Introduction Vaginal Birth After Cesarean (VBAC)defined:” a women who gives birth vaginally after having at least oneprevious cesarean birth”(Ricci,S.S,2017). One of the strategies developed to controlthe increase rate of cesarean birth. Cesarean sections as a rescue operationfor the mother and the fetus can be associated with many complications andcosts.
planned cesarean and repeat planned cesarean birth ratesare still increasing worldwide. Increased caesarean sections in most countriesincluding Jordan. One in three babies in the USA are born byCesarean sections (WHO,2013). South American rates of cesarean sections exceed 50% in many areas, with over 70% ofbirths in private healthcare settings being by cesarean sections .The concernin order to reduce overall rates of Caesarean sections is compounded withefforts to encourage the selection of patients, because women themselves oftenask for this mode of birth.
The largest contribution to the current high ratesof cesarean section come from a repeat Cesarean operations. Vaginal birth ratesworldwide after cesarean birth (VBAC) have dropped dramatically in recentyears. The United Kingdom has seen the actual VBAC rates fall from 45.
9% in1988 to 36% between 2004 and 2011.(Black et al. , 2016). Cesarean sections rate in Jordan is high (29.1%),More than a quarter of all births. The mostcommon cause of Cesarean sections scar uterus (59.4%), reflecting mostly previousCesarean sections.
Mother desire was one of the main reasons for plannedcesarean (Batieha et al. ,2017) .So, women are the primary decision makersabout of birth method but need knowledge . I am interested in this topic because many women who have had a cesareanbirth with their first pregnancy areinterested in a vaginal birth for their later births.
but I saw during clinicaldays , women who’d had a Cesarean birth were encouraged to skip vaginaldeliveries altogether and schedule Cesarean sections for all future births byher doctor . the most doctor and health care provider have this dictum “once acaesarean birth, always a caesarean birth”. One of the mother toldme” Please help me , my last birth was caesarean birth. I would like a normal birth this time but the hospitaland obstetrician all say that a repeat caesarean is my only option”. ThenI started think and research about it . Is a vaginal birth after cesarean birth (VBAC) safe option for many women and their babies? and what isthe nursing role in promotingvaginal birth after cesarean birth(VBAC)and reducing elective repeat caesarean birth ?. “Once a cesarean birth always a cesarean birth”. This viewpointhowever is not based on any evidencebased practice .
and given the right support, Women should be informed that whenshe give birth by cesarean the successrate of planned VBAC is 72–75% (RCOG, 2015). A trial of vaginal birth after previous cesarean birth has been accepted as a way to reduce the rate of cesarean birth, and also to allowwomen to choose the mode of birth. Many studies have supported theeffectiveness and safety of vaginal birth after cesarean birth (VBAC). Although the effectiveness and safety of vaginal birth after cesareanbirth (VBAC), the subject of VBAC has not received its consideration amongobstetricians. Women who request trialsare generally not allowed or given appropriate counseling and may receiveconflicting advice. Successful VBAC also reduce the overall rate of cesareansections and associated complications of cesarean section (Tahseen, & Griffiths, 2010). WHO recommend that the rate ofcesarean section should not exceed 10%to 15% in any country (WHO,2013) .
In Jordan the rate of cesarean birth hadexceeded the WHO recommended rate. One of the way to decrease caesarean birth;Implementation of a vaginal birth after previous caesarean birth (VBAC).Therefore we are needed to facilitatebest practice in ante-natal counselling and to promote education to women about decision-making an informed decisionscan help increase the uptake of a trial of labor after a cesarean and restorewomen independence. Therisks of rupture uterus vary by incision types. Low transverse incisions have abetter prognosis, rates of 0.
2 to 1.5 %.Classical and T-shaped incisions carry a higher risk of up to 9%. Low vertical incisions not involving the fundushave a risk of rupture between 1 and 7%. Other factors that increase the riskof uterine rupture include two or more privous cesarean birth and induction oraugmentation labor )ACOG,2010) . This paper will present the evidence currently available from bothqualitative and quantitative studies in order to compare findings.
Method Ten articles that met the selectioncriteria were reviewed. I searched inCINAHL ,PubMed, science direct, Scopus and google schooler without languagerestrictions, from to use multiple subjects headings and free text keywords related to modes of birth such as: vaginal birth after Cesarean, Cesarean section, VBAC ,repeat cesarean. Ourpopulation of interest included women who had one or more previous cesarean, women with history VBAC and a repeat cesarean birth. A review ofpublished research of the included following steps; comprehensive reading wasreviewed to identify areas of focus, identification of included and exclusioncriteria, literature search and retrieval, critical evaluation and analysis ofthe research evidence and synthesis of evidence was reviewed with the aims ofidentifying. Literature review In Jordan, The study is apart of a comprehensive national study was conducted between 2011 and 2012 todetermine the rate and causes of cesarean birth showed that the increased rate of cesarean birth . This study concludedthat cesarean birth rate in Jordan is high(29.1%).The most common cause forplanned cesarean was scarred uterus orprevious cesarean (59.
4%) .cesarean birth is related to an increased risk ofneonatal death. As most cesarean birth are currently based on doctor’s judgment, it may be extremely helpful todevelop and implement a national guidelines for performing cesarean section .Obstetricians’ adherence should be monitored to comply with theseguidelines .(Batieha et al.,2017) The other study showed that the mostcommon cause for cesarean being “absence of a clear indication”(AlRifai,2014). In Jordan, like in many Arab countries, there is a preference fora large families.
As cesarean birth limits the number of children, it becomes extremely important to performcesareans only when there are clear medical indications. Now the question becomes,previous cesarean section is a medical indication for repeat cesareansection? if the answer is “no”, thenwhat is the level of care for subsequent births after cesarean birth? manystudies have been done to answer this question, assessing the benefits andrisks of VBAC versus repeat cesarean birth (ERCD) in order tobetter patient guidance and practice decision. In a retrospective study,including uncomplicated women pregnancies and a history of one or more previous cesarean birth, whounderwent trial of vaginal birth,supported by midwife or nurse during theprenatal and intrapartum period. The purpose of this study was to examine thesuccess rate and safety of vaginal birth after cesarean birth, as well as thevalue of the contribution of midwives during the prenatal period andintrapartum period. 66 cases of trialvaginal birth after cesarean birth were examined between January /2013 andOctober /2014 in Greece. All were a high level of education, aged between 27-40 years old , under the care of the midwifes and the obstetricians during theprenatal and intrapartum period.
All pregnancies were uncomplicated withcephalic presentation. The most common indication previous cesarean, failedinduction of labor or the delay of labor progress (46%)( Nousia et al., 2014).During the prenatal period, midwivesgave details information about the process of VBAC for women. In addition,midwives attempted to provide emotional support to pregnant women and teachthem position exercises and breathing techniques during labor, in order toprepare them for a successful vaginal birth after cesarean birth .
During theintrapartum period labor process ismonitored. Pain management was achieved by encouragement of the ambulation, showers, emotional support andchanging positions of the mother. The obstetricians were responsible for thedecision to labor augmentation, oxytocin administration or epidural anesthesia( Nousia et al., 2014). The study found that results: In total, 79% of thisstudy success rate of vaginal birth after cesarean birth , as 52 out of the 66women study group achieved vaginal birth. Labor spontaneously began in 89% of cases. All newborn had good Apgar scoresin the first minute and fifth minute after labor.
No major complications, suchas uterine rupture or massive obstetric bleeding, were observed during thetrial of vaginal birth in any case. There was no need for blood transfusion,cesarean section or emergency hysterectomy in this study ( Nousia et al., 2014). This study the authors concluded that Itappears that pregnant women who have been informed and prepared from a midwife during the prenatal period achieved higher rates of vaginal birthand satisfaction from the experience. All pregnant women should be informedabout the complications after repeated cesarean sections in comparison with thepotential risks of vaginal birth after cesarean birth and a trial of vaginalbirth should be offered if they agree with the process in the absence of otherobstetrical indicators for cesareansection ( Nousia et al., 2014). In a systematic review studyby Rezai et al.
(2016), vaginal birthafter cesarean birth should berecommended for all women who have had previous cesarean birth, except : previous classical incision, previoushysterotomy or full thickness myomectomy, previous uterine rupture, anycontraindications to labor in this pregnancy (e.g. transverse lie ,placentaprevia , etc.
) (Rezai et al., 2016). This literature reviewsuggested the recommended by evidencegathered. That decision-making by doctors and patientson the basis of each individual case.
Twins, suspected fetal macrosomia, anddiabetes are not contraindications for VBAC. women who are planning for VBAC need one on one preparation, andshould be provide with individualizedassessment of the maternal and fetal risks for this particular pregnancy .Doctors and midwife should be provide with details risks and benefits of vaginal birth aftercesarean versus elective repeatedcesarean to the mother , this decision should be respected and documented.Induction of labor may be necessary in VBAC, membrane sweeping, AROM, andoxytocin , along with cervical ripening with Foley, but not by PGE2.If the woman is admitted in spontaneouslabor, she should be evaluated within 2hours and be on continuous monitoring. Cesarean birth is recommended if thereis a failure in progress, indicated byless than 1 cm per hour dilatation over or more 4 hours or no head descent withone hour active pushing in the secondstage.(Rezai et al., 2016) In another systematic review study by Nilsson et al.
(2015). interventions that could be to increase vaginal birth after cesareanbirth or success rates of vaginal birthafter cesarean birth were examined (Nilsson et al. ,2015). The objective of thestudy was to evaluate the effectiveness of interventions that focus on womenduring pregnancy and childbirth, and increased rates of vaginal birth aftercesarean birth and assessment of the effectiveness of the means to helpdecision-making for mode of birth andassess the effectiveness of the education program of prenatal care. It wasfound that demonstrate that neither theuse of decision aids and education of women have a significant impact on VBACrates. Nevertheless, Clearly, decision-makingaids greatly reduce women’s decisional conflict about mode of birth, andinformation programs greatly increase their knowledge of the risks and benefitsof possible birth patterns (Nilsson et al.
,2015). A study done byCox.(2014). The views women who havechosen vaginal birth after cesarean birth( VBAC ) compared with the birth of repeated cesareanbirth(ERCD) report increased satisfaction with their birth, and is oftenattributed to the feelings of selflessness.
They have a quicker recovery time of VB AC compared with ERCD because there is nosurgical wound . VBAC can also be cheaper than ERCD. However the costs arevariable and in the event of an emergency cesarean after trial of VBAC they canactually be more expensive. There is also a lower rate of maternal mortalityand morbidity associated with VBAC, though these are rare even with ERCD. Asuccessful VBAC also means it is more likely the woman will be able to haveanother vaginal birth in the future . All vaginal births are associated with decrees maternal depression(Cox, K.
J ,2014).In addition, breast-feeding is more likely to succeed withVBAC because it is easier for mothers without wound pain and can she feed inthe labor room immediately after birth. Needless to say ,that VBAC wouldalso avoid the risks that are unique toERCD (Wells,2015). Counseling mother with previous cesarean section about their optionsfor the mode of birth next time is a challenging and complex process. Serviceproviders need a variety of skills to assess women’s ability to understand andanalyze health information and communicate with them effectively about thebenefits and harms of both VBAC and ERCD. It can help to use the means to take decisions aids for decision-making to reducethe bias in the transfer of information and encourage women to incorporatetheir values and preferences in the decision-making process. In areas wheretrial VBAC access is limited or not available, there is still a commitment to service providers to counsel women aboutboth options for mode of birth. If a woman wishes to trial VBAC, if at allpossible the provider should referred her to other facilities that offer the option.
To increasepossibility of trial VBAC, it is necessaryto work together service providers within their states and regions to developrisk stratification frameworks and referral networks. Given the evidence infavor of trial VBAC as a safe option, women should not continue to force her toundergo surgery unwanted and undesirable (Cox, K. J ,2014).
A qualitative analysis study by Nilsson etal., 2017 , to improve maternal healthservice delivery and improve birth by increasing vaginal birth after cesareanbirth through the promotion of centeredmaternity care throughout Europe(Nilsson et al., 2017). This study focused on interviews withwomen from countries with high rates of VBAC :the Netherlands , Finland , andSweden .this study analyzed interviews with 22 women who had vaginal birthafter cesarean birth .
the authors usedcontent analysis (Nilsson et al., 2017). The study revealed severalfactors into account women’s perspective have to be taken into account: receiveinformation from supportive doctors , receive professional support from a confident midwife and obstetrician duringlabor, find out the advantages of VBAC, out of the previous birth inpreparation for the new birth, and display VBAC as the first alternative for all involved when there are nocomplications are present. The study concluded doctors must be aware that VBACrates are also related to social and cultural factors. According to theseresults, VBAC is facilitated when it is the first alternative for all involvedand no complications are present. Thus, these results not only reflect theneeds of women, but also social and cultural factors that influence their viewson VBAC (Nilsson et al., 2017). Shouldbe made conduct an individual assessment in women with factors that increase the risk of uterine rupture.
Factorsthat are likely to increase the risk of uterine rupture include a shortinterval (less than 12 months since last birth), postdate pregnancy, maternalage 40 or more obesity, pre-labor Bishop score and macrosomia .Arecent retrospective study included 3176patients assessed the safety of womenundergoing VBAC with a short interval.The study concluded that a short interval (less than 12 months) is not a risk factor for complications such as uterine rupture andmaternal death, but it is for preterm birth. There is a need for more databefore making sure of the safety of this approach. There is uncertainty in howto integrate this knowledge into prenatal counseling, and the presence of these risk factors does notcontraindicate trial VBAC. However, you can consider such factors during thedecision-making process, especially when considering induction or augmentationof VBAC labor (Kessous& Sheiner, 2013). Implication for Nursing and Health Policyin Jordan Cesareanrates in Jordan are still increasing .
The proportion of Cesarean may be unnecessary or undesirable. Maternalmortality after CS is 10 times greaterthan vaginal birth in developing countries . this is of concern and requires immediate action byhospital administrators ,health care professionals and policymakers. At the national level,maternity services policy to encourageevidence -based practice, and to devote the rights of women, and require adequate systems to ensurequality, including a review of the use of obstetric procedures. At the level ofhealth and institutional service providers, focus on improving the quality ofthe provision of information and emotional care provided to laboring women willincrease VBAC. Providingcontinuing professional development to inform practitioners of women’s rights,and teach women how to make decisions about mode of delivery ,as well as theinvolvement of women in decision-making, will facilitate respectful care.Informing women about mode of birth and birth procedures may help them tobetter understand and participate in the decision-making process. These factorssignificantly increase in the uptake of VBAC births.
It can help women to learnabout the safety, success rates, risks ,potential and benefits of VBAC births.can help women take a more informed decision. should be provided decision-aidsand information programs during pregnancy for all pregnant women in prenatalinstitution ,they do not affect the rate of VBAC but they decrease women?s decisional conflict and increase their knowledge about possible modesof birth. Hospitals should have guidelines to promote access to VBAC andactively monitor and improve quality of care for women who choose labor aftercesarean. Development of national evidence- based policies and qualityassurance systems would help to decrease the rate of unnecessary cesareans, andgive pay more attention to respect for women’s preferences during labor andbirth. Conclusion and Recommendation Every year 1.
5 million womenhave cesarean birth, and this population is still increasin. This paper concludthat VBAC is a reasonable and safe choice for the majority of women withprivousr cesarean. Furthermorer, there is evidence of serious harms relating torepated cesareans. Women who have had aprivous cesarean face many obstacles when choosing birth mode . There are manyfactors that affect the availability of a VBAC birth which makes it difficultfor mothers to access the facility and / or provider that will provide thisservice.
The lack of sufficient access to facilities providing VBAC birthaffect a mother’s autonomy to choose howshe wants to birth. Promoting education for mothers about making decision canhelp increase the uptake of a VBAC birth and help to restore a mothers’autonomy through the use of decisional aid . Women making decisions aboutmode of birth after a previous cesarean birth can benefit from access todecisional-aids by reducing their anxiety and decisional conflict and by increasing their knowledge about thepotential risks and benefits. These factors can greatly increase the uptake ofVBAC births. It can help women to identify safety, success rates, risks and potential benefits of VBACbirths and can help women make a more informed decision. Women with a privoscesarean need to be provide informationon both modes of birth available . Women have a right to choose and a right toknow the benefits and risks of both modes of birth so that they can makean informed- decision. The doctor and the women need to work together in theinformed decision process and doctor bias needs to be removed.
Overall, theimprovement of informed consent process by reducing bias and increasing patienteducation can help to increase theuptake of VBAC births References -American College of Obstetricians and Gynecologists (2010) ACOGPractice bulletin no. 115: Vaginal birth after previous cesarean delivery.Obstet Gynecol 116(2 Pt 1): 450-46.- Royal College of Obstetricians and Gynaecologists. Birth after acaesarean section Green-top Guideline.
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