Looking at perinatal outcomes of babies delivered by second-stage caesarean section versus vacuum extraction in a resource-poor setting, Eze et al (2020) evaluated the perinatal status of neonates delivered by assisted vaginal delivery (AVD) vs second-stage caesarean birth (CS).

Methods: A five-year retrospective study was conducted in a tertiary hospital. Data was analysed with IBM SPSS® version 25.0 statistical software using descriptive/inferential statistics.

Results: A total of 559 births met the inclusion criteria; AVD (37%) and second-stage CS (62%). Over 80% of the women were aged 20-34 years. More than half of the women were parous. The commonest indication for intervention in both groups is delayed second stage: 84% in the AVD group, and 68% in the second-stage CS group. There was a statistically significant difference in decision to delivery interval (DDI) between both groups: 93% of women in the AVD group had DDI of less than 30 min and 21 women (6%) in the CS group had a DDI of less than 30 min (p <0.001). During the DDI, there were three intra-uterine foetal deaths (IUFD) in the AVD and 5% in the CS group (p = 0.023).

After adjusting for co-variates, there were statistically significant differences between the AVD and CS groups in the foetal death during DDI (p = 0.029) and perinatal deaths (p = 0.040); but no statistically significant differences in severe perinatal outcomes (p = 0.811), APGAR scores at 5th minutes (p = 0.355), and admission into the NICU (p = 0.946). After adjusting for co-variates, use of AVD was significantly associated with the level of experience of the care provider, with resident (junior) doctors less likely to opt for AVD than CS (aOR = 0.45, 95% CI: 0.29–0.70).

Discussion

The present study showed that for women who needed assistance in the second stage of labour, there was no significant difference in immediate neonatal outcomes and admission into the NICU for both AVD and CS. This re-affirmed the findings from previous studies which showed no significant difference in immediate neonatal outcomes for AVD and CS. However, it was at variance with a similar study in Israel, where Shmueli et al reported that CS yielded poorer neonatal outcome than AVD.

Incidence of 2.3% AVD in this study is similar to 2% in Maiduguri, Nigeria, but higher than 1.5% reported in Enugu, Nigeria and 0.54% reported in Bauchi, Nigeria. Elsewhere in Africa, our incidence of AVD is slightly lower than the 3.1% reported in Kumasi Ghana and 2.8% reported in Kampala, Uganda; but higher than the overall average of about 2% reported in rural Tanzania. On the other hand, their incidence of second-stage CS (3.7%) is higher than the 3.3% reported in Kampala, Uganda. The need for interventions to resolve feto-maternal complications in the second stage of labour is necessary.

The current study showed that prolonged second stage of labour was the most common indication for 84.4% AVDs and 68.7% CSs. Other researchers have also reported similar indication for AVD and CS.

However, other studies have also reported poor maternal effort/ exhaustion and foetal distress as major indications for second stage interventions. Opoku et al reported an incidence of 10.9% for maternal exhaustion and 15.4% for foetal distress in AVD. Several studies have reported low incidence of AVD in many countries, including low-income countries of sub-Saharan Africa. However, the recent increase in Caesarean section rates in many countries has not resulted in any significant improvement in neonatal outcomes. In addition, several high-quality studies demonstrate that the use of AVD in well-selected patients remains a safe and effective method of delivering healthy neonates without compromising the overall birthing experience and outcome. AVD is therefore a safe alternative worldwide, but more so in low resource settings, where there is high aversion to CS due to several socio-cultural reasons. It is therefore disturbing that even for similar indications and similar set of women, resident doctors were less likely to opt for AVD than CS. This is mostly due to decreasing resident doctors’ experience in AVD.

If this low usage of AVD persists, it may further aggravate the increasing rates of CS that are already very high in this setting. Hence, given that mothers in this setting have very high aversion to CS and mothers who had AVD report better overall quality of life than mothers who had CS, it is imperative that AVD should be encouraged where conditions allow.

Although this study significantly adds to the body of evidence comprehensively contrasting perinatal outcomes for newborns born via AVD with newborns born by second-stage CS, it is not without some limitations. This study did not present similar analysis on maternal outcomes. Also, this study was also performed in one hospital, which could limit it applicability to other settings. There is, therefore, a need for a large multi-centre study with longer follow-up period, incorporating other methods of assessing immediate neonatal outcomes such as arterial blood gas, and qualitative studies to understand the factors driving resident (junior) doctors’ decision-making in second stage events and how these can be tackled to improve usage of AVD in these settings.

Conclusions

AVD compared with second-stage CS was not associated with worse perinatal morbidity and mortality. Junior doctors are short in confidence in the use of a vacuum device for AVD. With appropriate training, AVD could be a practical option in reducing the rising caesarean delivery rates without compromising the clinical status of newborns. Second-stage CS when compared with AVD was not associated with improved perinatal outcomes. AVD is a practical option for reducing the rising Caesarean delivery rates without compromising the clinical status of the newborn. AVD; vacuum extraction and CS are both obstetric procedures associated with enormous benefits and some complications to women and newborn babies. Either intervention can be undertaken during the second stage of labour for maternal and foetal indications, ranging from prolonged second stage, foetal distress, maternal exhaustion or maternal medical conditions. The procedure of choice should be individualised and depend on meeting prerequisite criteria, decision-delivery-interval (DDI) and medico-legal considerations.

While caesarean section rates have increased dramatically worldwide in the last decades, AVD is significantly under-utilised, particularly in sub-Saharan Africa; accounting for a meagre 1% of institutional births. Indeed, the decreasing trend in the utilisation of AVD in low and middle-income countries has largely been attributed to decreasing experience with skills required for AVD.

Unnecessary CSs place an unjustified burden on the scarce financial and human resources that barely meet the health needs of low-income countries. Fortunately, there is clear evidence indicating that high caesarean section rates can be offset by using AVD, especially in resource poor settings where aversion for CS is paramount. Costs of CS are exorbitant and non-operational universal health insurance schemes results in catastrophic out-of-pocket payment for service charges.

Reference

Eze P, Lawani LO, Chikezie RU et al. Perinatal outcomes of babies delivered by second-stage Caesarean section versus vacuum extraction in a resource-poor setting, Nigeria – a retrospective analysis. BMC Pregnancy Childbirth 20, 298 (2020). https://doi.org/10.1186/s12884-020-02995-9.