Perception and attitude of women with previous caesarean section towards repeat caesarean delivery

Objective.?To explore the perception and attitude of women with previous caesarean section towards repeat caesarean section.

Method.?Observational study of women with prior caesarean delivery using an anonymous semi-structured questionnaire. Information elicited include the socio-demographic characteristics, outcome of the last caesarean delivery, experience of complications or domestic violence, acceptance of repeat caesarean section if advised by the doctor and the reason for any refusal.

Results.?One hundred thirty-nine parturients participated in the study. Seventy-seven percent had 1 previous caesarean delivery while 24.46% will decline a repeat caesarean section. Major reasons for refusal were postoperative pain, cultural aversion, fear of death, and cost of caesarean delivery. The rate of acceptance was significantly higher amongst those with more than one prior caesarean section while the rate of refusal was significantly higher amongst those who experienced perinatal death in the last caesarean delivery. Twelve percent experienced domestic violence (almost entirely psychological) mainly from the spouse or his relatives.

Conclusion.?A significant proportion of women with previous caesarean delivery will decline a repeat caesarean section if medically indicated. There is need for bahavior change communication involving the community, improved postoperative pain management, and better counseling especially on safety of the procedure.     

Management of labour following caesarean section in a developing country

During recent years, the observed rise of the CS rate (17% in 1989) led the medical staff of the Maputo Central Hospital to consider the opportunity of admitting to trial of labour selected pregnant patients following one previous CS. The present study retrospectively evaluates maternal and fetal outcome following the adoption of this policy. 94 (52.51%) of 179 study group patients, having one previous CS, delivered vaginally after trial of labour. No maternal deaths were recorded among these patients. A very low (1.67%) maternal morbidity rate was observed. Five stillbirths and one early neonatal death occurred among the study group, accounting for a perinatal mortality rate of 33.52%, much lower than the overall hospital perinatal mortality recorded figure (68%).     

Blood transfusion and caesarean section in a developing country.

Our objective was to review blood transfusion practices during caesarean section in a developing country. An audit of 463 consecutive caesarean sections and blood transfusions over a 3-year period (2000 - 2002) was undertaken. The data were collected from the records department in a pre-designed proforma and analysed, using EPI - info Statistical Software version 6. A total of 117 out of 463 (25.2%) caesarean section cases were transfused. The rate of blood transfusion for the various indications were as follows: malpresentation (excluding breech), four out of six (66.7%); placenta praevia, 28 out of 49 (59.1%); uterine rupture, five out of nine (55.6%); breech delivery, eight out of 25 (32%); obstructed labour, 35 out of 124 (28.2%); precious baby, one out of four (25%); previous caesarean section, 24 out of 141 (17.0%); severe pre-eclampsia, five out of 45 (11.1%); fetal distress, three out of 28 (10.7%); and others, three out of 29 (10.3%). A total of 78 (67.2%) of caesarean section cases were emergency. A blood transfusion rate of 25.2% during caesarean section is high. The indications for the caesarean section, preoperative anaemia and quantity of blood loss during caesarean section were significant risk factor for blood transfusion. Efforts should be made to reduce the blood transfusion without increasing maternal morbidity and mortality. This is very important because of rising HIV infection in developing country and blood-borne disease.     

Cesarean section on request in a developing country.

OBJECTIVE: To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country. METHOD: Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed. RESULTS: The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies. CONCLUSION: The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice.     

Introducing routine trial of labour after caesarean section in a second level hospital setting

Objective: We analysed the impact on caesarean section (CS) rate of introducing a routine trial of labour (TOL) for patients with a previous CS. Study design: During 2007 and 2008, we offered a TOL to all women with one previous CS planning to give birth in our hospital. The adherence to the procedure, success of vaginal delivery, overall CS rate, incidence of symptomatic uterine rupture and other complications were evaluated. Labour induction was allowed only using castor oil or Amniotomy. Results: One hundred and ninety-four women were considered eligible for TOL. A total of 87.6% of them agreed to undergo the procedure (78.7% in the first year versus 95.2% in the second year, p?<?0.05). Of these, 63.5% delivered successfully (42.3% in the first year versus 78.8% in the second year, p?<?0.05); 10.6% underwent a primary CS because of failed spontaneous labour or failed labour induction and 25.9% a secondary CS during labour. The CS rate decreased significantly from 19.6% (in 2003–2006) to 14.9% (iN 2007–2008) (p?<?0.05). One case of symptomatic uterine rupture occurred, while no difference for other complications was observed. Conclusions: The CS rate decreased dramatically through introducing a TOL programme for patients with one previous CS. The possibility of symptomatic uterine rupture should be however considered and patients adequately informed.     

Second stage caesarean section at a tertiary hospital in South Africa

Objective.?An audit of second stage caesarean section (C/S) at a tertiary hospital was undertaken to compare the frequency of perinatal and maternal complications between first and second stage C/S and to evaluate the training level of physicians.

Methods.?A prospective chart audit of all women who underwent emergency C/S over a 7-month period at a tertiary hospital was conducted. The patients' hospital records were assessed on a daily basis and all relevant information recorded on a structured data sheet categorising demographics, indications for C/S, level of training of decision-maker and surgeon, a consultant's presence, operative complications and neonatal outcome at 5?min post-delivery. The frequency of maternal and neonatal complications was the main outcome measures.

Results.?There were 975 first stage and 116 second stage C/S. The commonest causes of second stage C/S were cephalo-pelvic disproportion, prolonged second stage and fetal distress. First stage C/S took a mean time of 35.5?min, while second stage C/S took an average time of 41.6?min to perform (p?=?0.001). There were 37 and 84 records of complications occurring in first and second stage C/S, respectively.

Conclusion.?Maternal complications were significantly higher in second stage C/S while neonatal complications were not significantly different between first and second stage C/S. There was little guidance from consultants at decision-making for second stage C/S.     

Laparoscopic excision of rudimentary horn pregnancy in a patient with previous caesarean section

A rudimentary uterine horn is extremely rare and often difficult to diagnose. The frequency of this pathology is approximately 1:100,000. The diagnosis is sometimes elusive even at surgery. We present a case report of pregnancy in a rudimentary horn in the patient with one caesarean and one normal vaginal delivery, and we successfully conduct a removal of the rudimentary horn pregnancy laparoscopically.     

Uterine incision and maternal blood loss in preterm caesarean section

Summary The purpose of this study was to compare maternal blood loss, as reflected by the perioperative changes in haemoglobin (Hgb), the incidence of severe bleeding (estimated blood loss >1000 ml) at operation, and the need for blood transfusion, between patients who had classical caesarean section (CCS) and lower segment caesarean section (LSCS) at 34 weeks gestation or less. The data from 31 women delivered by CSS between 25 and 34 weeks gestation were compared, in a retrospective case-control fashion, to another 31 women delivered by LSCS. Patients were matched for gestational age at delivery, the type of anaesthesia, and the prior use of tocolytic therapy. Excluded from the study were patients who had an antepartum haemorrhage or placenta praevia. There was a significantly greater reduction in maternal Hgb and an higher incidence of severe bleeding in the CSS group compared to the LSCS group (P<0.05). The results of this study suggest that for preterm caesarean sections, the classical incision is associated with increased blood loss compared to the lower segment incision.     

A comparison of two techniques of uterine closure in caesarean section

Objective: To compare the results of two different techniques of uterine closure in caesarean section operations in which assistant surgeons participated.

Methods: A total of 765 patients were separated into two groups.In Group1(n?=?380), the assistant surgeon, while pulling the suture in a caudal direction with the left hand, held the uterine wall from the joined site with the right hand to prevent upward tension of tissue. In Group 2 (n?=?385), the suture was placed by the assistant surgeon by pulling it in the cephalic direction with the right hand. These two techniques were evaluated in respect of the postoperative decrease in haemoglobin level ,the need for additional sutures and operative outcomes.

Results: The need for additional sutures was determined as statistically high in Group 2 at mean 0.5?±?0.6 compared to mean 0.2?±?0.5 in Group1 (p?<?0.001). The mean operating time was determined as statistically significantly longer in Group 2 (Group1, 38.0?±?5.6 mins and Group2, 41.3?±?4.3 mins) (p?<?0.001). The postoperative decrease in hb was statistically significantly greater in Group 2 (Group1, 1.1?±?0.4, Group2, 1.2?±?0.4) (p?=?0.002).

Conclusion: The cephalic direction placement of the suture with the right hand of the assistant surgeon in uterine closure leads to bleeding due to tissue cuts in the lower wound lip and thereby creating a need for additional sutures. Therefore, the suture should be placed in a caudal direction with the left hand.     

Timing of elective repeat caesarean section: maternal and neonatal morbidity and mortality

Timing of elective repeat caesarean section should take into account both fetal and maternal considerations. The percentage of caesarean deliveries has dramatically increased during the last decades. It undoubtedly leads to an increase in the number of women having multiple caesarean sections. While maternal morbidity increases with increased number of caesarean sections, when compared with their term counterparts, late pre-term infants face increased morbidity. Establishing the optimal time of delivery for both mother and child is a major challenge faced by clinicians. The aim of this review is to better understand neonatal and maternal morbidity and mortality that are associated with elective repeat caesarean section, and to provide an educated decision regarding the optimal timing for elective repeat caesarean section.     

The effect of caesarean section on self-esteem amongst primiparous women in South-Western Nigeria: A case-control study

Objective.?This study aims to assess the level of self-esteem of newly delivered mothers who had caesarean section (CS) and evaluate the sociodemographic and obstetrics correlates of low self-esteem in them.

Methods.?Newly delivered mothers who had CS (n?=?109) and who had spontaneous vaginal delivery (SVD) (n?=?97) completed questionnaires on sociodemographic and obstetrics variables within 1 week of delivery. They also completed the Rosenberg self-esteem scale.

Results.?Women with CS had statistically significant lower scores on the self-esteem scale than women with SVD (p?=?0.006). Thirty (27.5%) of the CS group were classified as having low self-esteem compared with 11 (11.3%) of the SVD group (p?=?004). The correlates of low self-esteem in the CS group included polygamy (odd ratio (OR) 4.99, 95% confidence interval (95% CI) 1.62–15.33) and emergency CS (OR 4.66, 95% CI 1.55–16.75).

Conclusions.?CS in South-Western Nigerian women is associated with lowered self-esteem in the mothers.     

Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean

Objectivesin the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for women's birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals.Designa national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS.Settinginstitutions included hospitals and clinics providing childbirth services throughout Japan.Participantsnursing managers from hospitals (n=303) and clinics (n=196) completed surveys about their institutional policies and practices around birth after CS.Findingsonly 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39, p<0.001; OR=2.96, p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with women's wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas.Key conclusionsinstitutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information.Implications for practicestrategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan.     

前置胎盘合并剖宫产史临床分析

目的探讨前置胎盘合并剖宫产史患者的临床特点及处理。方法回顾性分析2003年1月至2011年10月北京协和医院前置胎盘合并剖宫产史（再次剖宫产组,RCS组）患者母婴结局,并与同期前置胎盘行初次剖宫产（初次剖宫产组,FCS组）进行比较。结果 RCS组及FCS组分别有29例及243例患者。两组的平均年龄、孕周差异无统计学意义（P〉0.05）。RCS组患者手术时间长,产后出血量多,早产、产后出血、胎盘植入、输血、弥漫性血管内凝血和产科子宫切除的发生率均高于FCS组,差异有统计学意义（P〈0.05）,RCS组早产儿、新生儿窒息发生率及围产儿死亡率均高于FCS组（P〈0.05）。结论前置胎盘合并剖宫产史更易发生胎盘植入,产后出血、产科子宫切除及围产儿病率高,需要高度重视。     

A history of caesarean section: from ancient world to the modern era

Caesarean section has been recorded in history since ancient times in both Western and non-Western literature. Although the first use of the term in obstetrics was from the seventeenth century, its early history is obscured by mythology. The origin of the term caesarean is believed to be from the birth of Julius Caesar; however, this is unlikely considering his mother Aurelia Cotta lived for many years afterwards. In ancient times, it was performed only when the woman was dead or dying as an attempt to rescue the fetus. With few exceptions, this was the pattern until the era of anaesthesia in the nineteenth century. Developments in surgical technique from the later nineteenth century and through the twentieth century have refined the procedure, with resulting low morbidity and mortality. As a consequence, the objectives of caesarean section have evolved from rescuing the fetus or for cultural or religious reasons towards concerns for the safety of mother and child as well as considering the mother's preferences.     

剖宫产手术中羊水栓塞的防治

羊水栓塞是产科罕见但却是最为凶险的并发症,不仅是发达国家造成孕产妇死亡的主要原因,也逐步成为我国孕产妇死亡的前三位主要产科因素。文章回顾了近10年剖宫产手术与羊水栓塞的相关文献,对在剖宫产术中羊水栓塞的诊断、预防,尤其是包括产科、麻醉科等科室在内的多学科团队的联合救治进行了总结。     

Birth after caesarean section: changes over a nine-year period in one Australian state

Objectives

to describe the outcomes related to birth after a caesarean section (CS) in one Australian state, New South Wales (NSW), over a nine-year period. The objectives were to determine whether changes had occurred in the rates of attempted and successful vaginal birth after caesarean section (VBAC), induction of labour, place of birth, admission to special care or neonatal intensive care nursery and perinatal mortality.

Design and setting

cross-sectional analytic study of hospital births in New South Wales using population-based data from 1998-2006.

Participants

women experiencing the next birth after a CS where: the total number of previous CS was 1; the presentation at birth was vertex; it was a singleton pregnancy; and, the estimated gestational age was greater than or equal to 37 weeks. A total of 53,455 women met these criteria.

Measurements

data were obtained from NSW Health Department's Midwives Data Collection (MDC). The MDC includes all live births and stillbirths of at least 20 weeks gestation or 400 g birth weight in the state.

Findings

over the nine-year period, the rate of vaginal birth after caesarean section declined significantly (31-19%). The proportion of women who ‘attempted a vaginal birth’ also declined (49-35%). Of those women who laboured, the vaginal birth rate declined from 64% to 53%. Babies whose mothers ‘attempted’ a VBAC were significantly less likely to require admission to a special care nursery (SCN) or neonatal intensive care (NICU). The perinatal mortality rate in babies whose mothers ‘attempted’ a VBAC was higher than those babies born after an elective caesarean section although the absolute numbers are very small.

Key conclusions

rates of VBAC have declined over this nine-year period. Rates of neonatal mortality and proxy measures of morbidity (admission to a nursery) are generally in the low range for similar settings.

Implications for practice

decisions around the next birth after CS are complex. Efforts to keep the first birth normal and support women who have had a CS to have a normal birth need to be made. More research to predict which women are likely to achieve a successful VBAC and the most effective ways to facilitate a VBAC is essential. Midwives have a critical role to play in these endeavours.