| dc.description.abstract | Although introduction of lower transverse uterine incision for caesarean section has remarkably reduced the risk of uterine rupture during trial of labour (TOL), a consensus has not been reached regarding TOL for women with 1previous caesarean section delivery. There is also no single objective criteria for selecting patients for TOL which has a high predictive value for success. Occasional severe maternal and foetal outcomes in TOL especially when carried out in less than ideal situations are a deterrent to the practice. Lack of data especially for district hospitals where majority of hospital deliveries in Kenya occur on the safety and success of TOL acts as a hindrance to this practice.
Objective
To determine the pregnancy outcomes in patients with one previous caesarean section scar who had undergone trial of labour as compared to those who had elective repeat caesarean section at Kiambu District Hospital
Design
A retrospective cohort study whereby one group of patients had undergone trial of labour and the second group had undergone elective repeat caesarean section.
Outcome measures
Maternal morbidity was assessed primarily based on postnatal hospital stay. Other maternal morbidity measures including occurrence of uterine rupture, maternal death, need for hysterectomy, maternal blood loss, presence of visceral injury (bladder or gut) and post delivery infectious morbidity were analysed. In addition, the failure rate of trial of labour was determined. Foetal outcome was assessed based on APGAR score at five minutes, need for admission to the new born unit and the occurrence of early neonatal death.
Setting
Post natal wards of Kiambu District Hospital
Materials and Methods
The study compared maternal and foetal outcome among patients who had undergone TOL to those who had undergone ERCS. A total of 142 participants were recruited of which 71 had undergone TOL and 71 had undergone ERCS. Medical records were retrieved and key information on antenatal, intrapartum and immediate postpartum events used to complete questionnaires.
Results
Clinical pelvimetry was the commonest criteria used for selection of patients for TOL since 100% of all patients in the TOL group were assessed this way as compared to 80.3% in the ERCS group. The success rate of TOL was 50.7% in this study. Successful TOL was associated with less hospital stay since 91.6% stayed for 2 days or less as compared to ERCS where 84.5% stayed for 3-4days (P<O.OO I).
Similarly, blood loss was less for those who had successful TOL where 97.2% lost less than 500mls as compared to ERCS where 85.9(V<) lost 500mls or more. Maternal outcomes were worse in the 49.7% who failed TOL since only 57.1 (Yo of them had a postnatal hospital stay of 3-4days as compared to 84.5% in the ERCS group( p-0.029) and 42.9% of the failed TOL group stayed in the hospital for 5 days or more as compared to only 15.5% in the ERCS group(p=0.002).
Foetal outcome was worse in the TOL group since I 1.3% had an APGAR score of less than 8 at five minutes as compared to only 1.4% in the ERCS group(p=''O.O 16). Similarly, 14.1 % of newborns in the TOL group were admitted to the ncw born unit as compared to only 5.6% in the ERCS group(p=0.091). There were no early neonatal deaths reported in both groups.
Conclusion
Overall success rate for TOL was low necessitating emergency caesarean section of which the maternal' outcomes were worse than in the ERCS group. The foetal outcomes were better in the ERCS group as compared to the TOL group.
Recommendations
Given the high failure rate and lack of specific criteria for TOL in patients with one previous caesarean section scar, there is a need to consider ERes in order to prevent morbidities associated with failed TOL in level IV facilities. Further studies arc however needed to validate or discount these findings. | en_US |
