Cesarean section rates and indications in Greece: data from a 24-year period in a teaching hospital

OBJECTIVE: To assess the overall cesarean section rates and indications in a Greek teaching hospital over a period of 24 years. METHOD: Data from 34,575 deliveries between 1977 and 2000 were reviewed. Analysis of cesarean section rates and indications followed. RESULTS: The overall cesarean section rate increased progressively from 13.8% (1977-83) to 29.9% (1994-2000). Cesarean section rates due to previous cesarean delivery increased from 7.7% of all deliveries (1977-83) to 10.9% (1994-2000). Primary cesarean section rates increased more than three-fold from 6.1% (1977-83) to 19% (1994-2000). The main indications for primary cesarean section were: dystocia (including dysfunctional labor, cephalopelvic disproportion and malpresentations), fetal distress, breech presentation, and hypertensive disorders of pregnancy. CONCLUSIONS: The overall cesarean section rate increased more than two-fold over the study period. Previous cesarean section was the most common indication. However, the overall increase is mainly to increase of primary cesarean section rates.     

1389例剖宫产术回顾分析

回顾性分析１０年剖宫产术１３８９例。结果是平均剖宫产率为２３％，无孕产妇死亡，围产几平均死亡率为１２．６３‰。剖宫产主要指征为相对性头盆不称，胎儿宫内窘迫，臀位、骨盆狭窄。提示提高剖宫产率并不一定能降低围产儿死亡率，恰当掌握剖宫产指征，加强对孕期及产程的监测、管理，既可能降低母婴死亡率，又能适当控制剖宫产率。     

Modern indications for cesarean section.

Total cesarean section rates and rates of various indications for primary cesarean section were reviewed for four yearly periods during the past decade. The time periods studied were chosen to follow the introduction of new obstetric practices and technologic advances in monitoring fetal condition. The total cesarean section rate increased from 6.8% to 17.1% during this time. The most common indication for primary cesarean section was cephalopelvic disproportion, which represented approximately 40% of cases during each study period. Primary cesarean section for fetal distress increased to 28.2% but has decreased over the past 2 years to a present rate of 11.7%. Primary cesarean section for breech presentation increased from 12.3% to 21%. From the perspective of this review a total cesarean section rate of 15% is predicted for the future.     

Vaginal delivery after cesarean section: a five-year study

All pregnancies that were complicated by a previous cesarean section were reviewed for a five-year period from 1978 to 1982. Of 799 such pregnancies, 216 underwent a trial of labor, and 66% experienced successful vaginal delivery. When the primary cesarean section was for cephalopelvic disproportion, 54% delivered vaginally, 75% breech, and 70% for fetal distress or other nonrepeating indications. There was no evidence of uterine scar disruption in the vaginally delivered group. Vaginal delivery after previous cesarean section can be a safe alternative for carefully selected patients cared for in the proper environment.     

Lowering the cesarean section rate in a private hospital: Comparison of individual physicians' rates, risk factors, and outcomes

Objective: Our purpose was to compare the practice patterns and outcomes of physicians delivering in our institution to identify risk factors and management techniques that could explain the differences in individual cesarean section rates. Study Design: We retrospectively reviewed detailed computerized delivery records (n = 16,230) collected from May 16, 1988, to July 30, 1995. We excluded physicians who had <100 deliveries at our institution during the study period. The physicians were divided into two groups depending on whether their individual cesarean section rates were greater than (control group) or less than 15% (target group). Various cesarean section rates, risk factors for abdominal delivery, labor management techniques, and neonatal outcome parameters were calculated for each group. The cesarean section rates of the two groups were analyzed by year to assess changes. Results: As expected by study design, the overall cesarean section rate was markedly different between the two groups (13.8% vs 23.8%). In addition, the primary, repeat, primigravid, and multiparous cesarean section rates were all lower for the target group. The rates of cesarean section for fetal distress (1.5% vs 3.3%) and cephalopelvic disproportion (5.3% vs 8.5%) were also significantly less in the target group. The rates of breech presentation, third-trimester bleeding, and active herpes cesarean sections were not lower. The control group had more postterm (8.6% vs 14.7%) and >4000 gm infants (12.0% vs 13.7%) but similar numbers of low birth weight, multiple gestation, and preterm infants. The target group used more epidural anesthesia, oxytocin induction, and trial vaginal births after cesarean delivery and more successful trial vaginal births after cesarean sections. Over the study period the cesarean section rate in the target group remained unchanged, whereas it steadily declined in the control group. Conclusions: Individual physician's lower cesarean sections are primarily obtained by labor management and attempting vaginal birth after cesarean delivery. These practice patterns did not appear to lead to any increase in perinatal morbidity or mortality. Efforts to lower cesarean section rates of individual practitioners should focus on the areas of fetal distress, cephalopelvic disproportion, and repeat cesarean section. (Am J Obstet Gynecol 1998;178:1207-14.)     

Factors related to the increasing cesarean section rates for cephalopelvic disproportion

At the Highland Park Hospital the increase in cesarean section rates has paralleled the national increase. Data from cesarean deliveries performed for cephalopelvic disproportion (a leading reason for cesarean section) in 1969 to 1972 (group 1) and 1979 to 1982 (group 2) were evaluated to determine maternal, fetal, and delivery factors that might be related to the increase in the rates. The data suggested that the more frequent diagnosis of cephalopelvic disproportion and the increased size of the group 2 infants were the primary reasons for the increase in cesarean section rate. This increased rate was paralleled by a decline in forceps-assisted delivery and in perinatal mortality rates.     

Vaginal birth after cesarean section for arrest of labor: is success determined by maximum cervical dilatation during the prior labor?

The charts of 229 patients who attempted a vaginal birth after a cesarean section were reviewed. A total of 103 patients had a prior cesarean section for either failure to progress or cephalopelvic disproportion. On the basis of the maximum cervical dilatation in the prior labor, the patients were categorized into three groups: 0 to 5 cm, 6 to 9 cm, and 10 cm. The success rates for vaginal delivery of 61%, 80%, and 69%, respectively, were not significantly different among groups (p = 0.31). When arrest of labor was not the indication for primary cesarean section, 78% of the patients were subsequently delivered of their infants vaginally. This was not significantly different from the 70% overall success rate achieved by the group with failure to progress or cephalopelvic disproportion (p = 0.17). Similarly, when the success rate for a trial of labor was plotted against neonatal birth weight, the trends were comparable in the groups with and without failure to progress or cephalopelvic disproportion. These data suggest that patients with a prior cesarean section for arrest of labor are good candidates for a trial of labor and that the cervical dilatation previously reached does not determine the likelihood of success.     

Safety of term vaginal breech delivery

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.     

Maternal mortality following caesarean sections

A study of 26 maternal deaths following 3647 caesarean sections was conducted in Eden Hospital from 1974-1977. During the time period there were 35,544 births and 308 total maternal deaths (8.74/1000). Indications for Caesarean sections included: 1) abnormal presentation; 2) cephalopelvic disproportion; 3) toxemia; 4) prolonged labor; 5) fetal distress; and 6) post-caesarean pregnancies. Highest mortality rates were among cephalopelvic disproportion, toxemia, and prolonged labor patients. 38.4% of the patients died due to septicaemia and peritonitis, but other deaths were due to preclampsia, shock, and hemorrhage. Proper antenatal care may have prevented anemia and preclampsia and treated other pre-existing or superimposed diseases.     

Cesarean section: changing incidence and indications

There were 19,419 deliveries at Wilford Hall USAF Medical Center from 1970 through 1981. Of these, 1847 (9.5%) were by primary cesarean section and 800 (4%) by repeat operations. The most common indications for cesarean section (dystocia, breech presentation, repeat operation, and fetal distress) remained the same during this period. However, within these four indications and also between the three time periods of 1970 to 1973, 1974 to 1977, and 1978 to 1981, significant trends were apparent. From the periods of 1970 to 1973 through 1974 to 1977, the primary rate increased from 5.6% to 12.8% (P less than .0001). Dystocia (P less than .0001), breech presentation (P less than .0001), and fetal distress (P less than .0001) were responsible for this increase. However, from 1974 to 1977 through 1978 to 1981, the primary rate decreased to 9.6% (P less than .0001). This was related to significantly decreased rates for dystocia (P less than .0001) and fetal distress (P less than .0001). This decrease was temporally related to an initiation of various means to decrease the authors' overall cesarean section rate that approached 20% in 1976.     

Breech deliveries and cesarean section

Breech presentation is the most common malpresentation, with about 3-4% of singleton fetuses presenting breech at delivery. Management of breech presentation has been a contentious issue with a lowering threshold for cesarean section in recent years. Perinatal mortality and morbidity are estimated to be three times that of comparable infants with vertex presentation. Breech presentation is commonly associated with certain adverse maternal and fetal factors which inherently give rise to increased perinatal morbidity and mortality. At present, most obstetricians favor cesarean delivery for uncomplicated pre-term breech. Controlled prospective studies have shown that the outcome of breech fetuses weighing more than 1500 g was not dependent on the mode of delivery. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for pre-term breech. Vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500-3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia under continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. If these criteria are not fulfilled, or fetal monitoring cannot be performed, cesarean section is advisable.     

Cesarean birth: How to reduce the rate

The cesarean section rate, which approached 25%, has stabilized and started a modest decline. A stated United States national goal by the year 2000 is rate of 15%. Suggested rates are 12% for primary and 3% for repeat cesarean sections. The major indications for cesarean section are prior cesarean delivery (8%), dystocia (7%), breech presentation (4%), fetal distress (2% to 3%), and others. The major areas of reduction must occur in the categories of prior cesarean delivery and dystocia. An expanded use of trial of labor and vaginal birth after a prior cesarean section will produce further reductions. Countries in Europe achieve> 50% vaginal birth after a prior cesarean section compard with 25% in the United States. A heightened awareness must occur regarding the decision to perform the first cesarean section. The residual impact, a scanned uterus, affects 12% to 14% of women seen for delivery. Even if 50% achieve a vaginal birth after a prior cesarean section, the national goals are unachievable. The obstetrician must consciously consider the impact of “once a cesarean, always a scar.”     

Effect of indication for previous cesarean section on subsequent delivery outcome in patients undergoing a trial of labor

During the period January 1 through December 31, 1980, 308 patients who had undergone previous cesarean sections (C/Ss) underwent a trial of labor (TOL). Hospital records of these patients were examined retrospectively in an effort to correlate delivery outcome with the indication for the prior C/S. Patients with a previous C/S for breech had the highest incidence of subsequent vaginal delivery (81 of 94, or 86%), and patients with a previous C/S for cephalopelvic disproportion or failure to progress had the lowest (22 of 64, or 64%). However, the lower rate of vaginal delivery in the latter group was found only among the subpopulation who had never delivered vaginally. Fetal distress does not appear to be a significant recurring factor in patients given a TOL. Exclusion of patients from a TOL after a previous C/S for cephalopelvic disproportion/failure to progress does not appear to be justified.     

Management of term breech presentation: A protocl of external cephalic version and selective trial of labor

Objective: The results of a program of external version and selective trial of labor for term breech presentation are reviewed. This is a follow-up to our 1987 report describing management of singleton, term breech presentations and expands our 16-year experience to 1180 cases.Study design: All term breech presentations cared for in 1985 through 1992 are reviewed and outcome contrasted with those predicted in our earlier report. During these 8 years a trial of external version was offered if a breech presentation was identified after 36 completed weeks' gestation and before active labor. The criteria for allowing a trial of labor are detailed.Results: Four hundred sixty-four breech presentations were identified for review. Three hundred eighty-two (82%) were diagnosed before active labor. Of these, 344 (90%) underwent an attempt at external version, of which 174 (51%) were successful. The 290 breech presentations where version either was not attempted or was unsuccessful were stratified into three groups: cesarean section without labor (147), trial of labor with cesarean section (90), and trial of labor with vaginal delivery (53). The 174 cases where version was successful were stratified into two additional groups on the basis of the eventual route of delivery. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients resulted in vaginal delivery in only 37% but was achieved without an increase in fetal or maternal mortality or morbidity. Surprisingly, 54 of the 174 cases where version was successful were ultimately delivered by cesarean section. This 31% rate of cesarean delivery is significantly higher than the 15% rate observed for all cases of term, singleton vertex presentation. A higher prevalence of cases complicated by failed progress in labor and failed induction contributed to the excess.Conclusion: External version is successful in 51% of cases of term breech presentation. With careful selection, cases where version has failed can be allowed to labor and be delivered vaginally. The incidence of cesarean section (31%) for those cases where a version had been successful was surprisingly high, largely because of an increase in labor abnomalities and failed labor inductions.     

High cesarean section rate: a new perspective

Cesarean section rates in the United States have increased dramatically in recent years, whereas perinatal mortality rates have fallen. To investigate the hypothesis that these two events are not necessarily causally related, a prospective attempt to modify obstetric management directed at minimizing the rate of abdominal delivery while preserving excellent perinatal survival was done at a university-affiliated hospital in the Denver metropolitan area. Unselected patients who were admitted to separate services at the hospital were used for comparison, with one group subject to the specific management criteria. Corrected mortality rates and low five-minute Apgar scores on the two services were not significantly different after two years. The total cesarean section rate on the first service was 5.7%, and the total cesarean section rate on the comparison service was 17.6%. Analysis of the data showed major differences in indications for cesarean section in the areas of repeat cesarean section, cephalopelvic disproportion, breech presentation, fetal distress, and genital herpes. These data support the contention that excellent perinatal outcome can be achieved with modest abdominal delivery rates.     

Who is the elderly primigravida in Nigeria?

A retrospective study of 792 primigravidae, divided into four age-groups, was made in order to detect which group showed features of the elderly primigravida. Adolescent primigravidae showed significantly highest incidences of pre-eclampsia, anemia, premature labor and cephalopelvic disproportion. The 20-24 year age-group showed the least incidence of pregnancy and labor complications. The 25-29 year age-group showed significantly increased incidences of uterine fibroids, pre-eclampsia, post-term pregnancy, premature labor, slow labor, fetal distress, failed induction, vacuum and cesarean section deliveries, when compared with the 20-24 year age-group. Most of the complications in the 25-29 year age-group were continued into 30-34 years. A woman 25 years and above in her first pregnancy in Nigeria should be termed "elderly primigravida".     

Outcome of normal and dysfunctional labor in different racial groups.

Spontaneous labor in patients of different racial groups has been studied relating progress and outcome to whether labor was dysfunctional as defined by the partogram and action line. Forty-three percent of primigravidas and 17.6 to 25.8% of multigravidas passed the action line and had a lower admission cervical dilatation and a longer observed first stage than those patients whose labor progress remained to the left of the action line. White and black primigravidas whose labor progressed to the right of the action line had lower 1 and 5 minute Apgar scores and delivered heavier babies than those to the left. The cesarean section rates were 1.6% and 1.4% (left) and 7.6% and 18.2% (right) in white and black primigravidas, respectively. The cesarean section rate was significantly higher in black primigravidas irrespective of the relationship to the action line due to the high incidence of the complications of hypertension such as fetal distress and abruptio placentae in those in normal labor as well as those in dysfunctional labor due to cephalopelvic disproportion in those patients whose cervimetric progress went to the right of the action line.     

Vaginal delivery for the selected frank breech infant at term

A retrospective analysis of 254 term breech deliveries was done, with term breech presentations managed by a protocol in which cesarean section was done for nonfrank breech presentation, or estimated fetal weight in excess of 4000 g. Patients with frank breech presentation were assigned to one of three groups based on x-ray pelvimetry and estimated fetal weight. Of 70 group 1 patients (adequate pelvis with estimated fetal weight less than 3600 g), 79% had a vaginal delivery. Of 21 group 2 patients (borderline pelvis or estimated fetal weight of 3600 to 4000 g), 67% delivered vaginally. In group 3 (contracted pelvis or estimated fetal weight greater than 4000 g), all patients were delivered by cesarean section. The overall cesarean section rate for frank breech infants was 36%. Apgar scores were not significantly different for infants delivered vaginally or abdominally. The crude perinatal mortality rate was 11.8; the corrected perinatal mortality rate was 0. These findings further substantiate the safety of these criteria in management of term breech presentations.     

An audit of trial of labour after previous caesarean section.

The first aim of the study was to assess the success rate of vaginal delivery after a trial of labour in women with history of caesarean delivery. The second, was to analyse the management used and suggest recommendations that might improve the outcome. The caesarean section rate in Tameside hospital, in the period of 1995 and 1996, was (11%), 20% of which were repeat caesarean sections Fifty-one per cent of those with a history of previous caesarean section were allowed a trial of labour. The success rate of vaginal delivery in cases allowed trial of labour was 70%. But, if we include the 49% of cases who had elective repeat caesarean section in the calculation, the success rate for vaginal delivery would drop to 36%. More than one previous caesarean section was the main indication for elective repeat caesarean section. The second most common indication was cephalopelvic disproportion based on X-ray pelvimetry. Other indications included pregnancy-induced hypertension, breech presentation and maternal request. The main indication for repeat emergency caesarean section was fetal distress. Other causes included failure to progress, cephalo-pelvic disproportion, tender scar, ante-partum haemorhage and one case of ruptured uterus.     

Vaginal breech delivery of selected infants weighing more than 2000 grams. A retrospective analysis of seven years' experience

This retrospective study analyzes 580 term and near-term singleton pregnancies complicated by breech presentation from 1976 through 1982. Vaginal delivery was achieved in 174 patients (30%), 135 of which were selectively allowed a trial of labor. Six infant deaths occurred (1%); all were neonatal deaths directly related to lethal congenital anomalies, for a corrected neonatal mortality rate of 0%. No significant difference was found in the incidence of low Apgar scores, traumatic birth injury, or requirement for neonatal resuscitation between those infants delivered by cesarean section and those delivered vaginally. Although no maternal deaths occurred, cesarean section was associated with a 38-fold increase in significant maternal morbidity. These data suggest that with careful patient selection and fetal monitoring, vaginal delivery of the term or near-term breech infant remains a real alternative to routine cesarean delivery of all breech infants. A selection and management protocol is proposed.