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Mode of delivery after one cesarean section
International Journal of Gynecology and Obstetrics (2004) 87, 9--13
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ARTICLE
Mode of delivery after one cesarean section L.-J. van Bogaert * Department of Obstetrics and Gynecology, MEDUNSA Satellite Campus, Philadelphia Hospital, Dennilton, South Africa Received 23 January 2004; received in revised form 19 May 2004; accepted 19 May 2004
KEYWORDS Cesarean section; Vaginal birth after cesarean; Trial of labor; Dysfunctional labor
ABSTRACT Objectives: To investigate labor patterns and mode of delivery of vaginal births after cesarean (VBAC) versus unsuccessful trial of labor after cesarean (TOLAC) in a South African district hospital, and the influence of the indication for the primary cesarean section (C-section) on the subsequent mode of delivery. Methods: Retrospective audit of the partogram of 202 VBAC and 382 repeat C-section. There were 108 elective repeat cesarean deliveries (ERCD) and 274 emergency repeat C-sections after unsuccessful TOLAC. The indication of the primary C-section was known in 127: 43 (33.9%) VBAC and 84 (66.1%) repeat C-sections. Results: The indication for the primary C-section in terms of recurrent/non-recurrent did not affect the subsequent mode of delivery (v2=3.5; P=0.06; OR 0.49, 95% CI 0.23--1.04). The indication of the primary C-section in terms of dysfunctional/non-dysfunctional labor did not reoccur in the same parturients (v2=0.01; P=0.91; OR 0.94, 95% CI 0.35--2.55). Conclusion: Dysfunctional labor accounted for most primary and repeat emergency C-sections, but not as a recurrent condition in the same parturients. A 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Most of the information concerning the success or failure rate of vaginal birth after a cesarean (VBAC) has been forthcoming from tertiary institutions in the developed world. The set standards of practice that have resulted from these reports may well be out of reach of and irrelevant to non-academic institutions, especially in the developing world. Of major concern is the possible maternal morbid* Fax: +27-13-262-4339. E-mail address: [email protected] (L.-J. van Bogaert).
ity and mortality (mainly the risk of uterine rupture) resulting from a trial of labor after cesarean (TOLAC) birth. Therefore, selection criteria should be established in order to minimize the risk. VBAC is a safe practice provided there is appropriate selection of candidates [1]. The question then is: What are these appropriate selection criteria and what are the factors that may affect the success rate of VBAC in circumstances prevailing in African district hospitals? Younger maternal age, low birth weight, and increased parity have been reported to increase the success rate [2]. Maternal (viz. pregnancy-
0020-7292/$ - see front matter A 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.05.015
10
L.-J. van Bogaert
induced hypertension, diabetes mellitus, chorioamnionitis, and use of oxytocin) and fetal factors (male infant, macrosomia) are likely to lower the success rate [3]. The type of uterine incision (viz. low segment transverse or corporeal) and the type of suture of the uterus (viz. single or double-layer) affect the risk of rupture [4,5]. The influence of the indication of the primary cesarean section (Csection) is diversely appreciated. According to some, the risk of an unsuccessful TOLAC is increased if the primary C-section was for dystocia. Others reported a 65.6% success rate if dystocia occurred in the first stage and 75.2% if it occurred during the second stage of labor [4]. According to Impey and O’Herlihy [6], cephalopelvic disproportion is not a recurrent indication for an elective repeat cesarean delivery (ERCD). This, however, does not mean that it cannot recur and result in an unsuccessful TOLAC. The present study was carried out to investigate the labor patterns after one C-section in women having a VBAC or a repeat C-section after an unsuccessful TOLAC in order to find out whether the indication of the primary C-section affected the subsequent mode of delivery in a district hospital in a developing world setting.
2. Patients and methods The study was done in a South African 600-bed rural district hospital with a monthly average of 350 to 400 deliveries. Primigravidas and parturients who present an obstetrical risk factor such as malpresentation, multiple pregnancy, and previous C-section are referred from the 15 peripheral clinics for hospital delivery. Parturients are also referred from three community hospitals. Spontaneous vertex deliveries (SVD) are managed by midwives. Instrumental deliveries (i.e. vacuum extraction) and Csections are carried out by medical officers trained Table 1 Variable
by the only registered consultant obstetrician-gynecologist practicing in the hospital during the survey. Over the last 5 years, 15% of deliveries were by C-section and 3.5% by vacuum extraction. The percentage of uterine rupture for primary C-sections was 0.2. The perinatal mortality fluctuated around 35 per thousand. The study focused on women with one previous C-section who had a VBAC or a repeat C-section. The data were collected from the patients’ files after delivery and from the nursery. The following information was recorded: age, parity, mode of delivery (VBAC or repeat C-section, elective or emergency), birth weight, Apgar score, speed of cervical dilatation (cm/h), time spent right of the alert line (min) (defined as a rate of cervical dilatation of 1 cm/h), proportion of parturients reaching or crossing the action line (placed parallel to and 4 h right to the alert line) [7]. When possible, information was gathered either from the patient’s record or patients’ recall about the indication for the primary C-section and compared to the indication of the repeat C-section. An ERCD was carried out for the following indications: poor obstetrical history and/or advanced maternal age in pauciparous women, breech presentation, transverse lie, ante-partum hemorrhage, and severe pre-eclampsia (PE) or eclampsia (E) not responding to standard medical management (including failed induction). A TOLAC was allowed in the absence of any of the above. The decision to allow a TOLAC was left at the discretion of the practitioner on duty. Expectant management of labor was the standard practice. The departmental guidelines recommended a C-section for most breech presentations (aiming at a better outcome for the neonate) and a repeat Csection in grand multiparas with one previous Csection (because of the increased risk of uterine rupture). Because of the local conditions and perceptions about cesarean deliveries, a number of women reached the hospital in established labor
Demographic data and labor characteristics VBAC (n=202)
Repeat C-section (n=382) a
Age (years) 27.9 (27.1, 28.7) 28.8 (28.2, 29.4) Parity 3.0 (2.8, 3.1) 2.8 (2.6, 2.9) Birth weight (g) 3000 (2936, 3065) 3168 (3114, 3222) Speed of cervical dilatation (cm/h) 1.71 (1.50, 1.90) 0.78 (0.65, 0.91)b Time spent right of the alert line (min) 15.3 (8.6, 22.0) 116.8 (94.7, 139.0)b Reached the action line (%) 0.0 12.7 Crossed the action line (%) 0.0 3.2 a Values are means (95% confidence intervals) unless stated otherwise. b n=274 emergency repeat C-sections. c m2 values.
t
P
1.8 1.6 4.1 15.7 16.0 14.1c 3.4c
0.08 0.10 <0.0001 <0.0001 <0.0001 0.0002 0.065
Mode of delivery after one cesarean section and this did not provide the choice in all circumstances to proceed or not with a TOLAC. The indications for primary C-section were subdivided into two groups: recurrent and non-recurrent. This was based on the (debatable) assumption that dysfunctional labor was likely to recur, and that non-reassuring fetal status, breech, transverse lie, multiple pregnancy, ante-partum hemorrhage, severe PE/E, and a few other conditions were less likely to reoccur. Dysfunctional or prolonged labor was defined as cephalo-pelvic disproportion (CPD) (as evidenced by arrest of cervical dilatation and/ or of descent with molding 3+) and inefficient contractions (primary or secondary to CPD) [7]. The following statistical tests were carried out: descriptive statistics, contingency table analysis, and odds ratios (OR) with the 95% confidence intervals (CI). Statistical significance was set for a P value <0.05. The statistical package GraphPad from Prism (GraphPad, San Diego, CA) was used.
3. Results A total of 584 records were audited: only 202 (34.6%) had a VBAC and 382 (65.4%) a repeat Csection. Of these 108 (28.3%) were ERCD and 274 (71.7%) emergency C-sections for unsuccessful TOLAC. Out of 476 TOLAC, 202 (42.4%) were successful and 274 (57.6%) failed. Table 1 illustrates the comparative obstetrical characteristics. Neonates born by repeat C-section were heavier and the speed of cervical dilatation was significantly slower than with VBAC. Table 2 shows the comparative distribution by parity. More than half of the parturients in both groups was gravida 2 para 1. The indications for ERCD are listed in Table 3. There were 46 (42.6%) ERCD for patients with a poor obstetrical history. The other indications were standard indications for ERCD. The indications for repeat emergency C-section are listed in Table 4. Dysfunctional labor was the
Table 2
11 Table 3 Indications for elective repeat cesarean delivery (by parity) P1G2 a
Elective Breech Ante-partum hemorrhage Transverse lie Severe PE/EOthers Total a For poor history of high
P1G2a 105 (52.0%) P2G3 37 (18.3%) P3G4 35 (17.2%) Pz4Gz5 25 (12.4%) a P=para, G=gravida.
Pz4Gz5
2 2 --
17 2 1
Total 46 20 12
6 2 -2 10 5 2 2 -9 6 1 2 2 11 57 19 8 24 108 obstetrical history in pauciparas or number of fetal losses.
Table 4 Indications for repeat emergency C-section (by parity) P1G2 P2G3 P3G4 Pz4Gz5 Total
Repeat C-section (n=382)
Total
247 60 28 47
352 97 63 72
(64.7%) (15.7%) (7.3%) (12.3%)
8 3 3
P3G4
main indication (85.8%). Audit of the partograms showed that 29 of them (12.3%) did not show convincing evidence of dysfunctional labor; they were included in the group because the diagnosis of dysfunctional labor figured in the records as the indication for the C-section. The indication of the primary C-section was available in only 127 instances (21.7%): 43 of the VBAC and 84 of the repeat C-sections (Table 5). Twenty patients with a known indication for the primary C-section had an ERCD. Dysfunctional labor accounted for 41.7% of the primary C-sections: 37.2% in the VBAC and 61.7% in the repeat emergency C-sections (v2=0.01; P=0.91; OR 0.94, 95% CI 0.35--2.55). Contingency table analysis was carried out to establish to what extent a recurrent indication for the primary C-section was likely to reoccur as an indication for the repeat C-section. The subsequent mode of delivery was not significantly influenced by the indication of the primary Csection (v2=3.51, P=0.06; OR 0.49, 95% CI 0.23-1.04). There was no evidence suggesting that poor progress of labor as the indication of the primary Csection was likely to reoccur (v2=0.01; P=0.94; OR 1.03, 95% CI 0.43--2.47). The prevalence of vacuum extraction with VBAC was of 8 in 202 (4.0%). Vacuum extraction was attempted but failed in 3 out of 274 unsuccessful
Distribution by parity VBAC (n=202)
19 13 8
P2G3
(60.3%) (16.6%) (10.8%) (12.3%)
Dysfunctional labor: confirmed 137 not confirmeda 23 NRFSb 28 Cord prolapse 2 Total 190 a b
33 4 4 -41
15 2 2 1 20
At the audit of the partogram. Non-reassuring fetal status.
21 -1 1 23
206 29 35 4 274
12 Table 5
L.-J. van Bogaert Indication for the primary C-section
Indication
Mode of subsequent delivery VBAC (n=43)
Dysfunctional labor 16 (37.2)a Non-reassuring 7 (16.2) fetal status Breech 12 (27.9) Transverse lie 4 (9.3) Severe PE/E 2 (4.7) Twin pregnancy 2 (4.7) Cord prolapse -Other -a Values are numbers (%).
Repeat C-section (n=84) 37 (44.0) 15 (17.9) 13 6 6 4 2 1
(15.5) (7.1) (7.1) (4.8) (2.4) (1.2)
TOLAC (1.1%). Two parturients who had a VBAC delivered before arrival. There was one instance of an Apgar score <7 at 5 min with a repeat emergency C-section. Seven peri-natal deaths occurred in the repeat C-section group (25.5x). There were 8 uterine ruptures among the 274 parturients undergoing a repeat C-section for unsuccessful TOLAC (2.9%): two in 190 para 1-gravida 2 (1.1%), five in 41 para 3-gravida 4 (12.2%), and one in 23 grand multiparas (4.3%). Four of the neonates were alive and well and four were fresh stillbirths. During the study period, 13 women had a VBAC after two previous C-sections; they all were admitted in advanced first stage of labor. Only five out of the 13 neonates were alive and well. There were five intra-uterine fetal deaths on arrival; and three early perinatal deaths (all were cases of shoulder dystocia).
4. Discussion The findings in this report are subject to limitations that are almost unavoidable in a district hospital in a developing world rural setting. Poorly educated women are likely to try to avoid hospital delivery because it lacks the traditional support system and because of the fear of a C-section. They are aware of the fact that a uterine scar puts them at risk of a repeat C-section, and that at a third C-section the chances are great that they will be convinced to be sterilized. Therefore, many will go to the hospital as a last resort and this limits our ability to implement strict selection criteria in favor or against a TOLAC. It was frustrating to try to find out what was the indication for the primary C-section. Because hospital records are handled manually they
get easily misplaced and lost. A number of patients move in or out of the district. Therefore, this study lacks the statistical power needed to suggest management policies for the management of labor after one C-section. To the best of our knowledge, only a limited number of studies have been published on VBAC in community and district hospitals, especially in developing countries. In Bloemfontein (a South African tertiary institution), in a series of 189 cases, 21% had an ERCD; this compares well with our 18.6% of ERCD. Out of the 149 TOLAC in this study, 57% resulted in a VBAC (this was significantly better than our 42.4% of successful TOLAC). A uterine rupture occurred in 2.7% of the unsuccessful TOLAC (vs. 2.9% in the present series) [8]. The relatively high rate of rupture appeared to be linked to increased parity; an additional factor may have been the staff shortages and the lack of sufficient supervision inherent to our type of settings. A study from a tertiary institution in Saudi Arabia reported a 41.7% VBAC rate [9]. In a short series of 66 selected cases from Thailand, 76% had a VBAC (40% of them were assisted deliveries); the selection criteria were not mentioned [10]. In a large series of 531 cases from the Philippines, 69.4% underwent a repeat C-section and only 28.1% had a successful TOLAC (significantly less than our 42.4% of VBAC after TOLAC) [11]. Here also the selection criteria were not mentioned. Overall, these data support the view expressed by the Integrated Management of Pregnancy and Childbirth that in rural settings and developing world conditions one can expect a maximum of 50% of VBAC [12]. The question about selection criteria remains partly unanswered (with the exception of the clear indications for an ERCD). According to the American College of Obstetrics and Gynecology Practice Bulletin N 5 of 1999, if the indication for the primary C-section was CPD, the chances of VBAC are reduced to 30--60% [13]. This could be interpreted in the sense that CPD is likely to be a recurrent condition. Data from West, East and South Africa indicate that CPD constitutes close to 50% of the indications for primary CS-sections (a value close to the 51.5% at our institution) [14—16]. Some studies suggest that a previous C-section for dystocia is associated with a very high rate of unsuccessful TOLAC in the subsequent pregnancy [16,17]. It must be said, however, that the concept of dystocia is often used synonymously for CPD although dystocia encompasses not only CPD. This makes comparisons hazardous. Therefore, we used Philpott’s concept of dysfunctional labor rather than CPD. Already in 1972, Philpott and Castle [7] called attention to the
Mode of delivery after one cesarean section fact dysfunctional labor is the biggest problem in African parturients. This justifies the recommendation made by the ACOG that ‘‘global mandates for TOLAC are inappropriate because individual risk factors are not considered’’ [13]. It appears thus that in developing world settings, a success rate of 50% (or even less) of VBAC is to be expected. Dysfunctional labor is a major contributor to both primary and repeat C-sections; from our limited data, we cannot conclude firmly that it is a recurrent condition. The relatively high risk of uterine rupture must be kept in mind when selection is possible; the risk increases with increasing parity. A TOLAC for a third delivery and onwards may not be safe in rural district hospitals in developing world settings.
References [1] Paruk F, Moodley J. Severe obstetric morbidity. Curr Opin Obstet Gynecol 2001;13:563--8. [2] Hibbard JU, Ismail MA, Wang Y. Failed vaginal birth after cesarean section: how risky is it? Am J Obstet Gynecol 2001;184:1365--73. [3] Myles ThD, Santolaya-Forgas J. Vaginal birth after cesarean delivery: predictors of success or failure. Obstet Gynecol [(Suppl). Abstract 55S]. [4] Bujold E, Gauthier RJ. Should we allow a trial of labor after a cesarean for dystocia in the second stage of labor? Obstet Gynecol 2001;98:652--5. [5] Biswas A. Management of previous cesarean section. Curr Opin Obstet Gynecol 2003;15:85--90.
13 [6] Impey L, O’Herlihy C. First delivery after caesarean section for strictly defined cephalopelvic disproportion. Br J Obstet Gynaecol (Suppl. 105) [Abstract 169, 64]. [7] Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. J Obstet Gynaecol Br Commonw 1972;79:592--602. [8] Van der Walt WA, Cronje ´ HS, Bam RH. Vaginal delivery after one caesarean section. Int J Obstet Gynecol 1994; 46:271--7. [9] Mesleh RA, Kurdi AM, Algwiser AA. Intrapartum rupture of the uterus---19 years’ experience. Int J Gynecol Obstet 1999;64:311--2. [10] Saropala N, Suthuvoravut S. The outcome of the first VBAC program in Thailand. Int J Gynecol Obstet 1999;64:307—8. [11] Garcia-Tansengco ML. Elective repeat cesarean section versus trial labor after previous cesarean section: a cost-effectiveness analysis. XVI FIGO World Congress of Gynecology and Obstetrics; 2000. FIGO, Abstract P4.03.08. [12] Integrated Management of Pregnancy and Childbirth. WHO/ Reproductive Health Research/00.7. World Health Organization, Geneva; 2000, p. S--93. [13] American College of Obstetrics and Gynecology practice bulletin Number 5, July 1999. Vaginal birth after previous cesarean delivery. Int J Gynaecol Obstet 1999;66:197--204. [14] Urbani G, de Vries MMJ, Cronje ´ HS, Niemand I, Bam RH, Beyer E. Complications associated with cesarean section in HIV-infected patients. Int J Gynaecol Obstet 2001;74:9--15. [15] Ould El Joud D, Bouvier-Colle MH. Dystocia: a study of its frequency and risk factors in seven cities of West Africa. Int J Gynaecol Obstet 2001;74:171--8. [16] Rhalenbeck S, Hakizimana C. Deliveries at a district hospital in Rwanda: 1997--2000. Int J Gynaecol Obstet 2002; 76:325--8. [17] Hoskins IA, Gomez Jl. Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery. Obstet Gynecol 1007; 89:591--3.
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ARTICLE
Mode of delivery after one cesarean section L.-J. van Bogaert * Department of Obstetrics and Gynecology, MEDUNSA Satellite Campus, Philadelphia Hospital, Dennilton, South Africa Received 23 January 2004; received in revised form 19 May 2004; accepted 19 May 2004
KEYWORDS Cesarean section; Vaginal birth after cesarean; Trial of labor; Dysfunctional labor
ABSTRACT Objectives: To investigate labor patterns and mode of delivery of vaginal births after cesarean (VBAC) versus unsuccessful trial of labor after cesarean (TOLAC) in a South African district hospital, and the influence of the indication for the primary cesarean section (C-section) on the subsequent mode of delivery. Methods: Retrospective audit of the partogram of 202 VBAC and 382 repeat C-section. There were 108 elective repeat cesarean deliveries (ERCD) and 274 emergency repeat C-sections after unsuccessful TOLAC. The indication of the primary C-section was known in 127: 43 (33.9%) VBAC and 84 (66.1%) repeat C-sections. Results: The indication for the primary C-section in terms of recurrent/non-recurrent did not affect the subsequent mode of delivery (v2=3.5; P=0.06; OR 0.49, 95% CI 0.23--1.04). The indication of the primary C-section in terms of dysfunctional/non-dysfunctional labor did not reoccur in the same parturients (v2=0.01; P=0.91; OR 0.94, 95% CI 0.35--2.55). Conclusion: Dysfunctional labor accounted for most primary and repeat emergency C-sections, but not as a recurrent condition in the same parturients. A 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Most of the information concerning the success or failure rate of vaginal birth after a cesarean (VBAC) has been forthcoming from tertiary institutions in the developed world. The set standards of practice that have resulted from these reports may well be out of reach of and irrelevant to non-academic institutions, especially in the developing world. Of major concern is the possible maternal morbid* Fax: +27-13-262-4339. E-mail address: [email protected] (L.-J. van Bogaert).
ity and mortality (mainly the risk of uterine rupture) resulting from a trial of labor after cesarean (TOLAC) birth. Therefore, selection criteria should be established in order to minimize the risk. VBAC is a safe practice provided there is appropriate selection of candidates [1]. The question then is: What are these appropriate selection criteria and what are the factors that may affect the success rate of VBAC in circumstances prevailing in African district hospitals? Younger maternal age, low birth weight, and increased parity have been reported to increase the success rate [2]. Maternal (viz. pregnancy-
0020-7292/$ - see front matter A 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.05.015
10
L.-J. van Bogaert
induced hypertension, diabetes mellitus, chorioamnionitis, and use of oxytocin) and fetal factors (male infant, macrosomia) are likely to lower the success rate [3]. The type of uterine incision (viz. low segment transverse or corporeal) and the type of suture of the uterus (viz. single or double-layer) affect the risk of rupture [4,5]. The influence of the indication of the primary cesarean section (Csection) is diversely appreciated. According to some, the risk of an unsuccessful TOLAC is increased if the primary C-section was for dystocia. Others reported a 65.6% success rate if dystocia occurred in the first stage and 75.2% if it occurred during the second stage of labor [4]. According to Impey and O’Herlihy [6], cephalopelvic disproportion is not a recurrent indication for an elective repeat cesarean delivery (ERCD). This, however, does not mean that it cannot recur and result in an unsuccessful TOLAC. The present study was carried out to investigate the labor patterns after one C-section in women having a VBAC or a repeat C-section after an unsuccessful TOLAC in order to find out whether the indication of the primary C-section affected the subsequent mode of delivery in a district hospital in a developing world setting.
2. Patients and methods The study was done in a South African 600-bed rural district hospital with a monthly average of 350 to 400 deliveries. Primigravidas and parturients who present an obstetrical risk factor such as malpresentation, multiple pregnancy, and previous C-section are referred from the 15 peripheral clinics for hospital delivery. Parturients are also referred from three community hospitals. Spontaneous vertex deliveries (SVD) are managed by midwives. Instrumental deliveries (i.e. vacuum extraction) and Csections are carried out by medical officers trained Table 1 Variable
by the only registered consultant obstetrician-gynecologist practicing in the hospital during the survey. Over the last 5 years, 15% of deliveries were by C-section and 3.5% by vacuum extraction. The percentage of uterine rupture for primary C-sections was 0.2. The perinatal mortality fluctuated around 35 per thousand. The study focused on women with one previous C-section who had a VBAC or a repeat C-section. The data were collected from the patients’ files after delivery and from the nursery. The following information was recorded: age, parity, mode of delivery (VBAC or repeat C-section, elective or emergency), birth weight, Apgar score, speed of cervical dilatation (cm/h), time spent right of the alert line (min) (defined as a rate of cervical dilatation of 1 cm/h), proportion of parturients reaching or crossing the action line (placed parallel to and 4 h right to the alert line) [7]. When possible, information was gathered either from the patient’s record or patients’ recall about the indication for the primary C-section and compared to the indication of the repeat C-section. An ERCD was carried out for the following indications: poor obstetrical history and/or advanced maternal age in pauciparous women, breech presentation, transverse lie, ante-partum hemorrhage, and severe pre-eclampsia (PE) or eclampsia (E) not responding to standard medical management (including failed induction). A TOLAC was allowed in the absence of any of the above. The decision to allow a TOLAC was left at the discretion of the practitioner on duty. Expectant management of labor was the standard practice. The departmental guidelines recommended a C-section for most breech presentations (aiming at a better outcome for the neonate) and a repeat Csection in grand multiparas with one previous Csection (because of the increased risk of uterine rupture). Because of the local conditions and perceptions about cesarean deliveries, a number of women reached the hospital in established labor
Demographic data and labor characteristics VBAC (n=202)
Repeat C-section (n=382) a
Age (years) 27.9 (27.1, 28.7) 28.8 (28.2, 29.4) Parity 3.0 (2.8, 3.1) 2.8 (2.6, 2.9) Birth weight (g) 3000 (2936, 3065) 3168 (3114, 3222) Speed of cervical dilatation (cm/h) 1.71 (1.50, 1.90) 0.78 (0.65, 0.91)b Time spent right of the alert line (min) 15.3 (8.6, 22.0) 116.8 (94.7, 139.0)b Reached the action line (%) 0.0 12.7 Crossed the action line (%) 0.0 3.2 a Values are means (95% confidence intervals) unless stated otherwise. b n=274 emergency repeat C-sections. c m2 values.
t
P
1.8 1.6 4.1 15.7 16.0 14.1c 3.4c
0.08 0.10 <0.0001 <0.0001 <0.0001 0.0002 0.065
Mode of delivery after one cesarean section and this did not provide the choice in all circumstances to proceed or not with a TOLAC. The indications for primary C-section were subdivided into two groups: recurrent and non-recurrent. This was based on the (debatable) assumption that dysfunctional labor was likely to recur, and that non-reassuring fetal status, breech, transverse lie, multiple pregnancy, ante-partum hemorrhage, severe PE/E, and a few other conditions were less likely to reoccur. Dysfunctional or prolonged labor was defined as cephalo-pelvic disproportion (CPD) (as evidenced by arrest of cervical dilatation and/ or of descent with molding 3+) and inefficient contractions (primary or secondary to CPD) [7]. The following statistical tests were carried out: descriptive statistics, contingency table analysis, and odds ratios (OR) with the 95% confidence intervals (CI). Statistical significance was set for a P value <0.05. The statistical package GraphPad from Prism (GraphPad, San Diego, CA) was used.
3. Results A total of 584 records were audited: only 202 (34.6%) had a VBAC and 382 (65.4%) a repeat Csection. Of these 108 (28.3%) were ERCD and 274 (71.7%) emergency C-sections for unsuccessful TOLAC. Out of 476 TOLAC, 202 (42.4%) were successful and 274 (57.6%) failed. Table 1 illustrates the comparative obstetrical characteristics. Neonates born by repeat C-section were heavier and the speed of cervical dilatation was significantly slower than with VBAC. Table 2 shows the comparative distribution by parity. More than half of the parturients in both groups was gravida 2 para 1. The indications for ERCD are listed in Table 3. There were 46 (42.6%) ERCD for patients with a poor obstetrical history. The other indications were standard indications for ERCD. The indications for repeat emergency C-section are listed in Table 4. Dysfunctional labor was the
Table 2
11 Table 3 Indications for elective repeat cesarean delivery (by parity) P1G2 a
Elective Breech Ante-partum hemorrhage Transverse lie Severe PE/EOthers Total a For poor history of high
P1G2a 105 (52.0%) P2G3 37 (18.3%) P3G4 35 (17.2%) Pz4Gz5 25 (12.4%) a P=para, G=gravida.
Pz4Gz5
2 2 --
17 2 1
Total 46 20 12
6 2 -2 10 5 2 2 -9 6 1 2 2 11 57 19 8 24 108 obstetrical history in pauciparas or number of fetal losses.
Table 4 Indications for repeat emergency C-section (by parity) P1G2 P2G3 P3G4 Pz4Gz5 Total
Repeat C-section (n=382)
Total
247 60 28 47
352 97 63 72
(64.7%) (15.7%) (7.3%) (12.3%)
8 3 3
P3G4
main indication (85.8%). Audit of the partograms showed that 29 of them (12.3%) did not show convincing evidence of dysfunctional labor; they were included in the group because the diagnosis of dysfunctional labor figured in the records as the indication for the C-section. The indication of the primary C-section was available in only 127 instances (21.7%): 43 of the VBAC and 84 of the repeat C-sections (Table 5). Twenty patients with a known indication for the primary C-section had an ERCD. Dysfunctional labor accounted for 41.7% of the primary C-sections: 37.2% in the VBAC and 61.7% in the repeat emergency C-sections (v2=0.01; P=0.91; OR 0.94, 95% CI 0.35--2.55). Contingency table analysis was carried out to establish to what extent a recurrent indication for the primary C-section was likely to reoccur as an indication for the repeat C-section. The subsequent mode of delivery was not significantly influenced by the indication of the primary Csection (v2=3.51, P=0.06; OR 0.49, 95% CI 0.23-1.04). There was no evidence suggesting that poor progress of labor as the indication of the primary Csection was likely to reoccur (v2=0.01; P=0.94; OR 1.03, 95% CI 0.43--2.47). The prevalence of vacuum extraction with VBAC was of 8 in 202 (4.0%). Vacuum extraction was attempted but failed in 3 out of 274 unsuccessful
Distribution by parity VBAC (n=202)
19 13 8
P2G3
(60.3%) (16.6%) (10.8%) (12.3%)
Dysfunctional labor: confirmed 137 not confirmeda 23 NRFSb 28 Cord prolapse 2 Total 190 a b
33 4 4 -41
15 2 2 1 20
At the audit of the partogram. Non-reassuring fetal status.
21 -1 1 23
206 29 35 4 274
12 Table 5
L.-J. van Bogaert Indication for the primary C-section
Indication
Mode of subsequent delivery VBAC (n=43)
Dysfunctional labor 16 (37.2)a Non-reassuring 7 (16.2) fetal status Breech 12 (27.9) Transverse lie 4 (9.3) Severe PE/E 2 (4.7) Twin pregnancy 2 (4.7) Cord prolapse -Other -a Values are numbers (%).
Repeat C-section (n=84) 37 (44.0) 15 (17.9) 13 6 6 4 2 1
(15.5) (7.1) (7.1) (4.8) (2.4) (1.2)
TOLAC (1.1%). Two parturients who had a VBAC delivered before arrival. There was one instance of an Apgar score <7 at 5 min with a repeat emergency C-section. Seven peri-natal deaths occurred in the repeat C-section group (25.5x). There were 8 uterine ruptures among the 274 parturients undergoing a repeat C-section for unsuccessful TOLAC (2.9%): two in 190 para 1-gravida 2 (1.1%), five in 41 para 3-gravida 4 (12.2%), and one in 23 grand multiparas (4.3%). Four of the neonates were alive and well and four were fresh stillbirths. During the study period, 13 women had a VBAC after two previous C-sections; they all were admitted in advanced first stage of labor. Only five out of the 13 neonates were alive and well. There were five intra-uterine fetal deaths on arrival; and three early perinatal deaths (all were cases of shoulder dystocia).
4. Discussion The findings in this report are subject to limitations that are almost unavoidable in a district hospital in a developing world rural setting. Poorly educated women are likely to try to avoid hospital delivery because it lacks the traditional support system and because of the fear of a C-section. They are aware of the fact that a uterine scar puts them at risk of a repeat C-section, and that at a third C-section the chances are great that they will be convinced to be sterilized. Therefore, many will go to the hospital as a last resort and this limits our ability to implement strict selection criteria in favor or against a TOLAC. It was frustrating to try to find out what was the indication for the primary C-section. Because hospital records are handled manually they
get easily misplaced and lost. A number of patients move in or out of the district. Therefore, this study lacks the statistical power needed to suggest management policies for the management of labor after one C-section. To the best of our knowledge, only a limited number of studies have been published on VBAC in community and district hospitals, especially in developing countries. In Bloemfontein (a South African tertiary institution), in a series of 189 cases, 21% had an ERCD; this compares well with our 18.6% of ERCD. Out of the 149 TOLAC in this study, 57% resulted in a VBAC (this was significantly better than our 42.4% of successful TOLAC). A uterine rupture occurred in 2.7% of the unsuccessful TOLAC (vs. 2.9% in the present series) [8]. The relatively high rate of rupture appeared to be linked to increased parity; an additional factor may have been the staff shortages and the lack of sufficient supervision inherent to our type of settings. A study from a tertiary institution in Saudi Arabia reported a 41.7% VBAC rate [9]. In a short series of 66 selected cases from Thailand, 76% had a VBAC (40% of them were assisted deliveries); the selection criteria were not mentioned [10]. In a large series of 531 cases from the Philippines, 69.4% underwent a repeat C-section and only 28.1% had a successful TOLAC (significantly less than our 42.4% of VBAC after TOLAC) [11]. Here also the selection criteria were not mentioned. Overall, these data support the view expressed by the Integrated Management of Pregnancy and Childbirth that in rural settings and developing world conditions one can expect a maximum of 50% of VBAC [12]. The question about selection criteria remains partly unanswered (with the exception of the clear indications for an ERCD). According to the American College of Obstetrics and Gynecology Practice Bulletin N 5 of 1999, if the indication for the primary C-section was CPD, the chances of VBAC are reduced to 30--60% [13]. This could be interpreted in the sense that CPD is likely to be a recurrent condition. Data from West, East and South Africa indicate that CPD constitutes close to 50% of the indications for primary CS-sections (a value close to the 51.5% at our institution) [14—16]. Some studies suggest that a previous C-section for dystocia is associated with a very high rate of unsuccessful TOLAC in the subsequent pregnancy [16,17]. It must be said, however, that the concept of dystocia is often used synonymously for CPD although dystocia encompasses not only CPD. This makes comparisons hazardous. Therefore, we used Philpott’s concept of dysfunctional labor rather than CPD. Already in 1972, Philpott and Castle [7] called attention to the
Mode of delivery after one cesarean section fact dysfunctional labor is the biggest problem in African parturients. This justifies the recommendation made by the ACOG that ‘‘global mandates for TOLAC are inappropriate because individual risk factors are not considered’’ [13]. It appears thus that in developing world settings, a success rate of 50% (or even less) of VBAC is to be expected. Dysfunctional labor is a major contributor to both primary and repeat C-sections; from our limited data, we cannot conclude firmly that it is a recurrent condition. The relatively high risk of uterine rupture must be kept in mind when selection is possible; the risk increases with increasing parity. A TOLAC for a third delivery and onwards may not be safe in rural district hospitals in developing world settings.
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