Vaginal Cesarean Section, an Alternative to High-Risk Trigger on Scarred Uterus

The objective is to report a clinical case of vaginal cesarean section performed to expel a dead fetus in scarred uterus. For this indication, vaginal hysterectomy constitutes an alternative to vaginal expulsion with a high risk of uterine rupture and to classic abdominal cesarean section with risk of significant surgical trauma, particularly adhesions. However, this surgical technique, described since the 19th century, remains unknown to many practitioners and few publications exist on the subject throughout the world. Considered obsolete by some practitioners, it retains all its advantages in the practice of modern obstetrics. We report this case of expulsion of fetal death on a tri-scarred uterus performed by vaginal cesarean section at the Health District Reference Health Center (District Hospital) of Commune I in Bamako, Mali in a 37-year-old patient with a pregnancy of 27 weeks of amenorrhea.

Predictive Factors of Complications of Vaginal Delivery on Scarred Uterus at the YaoundéGynaeco-Obstetric and Paediatric Hospital

Objective: This study was aimed at identifying predictive factors of complications during vaginal delivery on scarred uterus. Methodology: During 9 months, from October 1st, 2015 to June 30th, 2016, a case control study was carried out at the Yaoundé Gynaeco-Obstetric and Pediatric Hospital. Eighty nine women each with a single scarred uterus who presented with complications during delivery (cases) were compared to eighty nine others who had a successfully trial of scar (control) during the study period. Data were analyzed using the CSPro version 6.0 and SPSS version 20.0 softwares with statistical significance set at P Results: We recruited 2 groups of 89 women, aged 17 to 40 years, with an average age of 29.05 years. The majority of women with complications were married (50.6%) and unemployed (42.8%). Following univariate analysis, predictive factors of complications were: prematurity (OR = 7.4), post-term (OR = 13.7), no history of vaginal delivery on scarred uterus (OR = 4.3), inter-pregnancy spacing period greater than 60 months (five years) (OR = 2.9), History of caesarian delivery indicated for cephalo-pelvic disproportion (OR = 6.6), less than four ante-natal consultations (OR = 3.6), antenatal consultations done in a Health Centre (OR = 2.7), ante-natal follow up conducted by a nurse (OR = 2.4;IC = [1.2 - 4.7]), referral from a different health unit (OR = 4.4, IC = 2.0 - 9.4), a Bishop score less than 7 on admission (OR = 12.4, IC = 5.6 - 27.4), a meconium stained amniotic fluid (OR = 9.9;CI = [3.6 - 26.8]). After logistic regression, the retained factors associated with complications were post-term (aOR = 34.5), absence of vaginal birth after caesarian delivery, (aOR = 11.7), previous caesarean section indicated for cephalo-pelvic disproportion (aOR = 6.1), a bishop score less than 7 (aOR = 12.0), meconium stained amniotic fluid (aOR = 13.6). Conclusion: Predictive factors of complications can help anticipate negative obstetric outcomes.

Delivery on Scarred Uterus at Souro Sanou Teaching Hospital, Burkina Faso (about 531 Cases)

Introduction: Therapeutic conduct for delivery via a scarred uterus is controversial in modern obstetrics. Some authors recommend a ceasarean section. The purpose of this study was to analyse the conduct and prognosis of delivery via scarred uterus at Souro Sanou Teaching Hospital in Bobo-Dioulasso. Methods: We conducted a descriptive cross-sectional study from January 1 to December 31, 2017. Data were collected from medical, birth, and operating room records. Result: In total, 531 scared uterus deliveries and 5293 deliveries have been recorded in our study;the frequency of deliveries via a scarred uterus was 9.96%. The average age of the patients was 28.02 years old, with extremes of 17 and 44 years. The average parity was 2.34, with extremes of 1 and 8. Patients with a spacing interval between births of at least 24 months accounted for 86.6% of observed patients. Patients with a single scar uterus made up 70.6% of the population. There were 349 (65.73%) patients who had an emergency caesarean section during a previous delivery. The trial of vaginal delivery via a scarred uterus was conducted on 182 patients with a success rate of 89.56%. There was no maternal death. However, we noted 23 foetal deaths (4.33%). Conclusion: More than 50% of parturient women with a single caesarean uterine scar who underwent the uterine test gave birth vaginally in our department. However, like most previous studies on the subject, we recommend vaginal delivery in the presence of a prior caesarean-scarred uterus whenever possible.

Rationale of the Cross-Sectional Descriptive Study on Factors Associated with Failure of Vaginal Delivery Trial after Cesarean Section in the University Clinics of Kinshasa, DR Congo

Background: Delivery in a scarred uterus is nowadays a real problem in Obstetrics practice, due to the inflation in the number of caesarean sections and the non-unanimous attitude of Obstetrics’ teams towards uterine scars. The factors associated with failed vaginal birth attempts after caesarean section (VBAC) are crucial information that would contribute effectively to deciding on the most appropriate mode of delivery for the mother and her fetus. Their identification would enable us to detect pregnant women at high risk of failure to attempt vaginal birth after caesarean section, and thus contribute to reducing the complications associated with this failure. Objective: We will study the factors associated with failure to vaginal delivery trial after caesarean section at the University Clinics of Kinshasa (UCK). Methods: This study will be a cross-sectional descriptive study with analytical aims. The minimum sample size will be 239. Our study population will consist of records of pregnant women with unicatricial uterus who underwent attempted vaginal delivery after caesarean section at UCK from January 2014 to June 2023. Results will be reported as percentage proportion and mean plus or minus standard deviation. Comparison of means between groups will be made using Student’s t-test, and of proportions using Pearson’s Chi-square test. Logistic regression will be used to generate Odds Ratios to measure the strength of association between variables. The test will be statistically significant for a p value 0.05. Data will be collected and processed confidentially and anonymously. Conclusion: This study will identify the factors associated with the failure of attempted vaginal delivery after caesarean section in order to contribute to the reduction of complications related to its failure in our setting. .

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

Background：Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery.This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia.Methods：Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized,double-blinded,dose-ranging study.Patients received 6,8,10,12,or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil.Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation.The 50％ effective dose （ED50） and 95％ effective dose （ED95） were calculated with a logistic regression model.Results：ED50 and ED95 ofintrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia （CSEA） were 8.28 mg （95％ confidence interval [CI]：2.28-9.83 mg） and 12.24 mg （95％ CI：10.53-21.88 mg）,respectively.Conclusion：When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery,the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg,respectively.In addition,this local anesthetic is unsuitable for emergent cesarean delivery,but it has advantages for ambulatory patients.