BIRTH OUTCOMES AFTER A PREVIOUS CESAREAN SECTION: AN OBSERVATIONAL CROSS-SECTIONAL STUDY IN BOMET COUNTY KENYA

Abstract

To curb the increasing cesarean section (CS) rates, a trial of labor after cesarean section (TOLAC) is recommended for women who have had one prior CS. However, TOLAC success rates from different regions are highly variable—with most available data originating from developed countries. Success rates in most low-resource countries, particularly those in Africa, remain largely unassessed. Data on TOLAC successes and risks is important to inform the selection of candidates likely to achieve a successful TOLAC, especially in low-resource settings. Thus, this study evaluated TOLAC success rates, associated outcomes, and factors associated with success/failure of TOLAC in Bomet County, a low-resource setting in Kenya. The study adopted a prospective observational cross-sectional approach to characterize the outcomes of TOLAC. The primary maternal and neonatal outcomes were compared in women who had a vaginal birth after a cesarean section (VBAC) with those who had an emergency repeat cesarean section (ERCS) following a failed TOLAC in pregnant women who presented at Tenwek Hospital and Longisa County Referral Hospital in Bomet, Kenya from 21st October 2022 to 8th June 2023. In total, 170 women with one previous scar who presented to the two study centers were included in the study. The TOLAC success rate was 48.2% with the most common indications for emergency repeat cesarean section being failure to progress (34.1%) and non-reassuring fetal status (31.8%). Factors associated with successful TOLAC included inter-delivery interval >60 months (p-0.044), parity 2-4 (p-<0.001) and previous vaginal delivery with focus on previous successful VBAC (p-<0.001). Mal-presentation, in particular breech presentation, and non-reassuring fetal status (NRFS), as indications for previous cesarean section, were associated with a successful VBAC (p-<0.001, 0.033). A birth weight of >3500g was associated with increased risk of ERCS. Moreover, a failed TOLAC was associated with a prolonged hospital stay of more than 4 days (p-0.012). Secondary outcomes considered in the study included both maternal and neonatal factors. For maternal outcome measures that were assessed; blood transfusion rate, delivery trauma, and maternal infection rates were at 6.5%, 11.8% and 9.4% respectively with no maternal mortality reported. For neonatal outcomes, neonatal death and NICU admission were at 2.9% and 15.3% respectively, with the most common indication for NICU admission being neonatal asphyxia and risk of sepsis. Altogether, these findings suggest that TOLAC remains a viable option with better outcomes if successful. However, TOLAC candidates should be evaluated based on the contextual factors of a given setting, hence careful patient selection is recommended to improve outcomes associated with TOLAC.