Influence of the indications and outcomes of previous cesarean section on planned mode of delivery in women with one previous cesarean section

Abstract

Background: Primary caesarean sections (CS) are on the increase worldwide. This means increasing number of women with previous cesarean section(s) are seen antenatally for subsequent delivery. There is paucity of data on the levels of maternal knowledge about the indications of previous cesarean delivery and its outcome, and how it influences the choice of birth plans in subsequent pregnancies. Objective: To determine whether a decision on mode of delivery has been made by 36-40 weeks gestation in women with one previous cesarean section. Methods: Cross sectional hospital based study conducted at Kenyatta National Hospital ANC clinic. The study recruited 169 women with single previous CS at 36 weeks to 40 weeks gestation. Data were collected using questionnaires administered to subjects during face–to-face interviews after obtaining written informed consent. Data Analysis: Data analysis was conducted using SPSS version 19.0. Descriptive univariate statistics [mean (SD), for continuous data and frequency distribution (percentages) for categorical data] were used to summarize sample characteristics. The percentage of women with good understanding of the indications for previous cesarean and proportion with a decision on mode of delivery were calculated and Chi square test of independence used to compare percentages (P value < 0.05 was considered significant). Any association between indications of previous CS and decision on planned mode of delivery was analysed. Findings: The mean age of women was 29 years (SD = 4), age range 21-40 years. Most women had secondary level of education 78 (46.7%), and 117 (67.5%) mothers had one living child. Most (167, 98.8%) mothers with a single previous scar had delivered through CS during the last pregnancy while 2 mothers (1.2%) had a normal delivery after a previous cesarean section. Poor progress of labour 44 (26%) and NRFS 44 (26%) were the leading causes for CS. Overall, for the index pregnancy, assessment of three issues was determined: doctor/nurse led discussion on mode of delivery (100%); substantive decision making on mode of delivery (100%) and knowledge of expected date of delivery (84.6%). All these three were significantly associated with marital status (p = 0.015) but not associated with the remaining client characteristics (p > 0.005). The knowledge on the indications of previous cesarean were grouped in non recurrent and recurrent indications. There was no association between recurrent indications and elective repeat cesarean section as the planned mode of delivery. Conclusion And Recommendations: Approximately 85% ANC clients with one previous caesarean section at KNH have a definite decision on mode of delivery by 36 – 40 weeks gestation. These findings are consistent with existing literature in similar settings and the fact that 15% of pregnant women did not have a definite decision on mode of delivery serves to highlight the need for continued inclusion of pregnant women in the planning of care and specifically decision making related to delivery mode. The fact that there was no association between recurrent indications for previous CS and ERCS as the planned mode of delivery points to poor decision making and the need for guidelines based on current literature when counseling women with one previous cesarean section and helping them choose appropriate plan on mode of delivery.