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The significance of a nursing care role during the process of labour and delivery is undisputable. Nurses provide physical, informational, and emotional support for women, assist doctors, and monitor the process of childbirth (Simpson & Creehan, 2008, p. 333). That is why they need to be aware of all aspects, possible risks, and interventions of the labour and delivery process. One of the most controversial conditions of labour trial for the vaginal birth studied nowadays is a previous caesarean section. This paper evaluates a quantitative research article titled "Outcome of Vaginal Birth after Caesarean Section in Women with One Previous Section and Spontaneous Onset of Labour". It has been written by K. A. Frass and A. H. Al Harazi and published in the Eastern Mediterranean Health Journal. The research itself is based on exploring a possibility "to tolerate VBAC (vaginal birth after caesarean section) and raise the threshold for recommending caesarean section if low-risk patients are carefully selected" (Frass & Al Harazi, 2011, p.650).

Title. The title is clear enough to describe the subject of the research article. It suggests an issue of the research, which is the vaginal birth outcome. It also indicates the study population, namely women who have experienced one previous caesarean section and with a spontaneous onset of labour. The title is not concise. However, it reveals the nature of the research, making it more specific. Thus, the purpose of this study becomes evident, especially its importance in terms of nursing.



Abstract. The authors provide an abstract for the article, which is brief and concise. It explains the purpose of the study and in details summarizes the results of the research. Its findings are represented via clear quantitative data, including the quantity and description of participants, including a study group and control group. However, the authors omit the methods and tools used for the participants' selection, data collection, and analysis. Nevertheless, it is easy for a reader to decide whether the article is in his or her field of interest.

Introduction. Frass and Harazi discuss the problem of the research, namely, the trial for VBAC as a well-established standart practice of care in their introduction. They highlight some important topics, such as success rates for VBAC, the factors associated with successful vaginal birth, risks of a failed trial, a main adverse outcome, and others. These topics help to understand an approach to the candidates' selection when attempting VBAC. Knowledge of the research subject is briefly summarized in the introduction. In the last sentence of the introduction, the authors state the purpose of the research: "to test the outcome of VBAC trial in women with one prior lower transverse caesarean and spontaneous onset of labour" (Frass & Al Harazi, 2011, p.647). This statement basically outlines the concepts and the population under the study.

Literature review and conceptual/theoretical framework. The literature review, as such, is absent. Hence, there is no description of a research relationship to the existing literature and to the previous research achievements. Most of sources, to which the authors are referencing, are published after 2003. References cited by the researchers are mainly journal articles; thus, they are based on secondary sources. Conceptual/theoretical framework can be traced in introduction and methods' sections. It provides a general background for the research and a general framework for data analysis and identifies variables as well as concepts. However, it does not define and explain those conceptual objects in sufficient details that may lead to complications in the study understanding.

The hypothesis or research questions. The hypothesis or research question statement is absent in the research article as a separate section. The purpose of the study is stated clearly in the introduction. The authors argue that, "The success rates for VBAC range between 60%-80% after one previous caesarean incision" (Frass & Al Harazi, 2011, p.647). This statement may be considered as a hypothesis. Except this, Frass and Al Harazi identify a question in the existing data being complex and conflicting. It is related namely to "which route of delivery is most appropriate and safe for women with the previous caesarean section, either VBAC or elective repeat caesarean delivery" (Frass & Al Harazi, 2011, p.647). This question has been investigated during the research.

Methods. "The study was carried out within the biggest public hospital in Yemen over a 1-year period" (Frass & Al Harazi, 2011, p.647). The research design envisages a detailed approach to the participants' selection and procedure implementation in order to minimize risks and complications. It may cause some limitation towards the study results; however, maternal and fetal safety comes first. The authors describe methods used for data analysis explicitly. It is a quantitative research based on numerical data analysed statistically.

Population. The population of this research has been clearly, accurately, and explicitly identified and described in sufficient details by the authors in a sample and setting section. The sample size has been adequate as well. Thus, there have been 357 women selected, who fulfilled all study criteria. They have been as follows: one previous caesarean section, the term from 37 up to 40 weeks, having a spontaneous onset of labour, and other obstetric or medical indications. There has been also a control group selected. The control group consists of 155 women without the previous uterine incision. The members of the study and control group have been matched for a certain set of criteria. They are "age, parity, gestational age, birth weight, Apgar score, use of oxytocin and mode of delivery" (Frass & Al Harazi, 2011, p.647).

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Data collection and measurement. The authors focus on the listing of variables and specific concepts rather than explaining them or describing actual methods, tools, and techniques used to measure those variables and concepts. "The data retrieved included: maternal age, parity, gestational age, indications for previous caesarean section, circumstances surrounding previous delivery, type of uterine incision, interval since the previous caesarean and previous vaginal delivery before or after caesarean section" (Frass & Al Harazi, 2011, p.647). The data have been received via obstetric and medical examinations. The frequency and types of analysis and assessments have been clearly identified and described. Pelvic adequacy has been assessed using digital pelvimetry in order to provide reliable and valid data. "The outcome measures were the duration of first and second labour stage, intrapartum complications, Apgar score, birth weight, postpartum complications, including, dehiscence, uterine rupture, and need for blood transfusion, and length of hospital stay" (Frass & Al Harazi, 2011, p.648). The authors do not explain conceptual and operational definitions for these variables. The specific instruments have been not adequately described as well whether being questionnaires, interviews, observations or records analysis. It may be considered as a major weakness of the research article. The conceptual and theoretical framework is not presented in sufficient details. Nevertheless, the data collected during this research is considered to be valuable for nursing practices.

Procedures. The description of procedures is given in details. All necessary equipment, possible interventions, infusions, and techniques for monitoring fetal and maternal conditions have been adequately identified and described. The appropriate procedures have been used to safeguard the rights of study participants. "Informed consent for participation was obtained from each participant and hospital ethical committee" (Frass & Al Harazi, 2011, p.647).

Results and findings. The statistical analysis has been conducted for collected data. The appropriate statistical methods have been used, given the level of measurement of variables, including the mean and standard deviation, percentage where appropriate, and the number of participants in each of two groups compared. "Differences in means were tested by Student t-test. Chi-squared tests were used to compare frequencies. Fisher exact test was used when appropriate" (Frass & Al Harazi, 2011, p.648). As a result, "311 out of 357 women were delivered vaginally" (Frass & Al Harazi, 2011, p.648). It gives a "VBAC success rate of 87.1%" (Frass & Al Harazi, 2011, p.648). According to Frass & Al Harazi (2011) "Statistical significance was taken as P value <0.05" (p.648). Thus, it was minimizing the type I errors. The findings were summarized, represented in tables, and described separately for each variable in text.

Discussion and implications. The authors discuss the current situation in the area concerning the research topic in the discussion section. Thus, describing the significance and importance of study findings' application in clinical practices. They also compare the results to other similar studies that confirm the research findings. According to Frass & Al Harazi (2011) "Statistically significant differences between the results in study and control group were not found (p.648). Moreover, Frass & Al Harazi (2011) argue that as compared to control group, "it was proven that vaginal delivery after one caesarean section is safe as regards neonatal outcomes" (p. 650). According to Frass & Al Harazi (2011) "it may encourage patients and obstetricians to choose VBAC trial with more confidence when other risk factors are excluded" (p.649). The most likely and probably one of the most dangerous complications of VBAC trial is uterine rupture. That is why the authors try to investigate and discuss a relationship between the dosage of oxytocin and uterine rupture case. However, it is stated that "additional studies are required to investigate cases of uterine rupture" (Frass & Al Harazi, 2011, p.650). Other possible risks and complications that may influence the choice of the VBAC attempt have been discussed as well. The authors address the issue of generalizability of findings. They state that "the research results are based on data from a single setting and may not be generalizable to other locations" (Frass & Al Harazi, 2011, p.650).

Global issues. The report is well-written and well organized. However, it is not sufficiently detailed. It lacks the literature review and detailed theoretical and conceptual framework. The variables are clearly identified, but not defined and explained. It makes it harder to understand the study to a less research-aware reader. It also lacks the details in methods of the data collection description. Thus, it is difficult to evaluate their relevance, reliability, and validity.

Summary assessment. There is a brief conclusion that summarizes the research results. The authors answer the study question concerning the possibility of successful VBAC. According to Frass & Al Harazi (2011), "The results show a high success rate (>85%) with no incresed risk of maternal and fetal morbidity or mortality" (p.650). Thus, the research findings may "encourage obstetricians to tolerate VBAC and raise the threshold for recommending caesarean section if low-risk patients are carefully selected" (Frass & Al Harazi, 2011, p.650). Despite the identified limitations, the findings of the study seem to be valid and applicable in nursing practices.

Conclusion. Frass & Al Harazi in their article "Outcome of Vaginal Birth after Caesarean Section in Women with One Previous Section and Spontaneous Onset of Labour" (2011) have made an attempt to investigate a complex and conflicting issue of a modern clinical and nursing practice field.

The main strengths of this study are the detailed description of the approach to participant selection, description of procedure aspects, including monitoring techniques, the clear lists of conditions and variables investigated, and the findings interpretation. The authors have managed to represent and discuss the results of their research, comparing them to other similar studies. The findings are the valuable data that may be used in clinical and nursing practices.

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The main weaknesses of this research are the lack of clear and explicit hypothesis statement, the absence of literature review, lack of theoretical and conceptual framework, and a blurred description of methods used for data collecting. These factors may influence the adequate understanding of all study aspects. Moreover, the limitations may impact the reliability and validity of findings. It also may be due to the specific issue that has been investigated. Such cases are very individual; and every candidate for the VBAC trial should be carefully selected. Nevertheless, the authors have managed to investigate main factors of the successful vaginal birth and to identify possible risks and complications connected with this process.

Despite the fact that "the success rate of VBAC trial was 87.1%" (Frass & Al Harazi, 2011, p.648), the further research may be required in order to expand the scope of investigation. Even though, the results of this research, conditions, risks, and complications may be useful to improve nursing and healthcare practices in the field of the labour and delivery process.

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