Analyzing the impact of private service on the cesarean section rate in public hospital Thailand

Objective  

To assess the cesarean section rate and compare the risk profiles of cesarean delivery in nulliparous women between private and non-private service.     

A critical appraisal of cesarean section rates at teaching hospitals in India.

OBJECTIVES: To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India. METHODS: Information was obtained on total number of normal and cesarean deliveries during 1993-1994 and 1998-1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality. RESULTS: The overall rate of cesarean section increased from 21.8% in 1993-1994 to 25.4% in 1998-1999. Among the 7,017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100,000 and 493/1,000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates. CONCLUSIONS: There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place.     

Deliveries after cesarean birth in two Asian university hospitals

The task force of the consensus conference on cesarean birth of the National Institutes of Health, USA, has recommended substituting a trial of labor and vaginal delivery for elective repeat cesarean section in selected women. This paper assesses the benefits and risks associated with that recommendation using data from two Asian teaching hospitals, one in Jakarta, Indonesia and the other in Colombo, Sri Lanka. Data recorded on the Maternity Record Form designed by the International Fertility Research Program and the International Federation of Gynecology and Obstetrics were used for analysis. Consistent findings were derived from the two hospitals, in spite of the different medical care delivery systems in their countries. No significant increase in maternal and infant mortality and morbidity were associated with women having vaginal delivery subsequent to cesarean birth as compared to those with repeat cesarean section. Savings in medical cost were considerable in the former group.     

A comparison of cesarean section frequencies in two Norwegian hospitals

The two largest Norwegian obstetrical departments, in the cities of Bergen and Stavanger, differ markedly with regard to the frequency of Cesarean section. During the 1970's the proportions rose in both departments, but the Stavanger rate remained about half of that in Bergen, the latter following the national average. These differences were not reflected in the perinatal mortality, which had the same rates and fell equally in both hospitals. To search for explanations, all records of Cesarean section cases from the years 1974 and 1979 were studied in both hospitals. We found that mechanical indications, meaning disproportion and prolonged labor, accounted for most of the difference, whereas there was no significant rise in the frequencies for the indication fetal asphyxia in either of the hospitals, these being numerically the most important indications. In fact, there was no significant rise for mechanical indications in Stavanger between 1974 and 1979, whereas in Bergen the increased frequency for this indication gave the highest significance level for any of the seven subgroups of indications. It is suggested that the chain of command may be an important cause of the observed differences between the two departments, although this is not reflected in any stated or conscious policy in either place.     

Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital.

OBJECTIVE: To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years. STUDY DESIGN: Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes. RESULTS: Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred. CONCLUSION: Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.     

Delayed cord clamping in cesarean section with general anesthesia

Delay in cord clamping after vaginal delivery increases the blood volume of the newborn. Similar effects have also been observed in cesarean section births. Other effects of delayed cord clamping in cesarean section have not been investigated. In a group of nineteen healthy mothers having elective cesarean sections the cord clamping time was increased from 0 minutes to 1.5 and 3 minutes. Significantly lowered PO2 and pH and elevated plasma lactate levels were observed in infants with 3 minutes' delay when compared with the early clamping group. We conclude that, when healthy mature newborns are considered, early clamping of umbilical cord in cesarean section with general anesthesia is preferable to late clamping.     

全身麻醉对剖宫产产妇分娩新生儿的影响

目的探讨剖宫产产妇实施全身麻醉对新生儿的影响。方法选择全身麻醉或硬膜外阻滞下行择期剖宫产产妇各20例,分别组成全身麻醉组和硬膜外阻滞组。全身麻醉组产妇先后静脉注射芬太尼每公斤体重2·0μg、异丙酚每公斤体重1·5mg及维库溴胺每公斤体重0·08mg,并给予气管插管。胎儿娩出前给予笑气吸入(笑气∶氧气为1∶1)。硬膜外阻滞组产妇应用1·73%碳酸利多卡因5ml(含1∶200000肾上腺素)椎管内注入。两组分别于胎儿娩出后30min抽取新生儿桡动脉血行血气分析,并记录两组新生儿出生后3~5d的新生儿神经行为评分(NBNA)。结果(1)血气分析:全身麻醉组新生儿pH值、二氧化碳分压(PaCO2)、氧分压(PO2)、氧饱和度(SPO2)及红细胞压积(Hct)分别为7·34±0·08、(40±11)mmHg(1mmHg=0·133kPa)、(73±17)mmHg、(96·8±1·0)%、(53±5)%;硬膜外阻滞组新生儿分别为7·35±0·05、(41±8)mmHg、(71±17)mmHg、(96·6±1·0)%、(54±6)%。(2)NBNA:全身麻醉组新生儿行为能力、被动肌张力、主动肌张力、原始反射、一般状态分别为(12·6±0·7)、(7·2±0·7)、(7·4±0·6)、(5·6±0·8)、(5·9±0·3)分。硬膜外阻滞组分别为(13·4±0·8)、(7·3±0·5)、(7·3±0·8)、(5·6±0·6)、(5·9±0·3)分。两组各项评分比较,差异均无统计学意义(P>0·05)。结论剖宫产产妇采用常规剂量药物实施全身麻醉对新生儿安全无明显影响。     

Abdominal cesarean section at the Cleveland Maternity Hospital

A series of 1,317 cases of abdominal cesarean section operated upon between the years 1932 and 1941 has been studied. This study included mortality and morbidity, the causes of morbidity and other considerations.     

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.)     

Comparison of neonatal effects of epidural and general anesthesia for cesarean section

We assessed the influence of anesthetic technique for cesarean section on neonatal outcome. Thirty parturient women (ASA I/II) were randomly allocated into two groups. In Group GA general anesthesia was induced with 4 mg.kg(-1) thiopental and 1.5 mg.kg(-1) succinylcholine. In group EA epidural anesthesia was performed with 20 ml 0.375% bupivacaine through L(3-4) inter-space. 1-min Apgar scores were significantly higher in group EA (p < 0.001). Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA (p < 0.001). In terms of blood gas values, umbilical arterial pH and pO(2) values were higher in group EA (p < 0.05 and p < 0.001, respectively). The first breast-feeding intervals were found to be shorter in group EA (p < 0.001). We conclude that in terms of better Apgar and NAC scores, acid-base status and earlier initiation of breast-feeding, the epidural anesthesia may be preferred to general anesthesia in cesarean section.     

Intraoperative complications and unexpected pathology at the time of cesarean section

During cesarean section, operative complications include injury to the uterus, urinary tract, and bowel. A variety of types of fetal injuries have been reported, and some are associated with permanent handicap. The relative risk of intraoperative complications varies widely depending on such clinical variables as gestational age, station of the presenting part, and the experience of the operating physician. Ideally, each physician should be able to review his or her rate and type of complications so that continuous improvement in technique is fostered. Gynecologic tumors (malignant and benign) are rarely associated with pregnancy, and their incidental finding at the time of cesarean section is also rare. Management of malignant tumors depends greatly on the stage of the tumor. Conservative management of early-stage malignant ovarian tumors is permissible. More advanced malignant ovarian tumors and malignant tumors of the uterus and fallopian tube should be treated aggressively with removal of the reproductive organs.