Maternal and perinatal outcome after previous caesarean section in rural Rwanda

Background: Offering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda. Methods: Audit of women's records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014. Results: Out of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n=23, 7.7%) compared with women who had an ERCS (n=5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2-5.4). There was no difference in neonatal admissions between women who underwent ToL (n=64/297; 21.5%) and those who delivered by ERCS (n=35/138; 25.4%: aOR 0.8; CI 0.5-1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n=40, 13.4%) compared to those who delivered by ERCS (n=15, 10.9%: aOR 1.9; CI 1.6-3.6). Perinatal mortality was similar among infants whose mothers had ToL (n=8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n=4; 29/1000 ERCSs). Conclusions: A considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL