**Abstract**

The rising rate of caesarean section has implications in the reproductive performance of a woman and increases the likelihood of complications during repeat operations, whether they are planned or performed on an emergency basis. A successful vaginal delivery after caesarean is associated with increased maternal satisfaction, reduced caesarean section rate, and appears to be cost effective. There is a need for careful selection of women that are willing to attempt vaginal birth after caesarean with a clear set of local protocols to increase overall success rate, reduce litigation and improve neonatal outcome. The benefits and risks of planned vaginal birth after caesarean and elective repeat caesarean section should be discussed in detail with the woman during antenatal care and reemphasized at admission to the labour ward. A decision to embark on VBAC should be free from coercion with full informed consent as the bedrock for such a decision. Facilities offering vaginal birth in women with prior caesarean delivery should be equipped with 24-hour standby emergency caesarean section capability. The intrapartum care should be carefully tailored to meet the woman's need with support from the health care team. Every obstetrics unit should debrief women after delivery irrespective of the outcome and should conduct regular audits to improve the care of women with previous caesarean sections.

**Keywords:** vaginal birth after caesarean (VBAC), elective repeat caesarean section (ERCS), trial of labour after caesarean (TOLAC), successful VBAC, uterine rupture

### **1. Introduction**

Vaginal Birth After Caesarean (VBAC) is one of the most contentious topics in obstetrics, therefore physicians and health workers in maternal health must navigate the complexity of the pros and cons when advising and counselling prospective mothers that wish to consider the vaginal route of delivery after a caesarean [1]. The increased rates of caesarean section and the short- and long-term complications thereof have made VBAC a reasonable and cost-effective alternative to planned Elective Repeat Caesarean Section (ERCS) [2]. The single most common indication for Caesarean Delivery (CD) in several settings in both developing and developed countries is a previous caesarean section and VBAC has the potential to plateau or flatten the exponential trajectory of CD [3]. However, the contribution of VBAC is jeopardised by the current upsurge of Caesarean Delivery on Maternal Request

(CDMR), increased litigation climate and the cloud of caesarean sections that are generally classified as unnecessary by the World Health Organisation (WHO) [4–6]. The pendulum in the trend in VBAC and ERCS continues to swing back and forth with the debate concerning the acceptable ideal caesarean section rate persisting despite the recommendation by WHO. It is believed that the ideal caesarean section rate should be between 10 and 15% [7], however, in the recommendations by WHO to reduce unnecessary caesarean sections using nonclinical interventions, it was noted that these quoted rates are population based and that the panel conclusions were from temporally limited data in a European context [6]. The rising caesarean section rate has been deemed medically unnecessary and potentially harmful and it is predicted that nearly one third (29%) of all deliveries might be by caesarean section by 2030 [8]. In Latin America and the Caribbean, the proportion of caesarean section has outnumbered vaginal delivery and the projected rate by 2030 will likely to be 63, 54, 50 and 45% in Eastern Asia, Latin America and Caribbean, Western Asia and Australia and New Zealand respectively [8]. Therefore, it is pertinent to closely study the causes of high caesarean section rates with the aim of mitigating them, while encouraging VBAC as an alternative.

## **2. Evolution of VBAC**

In 1916, Edwin B. Cragin in his classic publication on conservatism in obstetrics opined that once a caesarean delivery always a caesarean delivery which was later coined as the Dictum of Cragin. He argued that following surgical incision on the anterior abdominal wall and the uterine wall to deliver a fetus should rely on such method for future deliveries. In his article, he highlighted that the risk of uterine rupture is high in VBAC as the uterus is unable to withstand the shear stress of uterine contractions [9, 10]. The practice (of repeat caesarean delivery) was the standard of care until the late 1980s when its reputation was questioned by the National Institutes of Health in Bethesda, Maryland following an exponential surge in caesarean delivery rates and a review by the American Congress of clinical Obstetrics and Gynaecology which modified this recommendation and advocated that a woman can attempt vaginal delivery after one previous caesarean section [9, 11]. There has been remarkable progress in caesarean section techniques with Kerr's incision on the lower segment being the standard as opposed to the classical incision and caesarean section is now generally considered as a safe procedure with the risk of future uterine rupture considerably very low [12]. Evidence from systematic reviews and clinical guidelines suggest that planned VBAC is a safe and suitable method of delivery for most women after uncomplicated previous caesarean delivery [13–15].
