Childbirth on a Moderately Shrinked Pelvis at the Institut D’hygiene Sociale Hospital in Dakar

  

    
Palpate    introducer
    
Result of    the trial of work
    

    

  
  

    
Failure
    
Success
  
  

    
N
    
%
    
N
    
%
    
Total
    
P-value
  
  

    
Doubtful
    
10
    
90.9
    
1
    
9
    
11
    
0.013
  
  

    
Positive
    
2
    
33.3
    
4
    
66.7
    
6
    
 
  
  

    
Unspecified
    
54
    
64.3
    
30
    
35.7
    
84
    
 
  
  

    
Total
    
66
    
 
    
35
    
 
    
101
    
 
  

Table 7: Outcome of the trial of labour and results of the introducer palpation at the IHS hospital in 2020 (N=101).

Discussion

Epidemiology

Frequency: During the study period, we collected 101 birth records in a moderately narrowed pelvis, representing a frequency of 4.6% of all births. This frequency is lower than that found in the literature, particularly in the Cissé series which reported a rate of 5.3% [2]. It would certainly be underestimated if we know that osseous dystocia represented 12.6% of childbirths in Dakar in 2004 [2]. Indeed, in Senegal, only 65% of births are medicalized, which explains why some parturients can do their job and give birth at home without special assistance. Also, the small size of our study sample could also be an explanation. Thus, we should expect more trials of labour in our practice, which justifies the need for a good assessment of the prognosis of childbirth at the last prenatal follow-up visit and awareness of pregnant women for childbirth in hospital environment.

Epidemiological Profile of Patients

The profile of our patients was that of a primiparous (73.3%) young person aged on average 24 years, married (96.9%), having benefited from at least 3 prenatal consultations (90%) and carrier of term pregnancy (97%). This profile is comparable to that found in the Cissé study [2]. Indeed, in this series, primiparous were in the majority with an average age of 24 years and the average gestational age was 38 SA with extremes of 37 and 41 SA.

Clinical Data at Admission

Origin and mode of admission of patients: The majority of our patients were followed outside the Southern District (91.1%). We recorded an evacuation rate of 94%. This shows that our structure is a reference center in the South District and takes care, beyond its area of responsibility, of obstetric emergencies from other health structures in Dakar. This gives an idea of our workload, especially emergency activity. However, the high frequency of evacuation in parturients with a narrowed pelvis shows that there are still shortcomings concerning prenatal follow-up. Indeed, the latter should in principle be the subject of a referral to surgical maternities at the end of pregnancy.

Basin Pre-Assessment

The evaluation of the capacity of the pelvis was carried out by clinical pelvimetry and by scanopelvimetry. In our study, we mainly encountered two types of moderately constricted pelvis: symmetrical or “limit” (63.4%) and transversely constricted (36.6%). These two types of pelvic anomalies are by far the most frequent in the literature [3]. In the Cissé series, the same observation was made with rates superimposable on ours [2]. This situation is probably favoured by the tendency to a verticalization of the upper strait in the black African woman because of her natural arch [2-4]. For moderately narrowed pelvises, we cannot identify a risk profile, because they are most often patients with no particular history with a morphotype superimposable on that of the general population [2]. This observation justifies the need to carry out a meticulous examination of the pelvis at the last prenatal consultation or, failing that, upon admission to the labour room. Like the results of Cissé and those of other authors [2,5], we can say that clinical pelvimetry is efficient not only to assess the degree of permeability of the pelvis, but also to approach as closely as possible the type of existing anomaly. In our context of exercise, which is characterized by the weakness of the means, the indications of the scanopelvimetry must be more selective and limited to the case where the clinical examination of the pelvis is doubtful. This justifies the limited number of scanopelvimetry performed in our series.

Assessment of Prognostic Factors

The predictive factors for the success of the trial of labour found in our study are identical to those found in the literature [6,7]. In our series, the introducer palpate was performed in 17 parturients (16.8%) and it was positive in 5.9% of cases. These rates are much lower than those found in the literature. Indeed, in Cissé's series, introductory palpation was systematic in all patients after rupture of the membranes and was positive in 82.5% of cases [2]. This low prevalence of the introducer palpation noted in our series could be due to a lack of notification in the files or the absence of achievement. This last hypothesis would constitute a limit in the implementation of the trial of labour because the introductory palpation is a fundamental element which makes it possible to assess the cephalo-pelvic confrontation and to make a good selection of candidates for the trial of labour. Also, the Magnin diagram had not been used in any of our patients. It is the same in the study of Cissé [2] which recommends using the data of the cephalo -pelvic confrontation to the detriment of the indices and diagrams proposed by certain authors because the standards having been used for their confections are not relevant to the black populations.

Birth Data

Mode of Childbirth

In our series, the trial of labour ended in vaginal childbirth in 34.7% of cases. Our caesarean section rate, which was 65.3%, is much higher than those noted in the literature, in particular by Cissé, who had found a rate of 26.4% [2]. Several explanations could be given: The large proportion of evacuees in our study, most often at an advanced stage of labour with early anomalies that required cesarean section,

The preliminary evaluation of the prognostic factors which was incomplete with especially the absence of achievement of the palpating introducer which would have made it possible to select the good cases,

And the indications for caesarean section which were dominated by dynamic dystocia (83%) in particular cases of hypokinesia and stationary dilation which do not always require a caesarean section but which, in the absence of mechanical impingement, could be corrected by oxytocin infusion.

Factors Influencing the Outcome of the Trial of Labour

In our series, the failure of the trial of labour was more frequent when the introducer palpation was doubtful (90.9%) than when it was positive (33.3%) with a statistically significant difference (p=0.013). In gross analysis, a dubious introducer palpate would statistically significantly increase the risk of failure to the trial of labour. This same observation had been made by Cissé [2]. Indeed in his series, the trial of labour resulted in success in 8 out of 10 patients when the introducer palpate was positive [2].

The prevalence of failed trial of labour was 76.9% in nulliparous, 64.9% in primiparous, 72.7% in pauciparous and null in multiparous. However, there was no statistically significant relationship between risk of trial of labour failure and parity (p=0.082). The same was true for the mode of admission (p=0.685). This could be justified by our small sample size but also by the lack of systematic evaluation of the predictors of success in the trial of work. Also, the failure of the trial of labour was more frequent in patients with a borderline pelvis (79.5%) compared to those who had a transversely narrowed pelvis (68.7%) without having a statistically significant difference between the two groups (p=0.392).

Maternal and Fetal Prognosis

In our series, the perinatal prognosis was favourable in most cases (88.1%). Only 11.9% of new-borns had benefited from neonatal resuscitation. In Cissé's series, postnatal mortality in new-borns after a trial of labour was superimposed on that recorded in controls and linked to neonatal suffering almost always correlated with a lack of commitment [2]. This justifies a good evaluation at the start of the different levels of the pelvis and a good cephalo-pelvic confrontation to establish good indications for the trial of labour. Also, throughout the event, close monitoring must be instituted to detect probable complications early. A consensus exists on the need to judge the results of the trial of labour after a delay of 2 to 3 hours [2,7].

Maternal mortality was null in our series. Cissé [2] recorded the same result in his study. We also found no maternal complications.

Conclusion

Childbirths on a moderately narrowed pelvis are relatively frequent in our practice. They are associated with a good maternal and perinatal prognosis. However, this could be improved by a good selection of cases for the trial of labour and a referral before the onset of labour to a surgical maternity unit where the childbirth is to take place.

References

1. World Health Organization, Unicef, United Nations, et al. Trends in maternal mortality: 1990 to 2015: estimates by WHO; 2015. UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Available from: http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/.
2. Cisse CT, Kokaina C, Ndiaye O, Moreau JC. Trial of labour in moderate bone dystocia at the University Hospital of Dakar. J Gynecol Obstet Biol Repeat. 2004; 33: 312-8.
3. Cisse CT, Faye EO, de Bernis L, Dujardin B, Diadhiou F. Caesarean sections in Senegal: coverage of needs and quality of services. Sante. 1998; 8: 369-77.
4. Cisse CAT, Bernis LD, Faye EHO, Diadhiou. Ectopic pregnancy in Senegal. Cah Etudes Rec Francoph Health. 2002; 12: 271-4.
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7. Morin P, Barrat J, Bremont A, Dubecq JP, Magnin G, Steer CM. The foeto-pelvic disproportion: vitiated pelvis and trial of labour. In: Masson P, editor. Treatise on obstetrics; 1985.