BJOG Exchange
encouraged everywhere, and also in settings with such high complication rates. A second important flaw is the statement that ‘the overall rate of caesarean section in sub-Saharan Africa is still very low’. A population-based caesarean section rate will obviously be low when more than 60% of women do not give birth in places where caesarean section can be performed. But facility-based rates have increased at a worrying pace over the past decade, very often on dubious or even plainly wrong indications.2 Nowadays, in many hospitals caesarean section will be performed for ‘obstructed labour’ even with intact membranes. Inefficient uterine action in primigravid women is seldom treated with oxytocin augmentation, and instrumental vaginal delivery in the second stage of labour has become almost non-existent. From our experience, in many hospitals in East Africa VBACs are seldom tried, although this could be attempted safely in such clinics, where caesarean section can be performed at any time of day. Doctors or associate clinicians (in most places one will not find obstetricians), would have to be present in the labour ward when women have their trial of scar, however. Provided that clinicians in labour wards take their responsibility, this practice would not increase morbidity and mortality – to the contrary. Another issue related to the relative risk and high rate of caesarean section is that decision-making and performance of caesarean section in teaching hospitals are generally made by the least experienced clinicians available, often intern doctors and junior clinicians. This calls for much more supportive supervision in the often extremely busy labour wards in sub-Saharan hospitals. For all these reasons Africa should not follow the American dictum of ‘once a caesarean, always a caesarean’. Infering wrongly from a random shop around the medical literature is not a reliable basis for policy change.
910
Disclosure of interests We declare that we have no conflict of interest. &
References 1 Wanyoni SZ, Ngichabe SK. Safety concerns for planned vaginal births after caesarean section in sub-Saharan Africa. BJOG 2014;121:141–4. 2 Maalǿe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as an indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012;119:605–13.
J van Roosmalen & T van den Akker Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands Accepted 29 January 2014. DOI: 10.1111/1471-0528.12747
Authors’ reply Sir, We would like to thank the authors for their contribution to the topic. We agree that caesarean section is not entirely safe, and that the case fatality rate could indeed be higher in sub-Saharan Africa than it is estimated. It is also true, however, that the morbidity associated with vaginal birth after caesarean section (VBAC) could be significantly higher. It is therefore incumbent on clinicians to recommend delivery options that are safe in light of the available resources. Unlike VBAC, elective repeat caesarean section (ERCS) is planned, and hence the clinician has ample time to prepare for any complications. The likelihood of morbidity arising from an elective operation is therefore much lower than in an emergency situation,1 yet it is difficult to predict which women undergoing VBAC may eventually need an emergency caesarean section. Unfortunately, most women in sub-Saharan Africa present late in labour after unsuccessful attempts to deliver at home. Managing these women, especially those with scarred uteri, without proper monitoring could be disastrous. Considering that most
facilities are far from achieving a midwife/patient ratio that allows for adequate intrapartum monitoring, ERCS could avert such eventualities. We do not favour caesarean section per se, and even noted in our article measures to reduce primary caesarean section rates. We do agree with the authors on the need for proper decision making, active involvement of senior clinicians at all levels of management, and the judicious use of oxytocin as other measures to avoid unnecessary caesarean section. We also advocate for cost-effective models that would make caesarean section readily available and safe.2 The reluctance of women to have repeat caesarean section is down to several factors, ranging from previous experiences, poor outcomes attributed to the primary surgery, ignorance, unfounded fear, lack of confidence in the healthcare system, and high cost of the operation. Efforts should therefore be made to inform women on the implication of a previous scar and resources availed to boost their confidence in the health systems, rather than assuming ‘that is how they are’. Interventions should not be based on speculations without addressing the root cause. The facility-based caesarean section rates in sub-Saharan Africa are still low, and the operation is often performed too late, when it is least beneficial.1 There is therefore no rationale to advocate for lowering this rate any further. Instead, the operation should be made more available and safer. Fear for VBAC among practitioners in East Africa is triggered by the suboptimal conditions under which they work. Although they may be aware of the prerequisites for safe VBAC, most cannot offer it because of a lack of intrapartum monitoring, inadequate human resources, and deficient healthcare systems.3 Those who choose to practice under these conditions are put in a defenceless position should complications arise. Finally, we would like to emphasise that we do not subscribe to the dictum of ‘once a caesar always a caesar’, but
ª 2014 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
instead advocate for the most logical and safest delivery option. &
References 1 Shah A, Fawole B, M’Imunya JM, Amokrane F, Nafiou I, Wolomby J, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet 2009;107:191–7. 2 Kruk ME, Pereira C, Vaz F, Bergstrom S, Galea S. Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique. BJOG 2007;114:1253–60. 3 Wanyonyi ZS, Mwaniki AM, Stones W. Perspectives on the practice of vaginal birth after caesarean section in East Africa. East Afr Med J 2009;87:4–8.
ZS Wanyonyia & SK Ngichabeb a
University of Oxford, Nuffield Department of Obstetrics and Gynaecology, Oxford, UK; b Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya Accepted 6 February 2014. DOI: 10.1111/1471-0528.12748
Intrapartum management of trial of labour after caesarean delivery: evidence and experience
Sir, We read the review article, Intrapartum management of trial of labour after caesarean delivery: evidence and experience by Scott,1 with great interest. With the rising prevalence of caesarean sections in the UK, the intrapartum management of women who wish to have a trial of scar carries increasing relevance to our practice. On review of this article, it is clear that a thorough literature search was undertaken and we commend the author on this. Notably, the article was written in the context of obstetric practice in the USA. Despite the similarities in medical practice between the USA and the UK, the differences in the structures of the two health systems (with their variances medico-legally and in health economics) suggest that application of the recommendations to our
practice may be difficult in practical terms, although a review by the National Institute for Health and Care Excellence, before implementing recommendations in the UK within the National Health Service, could circumvent this. It was interesting to read the author’s representation of the logistical difficulties experienced in caring for this patient group in smaller rural obstetric units with no immediate access to emergency anaesthesia or caesarean section. Such circumstances would appear to be akin to midwifery-led birthing units in the UK, where strict criteria apply to those admitted (with previous caesarean section being one of the exclusion criteria). It is the section regarding the intrapartum management of vaginal birth after caesarean section (VBAC), that was of most interest to us. Unfortunately, we felt that the recommendations fell short, with no clear consensus on management. In particular, we sought guidance on suggested criteria for initiating induction of labour, but did not feel that we had gained any new information in this regard. Clarification by the author of the definitions applied in this article for uterine scar dehiscence and uterine scar rupture would have been helpful. We would also have benefited from the author’s clear distinction between factors that were absolute contraindications and those for which caution should be applied. Furthermore, some of the terms used for factors influencing the success of VBAC were often broad and vague. Terms such as patient enthusiasm are very subjective and, as we no longer formally perform clinical pelvimetry in the UK, this cannot guide our practice. The author states that the success rate of VBAC is increased if there was a previous vaginal delivery, but omit to state that this is particularly the case with previous VBAC. Although we commend the author on tackling such a ‘hot topic’ we did not feel that the article achieved the objec-
ª 2014 Royal College of Obstetricians and Gynaecologists
tive of providing clear recommendations for the intrapartum management of trial of VBAC. &
Reference 1 Scott JR. Intrapartum management of trial of labour after caesarean delivery: evidence and experience. BJOG 2014;121:157–62.
K Vusirikala, H Kak, O Greer, B Erinle, S-J Herrington, K Brown, A Pathan, N Syed, AZ Khatib & MA Mahran Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, Bedford, UK Accepted 24 October 2013. DOI: 10.1111/1471-0528.12586
Author’s reply Sir, I thank Dr Vusirikala and the nine other co-authors for their letter regarding my vaginal birth after caesarean section (VBAC) article and am grateful for the opportunity to address their comments and questions.1,2 The emphasis on obstetric practice in the USA is because much of the literature has been generated there, and that is where my 30 plus years of experience with VBAC has been. It is correct that differences in the UK (and also unique circumstances in every other country) will affect generalisability and how well any recommendations can be applied. Uterine rupture is defined as complete disruption of all uterine layers, including the serosa. Uterine dehiscence generally refers to an incomplete and frequently occult scar separation. Although patient enthusiasm may seem to be subjective, most authorities agree with me that the woman’s preference for VBAC, or not, is very important. Evidence for improved success rates of VBAC after previous vaginal delivery includes those both before and after caesarean delivery. The authors appear to want more dogmatic rules and specific recommendations regarding induction of labour and what defines caution versus abso-
911
encouraged everywhere, and also in settings with such high complication rates. A second important flaw is the statement that ‘the overall rate of caesarean section in sub-Saharan Africa is still very low’. A population-based caesarean section rate will obviously be low when more than 60% of women do not give birth in places where caesarean section can be performed. But facility-based rates have increased at a worrying pace over the past decade, very often on dubious or even plainly wrong indications.2 Nowadays, in many hospitals caesarean section will be performed for ‘obstructed labour’ even with intact membranes. Inefficient uterine action in primigravid women is seldom treated with oxytocin augmentation, and instrumental vaginal delivery in the second stage of labour has become almost non-existent. From our experience, in many hospitals in East Africa VBACs are seldom tried, although this could be attempted safely in such clinics, where caesarean section can be performed at any time of day. Doctors or associate clinicians (in most places one will not find obstetricians), would have to be present in the labour ward when women have their trial of scar, however. Provided that clinicians in labour wards take their responsibility, this practice would not increase morbidity and mortality – to the contrary. Another issue related to the relative risk and high rate of caesarean section is that decision-making and performance of caesarean section in teaching hospitals are generally made by the least experienced clinicians available, often intern doctors and junior clinicians. This calls for much more supportive supervision in the often extremely busy labour wards in sub-Saharan hospitals. For all these reasons Africa should not follow the American dictum of ‘once a caesarean, always a caesarean’. Infering wrongly from a random shop around the medical literature is not a reliable basis for policy change.
910
Disclosure of interests We declare that we have no conflict of interest. &
References 1 Wanyoni SZ, Ngichabe SK. Safety concerns for planned vaginal births after caesarean section in sub-Saharan Africa. BJOG 2014;121:141–4. 2 Maalǿe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as an indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012;119:605–13.
J van Roosmalen & T van den Akker Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands Accepted 29 January 2014. DOI: 10.1111/1471-0528.12747
Authors’ reply Sir, We would like to thank the authors for their contribution to the topic. We agree that caesarean section is not entirely safe, and that the case fatality rate could indeed be higher in sub-Saharan Africa than it is estimated. It is also true, however, that the morbidity associated with vaginal birth after caesarean section (VBAC) could be significantly higher. It is therefore incumbent on clinicians to recommend delivery options that are safe in light of the available resources. Unlike VBAC, elective repeat caesarean section (ERCS) is planned, and hence the clinician has ample time to prepare for any complications. The likelihood of morbidity arising from an elective operation is therefore much lower than in an emergency situation,1 yet it is difficult to predict which women undergoing VBAC may eventually need an emergency caesarean section. Unfortunately, most women in sub-Saharan Africa present late in labour after unsuccessful attempts to deliver at home. Managing these women, especially those with scarred uteri, without proper monitoring could be disastrous. Considering that most
facilities are far from achieving a midwife/patient ratio that allows for adequate intrapartum monitoring, ERCS could avert such eventualities. We do not favour caesarean section per se, and even noted in our article measures to reduce primary caesarean section rates. We do agree with the authors on the need for proper decision making, active involvement of senior clinicians at all levels of management, and the judicious use of oxytocin as other measures to avoid unnecessary caesarean section. We also advocate for cost-effective models that would make caesarean section readily available and safe.2 The reluctance of women to have repeat caesarean section is down to several factors, ranging from previous experiences, poor outcomes attributed to the primary surgery, ignorance, unfounded fear, lack of confidence in the healthcare system, and high cost of the operation. Efforts should therefore be made to inform women on the implication of a previous scar and resources availed to boost their confidence in the health systems, rather than assuming ‘that is how they are’. Interventions should not be based on speculations without addressing the root cause. The facility-based caesarean section rates in sub-Saharan Africa are still low, and the operation is often performed too late, when it is least beneficial.1 There is therefore no rationale to advocate for lowering this rate any further. Instead, the operation should be made more available and safer. Fear for VBAC among practitioners in East Africa is triggered by the suboptimal conditions under which they work. Although they may be aware of the prerequisites for safe VBAC, most cannot offer it because of a lack of intrapartum monitoring, inadequate human resources, and deficient healthcare systems.3 Those who choose to practice under these conditions are put in a defenceless position should complications arise. Finally, we would like to emphasise that we do not subscribe to the dictum of ‘once a caesar always a caesar’, but
ª 2014 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
instead advocate for the most logical and safest delivery option. &
References 1 Shah A, Fawole B, M’Imunya JM, Amokrane F, Nafiou I, Wolomby J, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet 2009;107:191–7. 2 Kruk ME, Pereira C, Vaz F, Bergstrom S, Galea S. Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique. BJOG 2007;114:1253–60. 3 Wanyonyi ZS, Mwaniki AM, Stones W. Perspectives on the practice of vaginal birth after caesarean section in East Africa. East Afr Med J 2009;87:4–8.
ZS Wanyonyia & SK Ngichabeb a
University of Oxford, Nuffield Department of Obstetrics and Gynaecology, Oxford, UK; b Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya Accepted 6 February 2014. DOI: 10.1111/1471-0528.12748
Intrapartum management of trial of labour after caesarean delivery: evidence and experience
Sir, We read the review article, Intrapartum management of trial of labour after caesarean delivery: evidence and experience by Scott,1 with great interest. With the rising prevalence of caesarean sections in the UK, the intrapartum management of women who wish to have a trial of scar carries increasing relevance to our practice. On review of this article, it is clear that a thorough literature search was undertaken and we commend the author on this. Notably, the article was written in the context of obstetric practice in the USA. Despite the similarities in medical practice between the USA and the UK, the differences in the structures of the two health systems (with their variances medico-legally and in health economics) suggest that application of the recommendations to our
practice may be difficult in practical terms, although a review by the National Institute for Health and Care Excellence, before implementing recommendations in the UK within the National Health Service, could circumvent this. It was interesting to read the author’s representation of the logistical difficulties experienced in caring for this patient group in smaller rural obstetric units with no immediate access to emergency anaesthesia or caesarean section. Such circumstances would appear to be akin to midwifery-led birthing units in the UK, where strict criteria apply to those admitted (with previous caesarean section being one of the exclusion criteria). It is the section regarding the intrapartum management of vaginal birth after caesarean section (VBAC), that was of most interest to us. Unfortunately, we felt that the recommendations fell short, with no clear consensus on management. In particular, we sought guidance on suggested criteria for initiating induction of labour, but did not feel that we had gained any new information in this regard. Clarification by the author of the definitions applied in this article for uterine scar dehiscence and uterine scar rupture would have been helpful. We would also have benefited from the author’s clear distinction between factors that were absolute contraindications and those for which caution should be applied. Furthermore, some of the terms used for factors influencing the success of VBAC were often broad and vague. Terms such as patient enthusiasm are very subjective and, as we no longer formally perform clinical pelvimetry in the UK, this cannot guide our practice. The author states that the success rate of VBAC is increased if there was a previous vaginal delivery, but omit to state that this is particularly the case with previous VBAC. Although we commend the author on tackling such a ‘hot topic’ we did not feel that the article achieved the objec-
ª 2014 Royal College of Obstetricians and Gynaecologists
tive of providing clear recommendations for the intrapartum management of trial of VBAC. &
Reference 1 Scott JR. Intrapartum management of trial of labour after caesarean delivery: evidence and experience. BJOG 2014;121:157–62.
K Vusirikala, H Kak, O Greer, B Erinle, S-J Herrington, K Brown, A Pathan, N Syed, AZ Khatib & MA Mahran Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, Bedford, UK Accepted 24 October 2013. DOI: 10.1111/1471-0528.12586
Author’s reply Sir, I thank Dr Vusirikala and the nine other co-authors for their letter regarding my vaginal birth after caesarean section (VBAC) article and am grateful for the opportunity to address their comments and questions.1,2 The emphasis on obstetric practice in the USA is because much of the literature has been generated there, and that is where my 30 plus years of experience with VBAC has been. It is correct that differences in the UK (and also unique circumstances in every other country) will affect generalisability and how well any recommendations can be applied. Uterine rupture is defined as complete disruption of all uterine layers, including the serosa. Uterine dehiscence generally refers to an incomplete and frequently occult scar separation. Although patient enthusiasm may seem to be subjective, most authorities agree with me that the woman’s preference for VBAC, or not, is very important. Evidence for improved success rates of VBAC after previous vaginal delivery includes those both before and after caesarean delivery. The authors appear to want more dogmatic rules and specific recommendations regarding induction of labour and what defines caution versus abso-
911
