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Original Article

Analysis of Indications of Caesarean Sections

Jasia Jabeen*, Muhammad Hassaan Mansoor,** Ammarah Mansoor** *Department of Obstetrics and Gynaecology, Combined Military Hospital, Rawalpindi,

**Army Medical College, Rawalpindi.

Abstract Background: To analyze indications and

frequency of caesarean section.

Methods:In this cross sectional study pregnant

females , who underwent caesarean section during study period were enrolled. Indications for caesarean sections and caesarean section rates (CSR) were studied..

Results: During study period, total number of

deliveries were 3049, out of which 1709 (56%) were caesarean sections. The commonest indication for caesarean section was repeat caesarean section (40.3%), followed by failed induction (13.5%) and fetal distress (11.2%)

Conclusion: The rate of C-sections is high.

Regular audits of CSR and indications for caesarean sections will help to reduce CSR.

Keywords: Caesarean section rate (CSR),

indications of caesarean section, failed induction,

Introduction High caesarean section rate has been recognized as a major health problem in many countries. There is a massive public interest and debate on both the cause

and appropriateness of increasingly employing a surgical procedure to short circuit or entirely bypass labour and delivery.1Although, caesarean delivery greatly improves obstetric outcomes when clinically indicated, excessively high caesarean delivery rates have raised concern about the health and economic consequences of this practice.2 Caesarean delivery has been shown to substantially increase the risk of maternal and perinatal morbidity. Maternal mortality among women who undergo caesarean section is 4-10 times higher than among women who deliver vaginally and uterine scarring from a caesarean can undermine reproductive health.3 4 A high CSR does not confer any additional benefits but have resource implications for health services. The increased morbidity due to C-sections is 5-10 times that for a vaginal delivery5. Countries with some of the lowest perinatal mortality rates in the world have CSR of under 10%.6

There is no consensus about the ideal CSR but WHO states that no additional health benefits are associated with CSR above 10-15%.7 Wide variations in CSR exist between different regions and maternity centers suggesting lack of proper protocols and variation in practice. WHO global survey showed that China had the highest CSR in South-East Asia region.8 In USA average CSR is 38%.9 The rates of caesarean section have been steadily increasing in both developed and developing countries. The epidemic of caesarean deliveries is likely to extend further and the impact of this trend on resource poor communities like ours cannot be underestimated.10

Patients and Methods This cross sectional study was conducted in department of Obstetrics and Gynaecology, CMH, Rawalpindi. Ladies who underwent caesarean section from Nov. 2011 to Oct. 2012 were included. Though, it is a military hospital meant for the families of army personnel but only about 30% ladies belong to this group and about 70% are non-entitled (private) cases. Demographic detail including age and parity was noted. Indications for caesarean section were also noted.

Results A total of 3049 patients had delivery during this study period. Out of these 1709 (56.06%) had caesarean sections (Table 1). Maternal ages ranged from 20 to 40 years. Majority of the patients belonged to lower-middle social class in non entitled group. Patients in the entitled group were the wives of army officers. Major indication for caesarean section was previous caesarean section (40.37%). Failed induction and fetal distress were 13.58% and 11.23% respectively. Fetal malpresentation including breech was seen in 6.73% cases (Table 2).

Table 1.Mode of Deliveries Mode of delivery No. of Cases

C-sections 1709

Vaginal births 1340

Total 3049

% of C section 56.05%

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Table 2. Indications for C-Sections(n=1079)

Indications No(%)

Previous scar 690(40.37)

Failed induction of labour 232(13.58)

Fetal distress 192(11.23)

Fetal Malpresentation 115(6.73)

Failure to progress 75(4.39)

CPD 55(3.22)

Polyhydramnios 8(0.47)

Oligohydramnios 80(4.68)

PIH 67(3.92)

IUD 5(0.29)

Preterm 12(0.70)

APH 28(1.64)

IUGR 35(2.05)

Twins 9(0.53)

Post-dates 9(0.53)

Decreased Fetal movements 17(0.99)

Poor Bishop 18(1.05)

PROM 13(0.76)

BOH 5(0.29)

GDM 18(1.05)

SROM 5(0.29)

Precious pregnancy 8(0.47)

Unspecified 13(0.76)

Discussion

Worldwide CSR has increased from 5-7% in 1970 to 25-30% in 2003.11 CSR of 56% in this study is much higher as compared to other local studies (20% and 60%). 12, 13 However, our CSR is comparable to a local study and a study from Brazil.14-16 Socio-demographic details of our study revealed that majority of cases belonged to upper and lower middle class which is in contrast to cases studied in similar studies at local level. Two studies from USA and England have shown that Caesarean section is more likely in women of high socioeconomic class than poor women. 17 The leading contributor to overall CSR is previous caesarean section (40%) which is comparable to other studies.18,19 A local study has reported previous caesarean section in just 19.2%. 20 The higher incidence of this indication is due to very rare occurrence of planned VBACs in our department, though it may vary from 0% to 90%.21,22 Up to 76% of women with previous one caesarean section may be able to successfully deliver vaginally.23,24 Therefore, careful selection and motivation of more women with previous caesarean section to undergo trial of VBAC is needed.

The second most common indication in our study group was failed induction of labour (13.5%). Current research suggests that labour induction makes a caesarean section more likely among first time mothers when cervix is unfavourable.25,26 This factor can be addressed by proper selection of cases on both indication and method of induction of labour. Fetal distress accounts for 11.2 % of caesarean sections. The diagnosis of fetal distress is often subjective and lacks standard clinical criteria in different health facilities.27 Continuous electronic fetal monitoring is being used routinely in our setup. Precise interpretation of fetal heart tracing is questionable and fetal PH determination is not done. Proper interpretation of fetal heart tracing and use of fetal PH might be effective in reducing caesarean section for this indication.28 Haver Kamp and colleagues and Leveno and co-workers have shown a high CSR for fetal distress when use of electronic fetal monitoring is compared intermittent auscultation of fetal heart.29 A feature of modern obstetrics is increased rate of elective LSCS for breech. In some countries CSR for breech is now the order of 80%. This trend has implications not only for the index pregnancy but increases the chance of repeat caesarean section in subsequent pregnancies. 30 CPD, oligohydramnios, and hypertensive disorders each contribute about 3-4% of all. Other indications(19.2%) included preterm, APH, twins, post-dates, diabetes, pre-labour rupture of membranes and bad obstetric history.Miscellaneous causes of caesarean section were 20% and 64% in Lyari General Hospital, Karachi and Isra Medical University, Hyderabad respectively.15,31,32 Critical appraisal is required to identify the problem in cases where poor Bishop score, decreased fetal movements and unspecified indications are mentioned. During the last two decades there have been an increased number of caesarean sections carried out ‘on demand’ i.e. at the patient’s request and not on any justifiable obstetric reason. Though, such an indication was not documented in our study but low threshold of caesarean section in certain cases cannot be ruled out. Academic groups and professionals are focusing more on preventing the complications of caesarean sections rather than on preventing unnecessary caesarean sections. In present study it is observed that non-availability of system of audit for caesarean sections on regular basis has resulted in poor documentation and record keeping. At the moment no solution is in sight, since few are inclined to analyze the problem in depth or to seek a solution, however,

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concerted efforts are needed to advocate for a rational use of caesarean sections in our setup.

Conclusion 1. The departmental obligation to avoid unnecessary

caesarean sections must be practiced. 2. Promotion of public health education on

advantages of natural delivery and risks associated with caesarean sections in antenatal and birth preparation classes or in pre-delivery discussions can help to reduce CSR.

3. Regular audits of CSR and indications for caesarean section should be maintained.

4. Adherence to standard guidelines and protocols for managing labour is required.

References 1. Wagner M. Choosing caesarean section. Lancet. 2000;

356:1677-80. 2. Petrou S, Henderson J, Glazener C. Economic aspects of

cesarean section and alternative modes of delivery. Best Pract Res Clin Obstet Gynaecol. 2001;15:145–63.

3. Yang Q, Wen SW, Oppenheimer L, Chen XK. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG.2007;114:609–13.

4. Onwere C, Gurol-Urganci I, Cromwell DA. Maternal morbidity associated with placenta praevia among women who had elective caesarean section.Eur J Obstet Gynecol Reprod Biol. 2011;159:62–66.

5. Sweet RD, Ledger WJ. Puerperal infectious morbidity. Am J Obstet Gynaecol 1973; 117:1093-100.

6. World Health Organization: Appropriate technology for birth. Lancet1985, 326(8452):436-37.

7. C-section rates around globe at epidemiclevel. The Associated Press; msn Canadan e w s 2 0 1 0 . A v a i l a b l e a thttp://www.msnbc.msn.com/id/34826186/

8. Lumbiganon P, Laopaiboon M, Gülmezoglu AM. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet . 2010; 375:490–99.

9. Barber EL, Lundsberg LS, Belanger K, Christian M. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011;118:29–38.

10. Leitch CR. Walkers JJ. Cesarean section rates.BMJ 1994; 308: 133-34.

11. Christilaw JE. Cesarean section by choice: constructing a reproductive rights framework for the debate. International J Gynae/Obs 2006: 94:262-68.

12. Ali L and Tayyab S. Cesarean section rate: current trends. J Surg Pakistan 2007; 12:64-66.

13. Choudhary SM and Ayaz A. Efforts to reduce Cesarean Section Rate. J Surg Pakistan 2003; 8:25-27.

14. Haider G, Zehra N, Munir AA, Haider A. Frequency and indication of caesarean section in a tertiary care hospital. Pak J Med Sci 2009;25(5)791-96.

15. Shamshad N. Factors leading to increased caesarean section rate. Gomal J Med Sci 2008;6( 1): 1-5.

16. Belizan JM, Althabe F, Barros FC. Rates and implications of caesarean sections in Latin America: Ecological study. BMJ 1993;319:1397-1400.

17. Wagner M. Born in the USA: How a broken maternity system must be fixed to put women and children first. 1 edition University of California Press; 2006.

18. Barley K, Bottle A, Jarman B. Social class and elective caesareans in the English NHS. Br Med J 2004; 328:1399-1403

19.Belgrave S. Caesarean section. NZ FamPhysic 2003; 30:269-72.

20. Sheikh L, Tehseen S, Gowani SA, Bhurgri H. Reducing the rate of primary caesarean section - an audit.J Pak Med Assoc 2008; 58:444-48.

21. Haider G, Zehra N, Munir AA, Haider A. Frequency and indication of caesarean section in a tertiary care hospital. Pak J Med Sci 2009;25(5)791-96.

22. Bhasker K. Changing trends in caesarean section. In: Obstetrics and Gynaecology for Postgraduates Vol 1. Eds.Ratnam SS, Rao KB, Arulkumaran S. Orient Longman Ltd. Madras India 1992: 132-42.

23. Notzon FE, Plack PS,Taffed SM. Comparison of national caesarean section rates. New England Journal of Medicine 1987; 316: 386-89.

24. Guise JM, Berli M, McDonagh M, Osterwell P. Safety of vaginal birth after caesarean section: a systematic review. Obstetrics and Gynaecology 2004; 103:420-29.

25. Wen SW, Rusen ID, Walker M, Liston R. Comparison of maternal mortality and morbidity between trial of labour and elective caesarean section among women with previous caesarean delivery. American Journal of Obstetrics and Gynecology 2004; 191: 1263-69.

26.Rayburn WF. Minimising the risk from elective induction of labour. J Reprod Med 2007; 52: 671-76.

27. Declercq E, Menacker F. Maternal risk profiles and the primary cesarean rate in united states, 1991-2002 Am J public Health 2006; 96:867-72.

28.Tang CH, Wang HI. Risk-adjusted Cesarean Section rate for the assessment of physician performance. BMC Public Health 2006, 6: 246-49.

29. Dabbas M, Al-Sumadi A. Cesarean Section rate: much room for reduction. Clin Exp Obstet Gynecol. 2007; 34: 146-48.

30. Haverkamp AD, Thompson HE, Mcfee JG. The evaluation of continuous fetal heart rate monitoring in the high risk pregnancy. Am J Obstetrics Gynaecology 1976; 125:310-20.

31.Gulfareen H, Nishat Z, Aftab AM, AmbreenH. Caesarean section ratePak J Med Sci 2009; 25:786-91.

32.. Karim F, Ghazi A, Ali T,Aslam R. Trends and determinants of caesarean section. Journal of Surgery Pakistan (International) 2011; 16 (1):22-27