Adverse maternal and perinatal outcomes in second-stage versus first-stage of labour primary caesarean deliveries at Moi Teaching and Referral Hospital, Kenya.

Abstract

Background: Caesarean deliveries are on the rise globally. Second-stage caesarean delivery may carry an additional risk owing to foetal head impaction into the pelvis and manipulations required to deliver the baby. At the national and institutional level, data on the outcomes and complications of this procedure are minimal. Broad Objective: To compare adverse maternal and perinatal outcomes between second-stage and first-stage of labour primary caesarean deliveries at Moi Teaching and Referral Hospital (MTRH), Eldoret. Methods: This was a hospital-based, ambi-directional cohort study. A total of 222 women with term, live singleton pregnancies in vertex presentation; who had undergone emergency primary caesarean delivery during active phase of labour were recruited within 24 hours postpartum. The exposure of interest was second-stage caesarean delivery. Medical records were reviewed, and retrospective data was collected with respect to intra-operative details. These participants were followed up until hospital discharge for in-hospital mortality and length of hospital stay outcome. All eligible second-stage caesarean deliveries (73) were compared to 149 first-stage caesarean deliveries. A 1:2 ‘exposed’ to ‘non-exposed’ ratio was used. The proportion of caesarean deliveries in the second-stage of labour was estimated. The composite adverse maternal outcome was evaluated. This was defined as any of the following; atony, adjacent tissue injury, hysterectomy, bladder injury, uterine incision extension, primary postpartum haemorrhage, blood transfusion, length of postoperative hospital stay >3 days or in-hospital maternal death. The composite adverse perinatal outcome was also assessed. It was defined as any of the following; neonatal trauma, newborn unit admission, Apgar score ≤3 at 5min or, death within 24 hours of caesarean delivery. The composite outcomes as well the frequency, relative risks and 95% confidence intervals for each of the components of composite outcomes were calculated. Univariate analysis examined the difference in distribution of each potential confounder between the two groups. Multivariate log-binomial regression models were used to estimate the association between stage of labour and composite adverse maternal and perinatal outcomes adjusting for potential confounding variables. The study was from 1st August 2021 to 31st July 2022. Results: Among women who underwent primary caesarean deliveries, the proportion of second-stage caesarean deliveries was 4.3% [95% CI: 2.9% - 4.7%]. Second-stage caesarean delivery was associated with an increased risk of adverse maternal outcomes compared to caesarean delivery in the first-stage labour (ARR 3.556, 95% CI 2.35-5.37, P < 0.001). There was no in-hospital maternal mortality within the study. Second-stage caesarean delivery was also associated with a significantly increased risk of adverse perinatal outcomes compared with caesarean delivery in the first-stage of labour (ARR 3.998, 95% CI 2.35– 6.79, P < 0.001). Conclusions: Caesarean deliveries performed in the second-stage of labour accounted for 4.3% of all primary caesarean deliveries at MTRH. Women who underwent caesarean delivery in the second-stage of labour had a significantly higher risk of adverse maternal and perinatal outcomes compared to the first-stage of labour caesareans. Recommendations: Prevention by early identification of scenarios that can result in caesarean delivery in the second-stage of labour are key in reducing the associated adverse outcomes.