A Clinical Audit About VBAC in A Palestinian Hospital (Hebron Governmental Hospital), shows high success rates of normal delivery in pregnant women how had previous one Cesarean section.

1. A CLINACAL AUDIT
ON THE OUTCOME OF VBAC
IN A PALESTINIAN HOSPITAL
(HGH)
FACULTY OF MEDICINE
ALQUDS UNIVERSITY
SUPERVISED BY:
DR.FATIMA SHARABATI
OBS & GYN DEP. AT HGH
DONE BY:
YAHYA A. KHATEEB
LOTFI M. SROOR
MOATH M. MOUSA
RECS
( Repeat
Elective
Cesarean
Section )

2. METHOD
• Retrospective study done at Obs & Gyn Department at
Hebron Governmental Hospital, under supervision of
Dr.Fatima Sharabati, with approval of Dr. Hisham Amro,
Head of the department.
• Study done by clinical review of patients’ medical records
between 1st Nov 2015 until 18th Nov 2015.
With follow up for any reported medical complications on
both Mothers and Babies., in the first month post partum.

3. No. of cases
Cases
excluded
No. of previous 1
CS
Elective
CS
VBAC
tried
Success
Failure
(urgent CS)
298 263 35 7 28 22 6
100% 88.3% 11.7% 20.0% 80.0% 78.6% 21.4%
Cases excluded
88.26%
Elective CS
2.35%
VBAC tried
9.40%
Cases of the study
Success
78.57%
Failure (urgent
CS)
21.43%
Results of VBAC

4. 0
1
2
3
4
5
6
7
8
15-19
20-24
25-29
30-34
35-39
40-44
AGE DISTRIBUTION
No. of success
No of cases included
Age No. of success No of cases included
15-19 1 1
20-24 3 7
25-29 6 8
30-34 5 7
35-39 5 7
40-44 2 5

5. No. of parity Success VBAC Failure of VBAC Elective CS
1 4 3 4
2 4 1 0
3 2 1 2
4 4 0 0
5 5 0 0
6 1 0 0
7 2 1 0
9 0 0 1
1 2 3 4 5 6 7
4 4
2
4
5
1
2
3
1 1
0 0 0
1
No.ofcases
Parity
Parity vs. Success
Success VBAC Failure of VBAC

6. No. of NSVD before CS Success Failure
0 9 4
1 or more 13 2
1 2 1
2 4 0
3 3 0
4 1 0
5 3 0
6 0 1
Success
87%
Failure
13%
NSVD before CS
Success
69%
Failure
31%
No NSVD before CS VS.
VS.
( Para 1 , Previous 1 )

7. Success
93%
Failure
7%
With Hx of VBAC
Success
64%
Failure
36%
Without Hx of VBAC VS.
VS.
No of previous VBAC Success Failure
0 9 5
1 or more 13 1
1 10 0
2 1 1
3 1 0
4 1 0

8. 0
1
2
3
4
5
6
7
26 27 31 32 37 38 39 40 41 42
Gestationl Age
GESTATIONAL AGE VS. SUCCESS
Success
Failure

9. WEIGHT OF BABY
Weight of baby Success Failure Elective
500 - 999 1 0 0
1000 - 1499 1 0 0
1500 - 1999 2 0 0
2000 - 2499 0 1 4
2500 - 2999 2 1 0
3000 - 3499 6 4 3
3500 - 3999 8 0 0
4000 - 4499 2 0 0

10. 0 1 2 3 4 5 6 7 8
500-999
1000-1499
1500-1999
2000-2499
2500-2999
3000-3499
3500-3999
4000-4499
Weight of baby VS. Success
Failure
Success

11. INDICATIONS OF
ELECTIVE REPEAT OF CS
CS Type Indication Cases
Urgent (Failed VBAC) Pathological Trace 6
Breech 2
Low laying placenta 1
Placenta previa centralis 1
Previous 4th degree tear 1
IVF Twin 1
IVF Infertality 1
Elective
CS Type Indication Cases
Urgent (Failed VBAC) Pathological Trace 6
Breech 2
Low laying placenta 1
Placenta previa centralis 1
Previous 4th degree tear 1
IVF Twin 1
IVF Infertality 1
Elective
Maternal Request
(IVF Twin , IVF Infertility) 2

12. INDICATIONS OF
URGENT CS
(FAILED VBAC)
CS Type Indication Cases
Urgent (Failed VBAC) Pathological Trace 6
Breech 2
Low laying placenta 1
Placenta previa centralis 1
Previous 4th degree tear 1
IVF Twin 1
IVF Infertality 1
Elective

13. DISCUSSION
Results of our study where compared with VBAC Guidelines -2015,
prepared by National Institute for health and Care Excellence (NICE)
for Royal College of Obs & Gyn in UK.

14. DISCUSSION
• The success rate of VBAC in our study was : 78.6% , more
than the overall chance of successful planned VBAC
according to the Royal college guidelines, which was (72-
75%).
• Increased Parity number was associated with decrease
failure rates.

15. DISCUSSION
• High success rates in those had History of previous
normal delivery before their first CS (87%), and lower
success rate (69%) in those without any history of
previous normal delivery before the CS.
• High success rates in those had History of previous VBAV
(normal delivery) after their first CS (93%), and lower
success rate (64%) in those with no history of previous
VBAV after the CS (this is the first VBAC).

16. DISCUSSION
• The term babies have more chance of successful VBAC,
with the highest success rate was at gestational age
between 39 and 39+6 weeks
• Although it was suspected to have more failure rates with
increase weights of babies, but in our study there was 10
cases included with weights of 3500-4500 , with success
rate of 100% and no reported maternal nor newborns
medical complications in the first month post partum.

17. DISCUSSION
• Indications of Elective repeat of CS included: Breech
presentations, low laying placenta, placenta previa
centralis, and history of previous 4th degree tear.
Also there were special cases like: Twin IVF, and Singleton
IVF after history of infertility for 17 years.
• Indication of urgent CS (failed VBAC) in the all 6 cases
was Pathological trace, which is commonly termed as
'fetal distress‘
This means : the CTG in labour shows a pathological
abnormalities that may imply possible hypoxia and birth
asphyxia.

18. DISCUSSION
• The number of reported cases of Uterine rupture during
VBAC trials in our study was ZERO !
On the other hand , Results of Royal collage study showed
that VBAC carries a risk of uterine rupture in 22-74/10,000.
• No reported newborns medical complications nor need for
NICU admition.
• In the first month post partum there was no reported
maternal medical complications.

19. PLANNED VBAC IN
SPECIAL CIRCUMSTANCES
According to Royal collage study :
• There is similar successful rates of VBAC in twin
pregnancies to that in singleton pregnancies.
• Also, there is increased risk of uterine scar rupture for
women with a short inter delivery interval (below 12-24
month).
Special case in Our study :
• G3P5A0 (Gave twins twice)
• 2013  CS : Twin
• Jan 2015  VBAC : Singleton
• Nov 2015  VBAC : Twin , with no recorded medical
complications in the first month post partum.

20. LIMITATIONS
• Sample size.
• Lack of prior research studies on this topic in Palestine .
• Lack of detailed data in the medical record of some
patients.

21. CONCLUSION AND
RECOMMENDATIONS
Through our study we found that VBAC is
undertaken in HGH with a Very good
results, so it should be undertaken in all
Palestinian hospitals.

22. FUTURE DIRECTIVES
• To improve our study by including a wider sample,
covering longer period of time, and inserting more
variables like: APGAR score of baby and Maternal BMI.
• Spread knowledge about benefits of VBAC and giving
good science based counseling for mothers with previous
1 CS who have to go VBAC.
• Re-audits should be undertaken regularly in other local
hospitals to make comparisons for similar clinical settings
in Palestine.

23. THANK YOU