The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

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.

Comparative study for success rate of vaginal birth after cesarean section following labor induction by two forms of vaginal dinosprostone: A pilot study

“…These findings are in agreement with some studies [28,29,33,37], but disagree with others [6,32] that demonstrated a higher rate of adverse neonatal outcome in association with a failed trial of scar, non-availability of modern neonatology equipment, or increased uterine rupture rate.…”

Determining Factors of Cesarean Delivery Trends in Developing Countries: Lessons from Point G National Hospital (Bamako - Mali)

“…With our restrictions on VBAC, we recorded fewer vaginal deliveries, but also less uterine rupture / dehiscence, as was found in rural Zimbabwe [Spaans et al, 1997]. In settings where such cautions were not applied, higher morbidity levels were observed , Adanu & McCarthy, 2007Olusanya & Solanke, 2009;Sepou et al, 2003;Nwokoro et al 2003;Oboro et al, 2010;Wanyonyi & Karuga, 2010]. A large multicenter propective study in a western country with a uniform and well organised delivery care system emphasized the greater perinatal risk associated with a trial of labor [Landon et al, 2004].…”

Stage of labor at admission among Ugandan women with a prior cesarean, and its impact on management and delivery outcomes

“…It is possible that this conservative approach favoring repeat cesarean procedures has emerged owing to human and physical resource constraints that limit the ability either to monitor both maternal and fetal well‐being closely, or to facilitate an emergency surgical response should uterine rupture or fetal compromise occur. However, more research is needed to understand decision making among providers because the TOL rate in the present study was lower than that reported in other settings where resource constraints are likely to be similar …”