounted for an estimated 52.2% of the total
population. Increased maternal age (>34 years) was identified as a potential risk factor for

28EVIDENCE BASED NURSING RESEARCH
VBAC. Furthermore, the reports suggested that females who gave birth by emergency caesarean
section for the first time displayed an increased likelihood of attempting VBAC, however,
manifested lower rates of success, in comparison to women who had been subjected to elective
caesarean section for the first time. Another potential risk factor was the history of failed labour
induction among women who gave first birth by emergency caesarean section
(p< 0.001). Additional risks associated with VBAC were namely, presence of a sign other than
non‐cephalic indication, and/or placenta praevia.
Comment: GRADE: High impact. The findings of the study successfully indicated that women
who had previously undergone C-section were eligible for a VBAC during their second birth,
however the process involved several complications Also, the study design was effective to
compare outcome
Article Number: 03
Author: Chao et al. 2018
Year: 2018
The Aim of the evidence/ article: Laparoscopic uterine surgery as a risk factor for uterine
rupture during pregnancy
Population: 22 cases among 20 women who experienced uterine ruptures
Intervention: Laproscopy procedure prior to C-section
Methods used in the evidence: Retrospective study

29EVIDENCE BASED NURSING RESEARCH
Outcomes: Upon conducting a retrospective study, it was found by the researchers that overall
rates of uterine rupture was 3.8/10,000 deliveries, which acts as a significant risk factor for
VBAC. A detailed statistical analysis revealed that of the identified cases, seven uterine ruptures
(32%) were accredited to a previous caesarean scar (CS rupture), 13 (59%) occurred due to non-
caesarean scars (non-CS ruptures), and remaining two (9%) occurred among females who were
not previously subjected to any caesarean sections. 76% cases of uterine ruptures were also
found amid women who previously underwent laparoscopic myomectomy
Comment: GRADE: Low. The findings of the research proved that caesarean sections result in
rupture of the uterine membrane that acts as a momentous risk factor for VBAC. The paper
lacked appropriate sample size for generalizing findings.
Article Number: 04
Author: Smith et al. 2014
Year: 2014
The Aim of the evidence/ article: The association between incision type and uterine rupture
among females attempting a trial of labour, succeeding a caesarean delivery
Population: 15,519 women who attempted VBAC after a C-section
Intervention: No specified intervention as it was an observational study
Methods used in the evidence: Prospective-multicenter observational study
Outcomes: The results suggested that rupture of the uterine wall was prevalent among 15,519
women (0.64%) who endeavoured for a trial of labour after their first caesarean

30EVIDENCE BASED NURSING RESEARCH
delivery. Nonetheless, lower odds of rupture of the uterus was found amid women who reported
presence of unknown scars (adjusted odds ratio, 0.71; 95% confidence interval, 0.37–1.37), in
comparison to those with recognised low transverse scars, thus illustrating uterine rupture and
low transverse incision as major risk factors for VBAC
Comment: GRADE: High. The findings clearly identified low transverse incision as a major risk
factor for VBAC. Significant sample size but the paper lacked valuable recommendations
Article Number: 05
Author: Claeys et al. 2014
Year: 2014
The Aim of the evidence/ article: The risk of uterine rupture after myomectomy: a systematic
review of the literature and meta-analysis
Population: Systematic review included papers from January 1970 to March 2013
Intervention: Systematic review of retrieved literatures, therefore no intervention
Methods used in the evidence: systematic review
Outcomes: Findings stated that there exists low risks of uterine rupture during labour and
delivery (0.75%). The researchers further stated that uterine rupture risks during pregnancy are
not meaningfully greater, following a laparoscopic method, when compared to traditional open
myomectomy (p= 0.119). Furthermore, it also elaborated on the wider prevalence of elective
caesarean sections, in contrast to conventional open technique, after laparoscopic myomectomy

31EVIDENCE BASED NURSING RESEARCH
(p= 0.001), thus elaborating on the fact that although incidence of a uterine rupture is occasional,
it is an austere impediment of myomectomy
Comment: GRADE: High. Appropriate study design and large sample population.
Article Number: 06
Author: Iyoke et al. 2014
Year: 2014
The Aim of the evidence/ article: Risks allied with succeeding pregnancy after caesarean
sections
Population: 870 women
Intervention: Trial of VBAC
Methods used in the evidence: Prospective Cohort Study
Outcomes: Results yielded higher prevalence of caesarean section among females having
undergone a previous caesarean section, in comparison to females with previous vaginal delivery
(Relative risk [RR] =3.78; 95% CI: 1.8, 6.2). Some of the common risk factors associated with
VBAC were labor dystocia (RR = 6.4, 95% CI: 3.2, 11.2), primary postpartum hemorrhage (RR
= 5.0, 95% CI: 1.5, 4.3.), placenta praevia (RR = 5.0; 95% CI: 2.6, 7.2.), intrapartum hemorrhage
(RR = 5.0, 95% CI: 2.1, 9.3), newborn special care admission (RR = 2.5; 95% CI: 1.1, 4.9), and
blood transfusion (RR = 6.0, 95% CI: 3.4, 10.6). In the words of Obeidat et al. (2013) cervical
dilatation≥ 7 cm during first caesarean section was an autonomous conjecturer of positive VBAC

32EVIDENCE BASED NURSING RESEARCH
(80% success rate). Women with previous VBAC demonstrated greater success odds (OR = 3.8
(95% CI: 1.5, 9.5), thus signifying the cervical dilatation< 7cm as a major risk factor
Comment: GRADE: Moderate. Appropriate study design and evaluation of primary data but
small sample size.
Article Number: 07
Author: Obeidat et al. 2014
Year: 2014
The Aim of the evidence/ article: Vaginal birth after caesarean section (VBAC) in women with
spontaneous labour: predictors of success
Population: 207 Jordian women
Intervention: Successful trail of VBAC in women with 7cm cervical dilation
Methods used in the evidence: Multivariate analysis
Outcomes: Women with previous VBAC demonstrated greater success odds (OR = 3.8 (95% CI:
1.5, 9.5), thus signifying the cervical dilatation< 7cm as a major risk factor.
Comment: GRADE: Low. Appropriate study design but poor sample size to generalize findings
with respect to population.
Article Number: 08
Author: Young et al. 2018
Year: 2018

33EVIDENCE BASED NURSING RESEARCH
The Aim of the evidence/ article: Mode of delivery after a previous cesarean birth, and
associated maternal and neonatal morbidity
Population: Discharge Abstract Database containing data of all Canadian hospital delivieries
except Quebec
Intervention: No intervention
Methods used in the evidence: Logistic regression model for comparison of data
Outcomes: Findings stated that absolute rates of stark maternal mortality and morbidity were
expressively higher after attempted VBAC, in contrast to elective repeat cesarean sections (10.7
v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Temporal
worsening of neonatal mortality and morbidity after VBAC also highlighted the importance of
careful delivery monitoring
Comment: GRADE: High. Excellent sample size and consideration of every parameters.
Article Number: 09
Author: Regan et al. 2015
Year: 2015
The Aim of the evidence/ article: Vaginal birth after cesarean success in high-risk women: a
population-based study
Population: 495 women
Intervention: No intervention

34EVIDENCE BASED NURSING RESEARCH
Methods used in the evidence: Population based retrospective cohort investigation
Outcomes: Success of a second vaginal delivery after a caesarean section was accredited to the
presence of several factors such as, Caucasian race, gain in weight less than 30 lbs, labour
augmentation and first vaginal delivery. Hence, prior caesarean section increased the risk of an
unsuccessful second vaginal delivery, thereby threatening the health of the mother and the
unborn child
Comment: GRADE: Low-Moderate. Adequate but not effective sample size
Article Number: 10
Author: Dahlen and Homer 2013
Year: 2013
The Aim of the evidence/ article: ‘Motherbirth or childbirth'? : a prospective analysis of vaginal
birth after caesarean blogs
Population: 311 blogs on VBAC
Intervention: No intervention
Methods used in the evidence: qualitative study
Outcomes: The results elaborated on the fact that whether females ultimately wrote that they
selected a repeat caesarean or VBAC, or the amount to which they followed their birth selection
was based on their perspectives. The women often considered the idea of VBAC depending on
its prospective as a good sacrifice made by the parents, for their baby, by prioritising the baby,

35EVIDENCE BASED NURSING RESEARCH
reduced inclination to take any health risks on childbirth, or focusing on the concept of a healthy
mother and healthy baby
Comment: GRADE: Moderate. Opinion oriented study. Difficult to grade in quantitative
parameter.
Article Number: 11
Author: Kelly et al. 2015
Year: 2015
The Aim of the evidence/ article: Women's perceptions of contributory factors for not achieving
a vaginal birth after cesarean (VBAC).
Population: 11 obstetricians and 21 pregnant women
Intervention: Risk management and effective counselling to guide the decision making process
Methods used in the evidence: Qualitative analysis
Outcomes: Findings explored the factors that governed the decision of women to undergo VBAC
and found certain themes namely, “hesitant obligation with lingering qualms,” “My body
nosedived me,” “Negotiated by a lengthier than bearable labor,” “Incapable to successfully self-
advocate in an environment of influence struggling and poor sustenance,” and “The stubbornness
of hospital procedures.” Thus, it was suggested that doubts of women being capable of achieving
VBAC were governed by a plethora of factors
Comment: GRADE: High. Provided recommendation and analysed the perspective of both the
pregnant women and obstetricians.

36EVIDENCE BASED NURSING RESEARCH
Article Number: 12
Author: Shorten et al. 2014
Year: 2014
The Aim of the evidence/ article: Complexities of Choice after Prior Cesarean: A Narrative
Analysis
Population: 187 participants
Intervention: No intervention discussed
Methods used in the evidence: Narrative analysis
Outcomes: Results stated that strong emotions were often expressed by the women, while they
explored birth option and were largely governed by anxieties and fears. They often opted for
VBAC in order to avoid the previous caesarean experiences, with the aim of a faster or better
recovery. Apprehensions regarding safety issues for the baby also made the women want a
vaginal delivery
Comment: GRADE: Low. Opinionated study and insufficient sample size.
Article Number: 13
Author: Wells et al. 2015
Year: 2015
The Aim of the evidence/ article: Choosing the route of delivery after cesarean birth

37EVIDENCE BASED NURSING RESEARCH
Population: 13,500 women attempting TOLAC for prospective cohort study and 8505 women for
retrospective cohort study
Intervention: Safe VBAC
Methods used in the evidence: Prospective cohort study and retrospective cohort study
Outcomes: Demand for VBAC is also influenced by better scheduled delivery, shorter
hospitalisation, and easy recovery. However, their perceptions are also controlled by the fact that
vaginal delivery are concomitant with pelvic trauma and easy accomplishment of post-partum
sterilisation
Comment: GRADE: High. Good sample size and experimental design
Article Number: 14
Author: Christopher 2018
Year: 2018
The Aim of the evidence/ article: Taking a stand for operative vaginal delivery
Population: 115 participants
Intervention: No intervention
Methods used in the evidence: Qualitative study
Outcomes: rates of operative vaginal delivery and the skills required to perform the procedure
are fast decreasing, besides the reduction in the opportunities for apprentices. Furthermore, steps
for caesarean section are consistent and predictable

38EVIDENCE BASED NURSING RESEARCH
Comment: GRADE: Low. Poor sample size
Article Number: 15
Author: Zakirhamidi et al. 2015
Year: 2015
The Aim of the evidence/ article: Vaginal delivery vs. cesarean section: A focused ethnographic
study of women’s perceptions in The North of Iran
Population: 12 pregnant women
Intervention: No intervention
Methods used in the evidence: Focused ethnographic study
Outcomes: suggested that women often considered vaginal delivery as a expediter of females’
physical and mental health advancement, besides considering it as a safe delivery method,
maternal instinct fulfilment procedure, and natural process with satisfying ending that made them
want VBAC. Hence, difficulties associated with caesarean section influenced their perception of
opting for a VBAC
Comment: GRADE: Low. Very poor sample size and no recommendation and intervention was
provided
Thus, it can be stated that although previous caesarean section increased the risks among
women for a second child birth via vaginal delivery, their thoughts and perceptions often
governed their choices for the delivery method.

39EVIDENCE BASED NURSING RESEARCH

40EVIDENCE BASED NURSING RESEARCH
Chapter 5
Conclusion:
Finally, in a nutshell, it can be inferred that this article performs a thematic analysis on
the topic of risk factors associated with the subsequent vaginal delivery following a caesarean
section. Around 30 articles were electronically searched and downloaded from the electronic
database for this purpose. The extracted research paper were critically analyzed according to
their merit. After a thorough research it has been found out that the findings and opinion form
these research paper can be segregated in two section. These two segments are: i) Risk factors
that militate vaginal delivery as second procedure and ii) Opinion and perception regarding
delivery. In case of the first segment, it has been found out that risk of infection increases after
the first caesarean section. Investigators have reported that the incidence rate of this infection is
about 12.6 per cent which was obtained after studying and investigating 648 cases.
Women with at least one caesarean sections have also reported the rupture of their
membrane, prior to the surgical procedure which in turn increases the chance of infection among
them. Hence, it can be concurred that the postpartum surgical site infection and wound infection
increase the length of hospitalisation of the women. This additional complication after birth
poses a threat to the overall health and increases the risk factors involving vaginal delivery.
Similar findings have been reported by the more than one publications. A logistic regression
model showed that almost 52.2 per cent women have tried vaginal birth after caesarean section
with a population size of 75,086 women. It has been observed that more than thirty four years of
maternal age poses a risk factor in case of vaginal birth after caesarean section. Women who

41EVIDENCE BASED NURSING RESEARCH
were forced with caesarean section in the first time due to emergency are more likely to perform
vaginal birth after caesarean section in comparison with the women who willingly opted for the
caesarean section in the first place. Additionally, uterine rupture can be attributed to the fact that
different risk factors can traumatize the myometrium. Investigators have reported 3.8 cases of
uterine rupture amongst a sample size of ten thousand deliveries. This indicates a potential risk
factor for vaginal birth after caesarean section. In detailed analysis, it has been perceived that 32
per cent cases of uterine ruptures occurred due to a previous caesarean scar and 59 per cent cases
of uterine ruptures occurred due to non- caesarean scars. Another bit of information which
elaborates the fact that caesarean section responsible for uterine rupture is that 76 per cent cases
of uterine ruptures were also found amid women who previously underwent laparoscopic
myomectomy. Association between incision type and rupture of the uterine wall also emboldens
the fact that caesarean section is a risk factor for uterine wall rupture and uterine wall rupture
was prevalent among 15,519 women who had gone through labour trial during their first
caesarean delivery. Although, researchers also investigated ways for low risk of uterine rupture
and have reported the procedure for low risks of uterine rupture during labour and delivery. On
the contrary, some researchers have also reported that incidence of a uterine rupture is
occasional. Studies have been conducted in which vaginal birth after caesarean section was
compared with females with previous vaginal delivery.
Few of the recurring risk factors which were associated with vaginal birth after caesarean
section were labor dystocia, primary postpartum haemorrhage, placenta praevia, intrapartum
haemorrhage, new- born special care admission, and blood transfusion. Investigators have also
pointed out to the fact that absolute rate of morbidity and mortality among the mothers was
significantly higher when the mothers have attempted to vaginal birth after caesarean section.

42EVIDENCE BASED NURSING RESEARCH
Vaginal birth after caesarean section also needed careful monitoring as it can worsen the
neonatal morbidity and mortality. Studies conducted with 459 women have reported that 32 per
cent of the participants failed to have a successful vaginal birth after caesarean section. However,
it is not rare or impossible to have a successful vaginal birth after caesarean section, although it
requires combination of several factors like Caucasian race, gain in weight less than 30 lbs,
labour augmentation, and first vaginal delivery. In case of Opinion and perception regarding
delivery, academics have suggested that opposition in philosophical outline that females held
about birth was a major theme. This investigation elaborates on the fact that the choice of their
delivery method was based on their perception. Often the pregnant women considers vaginal
birth after caesarean section as a good sacrifice for their baby which will reduce the health risks
on childbirth for the baby, or focusing on the concept of a healthy mother and healthy baby.
Therefore, investigators ruminated on the fact that various factors like inadequate body structure,
control and choice, and overestimating or minimizing the risks for their choice to opt for vaginal
birth after caesarean section. Sometimes women opted for normal delivery just because they
want to avoid the experiences of the previous caesarean section. Additionally, technical skills
required for caesarean section is fast decreasing and it also required longer recovery time. To
conclude, from the above discussion it can be said that the vaginal birth after caesarean section
has serious implication to the mother, but the mother’s choice of delivery method is often
influenced by their perceptions and beliefs.

43EVIDENCE BASED NURSING RESEARCH
Recommendations:
Therefore, it can be said that the proposed recommendations could help in preventing the
risks associated with a subsequent vaginal delivery after a C-section. The recommendations are
elucidated as follows:
 The studies included in the literature review talked about the risks in relation to uterine
rupture after a C-section. Therefore, it can be said that advanced education and training in
managing a caesarean delivery in case of an emergency can help in the prevention of
uterine ruptures which could ensure a safer vaginal delivery in subsequent pregnancies
 Another, important aspect indicated by the studies revealed that vaginal delivery after a
previous record of C-section posed a greater risk of complications. Imparting critical
training with respect to vaginal delivery could help in ensuring a safer normal delivery
 Finally, it should also be mentioned that subsequent pregnancies after a caesarean section
in mothers are laden with insecurities and anxiousness related to the wellbeing of the fetal
health. Care professionals play an integral part in the decision making process to
convince the patients to opt for a normal vaginal delivery. Effective patient counselling
enumerating a detailed discussion about the vaginal delivery procedure and the pros and
cons involved in the process can help in taking an appropriate decision.

44EVIDENCE BASED NURSING RESEARCH
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Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy. PloS
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Claeys, J., Hellendoorn, I.N.E.Z., Hamerlynck, T.J.A.L.I.N.A., Bosteels, J. and Weyers, S.,
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factors associated with its uptake and success. BJOG: An International Journal of Obstetrics &
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49EVIDENCE BASED NURSING RESEARCH
Grade Adapted Grade Approach Table:
Research studies Level of evidence Results and findings
Smith, D., Stringer, E.,
Vladutiu, C.J., Zink, A.H. and
Strauss, R., 2015. Risk of
uterine rupture among women
attempting vaginal birth after
cesarean with an unknown
uterine scar. American journal
of obstetrics and
gynecology, 213(1), pp.80-e1.
Study type: secondary analysis
High-quality The study revealed the incidences
of Uterine rupture and previous
incision types which was earlier
unidentified among the women
who had attempted a trial of labor
post a cesarean delivery. The
findings suggested that women
unaware of a uterine incision
were at a lower risk of
developing uterine rupture in
comparison to women who were
aware about a uterine transverse
incision
Christopher, Ng., 2018. Taking
a stand for operative vaginal
delivery. CMAJ, 190(24),
E.732-733.
Study type: clinical trial
Moderate Findings of the research study
reveals that the rate of vaginal
delivery or normal delivery is
significantly declining with the
advancing years with reference to
Canada and other developed
nations. The major cause
attributed for the above stated
reason includes the complex
nature of subsequent pregnancies
and associated labor pain.
However, the use of vaccum and
forceps in the recent times, have
popularized the concept of
operative vaginal delivery.
However, operative vaginal
delivery has also been associated
with a number of risks that
include, trauma within the mid-
pelvic region and high rates of
severe perineal trauma resulting
in high rates of morbidity
Claeys, J., Hellendoorn,
I.N.E.Z., Hamerlynck,
T.J.A.L.I.N.A., Bosteels, J. and
Weyers, S., 2014. The risk of
uterine rupture after
myomectomy: a systematic
Moderate The findings of the paper
emphasized on the increased
incidence of uterine rupture in
women who have previously
been subjected to myomectomy.
The results also reflected that

50EVIDENCE BASED NURSING RESEARCH
review of the literature and
meta-analysis. Gynecological
Surgery, 11(3), p.197.
Study type: systematic review
patients who has previously had a
caesarean delivery were prone to
encounter risks pertaining to
uterine rupture
Dahlen, H.G. and Homer, C.S.,
2013. ‘Motherbirth or
childbirth’? A prospective
analysis of vaginal birth after
caesarean
blogs. Midwifery, 29(2), pp.167-
173
Study type: prospective
analysis
Moderate The findings of the study
critically presented the increased
probability of poor maternal and
fetal health outcomes in patients
who had previously been
subjected to emergency C-section
in subsequent vaginal deliveries.
Iyoke, C.A., Ugwu, G.O.,
Ezugwu, F.O., Lawani, O.L.
and Onah, H.E., 2014. Risks
associated with subsequent
pregnancy after one caesarean
section: A prospective cohort
study in a Nigerian obstetric
population. Nigerian journal of
clinical practice, 17(4), pp.442-
448.
Study type: Prospective cohort
study
High-quality The research findings critically
focused on the morbidity and
mortality rate in women who had
opted for a vaginal delivery after
a previous record of C-section.
Further, complications with
respect to uterine rupture was
also highlighted in the research
study.
Knight, H.E., Gurol‐Urganci,
I., Meulen, J.H., Mahmood,
T.A., Richmond, D.H., Dougall,
A. and Cromwell, D.A., 2014.
Vaginal birth after caesarean
section: a cohort study
investigating factors associated
with its uptake and
success. BJOG: An
International Journal of
Obstetrics &
Gynaecology, 121(2), pp.183-
192.
Study type: Cohort study
High-quality The research paper critically
reflected the perception of the
patients who had previously
underwent a C-section and
encounter an emotional dilemma
with the method of delivery in
the subsequent pregnancy. In
addition to the above stated
factors, the paper also discussed
the importance of the care
professionals in positively
offering support to the patients in
the decision making process