Objective: To investigate the possibility of vaginal birth after two caesarean deliveries.
Patients and methods: This was a cross-sectional analytical study with prospective data collection, conducted from March 1st to September 30th 2016, in three maternities in reference hospitals in the Borgou department, Republic of Benin.
Results: Of the 162 patients registered, 87 (53.70%) began spontaneous labour and 75 (46.30%) benefited from a C-section before labour began. Of the 87 women who started spontaneous labour, 54 (62.07%) did not meet the requirements for vaginal birth, and benefited from a C-section; one patient (1.15%) gave birth in the course of referral, and 32 (36.78%) went through our trial. Of the 32 patients who went through the trial of scar, 28 (87.50%) delivered successfully; among them were two twin pregnancies. All four unsuccessful trials (12.50%) were due to the occurrence of acute fetal distress. Among the 28 successful cases, 03 (10.71%) developed to a vasculo-renal syndrome in the sequences of immediate layers. We encountered no case of scar dehiscence nor of child nor maternal death.
Conclusion: Vaginal birth in double scarred uterus is possible and can be considered, with minimum damage to the mother and the fetus. Nevertheless, the recruitment of subjects must be rigorous and labour surveillance done in a surgical environment.
Keywords: Double scarred uterus; Trial of scar; Benin
Child delivery in double scarred uterus remains controversial in our days  because of the higher risk of scar dehiscence. However Trial of scar has recently been reported in recent research, thus breaking the dogma that after two uterine scars, a c-section is an absolute indication and suggesting the possibility of delivery by natural ways. It is in this light that this study was initiated in three hospitals located in the Borgou department, Benin. These are hospitals that have a technical platform for the surgical management of obstetric emergencies whose main objective is to study the possibility of vaginal delivery in a double scarred uterus, after a well conducted uterine trial.
Cross-sectional study with prospective data collection, with analytical aim, conducted from March 1stto September the 30th of 2016, in three maternities of reference hospitals located in the Borgou department, Republic of Benin.
Gestation women with two (2) c-section scars; ongoing pregnancy of gestational age superior or equal to 28 weeks.
• Gestation women who refused partaking in the study.
• Pregnant woman presenting an add-on risq factor (cardiopathy, HIV, hemoglobinopathies, severe respiratory insufficiancies, gestational diabetes)
• Gestating woman with counter indication for uterine trial.
Non inclusion criteria
Other scars than c-section ones.
Natural delivery acceptability criteria
• Inter-births space superior or equal to 15 months,
• Clinically normal pelvis,
• Normally implanted placenta,
• Normal weight fetus when checked on ultrasound.
For management of the delivery work, careful monitoring is done by the partographin the presence of a midwife and an obstetrician. Besides the usual means were used, in case of hypokinesia, calcium or syntocynon infusion if the oxytocin score infusion is favorable (see Table 1). Data processing was performed with the software Epi data 3.1 and Epi Info 7.1.1. Chi-square Χ²) Pearson statistical, Yates or Fischer tests were used to compare proportions. The study received approval of hospital authorities and data confidentiality was guaranteed and respected.
|Rating||Maternal age||Parity||Caesarean rank*||Inter birth interval||Previous cesarean indication||Technique used||Postoperative effects|
|1||<30 yrs||<4||1-3||2 - 5 yrs||AFD irreducible dystociadynamic||Known valid||Normal|
|2||30 -35 yrs||4||4-5||6 mths to 2 yrs||Unknown||Unknown|
|3||>35 yrs||> 4||> 5||>5 yrs or <6 mths||Placenta previa Abruptioplacentaesyndrome pre rupture amniotic Infection||Invalid unknown Hysterotomy Fusion||Abnormal|
* Rank compared to vaginal deliveries
Interpretation: 7 to 10: Favorable for infusion 11-13: Conditionallyfavorablefor infusion >13: Unfavorable for infusion.
Table 1: Oxytocin infusion score.
Figure 1 shows that of 5070 deliveries, 258 uteruses were double scarred with 162 that meet the inclusion criteria.
The study focused on 162 included cases.
The average age of the women was 30.28 yrs ± 4.51 yrs.
Figure 2 shows that the 26 to 30 age range was the most represented, and the age limits were 21 yrs to 44 yrs.
The patients were pauci gestures (61.73%) and multi gestures (38.27%) with a gestity average of 1.26 ± 3.74. They were pauci pares (85.19%) and multi pares (14.81%) with an average parity of 2.64 ± 1.11. The types of uterine scar were unknown for the 1st Caesarean (95.68%) and the 2nd cesarean (75.93%) and segmental for the 1st Caesarean (04.32%) and the 2nd caesarean (24.07%). The patients came by themselves in 55.56% of cases and were in full term pregnancy in 79.01% of cases. The median inter birth interval was 37.65 months with ranges of 15 months to 110 months. The average of prenatal consultation was 3.69 ± 1.46 with extremes of 0 to 7. The 3rd semester ultrasound was made in 82.72% of cases.
Figure 3 shows that of the 162 women, 87 (53.70%) went spontaneously into labour, and 32 went through a uterine trail with 87, 88% success. 50%of these had a natural delivery.
During vaginal delivery, delivery was natural (8 cases, 28.57%) and artificial (20 cases, 71.43%). The uterine check was completed because there were no warning signs. In the postpartum, 3/28 (10.71%) new mothers had developed vascular-renal syndrome. A hemorrhagic shock state by placental debris retention was observed with the new mother prior to admission. Among the 28 infants, 04 were transferred to a neonatal care because of low birth weight representing a neonatal morbidity rate of 14.28%. No maternal, fetal or neonatal death was recorded.
The prevalence of double scarred uterus was 5.10% in this study. Jocelyne Thachinamurthi in France in 2012 had found a lower rate of 0.97% . The average age was 30.28 years ± 4.51 years ranging from 21 to 44. This result is comparable to that of Jocelyne Thachinamurthi in France (2012): 32.4 years with range of 23 and 43 years  and Macones et al. in the United States (US) (2005): 31.9 years . The average gestity was 3.74 ± 1.26. The pauci gestures were more frequent (61.73%). Macones et al. in the US (2005) had reported an average of 4 . As for parity, the average was 2.64 ± 1.11. The paucipares were more frequent (85.19%). Jocelyne Thachinamurthi in France (2012): 81%  and Lemouton in France (2014): 85.05%  had similar rates.
The gestational age was 37 weeks or more (79.01%), and direct admission to one of the centers more often than not (55.56%). Lemouton in France (2014), reports that 100% of these pregnant women had gestational age higher or equal to 37 weeks . These findings may be explained by the fact that patients included in this study were in the 3rd quarter and therefore not necessarily full term. Among the 162 women, 87 (53.70%) entered spontaneously into labor. Macones et al. in the US (2005) reported spontaneous labor in 35.00% of cases  and Tanuja et al. in India (2005) reported a proportion of 42% . This rate is slightly higher in our study, and could be explained by the fact that the triggeringis common practice in the other studies: Macones et al. in the US (2005): 30.10% ; Tanuja et al. in India (2005): 58% . Out of the 162 women, 32 (19.75%) met the criteria for acceptability. In the literature we find variable rates namely the one of Macones et al. in the US (2005): 27.25%, which is a proportion higher than ours because his study was conducted over 5 years in 17 hospitals  while ours took 18 months in 3 hospitals. Lemouton in France (2014) : 7.48%. This is lower than our rate because his study was conducted in a single center for 4 years. But it excluded pregnant with ruptured membranes, the premature labor; which is not the case in our study. Oxytocin infusion was used with one (01) woman (3.13%). In the literature, oxytocin was also used during labor as noted by Lemouton in France in 2014 (37.5%) . This rate is higher than ours. This could be explained by the fact that the use of oxytocin is conditioned by the oxytocin infusion score in this study. In other studies, oxytocin was used for delivery on multi scarred uterus as noted by Spaans et al. in 2003 (16%)  and Landon et al. in 2006 in the US (25%) . In this study the success rate of uterine trial was 87.50%. The 4 failure cases or 12.50% were due to fetal distress during the trial of labor. In 2009 a meta-analysis on double scarred uterine found on 5666 cases of uterine trial a success rate of 71.7% . In Jocelyne Thachinamurthi’s study, as well as this one, uterus examination was indicated in case of warning signs . In the literature, 100% of newborns were unique as in this study, due to the fact that the twin pregnancy was an exclusion criterion [4,7,8,10]. In our study, the neonatal mortality is zero. All newborns hospitalized in neonatology have been exit and no neonatal death was recorded. In the literature, the rate of zero perinatal mortality was reported [4,10-13]. Neither case of dehiscence of the old scar,nor uterine rupture was recorded. The same thing was observed by Jocelyne Thachinamurthi in France 2012 , and Bretelle et al.  Dehiscence is recorded by Abassi et al. in MOROCCO in 1999 (3.10%) (04/130) . Cases of uterine rupture were reported by Caughey et al. in the United States in 1999: 3.73% (5/134)  and by Macones et al. in the US (2005): 1.80% . No maternal deaths were recorded by Jocelyne Thachinamurthi in France in 2012 , Spanish et al. 2003 in Netherlands , Lemouton in France in 2014,  Ramp et al. . In the literature, history of vaginal birth was not predictive of successful uterine trial, but these studies were conducted on small sample, and the results were not significant [2,7]. Caughey et al. in the United States in 1999  found a rate four times greater of uterine rupture with women who vaginally delivered once, than those who had never experienced it (RR=0.26 CI 95% [0.08 0.88].
• Reluctance of certain gynecologists to perform the study;
• Lack of operatory detailed reporting from anterior sections. This is due to difficulties in finding old files and the fact that the patients (subjects) do not have their detailed reporting;
• Unavailability of a in the delivery room
Vaginal birth in double scarred uterus is possible and can be considered, with minimum damage to the mother and the fetus on condition of rigorous recruitment of subjects, strict surveillance with partogram in obstetric –chirurgical environment, and in the presence of a midwife and an obstetrician gynecologist.
At the end of this study,
The profile of the women with double scarred uterus who can be approved vaginal birth is the one who:
• has given free and informed consent after a thorough explanation;
• having an ongoing pregnancy with a gestational age higher than or equal to 28 weeks of amenorrhea (SA);
• free from any superimposed risk factors (heart disease, HIV, hemoglobinopathy, respiratory failure, gestational diabetes)
• with no counter indication of uterine trial, and with no absolutecounter indication previous to a vaginal delivery;
• having an reproductive interval ≥ 15 months;
• with clinically normal judged pelvis;
• having a normally inserted placenta;
• having a fetus in the vertex and normal weight;
To the Sapienza University of Rome, especially to Professors AM Angelici, and R. CORONNA, for their financial support in the realization of this study.