New trends in cesarean section

The Authors studied the frequency of Cesarean section in relation to deliveries in the last trimester of pregnancy, the frequency of repetitive Cesarean section, age and parity of the patients, indication for cesarean section, week of delivery, and perinatal and maternal morbidity and mortality at the First Clinic of Obstetrics and Gynecology, University of Catania, Catania, Italy, from 1972 to 1974 and from 1983 to 1985. The frequency of Cesarean section has increased from 12.07% (735 cases out 6,086 deliveries) to 16.89% (837 cases out of 4,955 deliveries). There was a decrease in frequency of repetitive Cesarean section from 30.47% (224 cases) to 27.95% (234 cases) and in perinatal mortality rate from 4.35% (32 cases out of 735) to 3.19% (27 cases out of 845 newborn). There were no cases of maternal death, while the most common cause of maternal morbidity was uterine atonia. From 1972 to 1974 mechanical causes were the most frequent indication for Cesarean section (28.16% -207 cases), while from 1983 to 1985 previous hysterotomy (32.73% -274 cases) was the main indications for Cesarean section.     

Cesarean section — A review of two annual periods separated by a ten-year interval

In the Soroka Medical Center in Beer-Sheba during the two annual periods 1969 and 1979, 693 cesarean sections were performed, of which 633 are presented. The main reasons for the rise in cesarean section rate from 2.6% in 1969 to 8.0% in 1979 were evaluated. Cesarean sections were performed more often for fetal indications during 1979 than in 1969, reflecting the change in our approach to the management of the fetus at risk. The increase in the cesarean section rate was concomitant with a drop in the perinatal mortality from 23/1000 in 1969 to 13.1/1000 in 1979.     

Incidence and indications for cesarean section in the Obstetrics Clinic in the University Hospital of Obstetrics and Gynecology "Maichin Dom" in Sofia

The incidence and the indications for Cesarean section in the Obstetric Clinic of the University Hospital of Obstetrics and Gynecology were analysed and compared to a study carried out 20 years ago In 2003 - 2004 there were 2700 pregnant women treated in the clinic 558 had Cesarean section (incidence 20.7%). For comparison the incidence of Cesarean section in 1985 was 6.67% (160 Cesarean sections for 2096 patients) and for 1986 the incidence was 7.63% (131 Cesarean Sections for 1865 patients. The leading indication for the both studies was "previous Cesarean section" the indication "contracted pelvis" was the second and infertility and breech presentation were on the third and forth place. There was no change in the indications for Cesqarean section in the present study and the study carried out 20 years ago. There was a relative increase of the indications 'contracted pelvis' and 'increased age in a nulliparous patiet' compared to the previous years.     

Reasons for the rising cesarean delivery rates: 1978-1984

This study was undertaken to estimate the cesarean delivery rate in United States hospitals and to determine whether the reasons for rise in this rate have changed since the National Institute of Child Health and Human Development Consensus Development Conference on Cesarean Childbirth in 1979. The cesarean delivery rate steadily increased from 9.1% in 1974 to 14.7% in 1978, and to 21.2% in 1984. One-third of the rise in the cesarean rate from 1974-1978 was due to repeat cesareans, and 9% was due to fetal distress. Since 1978, 47% of the rise in the cesarean rate was attributed to repeat cesareans, and 16% to fetal distress. Less of the recent rise in the cesarean rate was due to dystocia and breech presentation. The rate of cesarean delivery among those with a previous cesarean was 96%. Deliveries complicated by fetal distress increased from 1% in 1978 to 6% in 1984. The incidence of breech presentation dropped by 18% (2.8-2.3%), which may indicate an increase in the successful use of external cephalic version. If the number of vaginal deliveries after cesarean increases in the future, then the overall cesarean delivery rate will decrease or stabilize. Additional efforts should be focused on the diagnostic categories of fetal distress and dystocia, because it is likely that the definitions of these complications are changing to include less severe forms.     

关于剖宫产术几个问题的探讨

目的：对剖宫产术的发展予以简介；对剖宫产术的效用及其合理应用予以评价。方法：主要是文献复习，并结合个人的经验，介绍剖宫产术发展史、指征，术式与技术要求以及并发症的防治，最后作出合理应用的评价。结果：对剖宫产术的命名（古典式剖宫产术→腹膜内—腹膜外剖宫产术→腹膜外剖宫产术→子宫下段剖宫产术）；剖宫产术的指征（孕妇方面，胎儿方面，母、婴方面）；剖宫产术术式及技术要求（剖壁切口、子宫切口、胎儿娩出、胎盘娩出、附带手术）；并发症及其防治（手术指征、术中操作、术后观察与处理）均作出讨论。结论：剖宫产术对孕妇或胎儿的紧急情况造成出口，以便进一步采取治疗措施；剖宫产术率不宜硬性规定，对医院条件相同者，可以较其围产儿与孕、产妇的病率及死亡率，若剖宫产术者多于经阴分娩者，而两率反高，不难看出该医院产科工作质量之低下，反之，亦然。     

Epidemic of cesarean section at the general, private and university hospitals in Thailand

OBJECTIVE: To undertake a survey of cesarean section in the general, private and university hospitals in Thailand. METHODS: Postal questionnaires were sent to all the general, private and university hospitals with 200 beds or more. The questionnaires were prepared to find out the percentage, the indications and the trend of cesarean delivery, the measures taken to decrease cesarean section rate, and the practice of external cephalic version (ECV) and vaginal birth after cesarean section (VBAC) in the hospitals. RESULTS: The overall response rate was 88%. Mean cesarean section rates were 24, 48, and 22% in the general, private and university hospitals, respectively. Cesarean section rates in most of the hospitals were increased in the past 5 years namely 78% in the general hospitals, 50% in the private hospitals, 66% in the university hospitals. However, only 38% of the hospitals had measures to regulate this operation. Repeated cesarean section was the most common indication in the private (63%) and the university hospitals (88%) while failure to progress was the most common indication in the general hospitals (55%). ECV and VBAC were performed in 26 and 12% of the hospitals. They were, however, not the standard practices. CONCLUSION: Rising of cesarean section rate without any measure to regulate it is the problem in the developing countries. Standardised labor management and reduction of unnecessary primary cesarean section will automatically reduce repeated operation and overall cesarean section.     

Has use of cesarean section reduced the risks of delivery in the preterm breech presentation?

The effect of cesarean section on the condition at birth in cases of preterm breech presentation was studied in consecutively delivered infants in two time periods. Delivery was rarely (8%) by cesarean section in 1961 to 1974 and usually (89%) by cesarean section in 1978 to 1984. The increased cesarean rate did not reduce the incidence of severe depression, which was double that in control cases with cephalic presentations in both periods. Breech births did not have a higher mortality rate than cephalic births in either period; birth trauma and encephalopathy were similar in both periods. Cesarean section was therefore not found to reduce either the incidence of depression at birth or the mortality. However, head entrapment was responsible for the deaths of seven of 55 live-born infants delivered vaginally at 25 to 28 weeks' gestation, all weighing less than 1000 gm. Although cesarean section is at present performed least often among these extremely premature infants, it is in these cases that it may prove most beneficial.     

Cesarean section in California--1960 through 1975.

The cesarean section rate has been rising in California since 1965. In this article, we describe the trend in cesarean section rates in California from 1960 to 1975 in relation to maternal and infant variables. Approximately proportionate increases in cesarean section rates by infant birth weight and maternal race were found. Cesarean section rates for women under 20 years of age and for those of first parity have risen proportionately more than rates for other age and parity groups. We also found that cesarean section rates for births at gestational age's exceeding 42 weeks have risen proportionately more than rates for births at other gestational ages. Maternal mortality ratios associated with cesarean section were twice those associated with noncesarean births for the years 1973, 1974, and 1975. Possible explanations of the current cesarean section rate include an increase in indications for the procedure, use of the fetal monitor, and the current medical-legal climate. The potential problems that cesarean section may create for the mother and infant are higher rates of iatrogenic prematurity and respiratory distress and of maternal morbidity and mortality.     

Vaginal birth of twins after a previous Cesarean section

OBJECTIVE: To determine whether a vaginal birth of twins after a Cesarean section carried greater risk than for a singleton gestation as well as determining whether there was a similar likelihood of successful vaginal birth. METHODS: A retrospective study was carried out of all twin pregnancies in which vaginal birth was attempted after a Cesarean section, in 1991-99. The next three consecutive singleton pregnancies in which vaginal birth was attempted after a Cesarean section were also evaluated. Comparisons were made for successful vaginal birth after Cesarean section complications (blood loss, uterine rupture or dehiscence, hysterectomy, chorioamnionitis and neonatal morbidity). Where appropriate, X2 tests of association or Student's t tests were used. Significance was set at p < 0.05. RESULTS: A total of 19 twin pregnancies met the study criteria. There were 57 controls. Gestational ages differed slightly (twin pregnancies, 36.3 weeks; controls, 39.3 weeks). The success rate of vaginal birth after Cesarean section was 84.2% for twin pregnancies and 75.4% for controls. The incidence of postpartum hemorrhage was 5.3% for both groups. One uterine rupture occurred in the control group; none occurred in the twin pregnancy group. One uterine dehiscence occurred in each group. No significant differences were found for any of the other parameters tested. CONCLUSION: The option of vaginal birth of twins after Cesarean section appears to have a similar risk and shares a similar likelihood of success to those of a singleton pregnancy. In view of the lack of increased complications, this option can be offered to patients with twin pregnancies who are eligible for vaginal birth after Cesarean section.     

Neonatal outcome after cesarean section

Cesarean section is the most commonly performed procedure all over the world. Both American and European data reveal constant and steady increase of pregnancies resolved by a cesarean section. The reasons include: growing number of medical indications or requests of the pregnant women. Regardless of the fact that elective cesarean section decreases the risk of intrauterine hypoxia, meconium aspiration and injury during labor it remains a significant risk factor for respiratory failure in the course of transient tachypnea of the newborn, infant respiratory distress syndrome and pulmonary hypertension, both for term and late preterm infants. As a consequence, the infant requires a prolonged stay in the intensive care unit, together with advanced and often expensive medical procedures such as mechanical (often high-frequency) ventilation, nitric oxide therapy and extracorporeal membrane oxygenation. The American Association of Obstetricians and Gynecologists and the European Association of Perinatal Medicine recommend for a cesarean section due to medical indications to be performed after 39 weeks gestation, preferably after uterine contractions started, and elective cesarean section, particularly if there are indications to finish the pregnancy before 39 weeks gestation, after lung maturity has been assessed (in other case steroids ought to be administered prenatally to mature the lung muscles). That includes also cases of elective cesarean sections performed due to previous cesarean sections, which are the most frequent reasons for repeating procedure. The recommendations also restrict the indications for cesarean section in case of significant prematurity what in turn is connected with more restricted indications for resuscitation of extremely premature infants and babies with extremely low birth weight.     

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.     

A Review of Primary Caesarean Sections in Tasmania

In the years 1975-1982 inclusive there were 55,095 deliveries in Tasmania and of these 2,738 patients (4.9%) were delivered by primary Cesarean section. The primary Caesarean section rate increased from 4.3% in 1975 to 6.6% in 1982. This increase has been due to the increased incidence of primary Caesarean section associated with breech presentation and to a lesser extent fetal distress. Although the overall perinatal mortality rate fell from 19.5 per 1,000 births in 1975 to 10.8 per 1,000 births in 1982, there has been no corresponding fall in the perinatal mortality rate associated with primary Caesarean section. As an increase in Caesarean section will lead to an increase in maternal mortality and morbidity it is considered that an active review of the reasons for the rise in Caesarean section should be undertaken by those hospitals where the rate is unusually high.     

Changing Patterns of Caesarean Section

There has been a substantial rise in the rate of Caesarean section in the last 20 years. There are many reasons for this increase, but it has been argued that the fall in perinatal mortality justifies a higher Caesarean section rate. In this retrospective study 7,274 deliveries were reviewed and 650 Caesarean sections were analysed. There was only a marginal increase in the rate of Caesarean section (1.9%) during the 2 biennial periods studied (1974-1975 and 1984-1985), but overall perinatal mortality rate dropped by half during the second study period. This study confirms that in recent years the indications for Caesarean section have altered, but the marked rise in the Caesarean section rate cannot be explained purely on medical grounds and is certainly not solely responsible for the very significant drop in the perinatal mortality rate.     

剖宫产分娩对婴儿健康影响的前瞻性研究

目的:了解剖宫产分娩对婴儿健康的影响。方法:采用配对前瞻性队列研究,选取602名不具备剖宫产术绝对指征的妇女及其新生儿为对象,其中301名妇女为剖宫产分娩,301名妇女为阴道分娩,二组对象按照手术指征进行配对,分别在产后1个月、6个月及12个月进行随访,了解婴儿的健康状况。结果:产后近期及各次随访期间未发现剖宫产、阴道分娩二组婴儿疾病发生危险的差异。产后1个月剖宫产儿因病住院率相对低于阴道分娩儿,但1年总计,二组婴儿因病住院比例的差别无统计学意义。婴儿常见病1年总计比较的结果发现剖宫产后发生婴儿腹泻的危险是阴道分娩儿的1.25倍(95%CI:1.01-1.56)。结论:不具备剖宫产术绝对指征的妇女,剖宫产与婴儿疾病的发生没有关联,但有增加婴儿腹泻发生的危险。     

Increased cesarean section rates in Turkey.

The aim of this study was to examine the trend in Cesarean section deliveries and the factors associated with Cesarean sections in Turkey. Data come from the ever-married women questionnaire of the 1998 Turkish Demographic and Health Survey (TDHS-98). During the decade preceding the TDHS-98, the proportion of deliveries by Cesarean section increased from 5.7% to 20.8%. When only hospital births were considered, the percentage of Cesarean deliveries for the year 1998 was found to be 26.1%. The estimated rate for the year 2001 was around 30% (i.e. double the maximum rate of Cesarean sections defined by the World Health Organization). Logistic regression analysis performed for the births occurring in the most recent period of 1993-98 revealed that the highest Cesarean section rate was strongly associated with maternal education, maternal age, place of delivery, number with prenatal care and household welfare. These findings imply that women with higher socioeconomic status are more likely to accept Cesarean section than women with lower socioeconomic status. The trend of increasing Cesarean section rates is a problem in itself, but more importantly it may indicate that Turkey is headed toward a more costly medical delivery system. For all of these reasons, the reduction of Cesarean section rates should be a priority for any reproductive health program in Turkey in order to improve the quality of prenatal care and to reduce the number of maternal deaths and morbidity.     

The mode of delivery in patients with preeclampsia at term subject to elective or emergency Cesarean section

Purpose

Preeclampsia is accompanied by high maternal and fetal morbidity and mortality. Thus, delivery needs to be planned carefully. The aim of this study was to determine the most favorable delivery for patients with preeclampsia between the week 37 and 41 of gestation.

Methods

For this retrospective study, patient data from 2003 to 2011 was collected. Study participants were women having a Cesarean section during week 37 and 41 of gestation. The population was classified into four groups: patients without hypertensive disorders having an elective or emergency Cesarean section and patients suffering from preeclampsia with elective or emergency Cesarean section. Analysis included mode of delivery and neonatal outcome, defined by Apgar score, rate of NICU admission and pH value of the umbilical cord.

Results

A total of 130 cases of preeclampsia were recorded. Compared to the control group, we observed a significantly higher Apgar score in the study group with emergency Cesarean section. Furthermore, within the study group the Apgar score at 5 and 10 min was also significantly increased in cases delivered by emergency Cesarean section. Moreover, the pH value of the umbilical cord was significantly higher in the study group. Considering the delivery mode, significant differences were found in favor of the elective Cesarean section. There were no differences in the rate of NICU admission between the groups.

Conclusion

The most frequent mode of delivery for women suffering from preeclampsia is elective Cesarean section; however, neonates delivered by emergency Cesarean section did not show an adverse neonatal outcome.     

Cesarean sections for maternal indications in Kasongo (Zaire)

Cesarean section rates in a rural area in Eastern Zaire are described. Indications are stringent and section is essentially performed on maternal indications. In the urban area cesarean section was performed for 1.1% of the expected births over a 9-year period, but only for 0.3% of expected births in the rural area, indicating a major problem in access to the district hospital. Section rates are compared with those reported for other settings.     

In-hospital maternal mortality risk by cesarean and vaginal deliveries in two less developed countries--a descriptive study

Cesarean deliveries are increasing in both developed countries and less developed countries (LDCs). Recent studies in the U.S. have revealed a significantly higher mortality risk for women who delivered abdominally than for those who delivered vaginally, even when the effect of the conditions which necessitated cesarean delivery was taken into account. We chose for study from an international maternity monitoring network, five centers from two LDCs that reported an in-hospital maternal mortality rate (MMR) of around 10 per 1000 parturient women. The pooled data revealed an MMR of 5.1 per 1000 women with vaginal deliveries. For women with cesarean delivery, the total MMR was 36.2 and the MMR attributable to cesarean section was estimated to be 12.8; both rates were per 1000 procedures. The leading cause of death was eclampsia for the vaginal deliveries and sepsis for the cesarean deliveries. The risk of maternal mortality inherent with the cesarean section procedure per se (not counting the risk associated with the labor and delivery complications that necessitated cesarean section) as well as the practical avoidability of maternal deaths for either mode of delivery in these LDC hospitals are discussed.