Vaginal Birth after a Cesarean Section at Good Shepherd Mission Hospital at Tshikaji in Democratic Republic of the Congo (DRC) ()
1. Introduction
A trial of labor after cesarean (TOLAC) is a trial of labor for the current pregnancy to achieve a vaginal birth after a previous cesarean section scar (VBAC). Guidelines for VBAC indicate that TOLAC offers women with no contraindications and one previous transverse low-segment cesarean. For most women who had a cesarean section, VBAC is a reasonable and safe choice [1] .
Pregnancy and childbirth are special moments in life and pose a vital risk to both the mother and the newborn. This risk that strikes every Obstetrician explains the ongoing research to achieve the best conditions for a favorable outcome of pregnancy and childbirth [1] . The quote “caesarean one day, caesarean always” stated by D Craigin in 1916 still weighs on any woman with a prior cesarean section when she begins a new pregnancy [2] [3] . The main cause of the cicatricial uterus is a history of cesarean delivery. The increase in the rate of cesarean delivery in the last 20 years is a phenomenon widely shared in developed countries. In most of these countries, this rate is well above 15%, a threshold long defined as optimal by the WHO. This rate varies from around 15% in the Netherlands, Finland and Iceland to more than 40% in Mexico, Turkey, China and Brazil [2] [4] [5] . In France, the rate of caesarean section was 20.8% in 2010 against 15.5% in 1995. Simultaneously, the prevalence of the cicatricial uterus increased from 8% to 11% among parturients and from 14% to 19% among multiparous women, between 1995 and 2010. The delivery patterns of women with previous cesarean sections are very variable from one country to another. According to the 2010 national perinatal survey in France, 51% of these women have a caesarean section before labor; of those who begin labor, 75% give birth vaginally. In total, 36.5% deliver vaginally [2] [5] . The cicatricial uterus is, in developed countries, the main risk factor for uterine rupture with a global incidence estimated between 0.1% and 0.5% in women with previous caesarean section.
Although the cesarean section is one of the most performed operations worldwide, it is far from trivial and generates an increased risk of morbidity and mortality with, on one hand, a hemorrhagic risk at the action time, and on the other hand, a higher rate of infections and venous thromboembolic complications in the postpartum. Finally, in the long term, during a future pregnancy, parturient women with a history of cesarean section are at greater risk of placental localization abnormalities, adhesion formation but also and especially uterine rupture, the most common complication because of the high mortality associated with it. The risk of complete uterine rupture is significantly increased when attempting a vaginal delivery after cesarean section [2] [6] [7] [8] [9] . The choice of the safest possible delivery route not only for the mother but also for the child, considers several parameters relating both the characteristics of the current pregnancy such as the strength of the caesarean section scar and the cephalopelvic confrontation, but also the age or the weight of the parturient woman as well as her obstetrical antecedents.
Thus, our work aims to determine the epidemiological and clinical profile of delivery on a cicatricial uterus at the general hospital of reference of Tshikaji (Kananga, DRC).
Specific objectives:
· Identify the epidemiological profile of the women who have given birth on a cicatricial uterus;
· Evaluate the maternal and fetal prognosis of birth on a cicatricial uterus;
· Identify the most common mode of delivery on a cicatricial uterus in our environment;
· Identify the determinants of outcome of TOLAC in the studied women.
2. Patients, Material and Methods
We conducted a analytic study, at the Tshikaji Mission Hospital from January 1 to December 31, 2019.
All women with a single previous transverse lower uterine segment scar (LCSs) with no more contraindications for vaginal birth were included in this study. Cases with previous classical cicatricial on the uterus, previous two or more LCSs, with history of previous rupture of the uterus or scar dehiscence or cephalopelvic disproportion, and those having other medical or obstetrical complications associated with pregnancy were excluded from the study. A total of 126 women who fulfilled the selection criteria were enrolled in the study. Data were collected from delivery records, operative records and obstetrical records.
The population of this study was women with one previous CS scar who tried for a vaginal birth for current pregnancy. It was an exhaustive sample.
The variables of interest collected were age, parity, interpregnancy interval, indication of previous caesarean section, term of pregnancy, cervical dilation, amniotic sac, fetal presentation, mode of delivery, indication of current cesarean section and the maternal and fetal status and. The data were analyzed using SPSS version 20 to determine the outcome of TOLAC in the studied women.
Descriptive analysis was presented using tables and figures.
The relationship between the dependent variables, success or failure of vaginal birth after trial of labor (VBAC), and independent variables, such as socio-demographic factors and labor-delivery history, was determined by a chi-square test with 95% confidence intervals (CI) and p < 0.05. we used the logistic regression.
3. Results
During our study period from January 1, 2017 to December 31, 2019, we identified 126 deliveries on a cicatricial uterus among 1944 deliveries, a frequency of 6%.
Socio-Demographic date
This table shows that the age of parturient women ranged between 17 and 43 years with a clear predominance of the age group of 20 to 40 years, representing 95.2% of cases, The mean age was 28 ± 6 years old. Most of the women had no job (66.7%), 76.2% were married and 28.6% had no formal education.
Obstetrics characteristics
It was observed from this table that the interval between a previous CS and the present pregnancy was more than two years in 71.4% of the cases. Eighty-five
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Table 1. Distribution of the studied women according to their socio-demographic characteristics.
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Table 2. Distribution of the studied women according to the obstetrics data.
percent women had gestational age between 37 and 41 weeks, 55.6% women had carried more than 3 pregnancies.
In 59% of cases cervical dilatation was less than 3 cm.
For all newborns on a cicatricial uterus, there were 107 cases (85%) with a good Apgar score between 7 and 10 at birth.
We identified 16 newborns with hypotrophy (13%) and 15 newborns with macrosomia (12%) while 95 newborns were eutrophic (75%).
Table 3 presents the distribution of the studied sample according their mode of the present delivery. Eighty-five percent of women had successful VABC and 15% of the sample had ERCS due to either fetal distress (47.4%), failure of labor progress (21.0%), dehiscence of scar and cervical dystocia were present in 10.5% each.
Table 4 shows the factors influencing the success of the TOLAC in women who had successful VBAC. The successful VBAC were more likely to have more than 3 births (0.0001) and who had more than 3 cm at the admission (0.0001).
The indications of the previous CS influenced the TOLAC success, likely the fetal distress (0.0004), the malpresentation (0.0006) and the macrosomia (0.0009) influenced positively the TOLAC success.
4. Discussion
Rates of caesarean section have been steadily increasing in recent years, leading to an increased incidence of cicatricial uterus [10] [11] [12] [13] .
In response to this change in caesarean section rates, the World Health Organization (WHO) recommends a caesarean section rate of less than 15% [14] [15] [16] [17] [18] .
We compared our incidence of cicatricial uterus (6%) with those in the literature which ranged from 0.97% to 13.6% [19] [20] [21] [22] .
This rate is a function of the distribution of care facilities for obstetric emergencies. In our study, the TOLAC was authorized in 126 parturient women at a rate of 65% of all cicatricial uteri from the specific criteria. The course of labor allowed vaginal delivery in 107 women, which represents a success rate of 85% at the TOLAC (Table 5).
The study of the series of literature shows very disparate results. The uterine test is allowed in 27.8% to 88.2% and its success is between 45% and 92.5% [2] [23] . The disparity in results reported in the literature is due to the difference of medical conditions, and the lack of a uniform approach among obstetricians
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Table 3. Distribution of the studied women according to their mode of the present delivery and the indications of repeated cesarean section in the cases of failed TOLAC.
CS: cesaraen section; CPD: Cephalopelvic disproportion.
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Table 4. Determinants of success of the TOLAC in the studied women.
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Table 5. Incidence of the cicatricial uterus.
when dealing with a cicatricial uterus [25] [26] .
We noted the emergency repeated caesarian section in 19 women (15%), including 6 (47.4%) for the fetal distress, 21 (21%) after failure of progress of labor and 2 (10.5%) for cervical dystocia.
Factors influencing the mode of delivery
Parity: We found that parity more than 3 influenced significantly the rate of vaginal delivery. Many authors believe that multiparity is a weakening factor of the uterine scar and note that this risk is major among multiparas [26] . This difference depends on the lack of a uniform approach among obstetricians when dealing with a cicatricial uterus, the criteria for selection of cases is different between different authors [25] [26] .
In terms of maternal prognosis, it appears from our study that maternal morbidity after delivery on a cicatricial uterus is dominated by postpartum hemorrhage in 15% of cases. The maternal morbidity rate after vaginal delivery affected 3.96% of cases represented by postpartum hemorrhage, uterine rupture and cicatricial dehiscence. Postoperative infection, however, represents a morbidity of 7.14%.
Mahon, M.C. et al. found that maternal morbidity in cases of a cicatricial uterus is usually minor and that it occurs more in the caesarean delivery group. They noted 63.6% of major complications in case of failure of the uterine test [25] .
However, our data are not consistent with those in the literature and this high maternal morbidity rate after cesarean delivery is due to caesarean sections of second intention after failed uterine test.
In our series, we recorded 6 (5%) premature deliveries. Our results are consistent with those of the literature. According to Poulain et al., prematurity accounts for 5% of births and is responsible for more than 75% of perinatal mortality [23] .
We noted an Apgar test between 4 and 7 at the 10th minute of extrauterine life in 6 (15%) newborns via vaginal way against 3 (4.2%) via caesarian section. Our results are different from those in the literature as some authors point out that the percentage of depressed children (Apgar < 7) is greater (14%) in the group of children born by caesarean section than in the group of children born vaginally (7.9%). This difference in the results is due to the variance in the approaches among obstetricians when facing a cicatricial uterus. In our study we deplored 3 fetal deaths corresponding to an overall mortality of 2.2%. Our rate is similar to those found in the literature: Delary et al. revealed a mortality of 2.40%, Peter et al., 2.6%, and Picaud et al, 1.6% [27] . This mortality is a function of the technical platform for the resuscitation of the newborn.
5. Conclusion
Pregnancy on a cicatricial uterus is a high-risk pregnancy. The most important risks are dehiscence of the scar, uterine rupture and placenta previa. These are rare but serious events that may cloud the maternal and fetal prognosis. Thus, informing women about the need for a new caesarean section is of paramount importance. The awareness of the health personnel especially in remote areas is to be improved, because most of the iterative cesarean sections are performed urgently due to a lack of planning.