Maternal and perinatal outcome after previous caesarean section in rural Rwanda

Richard Kalisa,Thomas Van Den Akker,Jos Van Roosmalen,Stephen Rulisa

doi:10.1186/s12884-017-1467-5

Abstract

BackgroundOffering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda.MethodsAudit of women’s records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014.ResultsOut of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n = 23, 7.7%) compared with women who had an ERCS (n = 5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2–5.4). There was no difference in neonatal admissions between women who underwent ToL (n = 64/297; 21.5%) and those who delivered by ERCS (n = 35/138; 25.4%: aOR 0.8; CI 0.5–1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n = 40, 13.4%) compared to those who delivered by ERCS (n = 15, 10.9%: aOR 1.9; CI 1.6–3.6). Perinatal mortality was similar among infants whose mothers had ToL (n = 8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n = 4; 29/1000 ERCSs).ConclusionsA considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL.

Highlights

Offering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS
Gestational diabetes and hypertension were higher in women who delivered by elective repeat caesarean section (ERCS) (Table 1)
The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n = 40, 13.4%) compared to those who delivered by ERCS (n = 15, 10.9%: adjusted odds ration (aOR) 1.9; Confidence interval (CI) 1.6–3.6)

Summary

Introduction

Offering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. Previous CS is one of the main indications for CS in sub-Saharan Africa [3, 4]. In sub-Saharan African countries, ToL rates vary between 37 and 97% [3, 8, 9]. Successful vaginal delivery in women with ToL in these countries stood at 70-80% [2, 10, 11]. Clinical criteria to offer vaginal delivery to women who had prior CS in most countries in sub-Saharan Africa include single previous

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Discussion

Conclusion