Seffah JD, Adu-Bonsaffoh K>
Department of Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Accra, Ghana.

As the population of total deliveries increases, so does the number of women who undergo caesarean section. The primary caesarean section (CS) rate is increasing globally because some women have begun to demand for the operation even when there is no medical indication1. Caesarean section on maternal request poses a dilemma, and it can be an ethical issue in many settings.

Some decades ago the edit was “once a caesarean section, always a caesarean section”2. Now it is clear that a woman who has had a prior CS may undergo an elective repeat CS (ERCS) or trial of labor after CS (TOLAC). Both of these modes of delivery have more complications than when the parturient has not undergone any CS before. TOLAC may end up with a vaginal delivery (VBAC) or it may end up with an emergency CS. TOLAC is therefore known to have more complications than ERCS3.

It is known that when the patients are well selected, especially those who had had previous CS from a low transverse uterine incision, and have adequate pelvis and are carrying average sized fetuses, trial of labor after CS (TOLAC) results in a successful vaginal delivery and this is quite gratifying. The cost of delivery is reduced compared with the cost of a repeat CS. Yet some hospitals do not carry out TOLAC because they do not have adequate experienced staff or resources.

The current trend globally is that CS rate is increasing while the VBAC rate is reducing. This is because of litigation, tochophobia and the fear of complications such as uterine rupture and perinatal death.

There are well known complications associated with a parturient having multiple scars in the uterus. These include, in subsequent pregnancies, the development of placenta praevia, placenta accreta, uterine rupture and placenta abruption. The women undergo elective CS and the babies may suffer from iatrogenic prematurity, respiratory distress syndrome, delayed bonding with the mother and prevention of early breastfeeding. However, the elective repeat CS prevents complications such as uterine rupture, incontinence of urine or flatus and sexual dysfunction that may be associated with improperly supervised VBAC4.

The current paper points out that a good VBAC rate of about 61% is obtainable even in a low resource setting5. What is needed is good counseling of patients, good selection of parturients, good monitoring when in labour and dedicated staff who would pick up and treat all the complications as quickly as possible. This should be a challenge to most of our hospitals where deliveries are performed. The cost of delivery can be reduced and the women are given the chance to have the number of children they desire without being afraid of undergoing repeated surgery.

In conclusion, trial of labor after CS (TOLAC) is safe in good hands even in low resource countries, and we recommend the practice in order to achieve good vaginal birth after previous CS (VBAC) rates. This reduces the increasing CS rate with its attendant maternal and perinatal morbidity and mortality.


  • World Health Organization (WHO). News release: Caesarean sections should only be performed when medically necessary. April 15, 1015. Geneva, Switzerland.
  • Craigin EB: Conservatism in obstetrics. NY State J Med 104:1, 1916
  • Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: New insights. Evid Rep Technol Assess (Full Rep). 2010;(191)(191):1-397.)
  • Hashima JN, Eden KB, Osterweil P, Nygren P, Guise JM. Predicting va- ginal birth after cesarean delivery: a review of prognostic factors and screening tools. Am J Obstet Gynecol 2004;190:547-55.
  • Seffah JD and Adu Bonsaffoh K. Vaginal birth after a previous caesarean section: current trends and outlook in Ghana. J. West Afr. Coll. Surg 2014;4:1-25.

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