0

INDICATIONS FOR EMERGENCY CESAREAN SECTION AND ASSOCIATED CLINICAL MATERNAL AND

NEONATAL OUTCOMES AT WVSU-MC: A THREE-YEAR RETROSPECTIVE STUDY

OMAMALIN NG, ALCIDO MR, SUIB SJ, ORDONA MG, ARANDA D, DOLENDO V, HINOJALES R,

PANELO RM

College of Medicine, West Visayas State University, Iloilo City, Philippines

ABSTRACT

BACKGROUND: Pregnancy and parturition are events of considerable importance in the life cycle of women.

Cesarean section (CS) carries a higher maternal morbidity and mortality compared to vaginal delivery.

Given the rising global incidence of cesarean section, this study aims to reveal the clinical profile of

women undergoing ECS, the leading indications for ECS and the consequent maternal and neonatal

outcomes following ECS.

OBJECTIVE: To determine the leading indications for ECS and their associated maternal and neonatal

outcomes in West Visayas State University (WVSU-MC) from January 2005 to December 2007.

METHODOLOGY: The leading indications for E CS were determined in terms of frequency and percentage.

Clinical outcomes of the subjects and the delivered newborns were gauged by maternal mortality and

survival rates (i.e. within the hospital confinement) and APGAR scores (1 and 5 minutes), respectively.

STUDY SETTING: Data were collected from the records section of WVSU-MC and processed at the WVSU

College of Medicine, La Paz, Iloilo City

RESULTS: A total of 703 cesarean section procedures were performed from 2005-2007. Ninety-one (91%)

percent of these were ECS. Records of patients who underwent ECS were retrieved and comprised the

study population (N=533). The means of the age, gravidity and parity of the parturients studied were

29.9 yrs, 2.03, and 1.8, respectively. The mean age of gestation of neonates is 37.8 weeks. Neonates

delivered via ECS are mostly term (69.2%) with good APGAR scores 7-10 (94.4%) at 1 and 5 minutes..

Dystocia (30.8%) emerged as the leading indication for ECS followed by malpresentation (23.8%) and

repeat CS (17.3%). Hypertension was the most frequent morbidity to affect women who delivered via ECS.

Parturients with hypertensive disease underwent ECS due to dystocia. The clinical outcome of ECS is

favorable for both the mother and the child. Survival is 97.4% and 97.2% for parturients and neonates,

respectively. Similarly, mortality rate is less than 1% for both parturients and neonates.

CONCLUSIONS: Dystocia is the most common indication for ECS among women of reproductive age,

primigravid, primaparous and with no illness during pregnancy. Survival is 97.4% and 97.2% for parturients

and neonates, respectively. Mortality rate is less than 1% for both parturients and neonates. Non-

reassuring fetal tracing was the most frequent indication leading to death of both parturients and

neonates.

KEYWORDS: Emergency Cesarian Section, Indications, Clinical Maternal and Neonatal Outcome

1

INTRODUCTION

BACKGROUND OF THE STUDY

Pregnancy and parturition are events of considerable importance in the life cycle of women.

Pregnant women may deliver their children via normal spontaneous vaginal delivery or through

cesarean section. Parturition or giving birth is physiological; however, it poses a significant risk to the life

and well-being of both mother and child. Of all deliveries, however, approximately 10% are considered

high-risk, some of which require cesarean section.1 Paﾐlilio et al. desIriHes Cesareaﾐ seItioﾐ ふC“ぶ as さthe

delivery of a fetus through an abdominal incision (laparotomy) followed by incision of the uterine wall

(hysterotomy).ざ2 This definition excludes operation involving abdominal incision that aims to take out

the fetus from the abdomen during abdominal pregnancy or dislodgment of fetus in the abdominal

cavity when there is rupture of uterus.

CS is further divided into two sub-types as far as the urgency of operation is concerned. Elective

CS refers to さthose oIIasioﾐs ┘here a Iesareaﾐ is IoﾐduIted as a result of ad┗aﾐIed plaﾐﾐiﾐg.ざ3 It also

refers to a decision made more than 24 hours before delivery.4 An elective cesarean, due to its non-

emergency situation, may be perceived by the woman giving birth as a calm and positive experience.

Emergency cesarean section (ECS), on the other hand, is defined as any cesarean delivery that is

not planned or scheduled.4 A cesarean operation is considered an emergency if decisions are made

during the 24 hours before the delivery because of deteriorating fetal or maternal health before the

onset of labor.4 Indications for this non-elective CS are usually evident only after the onset of labor,

either in the early stage or after a woman has been in labor for a while. Since time is critical in this

operation, several studies attempted to set the standard interval time from the date and time of

decision to carry out the cesarean section to the date and time of delivery of the baby. The present

acceptable delivery interval is 30 minutes, although other studies have found out that even beyond this

period, as long as it does not exceed 75 minutes, emergency CS outcomes are still favorable. 5, 6

Rising Incidence of Cesarean Section

The incidence of cesarean section is steadily rising. In the last few decades, the cesarean rates

have increased dramatically in the developed world. The World Health Organization estimates that

2

the rate of cesarean sections is between 10% and 15% of all births in developed countries. In 2001–

2002, the Canadian cesarean section rate was 22.5%.7 In 2004, the cesarean rate was about 20% in the

United Kingdom. In 2005, the cesarean rate was 30.2% in the United States and has been increasing

since 1996.8

Among developing countries like Brazil, cesarean section rates have also increased. In the public

health network, the rate reaches 35%, while on the private hospitals network, the rate of cesarean

sections is at 79.6%.8

In India, data collected from 30 medical colleges/ teaching hospitals revealed that

cesarean section rates increased from 21.8% in 1988-1989 to 25.4% in 1993-19949. In a population

based cross-sectional study conducted in India, a cesarean section of 32.6% has been documented from

Madras City in South India.10

In the Philippines, an increasing trend of CS is also evident. In 1927-1950, the Philippine General

Hospital recorded a one percent increase in the incidence of CS.11

From 1945-1951, in the same

institution, CS constituted 3.06 percent of 25,183 deliveries. From UST Hospital11

and North General

Hospital, the a┗erage ┘as ン.ン perIeﾐt aﾐd 9.ヲ perIeﾐt iﾐ the ヱ96ヰ’s. 11,12,13

The Philippine Obstetrical

and Gynecological Society

explained the following reasons for the increasing trend of CS in the

Philippines: increasing safety of the operation due to antibiotics; availability of blood transfusions;

Hetter aﾐesthesia aﾐd the physiIiaﾐ’s high iﾐteﾐt to deli┗er a healthy HaHy aﾐd healthy ﾏother, ┘heﾐ

done for complications occurring during pregnancy and labor; preference for CS in the delivery of

HreeIh; the attitude of the physiIiaﾐ to┘ards the IoﾐIept of さOﾐIe a Iesareaﾐ al┘ays a Iesareaﾐざ; aﾐd

the attitude of the physician toward the diagnosis of fetal distress, especially when using the electronic

fetal monitor as a basis for the diagnosis.14

Cesarean Section and Associated Maternal and Fetal Outcomes

It is well documented that cesarean section carries a much higher maternal mortality and

morbidity as compared to a vaginal delivery.15

Even though cesarean section is being performed

for indications like fetal distress, perinatal mortality continues to be very high in cesarean

section deliveries.

3

A study published in the February 2007 issue of the Canadian Medical Association Journal found

that women who underwent elective CS had an overall rate of severe morbidity of 27.3 per 1000

deliveries compared to an overall rate of severe morbidity of 9.0 per 1000 planned vaginal deliveries.

The elective cesarean group had increased risks of cardiac arrest, wound hematoma, hysterectomy,

major puerperal infection, anesthetic complications, venous thromboembolism, and hemorrhage

requiring hysterectomy over those suffered by the planned vaginal delivery group.16

In a prospective observational study of 8070 elective cesarean sections in Malawi, Africa, 85

women died after CS, giving a mortality of 1.05%.17

In 1982, maternal mortality in one district of Malawi

was reported as 420/100, 000 pregnancies, and in 1992 in the whole of Malawi

it was 620/100,000.

17,18 It

has since risen to an estimated 1120 per 100, 000 compared with 10 per 100, 000 in developed

countries.

Cesarean section has a much higher mortality for mother and

baby in Africa than in

industrialized countries.19

Other complications believed to contribute to mortality were intra-operative

hypotension (64, 75% of deaths), operative hemorrhage (45, 53% of deaths), ventilation

difficulty (12,

14%), regurgitation of stomach contents (11, 13%), pre-eclampsia (7, 8% of deaths), and difficult

intubation (1, 1% of deaths). In 65 (77% of deaths) cases in which the mother died, the baby also died.

The overall three day survival rate for all babies was 88.8%19

.

However, not all CS cases have unfavorable outcomes. In the United Kingdom, on the other

hand, the overall death rate associated with cesarean section fell from 40/10 000 in 1952-1954 to

4/10,000 in the 1980s

20.

In a retrospective review of 25 consecutive emergency cesarean sections for umbilical cord

prolapse over a one-year period in a certain institution, no significant anesthetic complications such as

failed intubation or aspiration pneumonia occurred21

. There were also no maternal surgical

complications from the cesarean sections. The mean post-operative hospital stay was 4.2 (range 2-8)

days. Two babies suffered superficial cuts in the course of the cesarean deliveries. But neither required

any sutures nor any further follow up. The researchers attributed the improved neonatal outcome to

the practice of immediate cesarean section. Improved neonatal outcome also occurred in an emergency

CS of a poor risk patient in Nepal. Although unresponsive at birth, the child had an Apgar score of 10 at

15 min22

.

Given the rising global incidence of cesarean section and the relatively higher morbidity and

mortality of emergency cesarean section, this study aims to determine the profile of mothers and

neonates that may predispose ECS, the leading indications for emergency CS and their associated clinical

4

outcome. As there is a dearth of local data on this matter, results of this study will serve as a baseline

for emergency CS trend in WVSU-MC.

SIGNIFICANCE OF THE STUDY

Emergency CS has been associated with increased poor maternal and fetal outcomes.

Recognition of the factors that predispose emergency CS will help in identifying pregnant women who

are at high risk for emergency CS and if possible, alter modifiable factors through education and

anticipatory prevention, so as to prevent poor clinical outcomes.

The results of this study will benefit hospitals, clinicians, and researchers in anticipating

management of the mother and her child. It also aims to influence the decision-making among

clinicians, with the hope of decreasing maternal and neonatal morbidity and mortality, lowering

personal and institutional health care costs.

This study seeks to identify the common indications for emergency CS and will fill in the lack of

local data on emergency CS and could provide a valuable contribution to national and international data.

RESEARCH QUESTION

What are the indications for emergency Cesarean section and the associated maternal and

neonatal outcomes in WVSU-MC from 2005-2007?

GENERAL OBJECTIVE

To determine the leading indications for emergency CS and the clinical maternal and neonatal

outcomes following emergency caesarian section in WVSU-MC from January 2005 to December 2007.

5

SPECIFIC OBJECTIVES

The study specifically aims to:

1) determine the profile of maternal subjects according to:

a. age

b. gravidity

c. parity

d. types of previous deliveries

e. presence of maternal illness

2) determine the age of gestation (AOG) and APGAR scores at 1 and 5 minutes of neonates

born through emergency CS;

3) determine leading indications for ECS when maternal subjects are stratified by

a. age

b. gravidity

c. parity

d. types of previous deliveries

e. presence of maternal illness

4) determine leading indications for ECS when neonates are stratified by age of gestation

(AOG); and

5) determine clinical outcome through mortality and survival rates following emergency CS of

a. maternal subjects

b. neonates

LIMITATIONS OF THE STUDY

1. Mothers whose medical records were not found were automatically removed from the study.

2. Neonates whose medical records were not found were automatically removed from the study.

3. Clinical outcomes of parturients and neonates are limited by intrahospital confinement.

4. The causes of death of parturients and neonates were not determined.

6

CONCEPTUAL FRAMEWORK

INDEPENDENT VARIABLES INTERVENING VARIABLE DEPENDENT VARIABLES

MATERNAL AGE

GRAVIDITY

PARITY

MATERNAL ILLNESS

TYPE OF PREVIOUS

DELIVERIES

AGE OF GESTATION

MATERNAL OUTCOME

NEONATAL OUTCOME

MEASURED WITH

APGAR SCORE

INDICATIONS FOR

ECS

7

MATERIALS AND METHODS

STUDY DESIGN

A 3-year retrospective cross sectional design was employed in this study.

STUDY SETTING

This study was done in West Visayas State University Medical Center (WVSU-MC) in Iloilo City.

STUDY PERIOD

This study was conducted from September 2008 to February 2009.

STUDY POPULATION

Inclusion Criteria

All emergency cesarean deliveries documented from January 2005-December 2007 in the West

Visayas State University Hospital constitute the sample population.

Exclusion Criteria

All elective cesarean section deliveries from January 2005-December 2007 in WVSU-MC were

excluded from the study. Missing records were dropped from the sample population.

OPERATIONAL DEFINITIONS

Age of gestation- the stage of the embryo counting from the first day of the last menstrual period. On

the average, about 2 weeks longer than conceptional age, assuming a 28-day menstrual cycle.

APGAR Score- a method for assessing the need for resuscitation and the chances for survival in

newborns, taken during the first minute of life and every five minutes thereafter.

Cesarean delivery- the delivery of a fetus through an abdominal incision (laparotomy) followed by an

incision of the uterine wall (hysterotomy). It excludes delivery of extrauterine pregnancies or

extraction of dislodged fetus in the abdominal cavity in a ruptured uterus.

Clinical outcome- the status of the patient after exposure to disease or as in this study, the status of

the parturient and neonate (survived or died) after the emergency CS procedure.

8

Emergency cesarean section- immediate, unplanned or unscheduled termination of pregnancy via

cesarean section for the ultimate purpose of saving the life of both the parturient and her

offspring.

Grandmultigravida- a woman with a history of more than 5 gestations or pregnancies.

Grandmultipara- a woman with a history of having more than 4 deliveries.

Gravidity- total number of pregnancies including the current pregnancy irrespective of the pregnancy

outcome.

Maternal Illnesses- comorbid conditions of the mother incurred before or during pregnancy.

Mortality rate- percentage of maternal and neonatal subjects who died immediately following

emergency cesarean section or within the duration of hospital confinement.

Multigravida- a woman with a history of 2 or more but less than 5 pregnancies

Multipara- a woman with a history of having 2 or more but less than 4 deliveries.

Parity- the total number of pregnancies reaching viability. Therefore, completion of any pregnancy

beyond the stage of abortion bestows parity upon the mother. Parity is not greater if a single

fetus, twins, or quintuplets were delivered, nor lower if the fetus or fetuses were stillborn.

Parturient- A woman in the process of giving birth or childbirth. Also known as maternal subject.

Primigravid- a woman with no previous history of conception or pregnancy other than the current

pregnancy.

Primipara- a woman with no previous history of viable pregnancies or deliveries other than the current

viable pregnancy or delivery.

Types of previous deliveries- the manner by which the previous pregnancies were delivered (i.e. vaginal,

forceps, elective cesarean, or emergency cesarean).

DATA COLLECTION METHODS AND TOOLS

Acquisition of Permit

A letter requesting for access to the OB-GYNE records from Jan. 2005-Dec. 2007 was addressed

to the Hospital Director and the Head of Records Section of the West Visayas State University-Medical

Center (WVSU-MC).

9

Log Book Review

The list of patients who underwent CS operations from January 2005-December 2007 was taken

from the log book of OB-GYNE department, which served as a guide in requesting for the individual

chart of our subjects who satisfied our inclusion criteria.

Obstetrics Chart Review and NICU Chart Review

In conducting the chart review, the maternal data collection form was filled up noting the

factors considered in the study and the survival or death of the patient within the period of

confinement. For the neonates, the age of gestation, the APGAR scores (1 and 5 minutes) of the

neonates were recorded in the neonatal data collection form. The NICU chart was also consulted to

determine survival and mortality of newborn subjects within the period of hospital confinement.

DATA PROCESSING AND ANALYSIS

Statistical Software

All data were processed using the SPSS version 16.0 and Microsoft Excel 2007.

Descriptive Statistics

Frequency and percentage of the variables under study were used to determine the most

common indication for emergency CS and the survival and mortality rates for both the parturient and

neonates. The trends and behavior of variables were also described.

10

Flow Chart of Data Collection

11

RESULTS

From January 2005 to December 2007, a total of 703 cesarean section procedures were

performed in West Visayas State University-Medical Center. Six-hundred twenty seven of these cases

(91%) were listed as emergency cesarean (ECS) deliveries in the OB-GYN Department Logbook. Records

of patients who underwent ECS were retrieved and comprised the study population (N=533).

CLINICAL PROFILE OF PARTURIENTS

Maternal Age

Table 1 shows that majority of women (80.3%) who delivered through emergency CS belong to

the 18-35 years age group. Younger women (<18 years) who underwent emergency CS accounted for

only less than 1% of all emergency cases.

The mean age of parturients who underwent ECS is 29.9 years old. The youngest among the

parturients is 16 years old while the oldest is 44 years old.

Table 1. Distribution of Parturients According to Age, Gravidity, and Parity (N=533).

FREQUENCY PERCENT

AGE GROUP (YEARS)

< 18

18-35

>35

4

428

101

0.8

80.3

18.9

GRAVIDITY

1

2

3

4

5

>5

225

156

88

32

11

21

42.2

29.3

16.5

6.0

2.1

3.9

PARITY

1

2-4

>4

253

257

23

47.5

48.2

4.3

12

Gravidity

Primigravids comprised majority of ECS deliveries (Table 1). Meanwhile, multigravids who has

been pregnant for the 5th

time incurred the least number among ECS patients (2.1%).

Grandmultigravidas comprised only 3.9% of the total.

The mean number of gestations in patients who underwent ECS was 2.03.

Parity

Most of the women who underwent ECS are multiparas (48.2%). A slight difference exists in the

frequency of primaparas (47.5%) and multiparas (48.2%). Grandmultiparous women made up only 4.3%

of all ECS cases.

The mean number of deliveries in patients who underwent ECS was 1.8.

Type of Previous Deliveries

As shown in Figure 1, most of the parturients have a history of childbirth. Among these women,

cesarean section (26.5 %) predominates over vaginal delivery (21.6 %) as a common preceding mode of

delivery. Only 5% of the se women had given birth via both CS and vaginal deliveries prior to ECS.

Figure 1. Distribution of Parturients According to Type of Previous Deliveries (n=526).

13

Maternal Illnesses

As shown in Table 2, about 2/3 of the women who underwent ECS have no concurrent acute

and chronic illnesses with pregnancy. However, 1/3 of the population had some form of illness during

pregnancy. Hypertensive disease was the most common illness to affect women who underwent ECS.

Table 2. Distribution of Parturients According to Presence of

Illness During Pregnancy (N=533).

Figure 2. Frequency of Parturients with Illness During Pregnancy (n=350).

The three most common illnesses among women who underwent ECS are hypertensive disease,

urinary disease and endocrine disease (Table 3).

FREQUENCY PERCENT

WITH MATERNAL ILLNESS 183 34.3

WITHOUT MATERNAL ILLNESS 350 65.7

14

Table 3. Classification and Distribution of Maternal Illnesses Among Parturients

Who Delivered via ECS from 2005-2007 (n=183).

MATERNAL ILLNESS FREQUENCY PERCENT

HYPERTENSIVE DISEASE 62 33.9

Gestational HPN

Chronic HPN

Preeclampsia

URINARY DISEASE 31 16.9

Urinary Tract Infection

Urinary Stone Disease

ENDOCRINE DISEASE 26 14.2

Impaired Glucose Tolerance

Gestational Diabetes Mellitus

Hyperthyroidism

Hypothyroidism

Parathyroidism

PULMONARY DISEASE 21 11.5

Bronchial Asthma

Pneumonia

Upper Respiratory Tract Infection

GYNECOLOGIC DISEASE 15 11.5

Mullerian Duct Anomaly

Pelvic Endometriosis

Paraovarian Cyst

Adenomyosis

Paratubal Cyst

Endometrial Cyst

Breast Mass

INFECTIOUS DISEASE 10 4.9

Typhoid Fever

Hepatitis A

Hepatitis B

Varicella Infection

MULTI-SYSTEM INVOLVEMENT 10 4.9

Endocrine And Gynecologic

Hypertensive, Endocrine And Pulmonary

Endocrine And Urinary

Hypertensive, Urinary And Pulmonary

Hypertensive And Heart Disease

CARDIAC DISEASE 6 3.3

Mitral Regurgitation

Rheumatic Heart Disease

OTHERS 4 0.8

Slipped Disk, Scoliosis, Psychiatric Disorder

15

AGE OF GESTATION AND APGAR SCORES AT 1 AND 5 MINUTES NEONATES BORN THROUGH ECS

Table 4 shows that majority (69.2%) of neonates born through ECS are term, within 37-42

weeks. The mean age of gestation of neonates delivered via ECS is 37.8 weeks.

Majority of neonates have APGAR scores of 7-10 at 1 minute (88.2%) and 5 minutes (94.4%).

Table 4. Age of Gestation and APGAR Scores of Neonates Delivered via ECS

at 1 and 5 minutes (N=534).

CLINICAL OUTCOME OF PARTURIENTS AND NEONATES

Table 5 shows that majority of parturients (97.4%) survived following ECS while less than 1%

died. Parturients who went home against medical advice comprised 2.1% of all the cases.

Table 5. Clinical Outcome of Maternal Subjects and Neonates Following

ECS (N=533).

FREQUENCY PERCENT

AGE OF GESTATION (WEEKS)

< 28

28-36

37-42

>42

7

121

369

8

1.3

22.7

69.2

1.5

APGAR SCORE 1 MIN

0-3

4-6

7-10

16

31

470

3.0

5.8

88.2

APGAR SCORE 5 MIN

0-3

4-6

7-10

9

5

503

1.7

0.9

94.4

FREQUENCY PERCENT

PARTURIENTS

Survived

Died

Discharged Against Medical Advice

519

3

11

97.4

0.6

2.1

NEONATES

Survived

Died

519

15

97.2

2.8

16

Among neonates delivered via ECS, majority (97.2%) survived while only 2.8% died (Table 5).

Majority of the fatalities had APGAR scores 0-3 at 1 minute (62.5%) and 5 minutes (88.9%) (Table 6).

Table 6. Clinical Outcomes of Neonates Based on APGAR Scores at 1 and

5 minutes (N=534).

APGAR SCORES 1 MINUTE 5 MINUTES

Survived Died Survived Died

0-3 37.5 62.5 11.1 88.9

4-6 90.3 9.7 60.0 40.0

7-10 99.6 0.4 99.0 1.0

Clinical outcomes of neonates who had APGAR scores below 7 in the maternal chart were

further verified using the neonatal chart. Out of the 47 neonates with < 7 APGAR scores, 15 (31.9%) died

(Table 6).

Table 7. Clinical Outcomes of Neonates with <7 APGAR Scores (n=47).

CLINICAL OUTCOMES FREQUENCY PERCENT

Survived

Died

32

15

68.1

31.9

LEADING INDICATIONS FOR EMERGENCY CESAREAN SECTION

Dystocia (30.8%) emerged as the most common indication for ECS (Table 8). Malpresentation is

second only to dystocia as the leading indication for ECS. Furthermore, repeat CS (in labor) ranked third

among the indications for ECS (17.3%).

17

Table 8. Indications for Emergency Cesarean Section, 2005-2007

(N=533).

INDICATIONS FREQUENCY PERCENT

Dystocia 164 30.8

Arrest of Cervical Dilatation 92 17.3

Arrest of Descent 28 5.3

Cephalo-pelvic disproportion 24 4.5

Failure of descent 9 1.7

Midplane contraction 4 0.8

Prolonged latent phase 3 0.6

Failed induction of labor 2 0.4

Protracted active phase 2 0.4

Fetal Malpresentation 127 23.8

Breech Presentation 114 21.4

Transverse Lie 13 2.4

Repeat CS in Labor 92 17.3

Non-reassuring fetal tracing 75 14.1

Others 43 8.4

Placenta previa 19 3.6

PROM 12 2.3

Oligohydramnios 5 0.9

Polyhydramnios 3 0.6

Placenta previa marginalis 2 0.4

Abruption placenta 2 0.4

Bicornuate uterus 1 0.2

Presence of Maternal Illness 25 4.7

Severe pre-eclampsia 22 4.1

HELLP 1 0.2

Ischemic Heart Disease 1 0.2

Multiple Myoma Uteri 1 0.2

Fetal Problem 7 1.4

Fetal Macrosomia 2 0.4

Fetal hydrocephaly 2 0.4

Hydrops fetalis

Fetus with sacrococcygeal teratoma

1

1

0.2

0.2

Fetal cystic hygroma 1 0.2

18

MATERNAL FACTORS AND LEADING INDICATIONS FOR EMERGENCY CESAREAN SECTION

Dystocia is the most common indication among parturients in the reproductive age group, 18-

35 (31.4%) as well as among mothers aged greater than 35 (29.7%). Among maternal subjects aged less

than 18, dystocia, fetal malpresentation, non-reassuring fetal tracing and fetal anomaly are equally

represented (25%).

Among primigravids, dystocia ranked as the most common indication for ECS, followed by

malpresentation and non-reassuring fetal tracing.. As the number of gestations increased to 2 and 3,

dystocia was replaced with repeat CS (in labor) as the most frequent indication for ECS. The peak of

repeat CS cases was at the 2nd

and 3rd

pregnancies. By the 4th

pregnancy, a sharp decline is seen which

eventually continues with increasing number of gestations. With increasing gestations, malpresentation

emerges as a more frequent indication for ECS.

Table 8. Maternal Factors and Leading Indications for ECS (N=533)

MATERNAL FACTORS

INDICATIONS FOR ECS (%)

Dystocia Malpresentation

Non-

Reassuring

Fetal Tracing

Presence of

Maternal

Illness

Fetal

Anomaly Others

Repeat

CS (In

Labor)

AGE (YEARS)

<18

18-35

>35

25.0

31.4

29.7

25.0

22.9

24.8

25.0

15.3

8.9

0

5

4

25.0

1.2

1.0

0

7.8

9.9

0

16.5

21.8

GRAVIDITY

1

2

3

4

5

>5

42.4

26.1

19.3

21.9

27.3

9.5

25.4

22.9

6.8

40.6

27.3

42.9

18.8

12.4

9.1

9.4

0

14.3

4.0

3.3

6.8

12.5

0

4.8

1.3

0.7

2.3

0

9.1

0

8.0

5.2

12.5

3.1

0

23.8

0

29.4

43.2

12.5

36.4

4.8

PARITY

1

2-4

>4

41.7

22.0

13.0

26.6

18.5

39.1

17.9

10.6

13.0

4.0

5.5

4.3

1.2

1.6

0

7.9

7.1

21.7

0.8

34.6

8.7

TYPE OF PREVIOUS DELIVERIES

CS

NSVD

Mixed

No previous

deliveries

17.9

28.1

18.5

41.3

8.6

31.6

25.9

27.7

5.7

16.7

11.1

18.6

3.6

5.3

11.1

4.1

0.7

2.6

0

1.2

5.0

14.9

3.7

7

58.6

0.9

8.0

0

19

Similarly, among primiparas, dystocia is the most frequent indication for ECS while in

multiparous repeat CS in labor is the more common indication. Whereas, fetal malpresentation is the

usual indication among grandmultiparas.

A number (41.3%) of parturients were primiparas, thus no previous experience of delivery was

recorded.On the other hand, among parturients who previously delivered via NSVD and mixed (CS and

NSVD) fetal malpresentation is the leading indication while repeat CS is a frequent indication for ECS

among parturients who previously delivered by CS.

Table 9. Maternal Illnesses During Pregnancy and Indications for ECS (N=533).

MATERNAL

ILLNESS

INDICATIONS FOR ECS (%)

TOTAL Dystocia Malpresentation

Non-

Reassuring

Fetal Tracing

Presence of

Maternal

Illness

Fetal

Anomaly Others

Repeat

CS (In

Labor)

None 30.3 22.8 14.1 2.9 1.2 8.1 20.7 100

Infectious 44.4 44.4 0 0 0 0 11.1 100

Urinary 32.3 35.5 9.7 0 3.2 6.5 12.9 100

Hypertension 24.2 19.4 19.4 14.5 3.2 8.1 11.3 100

Pulmonary 38.1 28.6 4.8 4.8 0 4.8 19.0 100

Endocrine 42.3 11.5 19.2 3.8 0 7.7 15.4 100

Gynecologic 33.3 20.0 6.7 13.3 0 26.7 0 100

Cardiac 16.7 16.7 33.3 33.3 0 0 0 100

Multi-System 50.0 37.5 0 0 0 12.5 0 100

Others 25.0 25.0 50 0 0 0 0 100

The table above shows that the most common indication for mothers with no health problems is

dystocia (30.3%). The same indication ranked as the most common for parturients with hypertension

(24.2%), pulmonary (38.1%), endocrine (42.3%), gynecologic (33.3%) and multi-system (50%) problems.

For parturients with infectious diseases, dystocia and fetal malpresentation ranked equally as the most

common indication for ECS, each having a percentage of 44.4. For those with urinary problems, fetal

malpresentation (35.5%) ranked as the most common indication and this was followed closely by

dystocia (32.3%). Non-reassuring fetal tracing (33.3%) and presence of maternal illness (33.3%) are the

most common indication for mothers with cardiac problems. For other diseases namely scoliosis,

slipped disk, depression and bipolar I disorder, the common indication for ECS was non-reassuring fetal

tracing.

20

Dystocia (31.6%) was the leading indication for ECS among the parturients who survived ECS.

Among the subjects who died, the indications for ECS were: non-reassuring fetal tracing (66.7%) and

presence of maternal illness, particularly pre-eclampsia (33.3%). Eleven parturients (2.11%) were

discharged against medical advice.

Table 10. Clinical Outcomes of Maternal Subjects According to Indications for ECS (N=533).

INDICATIONS FOR EMERGENCY CS

MATERNAL OUTCOME

SURVIVAL RATE MORTALITY RATE DISCHARGED AGAINST

MEDICAL ADVICE

n % Survived n % Died n % DAMA

Dystocia 160 31.6 0 0 3 27.3

Malpresentation 117 23.1 0 0 4 36.3

Repeat CS in labor 90 17.8 0 0 2 18.2

Non-reassuring fetal tracing 68 13.4 2 66.7 2 18.2

Presence of maternal illness 22 4.3 1 33.3 0 0

Fetal anomaly 7 1.3 0 0 0 0

Others 43 8.5 0 0 0 0

NEONATAL AGE OF GESTATION AND LEADING INDICATIONS FOR ECS

The most frequent indication among pre-term (34.7%) and post-term (62.5%) neonates born

through ECS is fetal malpresentation. In term neonates however, dystocia (39.8%) is the most frequent

reason for conducting ECS (Table 11).

Table 11. Frequency (%) of Indications for ECS as Stratified by AOG (N=534).

INDICATIONS FOR ECS (%)

TOTAL Dystocia

Malpresentati

on

Non-Reassuring

Fetal Tracing

Presence of

Maternal

Illness

Fetal

Anomaly Others

Repeat

CS (In

Labor)

AOG (WEEKS)

<28

28-36

37-42

>42

0

10.2

39.8

12.5

0

34.7

19.0

62.5

0

11.9

15.2

12.5

42.9

11.0

2.4

0

0

1.7

1.4

0

57.1

15.3

4.9

0

0

15.3

17.3

12.5

100

100

100

100

21

Dystocia (31.0%) remains the most common indication for ECS among neonates who survived

while non-reassuring fetal tracing (33.3%) is the most common indication for ECS among the neonates

who died. (Table 12)

Table 12. Clinical Outcomes of Neonates According to Indications for ECS (N=534).

INDICATIONS FOR EMERGENCY CS

NEONATAL OUTCOME

SURVIVAL RATE MORTALITY RATE

n % Within

Indication

% of Total n % Within

Indication

% of Total

Dystocia 161 98.2 31.0 3 1.8 20.0

Malpresentation 127 100.0 24.7 0 0.0 0.0

Repeat CS (in labor) 90 97.8 17.3 2 2.2 13.3

Non-reassuring fetal tracing 70 93.3 13.5 5 6.7 33.3

Presence of maternal illness 23 92.0 4.4 2 8.0 13.3

Fetal anomaly 6 85.7 1.2 1 14.3 6.7

Others 41 95.3 7.9 2 4.7 13.3

22

DISCUSSION

LEADING INDICATIONS FOR EMERGENCY CESAREAN SECTION

This study identifies dystocia as the leading indication for emergency CS. Dystocia is a general

term to encompass the following causes of difficult childbirth: arrest of cervical dilatation, arrest of

descent, cephalopelvic disproportion, failure of descent, midplane contraction, prolonged latent phase,

protracted active phase and failed induction of labor. Among these, arrest of cervical dilatation

emerged as the most common form of dystocia that required ECS.

The identification of dystocia as the leading indication for ECS is supported by other studies. A

study IoﾐduIted at the Queeﾐ Mother’s Hospital, Glasgo┘, found out that dystocia was the main

indication in 16% of cesarean sections performed in 1991. The finding of dystocia in a parturient has,

directly or indirectly, influenced the decision to operate in up to 38% of all cesarean sections that year.40

However, in a study in Farwani Hospital in Kuwait, failure of descent (33.6%) ranked as the most

common indication for ECS under dystocias. In another study, failure of progress accounted for the

highest number of ECS.23

A study conducted by Stalberg et al in Sweden documented protracted labor

secondary to a narrow pelvic outlet, as most common indication for ECS.40

Nonetheless, these earlier

findings support the current finding that dystocia is the leading indication for ECS.

Fetal malpresentation, which includes breech presentation and transverse lie, ranked second as

the most common indication for emergency CS. About 26.6% of the maternal subjects whose babies

were of breech presentation were nulliparous. This finding is supported by the study of Lieberman et al

which noted that nulliparous women are of increased risk of breech presentation.41

Repeat CS ranked third as the most common indication for ECS (17.3%). Previous studies show

that repeat CS is the leading indication for ECS.9,10,44

Repeat CS, as one of the indications for ECS,

registers an increasing trend. Its incidence almost doubled, from 3.7% in 1993 to 6.1% in 2002.43

The

increasing trend for repeat CS may be explained, as in this study, by an early onset of labor prior to the

scheduled operation. Most women in this study presented at the emergency room with uterine

contractions, bleeding and ruptured bag of water. In western countries however, the increasing trend in

repeat CS is due to the option to undergo a trial of labor among women who previously delivered by

cesarean section. Smith et al demonstrated in their study that there is a higher rate of emergency CS

23

(25.4%) in women who underwent a trial of labor after a previous CS delivery compared to women with

no prior cesarean delivery, i.e. nulliparous women (12.5%) and multiparous women who delivered via

vaginal delivery (2.4%).45

In another study, among 3775 women who had a prior cesarean delivery who

attempted a trial of labor, 1791 (47.2 %) underwent emergency cesarean delivery.16

The risk of ECS is

9.37 times higher (Adjusted Relative Risk, 95% CI) in women who experienced a trial of labor than those

who did not.

Non-reassuring fetal tracing is the fourth leading indication for ECS. Two studies linked fetal

factor as common indications for ECS. A national cross sectional survey conducted in England and Wales

analyzed 17,780 singleton births (99% of all births) delivered by emergency cesarean section.

Presumed

fetal compromise, intrauterine growth retardation or an abnormal cardiogram accounted for 35% of all

emergency CS. 5

According to Bloom et al, emergency cesarean deliveries were performed for

indications such as non-reassuring fetal heart rate, umbilical cord prolapse, placental abruption,

placenta previa with hemorrhage, or uterine rupture.42

MATERNAL AGE

This study show that majority of maternal subjects (80.3%) belong to the reproductive age

group, 18-35 years old. The high rate of ECS among this age group is expected because majority of

childbirths occur within this age range. Al Nuaim et al. observed the same trend in the rate of

emergency CS in this age group.23

They noted a higher incidence of emergency CS (79%) in younger age

groups (<35 years) compared with 21% in older patients (>35 years).25

Almost 1/5 of the parturients who underwent ECS belong to the > 35 yo age group. Several

studies have demonstrated that high incidence of emergency CS is associated with advancing

age.24,25,26,27,28,29,30,31

This may be due to an increased incidence of placental abruption, placenta previa,

breech presentation, preterm labor, and multiple gestation in parturients of advanced maternal age, not

to mention the presence of chronic diseases associated with advancing age. Advanced maternal age is

also associated with increased incidence of breech presentation.24,27,32,33

Results of this study show that breech presentation is the second leading indication for ECS

(24.8%) among the > 35 age group. This finding is supported by Dildy et al who reported an incidence of

11% breech presentation in parturients > 45 years of age.24

This may be due to the tendency of older

24

women to have heavier babies with abnormal presentation. Abu-Heija et al found the same observation

in their study wherein majority of neonates of older women have larger birth weight and of abnormal

presentation compared to those of younger parturients28

.

Parturients within the < 18 years old age group who delivered through ECS accounted for only

less than 1% of ECS deliveries. These finding may be due to the fewer pregnancies and deliveries in this

age group.

Among 533 patients in the sample population, 507 survived, 3 died and 11 were discharged

against medical advice. The patients who died belong within the 18-35 years age range.

GRAVIDITY

Results of this study show that with increasing gravidity, the frequency of ECS deliveries

decrease. Most of the women who underwent ECS were primigravids. This finding may be explained by

the fact that most primiparas undergo a trial of labor before delivery via cesarean section is entertained.

Cnattingius et al. found in their study that the risk of cesarean delivery is increased among nulliparous

and primigravid (adjusted OR = 4.92, 95% CI = 2.81–8.61), short (adjusted OR = 2.20, 95% CI = 1.06–4.59),

and obese women (adjusted OR = 2.03, 95% CI = 1.07–3.84).35

This finding supports the study of Patel et

al. which showed that increasing number of gestations was associated with a decreased chances for

CS.34

Among primigravids, dystocia ranked as the most common indication for ECS, followed by

malpresentation and non-reassuring fetal tracing. As the number of gestations increased from 2 to 3,

repeat CS replaced dystocia as the most frequent indication for ECS. The peak of repeat CS cases is at

the 2nd

and 3rd

pregnancies. By the 4th

pregnancy, a sharp decline is seen which eventually continues

with increasing number of gestations. This finding may be due to the fact that women who underwent

repeated CS limit themselves to 2-3 pregnancies as more pregnancies would increase the risk for CS-

related birth complications such as uterine rupture. With increasing gestations, malpresentation

emerged as a more frequent indication for ECS.

Majority (97.31%) of 521 patients in the sample population survived. Of the 3 patients who

died, 2 were multigravids while the other was a primigravid. Eleven patients discharged against medical

advice were multigravids.

25

PARITY

Results of this study show that with increasing parity, the frequency of ECS deliveries decrease.

This finding agrees with the result of the study done by Al Nuaim et al. where they demonstrated a

statistically significant association between low parity and ECS (P<0.001).25

Patel et al sealed further the

strong relationship between low parity and emergency CS when they reported that increasing number

of deliveries was associated with a decrease in risk for both elective and emergency CS.

34

In primiparas, dystocia is the most common indication found while repeat CS is the most

common indication for multiparas. As in gravidity, repeat CS is highest among women who had 2-3

previous deliveries and a sharp decline is observed with increasing parity. Among grandmultiparas, fetal

malpresentation is the most common indication for ECS.

Of the three parturients who died, two were multiparous (2-4 deliveries) and one was

primiparous. No fatality was recorded among grandmultiparous parturients (Appendix A).

TYPE OF PREVIOUS DELIVERIES

Majority of the parturients in the study were primiparas i.e., with no history of childbirth.

Among multiparas, CS (55%) proved to be the most common precedent mode of delivery primarily by

repeat CS. Parturients who delivered under the indication repeat CS were in labor which warranted ECS.

Another possible reason for the high repeat CS rate is the physiIiaﾐ’s prefereﾐIe in delivering

succeeding pregnancies via CS with a previous CS delivery. This observation is supported by Cnattingius

et al in their case-control study that evaluates the risk factors for ECS, who found out that women with a

previous cesarean delivery had high chances of cesarean delivery (adjusted OR = 10.10, 95% CI = 3.30–

30.92).35

NSVD (45%) came second to CS as the most common precedent mode of delivery. Most

women in this category had malpresentation and dystocia as the indications for ECS. Multiparas who

previously had delivered via both NSVD and CS had to undergo ECS due to repeat CS and

malpresentation.

26

MATERNAL ILLNESSES

One of the most important risk factors affecting the decision to perform cesarean section is the

presence of maternal illness.36

Of the 533 subjects, 34.3% presented with illness during the pregnancy.

Most of these women have hypertensive disorders specifically, gestational hypertension, chronic

hypertension and pre-eclampsia. Other disorders present in women who underwent ECS were urinary

problems, followed in descending order by endocrine, pulmonary, gynecologic, infectious, multisystem,

and cardiac diseases.

Hueston studied the clinical and non-clinical factors associated with increased likelihood of

cesarean delivery in four hospitals. He found out that among the clinical factors, maternal hypertension,

preeclampsia, previous cesarean delivery, premature rupture of membranes, postdate pregnancy and

asthma are associated with increased risk of CS37

. Moreover, his findings also show that pre-eclampsia

is consistently associated with increased risk of CS. In another study by Omu et al., among women who

underwent emergency cesarean section due to failed induction of labor, most of them are either

postdates or have maternal disorders like diabetes mellitus, and hypertension.38

Findings of these

studies are consistent with the results of the current study where at least 1/3 of the women who

underwent ECS had an illness with hypertension as the most common co-morbidity.

AGE OF GESTATION

Majority (69.2%) of the ECS deliveries were term. This finding is similar with the retrospective

analysis of 25 consecutive emergency cesarean section for umbilical cord prolapse, which showed that

out of twenty-five, 17 patients were born term (68%).21

In this study, the percentage of neonates born before term were 21.7% for neonates <37 weeks

and 1.3% for neonates <28 weeks. Hilleman et al reported thirty-three (30.3%) of the emergency

cesarean sections had a gestational age below 32 weeks and 60 (55%) below 37 weeks.46

Jolly et al

found in their study that parturients of advanced maternal age are more likely to deliver prior to term

and more likely to delivery at < 32 weeks gestation.27

Pugliese et al. also reported that women > 40

years of age are more likely to deliver preterm (18%) than younger women (12%).48

The presence of

multiple gestations also contributes to an increased incidence of preterm labor and delivery. 31

However,

in this study even with advanced maternal age, most of the neonates were born term and singly.

27

The mean age of gestation in neonates is 37.8 weeks. In contrast, Hillemann et al. reported the

mean age of gestation in neonates born through emergency CS is at 34.8 weeks.

MATERNAL OUTCOME

Survival rate for ECS is relatively high (97.4%). Some of the reasons cited by The Philippine

Obstetrical and Gynecological Society for the increasing trend of CS in the Philippines are11

: increasing

safety of the procedure due to antibiotics; availability of blood transfusions; better anesthesia and the

physiIiaﾐ’s high iﾐtent to deliver a healthy or undamaged baby and leave a healthy mother, when done

for complications occurring during pregnancy and labor; and the relatively newer concept of delivery of

breech by cesarean section intended for better fetal outcome.

Mortality rate was less than 1%. Among the three fatalities, two maternal subjects had non-

reassuring fetal tracing while the other had a medical illness as indications for ECS. Two of the women

who died had chronic hypertension and pre-eclampsia. In a prospective observational study of 8070

elective cesarean sections in Malawi, Africa, pre-eclampsia was cited as one of the complications

believed to contribute to mortality (7, 8% of deaths1).17

Furthermore, Onrust, in another study, found

that hypertensive disorders of pregnancy are the main cause of maternal mortality in most countries. In

more than half of these cases, the HELLP syndrome is involved.39

NEONATAL OUTCOME

Based on the data gathered, the success rate in delivering a live neonate by emergency cesarean

section is high (97.2%). This current finding is congruent with the results of the study done by Bloom et

al. which illustrates that most infants delivered by ECS are in good condition when delivered less than or

more than the standard decision-to-incision time (30 minutes from the time the decision is made to

proceed with ECS).42

A higher mortality rate is recorded among neonates with low (0-3) APGAR scores of at 5 minutes

(88.8%) with its counterpart at 1 minute (9.68%) (Table 6). The same is true in neonates who with

average APGAR scores (4-6 at) 5 minutes wherein 40% died as compared to its counterpart at 1 minute

28

where in 9.7% of the neonates died. This finding signifies that the APGAR score at 5 minutes is a better

predictor for neonatal survival than the APGAR score at 1 minute, as the latter predicts the need for

resuscitation. Survival rates in neonates with APGAR scores 0-3 (37.5%) and 4-6 (90.3%) at 1 minute

decreased to 11.1% and 60%, respectively at 5 minutes. This finding is congruent with the study of Al

Nuaim et al. who found out that neonates born through ECS with an APGAR score of 0-3 at birth had the

highest risk of neonatal death. Furthermore, the risk of neonatal death in term infants was 0.2 per 1000

for those with scores of 0 to 3 at birth.23

As expected, low mortality rate was seen among neonates with high APGAR scores (7-10) at 1

minute (0.4%) and 5 minutes (5%).

29

CONCLUSIONS

Majority of the women who delivered via ECS belong to the reproductive age group 18-35 years,

primigravid, primiparous, with no history of co-morbidity. The means of the age, gravidity and parity of

the parturients studied were 29.9 yrs, 2.03, and 1.8, respectively.

Dystocia was the leading indication for ECS among primigravids and primiparous women.

Among multigravid and multiparous women, repeat CS (in labor) was the most frequent indication for

ECS whereas in grandmultiparas, fetal malpresentation was the indication for ECS procedures. Among

parturients with preceding NSVD and mixed deliveries, fetal malpresentation was the typical indication

for ECS.

The occurrence of hypertensive diseases (33.9%) in women with associated morbidities, who

delivered via ECS, was a common finding. Most of these women presented with dystocia which

warranted the conduct of ECS. Among women with urinary problems (16.9%), malpresentation was

the most common indication for ECS while women with endocrine disease (14.2%) underwent ECS

because of dystocia.

The neonates delivered by ECS are mostly term (69.2%) with good APGAR scores of 7-10 (94.4%)

at 1 and 5 minutes. The mean age of gestation of neonates was 37.8 weeks

Dystocia is the leading indication for ECS in term neonates, while fetal malpresentation is the

leading indication for ECS among post-term and pre-term neonates.

The clinical outcome of ECS was favorable for both the mother and the child. Survival was high,

97.4% and 97.2% for both parturients and neonates, respectively. Similarly, mortality rate was less

than 1% for both parturients and neonates. Non-reassuring fetal tracing (66.7 % and 33.3%) was the

most frequent indication for ECS among parturients and neonates who died, respectively.

30

RECOMMENDATIONS

A multi-center study, involving private and government institutions, may be attempted to

compare the rates and indications for ECS.

A longer study period may establish patterns in the rate and indications of ECS over the years.

Variables such as length of hospital confinement, birth complications, anesthesia used, and

prenatal care may also influence the maternal clinical outcomes following ECS.

Other predictors of neonatal outcome aside from APGAR score such as postpartum hospital stay

and umbilical artery blood pH, may be used to further predict neonatal survival and mortality.

Future studies should not only look into the leading indications for ECS but also on ways to

decrease the incidence of ECS by modifying the factors associated with ECS.

31

ACKNOWLEDGMENT

The researchers would like to thank Dr. Deb Palmes, their adviser, for the guidance and devotion

poured into this work. Prof. Charmaine Malata for reviewing the manuscript and giving structure to

the paper. Dr. Teila Matilda Posecion for her help in data encoding and analysis. Ma’am Lenny and

Manong Buboy of the Records Section of WVSU-MC for their assistance in data gathering.

32

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35

APPENDIX A

INVESTIGATORS’ BIODATA

Name: MA. ROWENA H. ALCIDO

Age: 24 Birthdate: Nov. 15, 1984

City Address: 36-A DB Ledesma St., Jaro, Iloilo City

Permanent Address: 353 San Fernando St., Borongan City

Contact No: 09274813769

E-mail Address: rowena_alcido@yahoo.com

Undergraduate Course: BS Biology Major in Cell & Molecular Biology

Undergraduate School: University of the Philippines – Los Baños

Research Experiences:

1. Effect of Chlorella sp. on Length and Weight of Male Albino Rats (Rattus norvegicus Sprghe-Dahly)

2. Screening of E. coli in Selected Water sources in West Visayas State University

3. Antimitotic Properties of Crude and Commercial Mangosteen (G. magostuna) Extracts in Onion

(Allium cepa)

Name: DENNIS F. ARANDA

Age: 23 Birthdate: Nov. 14 , 1984

City Address: 36-A DB Ledesma St., Jaro, Iloilo City

Permanent Address: #45 Rizal St., Oton, Iloilo

Contact No: 09158599341

E-mail Address: densaranda2003@yahoo.com

Undergraduate Course: BS Medical Technology

Undergraduate School: University of San Agustin

Research Experiences:

1. Awarenss on the Sources and Effects of Trans Fatty Acids and the Extent of Preventive Practice among

Faculty and Staff of West Visayas State University

2. Effects of Combined Lotus Leaf, Ginseng, Hawthorn, Medlar and Polyphenol in Commercially-Available

Slimming Pills (Ballerina) on SGPT and Creatinine levels in Rabbits

36

Name: VANESSA DOLENDO

Age: 24 Birthdate: July 16, 1984

Permanent Address: 276 B. Javellana Ext., Jaro, Iloilo City

Contact No: 09172430429

E-mail Address: van016_bunny@yahoo.com.ph

Undergraduate Course: BS Biology

Undergraduate School: West Visayas State University

Research Experiences:

1. Knowledge, Awareness, and Perception of Barangay Captains on the Anti-Violence Against

Women and Their Children (RA9262)

2. Isolation and Characterization of Cytotoxic Protein from the Summer Jellyfish (Cassiopea

medusae)

Name: REUBEN V. HINOJALES

Age: 27 Birthdate: July 6, 1981

City Address: Sta. Rosa Subdivision, Tagbak, Jaro, Iloilo City

Contact No: 09064670055

E-mail Address: Kilz2@yahoo.com

Undergraduate Course: BS Biology

Undergraduate School: La Sierra University – California, USA

Research Experiences:

1. Awareness on the Risk of Cervical Cancer among Commercial Sex Workers

2. Effect of Prolonged Intake of Virgin Coconut Oil in Total Cholesterol (T chol); Low Density Lipoprotein

ふLDLぶ aﾐd High Deﾐsity Lipoproteiﾐ ふHDLぶ le┗els of LaHoratory RaHHits iﾐ Coﾏparisoﾐ ┘ith a α-

tocopherol: A Placebo Controlled Trial

37

Name: NORIE GRACE D. OMAMALIN

Age: 26 Birthdate: July 16, 1982

City Address: Door 4, Javelosa Apts., Javellana St., Jaro, Iloilo City

Permanent Address: Sta. Clara, Naga, Zamboanga Sibugay Province

Contact No: 0922-2463921

E-mail Address: ndomamalin@yahoo.com

Undergraduate Course: BA Political Science

Undergraduate School: University of the Philippines – Diliman

Research Experiences:

1. Degree of Fecal Contamination of the Three Point Sources in the Southern Iloilo Coastline In Relation

to the Incidence of Health Risks

2. Efficacy of Pure and Combined Extracts of Lantana camara (Baho-Baho) Flowers and Leaves and

Citrofortunella mitis (Calamansi) peel as an Adulticidal Spray against Aedes aegypti

Name: MARY-GRACE A. ORDONA

Age: 23 Birthdate: June 23, 1985

City Address: ンM’s Apartﾏeﾐt, R. Mapa “t., Maﾐdurriao, Iloilo City

Contact No: 09208023817

E-mail Address: mergs_23@yahoo.com

Undergraduate Course: BS Public Health

Undergraduate School: University of the Philippines – Miag-ao

Research Experiences:

1. Awareness on the Risk of Cervical Cancer among Commercial Sex Workers

2. Effect of Prolonged Intake of Virgin Coconut Oil in Total Cholesterol (T chol); Low Density Lipoprotein

(LDL) and High Density Lipoproteiﾐ ふHDLぶ le┗els of LaHoratory RaHHits iﾐ Coﾏparisoﾐ ┘ith a α-

tocopherol: A Placebo Controlled Trial

38

Name: REDAN MARK PANELO

Age: 23 Birthdate: April 11, 1985

Permanent Address: Block 8 Lot 13 Imperial Village, Guzman St., Mandurriao, Iloilo City

Contact Number: 0920-3893565

Email: redanmark@yahoo.com

Undergraduate Course: BS Biology

Undergraduate School: West Visayas State University

Research Experience:

Antihyperglycemic Effect of Psyzigium Cuminii Bark and Seeds on Mice

Name: JULYHA SITTI SUIB

Age: 23 Birthdate: July 4, 1985

Permanent Address: Block 10 Lot 19 Gensanville Subd., Gen. Santos City

Contact Number: 0916-4968226

Email: july_0704@yahoo.com

Undergraduate Course: BS Biology, Major: Ecology

Undergraduate School: UP-Mindanao

Research Experiences:

1. Reactions of Different Durian Cultivars to Phytophthra Fruit Rot Under Controlled Conditions

2. Level of Awareness, Knowledge, and Attitude of Mothers in Iloilo City to Sangkap Pinoy Program