Abstract
BackgroundThe rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.MethodsA retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.ResultsA total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0[1-4]. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.ConclusionsBesides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.
Highlights
The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri
A total of 278 women with one previous caesarean section were booked at the prenatal clinic and followed up till delivery
The indications for the previous caesarean section among the 89 women who underwent a trial of labour (VBAC) were compared based on the outcome of labour and are listed in table 2; The demographic and labour characteristics of women with failed and successful vaginal birth after caesarean section (VBAC) were compared table 3
Summary
The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri Subsequent pregnancies in these women are risk-prone and may complicate. Care pathways could be a methodology for the mutual decision-making and organization of care for a well-defined group of patients protocols These tools could be used to enhance perinatal outcomes in most conditions. The practice of VBAC has persisted in most countries in sub-Saharan Africa despite lack of clear evidence based guidelines like the ones used in the industrialized nations [15,16,17,18] Absence of such guidelines could compromise both maternal and fetal safety. The use of institutional protocol-based care could reduce the incidence of such adverse events in mothers with previous cesarean section if the recommended interventions are implemented [19]
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