C-section Rate Research Articles

EFFECTS OF SHORT INTER-DELIVERY INTERVAL ON MODE OF DELIVERY IN PREVIOUS ONE CAESAREAN SECTION CASES

OBJECTIVE: To determine the effects of short inter delivery interval (IDI) on mode of delivery in patients with immediate previous one caesarean section (C-Section). METHODS: This is a retrospective chart review of 120 patients treated at Khyber Teaching Hospital, Peshawar, Pakistan from December 2017 to December 2019. Patients of previous one C-Section and with gestational age of >37 weeks were included in this study. Outcome variables were mode of delivery whether operative or vaginal delivery, maternal and fetal complications such as scar dehiscence or scar rupture and fetal distress. RESULTS: Mean age of the patients was 28.9±2 years. IDI was <18 months in 35/120 (29.2%) cases, 18-24 months in 54/120(45%) cases and >24 months in 31/120 (25.8%) cases. Out of 120, 102 (85%) patients underwent trial of labour after C-section (TOLAC). TOLAC was successful in 64 (62.7%) cases. Patient who underwent TOLAC with IDI of <18 months, 5/21 (23.8%) patients delivered vaginally and 16/21 (76.2%) patients had emergency C-Section while those with 18-24 months IDI, 38/51 (74.5%) patients delivered and 13/51 (25.4 %) patients had emergency C-Section. Main indications for emergency C-Section were scar tenderness and maternal tachycardia (n=16; 42.10%) and fetal distress (n=11, 28.9%). There were two cases of interauterine deaths. Uterine scar dehiscence was observed in 14.28% and 2.4% in short and normal IDI respectively. CONCLUSION: Patients with short IDI had high C-section and uterine scar dehiscence rate. IDI of >18 months is recommended to avoid the maternal and fetal morbidity and mortality.

Khuyết sẹo mổ lấy thai: Tổng quan về triệu chứng, chẩn đoán, thực trạng, một số yếu tố liên quan và điều trị

Abstract: The study aimed to review studies on cesarean scar defect incidence and its associated factors, diagnostic criteria, and treatments. The study reviewed 44 articles from PubMed in August 2022. Results showed that transvaginal ultrasound and contrast-enhanced hysterosalpingogram were the two most 17 common methods, often used together for diagnosing. The rate of cesarean scar defects ranged from 19% to 84%, depending on the diagnostic method. Common symptoms were irregular menstrual cycles, abnormal bleeding after menstruation, lower abdominal or lower abdominal pain, menstrual cramps, and infertility. Factors associated with cesarean section scar defects included individual factors (parity, number of cesarean deliveries, history of diabetes, uterus recline, maternal body mass index) and medical service factors (stitching technique at cesarean section, prolonged labor period). Treatment included both medical and surgical, but should only be done when there were symptoms affecting the mother's health. Given the high rate of C-section in Vietnam and very few studies on cesarean scar defects, it is necessary to conduct research on this topic in the future. Keywords: cesarean section scar defect, cesarean section, infertility, lower abdominal pain, abnormal bleeding between two menstrual cycles.

Flat trend of high caesarean section rates in Peru: A pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020

SummaryBackgroundNational and subnational C-section rates are seldom available in low- and middle-income countries to guide policies and interventions. We aimed to describe the C-section rates at the national and subnational levels in Peru (2012-2020).MethodsBased on the Peruvian national birth registry, we quantified C-section rates at the national, regional and province levels; also, by natural regions (Coast, Highlands, and Amazon). Using individual-level data from the mother, we stratified the C-section rates by educational level, healthcare insurance and provider. Ecologically, we studied the correlations between C-section rates and human development index (HDI), altitude above sea level, proportion of the population living in poverty and proportion of rural population.FindingsC-section rate in Peru decreased slightly from 2012 (39·7%) to 2020 (38·0%). A widening gap of C-section rates was observed through the study years among the Coast that showed higher rates and the other natural regions that showed lower rates. The rates in most of the 25 regions showed a flat trend, particularly in the last four years and some provinces showed a very low rate. The rates were highest in mothers with higher education and in users of private health insurance. Higher HDI, health facility located at lower altitude, lower poverty and urbanization were positively correlated with higher C-section rates.InterpretationC-section rates in Peru are above the international recommendations. Large differences by natural region, provinces and women socioeconomic status were found. Further efforts are needed to achieve the recommended C-section rates.FundingAcademy Ter Meulen grant of the Academy Medical Sciences Fund of the Royal Netherlands Academy of Arts & Sciences (KNAWWF/1327/TMB202116), Wellcome Trust (214185/Z/18/Z), Fogarty (D43TW011502).

Factors Associated with Development of Ventral Hernias and Healthcare Seeking Behaviors in a Cohort of Pakistani Women

Background: Anterior abdominal wall hernias constitute one of the most common surgical presentations. According to the World Bank data Pakistan has one of the highest birth rates per woman in the region at 3.6 births per woman. In Pakistan there has also been a large increase in C-section rates with nearly 20% of all pregnancies being delivered via C-section, nearly 1 out of every 5 births. Multi-parity is a risk factor for developing paraumbilical hernias and C-sections lead to incisional hernia developments. Methodology: The study conducted was a cross-sectional study at a tertiary care hospital in the department of surgery from 1st June 2021 till 1st September 2021. Any woman presenting with a ventral hernia to the clinic was asked to fill out a questionnaire. 60 women presented over the study period and were enrolled. Results: Fifty five percent paraumbilical hernias and 41.7% incisional hernias were reported. The mean number of pregnancies was 4.10 S.D 1.531 with a range from 0-8. C-sections were 2 times more common than SVDs. Increasing number of pregnancies associated with younger age of onset. Higher number of vaginal deliveries and C-sections were each associated with the development of a ventral hernia. Conclusion: The high fertility rate and C-section rate in Pakistan incurs a huge risk to women developing ventral hernias and poses a burden to the public healthcare system. Keywords: Paraumbilical hernia; parity; Pakistan

High prevalence of reduced fertility and use of assisted reproductive technology in a German cohort of patients with peripartum cardiomyopathy

BackgroundOver the past decades the use of assisted reproduction technology (ART) increased worldwide. ARTs are associated with an elevated risk for cardiovascular complications. However, a potential relation between subfertility/ARTs and the heart disease peripartum cardiomyopathy (PPCM) has not been systematically analyzed yet.MethodsA retrospective cohort study was carried out, including n = 111 PPCM patients from the German PPCM registry. Data from PPCM patients were compared to those from postpartum women in the German general population.ResultsThe prevalence of reported subfertility was high among PPCM patients (30%; 33/111). Most of the subfertile PPCM patients (55%; 18/33) obtained vitro fertilizations (IVF) or intracytoplasmic sperm injections (ICSI). PPCM patients were older (p < 0.0001), the percentage of born infants conceived by IVF/ICSI was higher (p < 0.0001) with a higher multiple birth (p < 0.0001), C-section (p < 0.0001) and preeclampsia rate (p < 0.0001), compared to postpartum women. The cardiac outcome was comparable between subfertile and fertile PPCM patients. Whole exome sequencing in a subset of n = 15 subfertile PPCM patients revealed that 33% (5/15) carried pathogenic or likely pathogenic gene variants associated with cardiomyopathies and/or cancer predisposition syndrome.ConclusionsSubfertility occurred frequently among PPCM patients and was associated with increased age, hormonal disorders, higher twin pregnancy rate and high prevalence of pathogenic gene variants suggesting a causal relationship between subfertility and PPCM. Although this study found no evidence that the ART treatment per se increases the risk for PPCM or the risk for an adverse outcome, women with subfertility should be closely monitored for signs of peripartum heart failure.Graphical abstract

Mode of Delivery and Incidence of Bronchopulmonary Dysplasia: Results from the Population-Based EPICE Cohort

Introduction: Bronchopulmonary dysplasia (BPD) represents a tremendous disease burden following preterm birth. The strong association between compromised gas exchange after birth and BPD demands particular focus on the perinatal period. The mode of delivery can impact on lung fluid clearance and microbial colonization, but its impact on BPD and potential trade-off effects between death and BPD are not established. Methods: A total of 7,435 live births (24+0 to 31+6 weeks postmenstrual age) in 19 regions of 11 European countries were included. Principal outcomes were death and BPD at 36 weeks. We estimated unadjusted and adjusted associations with mode of delivery using multilevel logistic regression to account for clustering within units and regions. Sensitivity analyses examined effects, taking into consideration regional variations in C-section rates. Results: Compared to vaginal delivery, delivery by C-section was not associated with the incidence of BPD (OR 0.92, 95% CI: 0.68–1.25) or the composite outcome of death or BPD (OR 0.94, 95% CI: 0.74–1.19) after adjustment for perinatal and neonatal risk factors in the total cohort and in pregnancies for whom a vaginal delivery could be considered. Sensitivity analyses among singletons, infants in cephalic presentation, and infants of ≥26+0 weeks of gestation did not alter the results for BPD, severe BPD, and death or BPD, even in regions with a high C-section rate. Conclusions: In our population-based cohort study, the mode of delivery was not associated with the incidence of BPD. The intention to reduce BPD does not justify a C-section in pregnancies where a vaginal delivery can be considered.

P300 Comparison of birth rates, gestational diabetes and non-standard maternal deliveries between Takayasu arteritis patients and the England and Wales population

Abstract Background/Aims Takayasu arteritis (TAK) is a chronic, inflammatory vasculitis of the aorta and primary branches, particularly prevalent in women of childbearing age. We studied pregnancy outcomes for women with TAK compared to the general population. Methods All people in England with an ICD-10 diagnostic code for TAK 1997/98 to 2020/21 were identified from Hospital Episode Statistics (HES) using National Congenital Abnormality and Rare Disease Registration Service (NCARDRS) data (CAG 10-02(d)/2015). To improve precision of estimated date of diagnosis, we used an English hospital case register of 122 TAK patients. We analysed all HES admissions occurring after their clinician-confirmed diagnosis date and before their first TAK ICD code in HES to identify codes which indicated likely TAK-related activity, and then applied these to the whole NCARDRS cohort. Maternity-related ICD-10 and OPCS-4 code admissions after the estimated diagnosis date were extracted and age-specific values were calculated for number of births, TAK patient years and birth rates. ONS published national data was used for comparison. Results We identified 1,437 people with TAK. Between 2001 and 2021, there were 133 babies born (129 singleton, 2 twin births, no stillbirths) to 85 mothers. Mean maternal age at first delivery was 32.2 years (SD 5.3, median 33.2), above the UK mean of 27.8, with age-specific birth rates compared to the 2019 general population (see table). Overall birth rate in women with TAK was 68% of the national England/Wales rate. Gestational diabetes (GDM) was present in 13/131 (9.9%) but large variation in UK prevalence estimates makes national comparison difficult. Mothers with GDM had a median age of 37 and delivery was by C-section in 9/13 cases. For non-GDM, 50% (95% CI: 41%, 59%) were C-section; this is significantly higher than the UK level of 26%. 12% were vacuum and/or forceps assisted deliveries, approximately equal to the general population. Conclusion The birth rate in women with TAK is lower than the general population and C-section rates higher. Causes are complex and might include patient choice, reduced fertility related to cytotoxic treatment, or physician recommendation, highlighting the importance of equitable access to specialist pre-conception counselling for people with rare autoimmune diseases. Disclosure D.J. Groves: None. M. Rutter: None. P.C. Lanyon: None. M. Odingo: None. M.J. Grainge: None. M. Bythell: None. J. Aston: None. S. Stevens: None. J.R. Hannah: None. J. Mason: None. F.A. Pearce: None.

Estimating c-section coverage: Assessing method performance and characterizing variations in coverage

BackgroundCesarean section (c-section) is an essential tool for preventing, stillbirths, maternal, and newborn death. However, data on coverage of medically necessary c-section is limited in low- and middle-income settings.MethodsWe estimated national c-section coverage using household survey data from 98 low- and middle-income countries. To disaggregate elective and medically necessary c-sections, we estimated the proportion of women in each survey wealth quintile who gave birth via c-section assuming a denominator that 12.5% of births necessitate a c-section delivery. We capped stratum coverage at 100%. We estimated national c-section coverage weighting for the proportion of births occurring in each wealth quintile. We examined 1) variation in estimated c-section by wealth quintile, national income classification, and stage in the obstetric transition, 2) how varying definitions impact the classification of countries' access to c-section, and 3) correlation between c-section and related mortality outcomes.ResultsBoth increasing national and household wealth are associated with increasing levels of c-section coverage and c-section rate. C-section coverage was highly inequitable by wealth within a country. Differentials in coverage were most pronounced in countries with c-section rates below 10%; however, some countries showed significant gaps in c-section coverage in poor subpopulations despite high c-section rates nationally. The choice of indicator and threshold altered whether a country was classified as having adequate access to c-section services. C-section coverage estimates showed a stronger relationship with closely related health outcomes than national c-section rates.ConclusionsGenerating estimates of c-section coverage is crucial for gauging gaps in c-section access. Our approach for calculating c-section coverage using stratification by wealth to adjust for potential elective c-sections is supported by the strong correlations between household wealth and subnational c-section rate, and the association between our coverage estimates and health outcomes at a national level. Looking at national c-section rates alone may paint an inaccurate picture of c-section access and mask subnational inequities in coverage. The need to accurately measure access to c-section will continue to increase as growth in LMICs drives inequities in coverage and introduces dual concerns related to c-section overuse in some populations while others lack access to care.

Estimating the differences in Caesarean section (C-section) rates between public and privately insured mothers in Florida: A decomposition approach.

BackgroundCaesarean section (C-sections) is a medically critical and often life-saving procedure for prevention of childbirth complications. However, there are reports of its overuse, especially in women covered by private insurance as compared to public insurance. This study evaluates the difference in C-Section rates among nulliparous women in Florida hospitals across insurance groups and quantifies the contribution of maternal and hospital factors in explaining the difference in rates.MethodsWe used Florida’s inpatient data provided by the Florida Agency for HealthCare Administration (FLAHCA) and focused on low-risk births that occurred between January 1, 2010, and September 30, 2015. A Fairlie decomposition method was performed on cross-sectional data to decompose the difference in C-Section rates between insurance groups into the proportion explained versus unexplained by the differences in observable maternal and hospital factors.ResultsOf the 386,612 NTSV low-risk births, 72,984 were delivered via C-Section (18.87%). Higher prevalence of C-section at maternal level was associated with diabetes, hypertension, and the expectant mother being over 35 years old. Higher prevalence of C-section at the hospital level was associated with lower occupancy rate, presence of neonatal ICU (NICU) unit and higher obstetrics care level in the hospital. Private insurance coverage in expectant mothers is associated with C-section rates that were 4.4 percentage points higher as compared to that of public insurance. Just over 33.7% of the 4.4 percentage point difference in C-section rates between the two insurance groups can be accounted for by maternal and hospital factors.ConclusionsThe study identifies that the prevalence of C-sections in expectant mothers covered by private insurance is higher compared to mothers covered by public insurance. Although, majority of the difference in C-Section rates across insurance groups remains unexplained (around 66.3%), the main contributor that explains the other 33.7% is advancing maternal age and socioeconomic status of the expectant mother. Further investigation to explore additional factors that explain the difference needs to be done if United States wants to target specific policies to lower overall C-Section rate.

Gestational diabetes prevalence and outcomes in women undergoing assisted reproductive techniques (ART)

Infertility affects millions worldwide and use of assisted reproductive techniques (ART) is in high demand. AimsTo investigate whether women that underwent ART at our hospital had a higher incidence of GDM than women who conceived spontaneously, if the ART subtype affects the GDM rate and to study obstetrical outcomes in women with GDM in both groups. MethodsThis was a retrospective analysis of prospectively collected data of singleton pregnancies attended at Hospital Universitari Dexeus between 2008 and 2019. Age<18 years, pregestational diabetes, metformin prior to pregnancy and multiple pregnancies were excluded. ResultsA total of 29,529 patients were included. Pregnancy was achieved by ART in 2596 (8.8%): in vitro fertilisation (IVF/ICSI) 32.8%, frozen embryo transfer (FET) 37.7%, oocyte donor receptors (ODR) 17.2% and insemination 12.2%. The GDM rate was 8.9% (12.7% in ART vs 8.5% in non-ART, p<0.001). The GDM was 11.2% in IVF/ICSI, 17.7% in ODR, 13% in FET and 9.1% in the insemination group (p=0.001). In a multivariable analysis adjusting for age, parity and BMI, ART was not associated with GDM [OR 1.03 (0.90–1.19)], nor was type of ART. Pregnancy outcomes in GDM patients were similar in both groups except for C-section rates (30.0% in ART vs 15.9% in non-ART (p<0.001). ConclusionsDespite a higher prevalence of GDM in ART pregnancies, ART was not associated with an increased risk of GDM when adjusting for age, parity and BMI. The prognosis of GDM in ART and non-ART was similar except for C-section rates.

The Differential Effects of Malpractice Reform: Defensive Medicine in Obstetrics

Abstract Recent studies argue that different types of patients are affected differently by changes in malpractice pressure. We argue that defensive medicine causes these differential effects. Our theoretical model predicts that reduced malpractice pressure decreases health care spending among patients with good access to care, but increases spending among those with poor access. We test this theory by estimating the effects of tort reforms on birth by cesarean section. Reduced malpractice pressure through collateral source rule reform decreases C-section rates by 4.75% for mothers with timely initiation of prenatal care. On the other hand, reduced pressure through noneconomic damages caps increase C-section rates by 7.59% for mothers without timely initiation. These findings are consistent with defensive medicine. Further investigation suggests that reduced pressure improves access to care for vulnerable populations and reduces utilization among well-served consumers. These findings explain the literature’s conflicting assessments of defensive medicine, despite its practice being widespread.

Cesarean section rate and outcomes during and before the first wave of COVID-19 pandemic.

Objectives:The objective of the study was to assess how the current COVID-19 pandemic has affected cesarean section (C-section) rates, indications, and peripartum outcomes.Methods:This was a retrospective cross-sectional study that compared a 3-month rates of and indications for C-sections at three tertiary health care institutions in Nigeria before (October 2019–December 2019) and during the first wave of COVID-19 pandemic (March 2020–May 2020). Primary outcomes were C-section rate and indications between the two periods. Data were analyzed using SPSS 26.0 IBM Corporation. Rates and odds ratios with 95% confidence intervals were used to quantify indications and peripartum outcomes and statistical significance was accepted when p value was <0.05.Results:The baseline characteristics of the two groups were similar. The C-section rate during the COVID-19 period was significantly less than the period prior to the pandemic (237/580, 40.0% vs 390/833, 46.8%; p = 0.027). The rates of postdatism (odds ratio = 1.47, 95% confidence interval = 1.05–2.05, p = 0.022), fetal distress (odds ratio = 3.06, 95% confidence interval = 1.55–6.06, p = 0.017), emergency C-section (odds ratio = 1.43, 95% confidence interval = 1.01–2.05, p = 0.042), and anemia (odds ratio = 1.84, 95% confidence interval = 1.12–3.03, p = 0.016) were significantly higher during the pandemic than prepandemic.Conclusion:The overall C-section rate during the first wave of COVID-19 was significantly lower than the prepandemic period. There were higher rates of postdatism, fetal distress, emergency C-section, and postpartum anemia. Further studies on this changing C-section trend during the pandemic are needed.

Obstetric interventions in a maternity hospital with a collaborative model of care: a comparative observational study.

Collaborative models (CM) focused on intrapartum care shared between both midwives and obstetricians have been proposed as a strategy to reduce these rates. Our aim was to compare use of evidence-based practices, obstetric interventions and c-section rates in two settings: a maternity hospital that applies a CM of care (MRJ) and data from a pool of maternity hospitals included in the Birth in Brazil Survey (NB) that do not adopt a CM. Data was abstracted from medical and administrative records in MRJ and from medical records and face-to-face interviews in NB. Differences were compared using chi-square test, with significance level set at p<0.05. MRJ showed a higher frequency of labour companionship, labour care provided by nurse midwives, non-pharmacological pain relief methods, food intake during labour, and less use of oxytocin, analgesia and amniotomy. More women also had second stage assisted by a nurse midwife and in a vertical position, as well as lower use of episiotomies and vacuum-extractor/forceps. The c-section rate was lower at MRJ. Shared care between midwives and obstetricians can be an effective strategy to improve quality of intrapartum care.

Unnecessary Cesarean Section Delivery Causes Risk to Both Mother and Baby: A Commentary on Pregnancy Complications and Women's Health.

In Bangladesh, 3.6 million babies are born each year. But the country is now facing a quickly rising rate of cesarean section (C-section) utilization. Here about 50% of total deliveries are institutional. Among them, two-thirds are in private care facilities, where the rate of C-sections is very high (83%). The present C-section rate is 2.5 times higher than in the previous decades. In Bangladesh, many physicians from private facilities are recommending C-section regardless of the mother’s physical condition and the position of the fetus. Therefore, mothers are more likely to choose C-section delivery who receive antenatal care from a private facility. Moreover, several socio-economic and demographic factors might be responsible for these increased C-section deliveries. Also, many private hospitals prefer C-section delivery due to their profit-making tendency. The unnecessary C-section delivery causes risk to both mother and baby Also, the high prevalence of C-section in Bangladesh is putting women’s health at risk. Therefore, the government healthcare authorities should ensure proper utilization of C-section facilities and encourage people for normal births at any health facility. Also, they can develop a national guideline for the use of C-sections and normal delivery depending on the physical condition of the mother and fetus.

Perinatal Outcomes of Using Ursodeoxycholic Acid to Treat Monochorionic and Dichorionic Twin Pregnancy Complicated by Intrahepatic Cholestasis of Pregnancy

To study the effect of using ursodeoxycholic acid (UDCA) to treat monochorionic and dichorionic twin pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP) and to examine the differences in perinatal outcomes. A total of 406 twin-carrying pregnant women who had ICP and received care at West China Second Hospital, Sichuan University between January 1, 2015 and November 1, 2018 were included in the study. The clinical data of monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twins with ICP were analyzed. Analysis was done to compare the treatment effect for lowering serum total bile acid (TBA) and the perinatal outcomes with simple UDCA medication or combination medication. There were no statistically significant differences in TBA levels, early-onset ICP, simple UDCA medication or combination medication, neonatal Apgar score, birth weight, length of hospital stay, C-section rate, and perinatal mortality between the MCDA and the DCDA twin groups with ICP. However, maternal age, BMI, scarred uterus, in vitro fertilization-embryo transfer, preeclampsia, twin comorbidity rate of the two groups showed statistical differences. Further comparison between twin pregnancies with mildly-elevated TBA and those with severely-elevated TBA showed significant difference in preterm birth rate ( P<0.05). Simple UDCA medication or combination medication may have the same therapeutic effect on MCDA and DCDA twin pregnancies with ICP. Monochorionic twin pregnancy, twin comorbidities and pregnancy complications were still important factors affecting pregnancy outcomes of twin pregnancies with ICP. Twin pregnancies with slightly elevated TBA have been managed as severe ICP, which may be associated with increased iatrogenic preterm births.

The Impact of Large Financial Incentives on C-Section Rates: Evidence from Iran

The Impact of Large Financial Incentives on C-Section Rates: Evidence from Iran

A Study on Factors Associated with Caesarean Section Delivery at Tangail District of Bangladesh

<i>Background and Objectives</i>: Caesarean section or C-section is a major obstetric life-saving intervention that has a substantial effect on maternal and neonatal health. This study sought to explore factors associated with increasing C-section rate at Tangail district in Bangladesh. <i>Materials and Methods</i>: A cross-sectional survey was conducted using a structured questionnaire at different hospitals and clinics in Tangail among 200 women who underwent cesarean. For analyzing the factors of C-section, the explanatory variables were demographic and anthropometric data, pre-pregnancy history, pregnancy period and delivery information. <i>Results</i>: The common medical indicators for C-section were prolonged labor (21%), fetal distress (19%), previous C-section (13%), amniotic rupture (12.5%), abnormal presentation of the baby (12%), uterine rupture (8.5%), failed labor induction (7.5%) and eclampsia/hypertension (3%). The majority (49.5%) of C-section was performed because of maternal request, 34% were emergency and 16.5% were elective. Majority of the respondents showed neutral (46%) to negative (51%) mindset towards C-section. C-section decision making influences included family pressure (25%), afraid of labor pain (11.5%), mother’s health risk (15%), baby’s health risk (38.5%), both mother and baby’s health risk (19.5%), presence of medical complications (62%), respondent’s choice (23%), doctor’s preference (5%), other related reasons (10%). <i>Conclusions</i>: It is concluded that a combination of both medical and non-medical factors is associated with C-section delivery.

Abdominal wall endometriosis: Case-series study and a systematic review

Abdominal wall endometriosis (AWE) is the presence of endometrial gland and stroma in the abdominal wall that should be kept in mind in differential diagnosis of pelvic pain due to especially increased C-section rates. Between January 2000 and July 2018, MEDLINE and EMBASE databases were systematically reviewed using the search criteria "abdominal wall endometriosis," "abdominal wall endometriomas,”. Only the studies having over 20 patients were included. Case-series, case-control studies, and articles in languages other than English were excluded. Number of the patients, patients ‘age, study design, previous surgical history, most common symptom, time interval to symptoms, treatment, recurrence rate, and tumour size were investigated. In Total, 18 studies and 994 women were included in the study. Case studies, studies with less than 20 cases, non-English articles were excluded from the study. In the included studies, the numbers of minimum and maximum woman were 20 and 227, respectively. AWE significantly impairs the quality of life in reproductive age patients and is commonly seen in women with previous history of laparotomy, especially those who underwent cesarean section. Therefore, it must be kept in mind in the differential diagnosis of women who have a history of pain and a history of previous surgery.

Use of Modified Robson Criteria for an audit of Caesarean Section at a Tertiary Care Hospital

Objective: To find out the incidence of C-Section rate and reducing it after auditing by use of Modified Robson Criteria. Methodology: This study was conducted by collecting data prospectively. All C-Sections were classified according to Modified Robson Criteria in 12 Groups after modification. Calculations were made as size of each group, rate of C-Section and contribution of each group. Audit of C-Section carried out after first six months, and then strategies were made to reduce the rate, which was implemented. Re-audit was carried out after six months, thus completing the audit cycle. Frequency and percentage were calculated by data analysis using Excel 2010 Result: C-Section rate was 51.54% initially then re-audit showed a reduced rate of 39.74%. Maximum contribution 26.05% to total C-Section rate was made by group 5 which was reduced to 20.04% in re-audit. While 11.48% was contributed by group12 which was reduced to 8.44% in re-audit. Conclusion: Modified Robson Criteria is an effective tool for the audit of C-section. It also allow us for exact identification of area for improvement and making modification of clinical practice to reduce C-Section rate Keywords: C-Section rate, Modified Rosbson Criteria, Clinical Audit and Re-Audit.

Accounting for the Rising Caesarean Section Rate in Canada: What Are the Roles of Changing Needs, Practices, and Incentives?

In most high-income countries, including Canada, the share of births by Caesarean section (C-section) has risen over the past decades to far exceed World Health Organization recommendations of the proportion justified on medical grounds (15 percent). Although unnecessary C-sections represent an important cost for health care systems, they are not associated with clear benefits for the mother and the child and can sometimes represent additional risks. Drawing on administrative records of nearly four million births in Canada, as well as macro data from the United States and Australia, we provide a comprehensive account of rising C-section rates. We explicitly consider the contributions of the main factors brought forward in the policy literature, including changing characteristics of mothers, births, and physicians as well as changing financial incentives for C-section deliveries. These factors account for at most one-half of the increase in C-section rates between April 1994 and March 2011. The majority of the remaining increase in C-sections over the period occurred in the early 2000s. We suggest that some event or shock in the early 2000s is likely the primary determinant of the recent strong increase in the C-section rate in Canada.