Proposing a Hybrid Model Based on Robson’s Classification for Better Impact on Trends of Cesarean Deliveries

Aim and Objectives

To construct a hybrid model classification for cesarean section (CS) deliveries based on the woman-characteristics (Robson’s classification with additional layers of indications for CS, keeping in view low-resource settings available in India).

Methods

This is a cross-sectional study conducted at Nalanda Medical College, Patna. All the women delivered from January 2016 to May 2016 in the labor ward were included. Results obtained were compared with the values obtained for India, from secondary analysis of WHO multi-country survey (2010–2011) by Joshua Vogel and colleagues’ study published in “The Lancet Global Health.” The three classifications (indication-based, Robson’s and hybrid model) applied for categorization of the cesarean deliveries from the same sample of data and a semiqualitative evaluations done, considering the main characteristics, strengths and weaknesses of each classification system.

Results

The total number of women delivered during study period was 1462, out of which CS deliveries were 471. Overall, CS rate calculated for NMCH, hospital in this specified period, was 32.21% (p = 0.001). Hybrid model scored 23/23, and scores of Robson classification and indication-based classification were 21/23 and 10/23, respectively.

Limitations of the Study

Single-study centre and referral bias are the limitations of the study.

Conclusion

Given the flexibility of the classifications, we constructed a hybrid model based on the woman-characteristics system with additional layers of other classification. Indication-based classification answers why, Robson classification answers on whom, while through our hybrid model we get to know why and on whom cesarean deliveries are being performed.

     

Cesarean section: the pediatricians’ views

Cesarean sections (CS) have greatly increased and many reasons are often evoked. Safer anesthetics and surgical procedures have rendered CS a popular choice for both professionals and mothers alike. CS on maternal request, for nonmedical reasons, is the subject of scientific, legal and ethical dispute. We shall address the CS issues, primarily, from the pediatrician’s point of view. The immediate neonatal problems of the more mature neonate are well recognized. For preterm birth, contradictory results on mid- and long-term outcomes do not confirm the earlier reports on neonatal advantages of CS over vaginal delivery; therefore, their mode of delivery should be based on individual circumstances. The intestinal flora of neonates delivered by CS is often deprived of the normal colonization by maternal vulvovaginal and rectal flora. Whether this adverse microbiome will play a role in the late development of multiple morbidities in children and adults is an interesting possibility open to consideration. The consequences of unnecessary CS demands a reflection for all the involved parties and the decision to perform a CS shall, then, be based on the net clinical benefit to all: the mother, the child and the future adult.     

Are Women’s and Obstetricians,Views on Mode of Delivery Following a Previous Cesarean Section Really OCEANS Apart?

Purpose

Most women with one previous cesarean section (CS) are suitable for either a vaginal birth after CS (VBAC) or an elective repeat CS. Previously, nurse-led prenatal education and support groups have failed to have an impact on the mode of delivery, which women opted for after one CS. A novel one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) has been developed to inform and empower women in their decision-making following one previous CS. The objective of our study was to evaluate how OCEANS influences the mode of delivery for women who have previously had one CS.

Study Design

Two-hundred and sixty-six women who had a single previous lower segment CS were invited to attend OCEANS, which is a 1-h discussion group of women between 5 and 15 in number, facilitated by an experienced obstetrician. Data were collected prospectively on women who were invited to attend OCEANS over a 12-month period commencing on the 1st January 2012.

Results

188 (71 %) attended the group, while 20 (8 %) canceled their appointment and 58 (22 %) did not keep their appointment. Those who attended OCEANS were 38 % more likely to opt for a VBAC than those who did not attend. There was no difference in the rates of successful vaginal delivery between women who attended OCEANS and those who did not (56 vs. 61 %, p = 0.55).

Conclusions

While nurse-led prenatal education and support groups have no impact on mode of delivery after one CS, a dedicated obstetrician-led clinic increases the rate of those opting for VBAC by 38 %. Such clinics may be a useful tool helping in empowering women in their decision-making and reduce the rate of CSs.     

A Paradigm Shift to Check the Increasing Trend of Cesarean Delivery is the Need of Hour: But How?

Objectives

To check the progressive increasing trend of caesarean delivery in a tertiary facility care centre.

Aims

The purpose of this study is to implement a paradigm shift in caesarean delivery by introducing a new classification system and a check list based management protocol.

Methods

The study was conducted from 1st January, 2007 to 31st December, 2008 at CNMC G&O Department. All deliveries in the year 2007 were compared retrospectively and all deliveries in the year 2008 under prospective study with implementation of a new strategic protocol. Comparative audit and analysis of deliveries in retrospective and prospective year reveals significant changes in the caesarean delivery rate.

Results

In retrospective group all women in labour were allowed for spontaneous delivery and in prospective group all women were subjected to intervention protocol and caesarean delivery done in both the groups in need for risk of fetal and maternal salvage. Incidence of caesarean delivery (CD) in retrospective group was 29 % while in the prospective group it was 18.4 %. Marked decrease in CD was observed for augmentation, induction and trial of labour (TOL) for delivery in prospective group. The result was compared with Robson’s studies following similar type of classification system.

Conclusion

Marked improvement was noticed in this new paradigm and more multicentric trial is needed to check the increasing trend of CD.     

The Clinical Outcome of Post Placental Copper-T-380A Insertion with Long Placental Forceps (Kelly’s Forceps) After Normal Vaginal Delivery and Cesarean Section

Objectives

To study the efficacy safety effect on menstrual cycles, expulsion, continuation, and failure rate of post placental Copper-T-380A after vaginal and cesarean birth in a tertiary center, over the period of 1 year.

Methods

A total of 150 women who opted for insertion of Copper-T-380A within 10 min of expulsion of placenta whether delivered vaginally or by cesarean section were enrolled into study. Women having past history of ectopic pregnancy or any genital tract infection or hemorrhagic disorders, uterine anomaly, chorioamnionitis, LPV > 18 h, unresolved PPH, Hb < 8 g% were excluded from the study.

Results

No incidence of perforation, PID, and failure of contraception was detected. Percentage satisfaction among users after 6 weeks—91.7 %, 3 months—92.9 %, and 6 months—95.6 %.

Conclusion

Although there was high incidence of missing IUCD threads (probably owing to coiling of long threads), the actual expulsion rate was far lesser. Removal rate due to menorrhagia, pain in abdomen, and vaginal discharge was low, and 6 months continuation rate was considerably good.     

Two Models for Delivery of Women’s Continence Care: The Step-Wise Continence Team Versus the Traditional Medical Model

BackgroundThe current pyramidal system of health care delivery, in which subspecialized physicians with the most complete knowledge and expertise are difficult to access, is inefficient and ineffective at delivering the best care to the majority of patients. Urinary incontinence care exemplifies this problem. Patients can wait up to one year to see a urogynaecologist, regardless of the complexity of their problem. Many women who do not require subspecialized care could have their incontinence managed in a more timely fashion if they had access to education and conservative interventions via a new, more accessible model of care.MethodsWe studied a modification of urinary incontinence care that departed from the traditional methods of care delivery in two distinct ways. First, patients were permitted to refer themselves directly to the specialty care team. Second, standardized questionnaires and evaluation tools facilitated assessment and management of the patients by a continence educator and nurses, without direct contact between patient and physician. This step-wise model of care was compared with the traditional method of care delivery (medical model), in which the management of all patients was provided by a physician.ResultsTwo hundred thirty-two women participated in this study: 154 in the step-wise arm and 78 in the medical model arm. Neither the demographics nor the pre-treatment incontinence severity of the two groups differed significantly. Patients in both groups showed significant improvement in all measures of urinary incontinence after treatment. Patients in the self-referral model experienced significantly better resolution of stress incontinence and irritated bladder symptoms. Their quality of life was also significantly better and their treatment satisfaction higher.ConclusionThe step-wise model of care delivery involving a continence advisor and nurses was as effective in the management of urinary incontinence as the traditional medical model.     

Full-Term Pregnancy and Vaginal Delivery After Treatment for Non-Hodgkin’s Lymphoma of the Cervix and Lower Uterine Segment: A Case Report

BackgroundPrimary gynaecologic non-Hodgkin’s lymphomas are rare. We present a case of primary large B-cell lymphoma localized to the lower uterine segment and endocervical stroma that was successfully treated with chemotherapy and immunotherapy. Treatment was followed by a disease-free interval and successful term vaginal delivery.CaseA 21-year-old nulliparous woman presented with dysfunctional uterine bleeding. Radiologic assessment of a posterior lower uterine segment mass and pathologic evaluation of cervical biopsies demonstrated diffuse large B-cell lymphoma involving the endocervical stroma. The patient was treated with chemotherapy and immunotherapy. She had a normal, uncomplicated full-term pregnancy and spontaneous vaginal delivery six years after treatment.ConclusionAggressive diagnosis and treatment of primary non-Hodgkin’s lymphomas of the cervix do not preclude the possibility of a successful pregnancy and term vaginal delivery.     

Primary non-Hodgkin’s lymphoma of the uterine cervix

We present a patient with primary malignant lymphoma of the uterine cervix, which is extremely rare. She had a complete remission with a combination of chemotherapy and radiotherapy. Measurement of the serum soluble interleukin-2 receptor level was a useful index of the effectiveness of treatment. Received: 23 August 2000 / Accepted: 17 October 2000