Delivery on Scarred Uterus at Souro Sanou Teaching Hospital, Burkina Faso (about 531 Cases)

Introduction: Therapeutic conduct for delivery via a scarred uterus is con-troversial in modern obstetrics. Some authors recommend a ceasarean section. The purpose of this study was to analyse the conduct and prognosis of delivery via scarred uterus at Souro Sanou Teaching Hospital in Bo-bo-Dioulasso. Methods: We conducted a descriptive cross-sectional study from January 1 to December 31, 2017. Data were collected from medical, birth, and operating room records. Result: In total, 531 scared uterus deliveries and 5293 deliveries have been recorded in our study; the frequency of deliveries via a scarred uterus was 9.96%. The average age of the patients was 28.02 years old, with extremes of 17 and 44 years. The average parity was 2.34, with extremes of 1 and 8. Patients with a spacing interval between births of at least 24 months accounted for 86.6% of observed patients. Patients with a single scar uterus made up 70.6% of the population. There were 349 (65.73%) patients who had an emergency caesarean section during a previous delivery. The trial of vaginal delivery via a scarred uterus was conducted on 182 patients with a success rate of 89.56%. There was no maternal death. However, we noted 23 foetal deaths (4.33%). Conclusion: More than 50% of parturient women with a single caesarean uterine scar who underwent the uterine test gave birth vaginally in our department. However, like most previous studies on the subject, we recommend vaginal delivery in the presence of a prior caesarean-scarred uterus whenever possible.


Introduction
The procedure for proper therapeutic conduct in the case of a scarred uterus is a frequently discussed topic in modern obstetrics. Some authors tend to recommend caesarean section as a method of managing delivery for a patient with a scarred uterus [1]. Other authors recommend vaginal delivery to slow the global increase in the rate of cesarean sections if specific parameters are observed [2].
Indeed, the rate of caesarean sections in the United States rose from 8.8% in 1970 to 21.4% in 2001 [3]. In France, the number of caesarean sections has increased threefold in the last 30 years, from 6.1% in 1972 to more than 20% in 2007. This phenomenon is reflected in the correlated increase in the number of patients with a scarred uterus, which now stands at around 10% [4]. In Africa, the rate of delivery via a scarred uterus varies from one city to another. For instance, the rate is 5.92% in Bobo-Dioulasso [5] and 8.45% in Niamey [6].
In our department, there is no formal therapeutic protocol for delivery via a scarred uterus. The purpose of this study was to evaluate the conduct and prognosis of delivery via a scarred uterus at Souro Sanou Teaching Hospital in Bobo-Dioulasso.

Methods
We conducted a cross-sectional descriptive study in the Department of Gynaecology, Obstetrics, and Reproductive Medicine of Souro Sanou Teaching Hospital in Bobo Dioulasso, Burkina Faso, from January 1 to December 31, 2017. All patients with a scarred uterus admitted to the department during the study period for either labour or elective cesarean section procedures were included in the study. Only the scars of previous caesarean sections were taken into account, thus excluding myomectomy scars and other surgical scars on the uterus. Data was collected from clinical, and delivery and operating room records. The variables studies were the socio-demographic characteristics, clinical aspects, therapeutic aspects, and maternal and foetal prognosis. The collected data was entered and analysed on a microcomputer using SPSS software (Version 12.0). Microsoft Excel and Word 2013 were also used to complete this study.

Patient Characteristics
In 12 months, we recorded 5293 deliveries, 531 of which were via a scarred uterus, corresponding to a frequency of 9.96%. The average age of the patients was 28.02 years with extremes of 17 and 44 years old. The 25 -29 age group represented 31.07% of the total population (

Uterine Scars
Patients with single, double, triple, or more uterine scars accounted for 70.62%, 23.54%, and 7.72% of the population, respectively. In our department, patients with an intergenesic period (IGP) of 6 -24 months accounted for 12.62% of the population, while 86.62% of patients had an IGP longer than 24 months.  (Table 3).

Uterine Test
Of the 531 patients with a scarred uterus, a uterine test was indicated in 182, which corresponds to 34.27% of the population. All had a single uterine scar. Of Open Journal of Obstetrics and Gynecology (once the operating protocol was known), an ultrasound-based estimated foetal weight of less than 3800 grams, a clinically normal pelvis, a placenta non covering, an absence of foetal distress or any other obstetrical emergency, and the continuous presence of medical personnel in the labour room.

Failure of the Uterine Test
There were 19 cases of unsuccessful uterine tests, which represented 10.44% of all tests. All these parturient women did not give birth vaginally; all underwent caesarean section. The causes of failure of the uterine test were dominated by dynamic dystocia (52%) and acute foetal distress (35%).

Maternal and Foetal Prognosis
There were no maternal deaths; however, out of a total of 20 complications cor-

Discussion
Over the course of this century, doctors' opinions and attitudes about the proper method of delivery needed for patients with a scarred uterus have changed. Over the century people's attitudes toward women with women with scarred uteruses have evolved. A choice must be made between the two extremes of making iterative caesarean sections systematic and making the percentage of caesarean sections comparable to that of secondiparous women who deliver vaginally [1] [7]. During our study period, 9.96% of patients that delivered had at least one prior caesarean scar. This rate is lower than that of previous studies conducted by Cissé (1.5%) [3], Tshilombo (2.4%) [8], and Dembélé (4.92%) [5]. The high proportion in our study can be attributed to the fact that the majority of high-risk deliveries are referred to our facility, including deliveries via scarred uterus. Women with a scarred uterus and an IGP longer than 24 months accounted for 86.62% of patients. This rate is higher than those of studies by Koulimaya [8] and Nayama [9], who reported 37.9% and 56.8%, respectively. This is due to a variety of reasons: 1) increased practitioner emphasis on family planning counselling and related medical indications of such planning; 2) women's increased awareness of the risks associated with more than one pregnancy within a two-year period; and 3) the increased availability of free contraception in our country over the past three years.
Of all patients with a scarred uterus, 65.73% had a systematic caesarean section and 12.61% had a caesarean section because of bone dystocia, which is a permanent indication of cesarean section. Lieberman's study found a 24% rate for systematic caesarean sections [10] while B. Mercer's revealed a 32% rate [11]. The variability of the rates among these studies is justified by the variability of the systematic indications of caesarean section on scarred uterus. The two most common indications in the literature for systematic caesarean section on scarred uterus are bone dystocia and breech presentation [7].
No uterine tests were attempted in parturient women with two or three uterine scars. This attitude is the one that seems to have been adopted in previous studies on the same subject conducted in West Africa [12] [13].
In our department, 34.27% of patients with a scarred uterus underwent a uterine test. All those who underwent the test had single uterine scars, and 89.56% of them gave birth vaginally. This success rate is similar to that of El Hanchi [14], who experienced an 87.5% success rate in his study. However, in some studies, the mode of delivery had a surgical tendency [15], as did ours (65.73%). Attitudes vary, but the authors are almost unanimous on one point: the vaginal approach is preferred, even for patients with two priors caesarean scars [11] [12] [16]. The nine cases (1.69%) of infectious complications that we reported are most likely due to the operating conditions in our facility and a lack of antibiotic therapy in the postoperative period.
In the literature, some authors report a low mortality rate for vaginal deliveries via scarred uterus, or even its absence, as was the case in our study [9] [17] [18].

Limits
The study has some limitations related to the cross-sectional type, and the extent of missing data due to poor filling of medical records and patients' register. But the results obtained are interesting and have been discussed, commented on,and compared to the data of the literature.

Conclusion
Less than half (34.27%) of the patients with a single uterine scar who came to our department for delivery were allowed to deliver vaginally. There was an 89.56% success rate in those who had uterine tests in the context of no protocol. In our study, the mode of delivery had a surgical tendency; however, with study results on this topic, vaginal deliveries are recommended for patients with scarred uterus whenever possible.