The optimal mode of delivery in women with eclampsia remains controversial in the modern practice of obstetrics and gynaecology. In this study, the caesarean delivery rate was slightly higher than that of women who had normal vaginal delivery. This contrasts with the findings from the study done by Priti Kumari and colleagues, in which the rate of vaginal delivery was higher than that of caesarean delivery [7]. However, in most studies across the world, caesarean section delivery has been repeatedly reported to be higher in women with eclampsia [8₋10]. The plausible explanation for the difference is that in most protocols, including ours, with respect to the management of eclampsia, it is recommended that delivery should occur within 12 hours following seizure(s), and only pregnant women admitted in the active phase of labour or with favourable Bishop scores are allowed to progress within the 12 hours if the foetal status is preserved. Additionally, the extensive use of cardiotogram (CTG) machines to monitor labour and the lack of consensus on the interpretation of the tracing have widely contributed to an increased rate of caesarean delivery [11₋13]. Another aspect that could explain the increased rate of C-section delivery in eclamptic mothers is the panic attitude of midwives during seizer(s), while most of today’s midwives do not agree to monitor the labour of women with eclampsia. Experience and good exposure in the field, as well as evidence-based practice of the art of obstetrics in resource-limited settings, may curve the trends of caesarean delivery among eclamptic mothers.
Socio-demographic factors such as maternal age, education level, occupation, healthcare insurance coverage, and geographic location were not significantly associated with mode of delivery. This finding contrasts with those of previous studies in which maternal age, educational level, parity, household socioeconomic status, rural residence location, and household level of education were associated with caesarean section delivery [14, 15]. However, low maternal education increased the risk of caesarean delivery among affected women. This could be due to the easy accessibility of comprehensive emergency obstetric care, including caesarean section. We also noticed that some of these patients were operated on at county hospitals and were referred for further management of persistent seizures after delivery.
Clinical factors, including symptoms of the disease, parity, history of pregnancy loss, antenatal care attendance and facility attended for ANC, mode of admission, treatment of hypertension, and medications received during seizures, were not associated with the mode of delivery. Begun N and colleagues reported similar findings [16]. This could be explained by the good patient response to treatment. Moreover, evidence recommends that the pregnant mother with eclampsia should be stabilized before making decisions regarding delivery [17]. However, the goal of stabilizing the patient with medications is not to conserve the pregnancy but to allow for better assessment and the ability to determine the optimal and safest mode of delivery within a reasonable amount of time. Thus, the method of initiation of labour was significantly associated with the mode of delivery, where induction of labour (IOL) with Cytotec alone, Foley catheter alone or a combination of the Foley catheter and Cytotec showed reduced morbidity related to caesarean delivery. Pregnant women in whom labour was initiated artificially had an unfavourable cervix (poor Bishop score). However, the duration of labour was not recorded, but the absence of emergency caesarean section delivery among those women showed that vaginal delivery was achieved within a reasonable time of 12 hours. In a randomized study conducted by Seal SL and colleagues on eclamptic patients, IOL was preferably the safest mode of delivery and did not increase the risk of caesarean section delivery [18]. Therefore, the authors of the current study recommend IOL in eclamptic mothers to achieve vaginal delivery, even with an unfavourable cervix. This has a reasonable implication and advantage in terms of cost and the prevention of primary caesarean section with good outcomes.
Regarding maternal outcomes, there was no maternal death reported in this study. This finding contrasts with previous studies conducted in a similar context of resource-limited settings of sub-Saharan Africa and other developing countries, where maternal mortality from eclampsia was higher [16–21]. This is the result of a clear and tight protocol for the management of the disease, as well as interdisciplinary care. For example, patients who were in critical condition after delivery were admitted to the ICU, where they were managed with a multidisciplinary team that included obstetricians, physicians, nephrologists, anaesthesiologists, neurologists and neurosurgeons, and trained nurses in intensive care. Such management approaches, as well as ICUs, are widely lacking in most resource-limited settings in sub-Saharan Africa. Therefore, improving maternal and newborn care in developing countries cannot be achieved on paper but rather through investment in health infrastructure and staff. Moreover, the World Health Organization is defined as a standard roadmap for improving maternal and newborn care in health facilities [22]. Maternal complications from the disease included HELLP syndrome, acute kidney injury, and stroke, which were not associated with the mode of delivery. Given the current evidence, caesarean section delivery is discouraged with HELLP syndrome and AKI due to the risk of uncontrolled bleeding and poor elimination of anaesthetic drugs [23₋26]. The incidence of these complications was also less frequent than that reported in other studies [1–5]. However, the reason for prompt delivery in eclampsia is to prevent serious maternal complications, including death. Townsend and colleagues state that the only cure for preeclampsia and eclampsia is the delivery of the placenta, while all other approaches merely serve to manage symptoms and stabilize the mother [6]. In line with this, the Riley Mother and Baby Hospital (RMBH) protocol has made “delivery” the gold standard for the management of eclampsia, regardless of gestational age and foetal status. Any attempt toward the conservative management of eclampsia is not permitted. To date, if several studies have agreed on non-conservative management and prompt delivery, controversy regarding the mode of delivery has persisted. However, in the current study, even if there was no maternal death, caesarean section delivery was not associated with better maternal outcomes in terms of morbidity and ICU admission. This is congruent with the findings of a randomized controlled study performed by Seal SL and colleagues, who found that C-section was not associated with better outcomes [18].
Maternal convulsive seizures are also dangerous for the foetus. However, perinatal outcomes and maternal clinical characteristics, especially previous history of eclampsia, symptoms of the disease, history of pregnancy loss, antenatal care attendance and facility attended for ANC, mode of admission, treatment of HTN, and medications during eclamptic seizures, were not associated with the risk of infants being admitted to the NBU. This is because eclampsia is associated with transient maternal hypoxic status, which has minimal transient effects on the foetus [17]. In settings where there is a CTG machine, the effects of maternal hypoxia on the foetus during seizures are shown by transient reduced variability and bradycardia for up to 20 minutes after maternal seizures [17]. Persistent reduced variability may be related to the effects of drugs used to control and stabilize maternal conditions and/or persistent maternal hypoxia during status eclampticus [6]. In this study, parity, mode of delivery, indication of C-section delivery, and method of initiation of labour were significantly associated with the risk of infants’ admission to the NBU. Regarding parity, Melese MF and colleagues had similar findings, especially in nulliparous and multiparous patients [27, 28]. This could be related to individual factors such as the severity of the disease, drug effects, prematurity, and/or mode of delivery. In addition, caesarean section delivery increased the risk of newborns’ admission to the nursery, especially those for whom the indication for C-section was eclampsia, whereas IOL significantly reduced the risk of NBU admission. C-section also slightly increased the rate of perinatal death. Indeed, several factors could have contributed to the occurrence of the observed adverse perinatal outcomes. Surgical skills during the procedure, “difficult extraction in young hands”, and the effects of anaesthesia are major contributors, among others. Therefore, caesarean section delivery is not associated with better perinatal outcomes. It should be performed for obstetric reasons.