Determinants of Delivery Among Women with History of Previous Cesarean Scar

Abstract

Objectives: Delays in delivering pregnant women with history of prior Cesarean scar and increased rate of repeat CS together with low rate of VBAC are associated with maternal and neonatal morbidity and mortality. The objective of our study is to evaluate the determinants of timing and mode of delivery for women with history of previous cesarean scar.

Methods: This is a prospective descriptive cross-section study conducted from February to May 2021. Demographic and Clinical data from women with history of previous cesarean scar at gynecological department of Kigali University teaching hospital (CHUK) and Masaka district Hospital, were collected by patients interview and theater register review on a designed questionnaire.

Results: Four hundred women with history of previous cesarean scar were recruited, the rate of Cesarean delivery was 48.9% (CHUK: 59.50%, Masaka DH: 44.9%). 71 of the participants (17.7%) had delayed delivery (39.4%/CHUK, 60.6%/Masaka DH), this delay was due to lack of knowledge of the due date and/or waiting for spontaneous contractions (78.9%) followed by having had a wrong date (15.5%) and poor socio-economic issues (5.6%). The delay was influenced by the lack of education on timing and mode of delivery (P<0.001), having had only one prior scars (P=0.008), not living with one’s partner (P=0.024) ANC visits less than 4 (P=0.025) and Nurse as ANC health care provider (P=0.012). Among all participants, 66.2% Knew their Due Date, around a half 56.3% were educated on both the timing and mode of delivery and only 29.9% were educated on risks and benefits of TOLAC. The rate of Repeat CS in eligible for TOLAC group was 84.3% and 40.7% of them was due to health care provider influence, 32.3% due to maternal request and 27% due to obstetrical indication. TOLAC rate was 20% and VBAC rate was 15.7% (76% of the TOLAC). Successful VBAC was influenced by presentation at Health care facility with advanced stage of labor and/or a busy operating theater (50%), patient willing to TOLAC (44.7%) and IUFD (5.3%). The mode of delivery was influenced by number of scar (P=0.001), Spontaneous labor (P<0.001), history of vaginal delivery (P<0.001), Delivery setting (P=0.002), level of patient’s education (P=0.001), ANC health care provider (P<0.001) and presence of comorbidities (P=0.002).

Conclusion: The most common cause of delay was found to be the lack of knowledge of when and how women with prior CS scar should be delivered and of the fact that not all pregnant women should wait until the onset of spontaneous labor. In eligible for TOLAC group, health care provider influence and maternal request were found to be the main causes of repeat CS. Successful VBAC was influenced by presentation at advanced stage labor and patient’s commitment to TOLAC. Delivery at referral hospital compared to district hospital was associated with less delayed deliveries but also with less TOLAC and VBAC. There is a need to foster education of pregnant women with prior CS scar on their early stage of pregnancy during ANC at all healthcare levels about timing and mode of delivery to improve maternal and neonatal outcome