Elective Cesarean Research Articles

Audit of massive obstetric haemorrhage in southmead hospital using modified Scottish confidential audit of severe maternal morbidity (SCASMM) data collection tool: Nov 2010 – OCT 2011

To fulfil both risk management and CNST, we audit all haemorrhage >2000ml identified through EuroKing, against our departmental guideline, in a monthly multidisciplinary risk meeting (including laboratory staff). A modified...

The association of prenatal attachment and perinatal factors with pre- and postpartum depression in first-time mothers

This prospective study investigated associations between prenatal attachment of adult first-time mothers to the unborn child, perinatal factors and levels of depression before and up to 18 months after delivery. Primiparas (N = 161) without specific risk factors answered the following questionnaires during the last term of pregnancy (t1): Edinburgh Postnatal Depression Scale (EPDS), Maternal Antenatal Attachment Scale (MAAS), questionnaire on the schema of the unborn child, and a questionnaire about the pregnancy. Perinatal data were taken from the patients' files. The EPDS was answered 3 weeks (t2, N = 157), 6 months (t3, N = 159), and 18 months (t4, N = 132) postpartum. During pregnancy, 16.9 % of the women indicated mild depressive symptoms, and 7.5 %, medium to severe symptoms of depression. Mild symptoms of depression were found in 25.5 % at t2, 10.1 % at t3, and 12.2 % at t4; medium to severe symptoms were reported by 7.6, 1.9 and 5.6 %, respectively. Women with low control during delivery (emergency Caesarean) showed a tendency for higher levels (p = 0.067) of depression at t3 than women with elective Caesarean did. The quality of prenatal attachment to the unborn child correlated negatively with depressive symptoms at t1-t4. The closer the prenatal attachment of a mother to her unborn child, the less symptoms of depression she reports during the last term of pregnancy and postpartum. Therefore, promoting good mother-child attachment during pregnancy might influence the level of postpartum depression.

Effect of ropivacaine administered intrathecally on pulmonary function after caesarean section

Objective To investigate the effect of ropivacaine administered intrathecally on the pulmonary function after caesarean section.Methods Thirty-six ASA Ⅰ or Ⅱ parturients,aged 22-34 yr,with body mass index ≤35 kg/m2,undergoing elective cesarean section,were randomly divided into 2 groups (n=18 each):bupivacaine group (group B) and ropivacaine group (group R).Spinal anesthesia was performed at L3,4 interspace and 0.5％ bupivacaine 1.8 ml (in cerebrospinal fluid 3 ml) and 1.0％ ropivacaine 1.4 ml (in cerebrospinal fluid 3 ml) were injected into the subarachnoid space over 10 s in groups B and R respectively.Forced vital capacity (FVC),forced expiratory volume first second (FEV1) and peak expiratory flow (PEF) were measured by spirometry before surgery (T0),and at 1,1.5 and 2 h after intrathecal injection (T1-3).The motor block score was recorded at T1-3.It is regarded as the criteria for respiratory dysfunction that the measured values of FVC and FEV1 are lower than their 80 ％ and 70 ％ predicted levels respectively.Results FVC and FEV1 were significantly decreased at T1 compared with the baseline value at T0 in both groups (P＜0.05).Compared with that at T1,PEF was significantly increased at T2,3 in group R (P ＜0.05).Compared with group B,PEF at T1 and motor block score atT3 were significantly decreased in group R (P＜0.05).The respiratory dysfunction was not found in both groups.Conclusion Spinal anesthesia with ropivacaine and bupivacaine can inhibit the parameter level of carly pulmonary function afrer caesarean section in parturient without respiratory complications,but the pulmonary function still remains normal. Key words: Amides; Bupivacaine; Subarachnoid space; Cesarean section; Respiratory function tests

Application of clinical pathway in health education in elective Caesarean section

Objective To investigate the value of clinical pathway in health education in elective Caesarean section.Methods 100 pregnant women undergoing elective Cesarean section were randomly divided into clinical pathway group and control group.Length of hospital stay,medical costs,level of health knowledge, and patient satisfaction with medical services.Results The clinical pathway group was superior to the control group in length of hospital stay,medical costs,level of health knowledge,and patient satisfaction with medical services.Conclusions Health education by using clinical pathway can increase levels of health knowledge and patient satisfaction with medical services,and shorten length of hospital stay,and lower medical costs. Key words: Elective Caesarean section; Clinical pathway; Health education

Association Between Mode of Birth and Self-Reported Maternal Physical and Psychological Health Problems at 10 Weeks Postpartum

AIM:To determine the association between mode of birth and physical and psychological health problems reported at 10 weeks postpartum.METHODS:A cross-sectional, self-report survey was completed by 2,699 Western Australian women at 10 weeks postpartum. Information on birth mode and physical and psychological health was sought. Descriptive statistics and frequency distributions were performed to describe the sample. Logistic regression was used to determine the association between mode of birth and the reported number of physical health problems (two or more and three or more) and two psychological health problems.RESULTS:The occurrence of physical health problems for all women were incontinence (11.5%), no bowel control (2.6%), backache (41%), heavy bleeding (14.1%), and excessive fatigue or tiredness (35.7%). A significant association was found between all cesarean sections (elective and emergency) and the number of physical health problems compared to spontaneous vaginal births. Women who had an emergency cesarean were most likely (OR= 3.15, CI = 2.40–4.13,p< 0.0005) to report two or more physical problems, whereas women who had an elective cesarean were more likely (OR= 2.75, CI = 2.08–3.63,p< 0.0005) to report three or more physical problems.Nearly 15% of women reported being unhappy for more than a few days. This was highest in women having an emergency cesarean (16.4%) and lowest in women giving birth spontaneously (13.5%). Some 6.4% of women stated they were constantly reliving negative thoughts of birth and/or labor. Women who had an emergency cesarean were more likely (OR= 3.10, CI = 1.96–4.89,p< 0.0005) to choose this item and they were also more likely (OR= 2.04, CI = 1.01–4.13,p< 0.047) to experience both psychological health items.CONCLUSION:Women’s reports of health problems within the first 10 weeks postpartum are concerning and warrant ongoing attention. The prevalence of health problems was higher in women who had experienced a cesarean. This information on morbidity postbirth is essential for women and their care providers in making informed decisions around available birth options.

Twin Gestation in a Septate Bicornuate Uterus

Bicornuate and septate uteri are among the commonest Mullerian anomalies. They are sporadic and fairly distinguished, but hybrid deformities can occur. This combination creates aetiological and clinical difficulties. The alternative theory of concurrent fusion and septal resorption of the Mullerian duct is seen as the basis of the altered foetal embryology, while the favourable outlook of a bicornuate uterus may be offset by the suboptimal implantation across the avascular septum. Obstetric care is based on empirical interventions deduced from case series, with varied and inconsistent outcomes. We present a 32-year-old primipara with a dizygotic twin gestation in separate compartments of a septate bicornuate uterus. She had an elective bilateral caesarean delivery at term with an accidental septal resection for morbidly adherent placenta. Although a summation of obstetric risks is a possibility, an excellent outcome was observed.

681: The MFMU Cesarean Registry: cost-effectiveness of a trial of labor compared with an elective repeat cesarean delivery after a previous cesarean in a minimally biased cohort

of a trial of labor compared with an elective repeat cesarean delivery after a previous cesarean in a minimally biased cohort Sharon A. Gilbert For the Eunice Kennedy Shriver National Institute of Child Health and Human Development, MaternalFetal Medicine Units Network, Bethesda, MD OBJECTIVE: To determine the most cost-effective strategy for women eligible for a trial of labor (TOL) with one prior cesarean delivery and balanced baseline characteristics. STUDY DESIGN: We developed a decision analysis model comparing TOL after one prior cesarean with an elective repeat cesarean delivery (ERCD) for a hypothetical cohort of 100,000 women with no contraindication to a TOL. To derive probability estimates, a group of women who underwent either TOL or ERCD were selected from a 1999-2002 prospective study. The final probabilistic estimates were obtained from women who underwent TOL or ERCD and were selected by propensity score analysis as being matched according to their baseline characteristics. Cost data were obtained from national databases and included hospital, obstetrician, pediatrician, and anesthesiologist costs as well as opportunity costs of the mother and a caregiver. Quality adjusted life-years (QALYs) were obtained from the literature. Probability, cost and QALY data for the outcome of cerebral palsy were obtained from the literature as well. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY. RESULTS: According to baseline estimates, the TOL strategy dominated the ERCD strategy, with $142.4 million saved and 1793 QALYs gained per 100,000 women. The model was sensitive to five variables (table). Bivariable analysis on the probability of successful TOL and uterine rupture indicated when the probability of success was at the base value, 68.5%, TOL was preferred if the probability of rupture was 4.6% or less (graph). When uterine rupture was at the base value, 0.8%, TOL was preferred if the probability of successful TOL was 40.8% or more. CONCLUSION: A TOL after one prior cesarean is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics; these results are sensitive to five variables, which need to be considered in cost-effective assessment. www.AJOG.org Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health PosterSessionIV

29: The MFMU cesarean registry: propensity score analysis for bias reduction in comparing elective repeat cesarean delivery with trial of labor after a previous cesarean

Checklist (CBCL). The ASQ is designed to detect developmental delay and the CBCL is a standardized parental report of children’s behavior. We compared the number of children with an abnormal outcome in both arms, as well as the effect of perinatal morbidity, morbidity assessment index for newborns (MAIN score), gestational age at birth and birth weight on long-term outcome. Perinatal morbidity was defined as a 5 minute Apgar score 7, umbilical arterial pH 7.05 or NICU admission. The MAIN score is a validated numeric index of early neonatal outcomes. RESULTS: We approached 488 (75%) of the 660 parents of children randomized in the trial. The response rate was 60%. 27% and 14% of the children had an abnormal score on the ASQ and CBCL, respectively (Table 1). Results of the questionnaires were comparable for both interventions. However, poor neonatal condition after birth and the MAIN score both strongly increased the chance of an abnormal ASQ score (Odds Ratios of 18 (95% CI 1.5-212, p 0.02) and 1.005 (95% CI 1.002; 1.005, p 0.01), respectively). We found no association between birth weight or gestational age at birth and the outcome of the ASQ or CBCL. CONCLUSION: In women with IUGR at term, a policy of induction of labor does not affect developmental and behavioral outcome when compared to expectant management. However, in both policies adverse neonatal outcome and MAIN score (corrected for other possible variables) both have negative effects on the outcome on the long-term child development.

Antenatal Corticosteroids at the Beginning of the 21st Century

Corticosteroids administered to women in preterm labor are the standard of care for reducing neonatal morbidity and mortality associated with prematurity. These agents promote lung development and reduce the incidence of neonatal intraventricular hemorrhage. Several studies have investigated the method by which fetal lung fluid is cleared after birth. This exploration resulted in the elucidation of the Starling equation or the hypothesis that fluid filtration through capillary membranes is dependent on the balance between the pressure blood places on the capillary membranes and the osmotic pressure of the membranes. The clinical observation that a neonate experiences a vaginal squeeze during a vaginal birth may be important, but it can account for only a small percentage of the lung fluid absorbed. Perhaps more importantly, amiloride-sensitive sodium transport channels (ENaCs) have emerged as key factors in the movement of alveolar fluid from the lung into the vascular system. Several potential clinical applications have been developed from this new knowledge about the physiology of lung fluid clearance at birth. Neonates born late preterm or at term by elective cesarean before the onset of labor are more likely to develop respiratory distress than those born vaginally. Based on the mechanism of action of antenatal corticosteroids, these drugs may be beneficial in the clearance of fetal lung fluid in this population. This article reviews how fetal lung fluid is cleared; the pharmacologic effects of corticosteroids on the fetus; and the risks, benefits, and controversies associated with corticosteroid use.

Maternal prenatal anxiety and downregulation of placental 11β-HSD2

Raised maternal anxiety during pregnancy is associated with increased risk of adverse neurodevelopmental outcomes for her child. The mechanisms underlying this are not known but animal studies suggest prenatal stress may alter the function of the placenta. Here we determined whether maternal prenatal anxiety was associated with a downregulation of placental 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2), the enzyme which metabolises cortisol. We recruited mothers the day before delivery by elective caesarean, and gave them the Spielberger Trait and State anxiety and Edinburgh Depression self-rating scales. Placentae were collected and aliquots stored for later analysis. Prenatal Trait anxiety was negatively correlated with placental 11β-HSD2 mRNA expression (r=-0.40, p<0.01, n=56). Results were similar with male and female fetuses (r=-0.39, p=0.04, n=28; r=-0.40, p=0.03, n=28) respectively. Results were also significant with State anxiety (r=-0.27, p=0.05, n=56) but somewhat weaker for depression (r=-0.20, p=0.13, n=56). Preliminary analyses on a subset of cases (n=25) suggested parallel results for enzyme activity. These findings provide evidence for an association between prenatal maternal mood and downregulation of placental 11β-HSD2. Results are consistent with raised maternal anxiety being associated with increased fetal exposure to maternal cortisol, and support the hypothesis that this may be one mechanism underlying fetal programming by prenatal stress.

The Over Roofing Rates of Caesarean Section

The Over Roofing Rates of Caesarean Section

Generation of induced Pluripotent Stem Cells from Human Amnion Epithelium

Generation of induced Pluripotent Stem Cells from Human Amnion Epithelium

Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

Effect of parecoxib on efficacy of epidural analgesia with different doses of morphine after cesarean section

Objective To evaluate the effects of parecoxib on efficacy of patient-controlled epidural analgesia(PCEA) with different doses of morphine after cesarean section.Methods Three hundred ASA Ⅰ or Ⅱ parturients at full term aged 20-40 yr weighing 54-89 kg undergoing elective cesarean section were randomly divided into 3 morphine groups-regular,median and small dose (groups Ⅰ,Ⅱ[ and Ⅲ) ( n ＝ 100 each).Each group was further divided into 2 subgroups ( n ＝ 50 each):parecoxib group (groups P1.2.3 ) and control group (groups C1,2.3 ).In groups P1.2.3 psrecoxib 40 mg was administered iv at the end of operation while in groups C1.2.3 normal saline (NS) was administered instead of parecoxib.Groups Ⅰ,Ⅱ and Ⅱ received a loading dose of morphine 2.0/1.5/1.0 mg+ 0.15％ ropivacaine 8 ml respectively.The PCEA solution contained morphine 3.0/2.0/1.5mg+ ropivacaine 150 mg + granisetron 3 mg+ dexamethasone 5 mg in 100 ml of NS in groups Ⅰ,Ⅱ,and Ⅲ respectively.PCEA pump was set up with a background infusion of 2 ml/h,and a bolus dose of 0.5 ml with a lockout-interval of 15 min.VAS was used to assess intensity of pain (0 ＝ no pain,10 ＝ worst pain).VAS score ≤4 was considered as effective analgesia.Adverse effects including nausea and vomiting and pruritus were recorded.Results There was no significant difference in the rate of effective analgesia between groups P1,P2 and C1,C2 The rate of effective analgesia during movement was significant higher in group P3 than in group C3.The incidence of nausea and vomiting and pruritis were significantly lower in group P3 than in groups P1 and P2.Conclusion Parecoxib can enhance the efficacy of PCEA with small dose of morphine. Key words: Cyclooxygenase inhibitors; Morphine; Pain,postoperative; Analgesia,epidural; Cesarean section

Obstetric conditions and risk of first ever mental health contact during infancy, childhood and adolescence

Objectivethe main aim of this study was to investigate whether risk of first ever occasion of outpatient or inpatient service for a mental disorder among male children and adolescents may be associated with obstetric conditions. Design, setting and participantsthis study was a population-based birth-cohort study of males born between 1980 and 1984 in Western Australia (WA). Males were identified using birth registry records and followed-up over a 19 year period using linked health data available through the Western Australian Data Linkage System. Measurementsmultivariate logistic regression was employed to estimate the risk of first ever mental health contact at different stages of mental development in childhood and adolescence. Main findingsvacuum and forceps assisted delivery and emergency caesarean were associated with an increased risk of first ever mental health contact. The risk of first ever mental health contact was similar for spontaneous vaginal delivery and elective caesarean. Although outcomes varied by age group, children with stillborn siblings were at increased risk of first ever mental health contact as were babies with 7–9 Apgar score at 5mins and those born to mothers with several previous live births. Conclusions and implicationsvacuum and forceps assisted delivery and/or the pathophysiological causes that lead to these clinical procedures, as well as other obstetric conditions, which may be associated with (asymptomatic) brain injury at birth, which may increase the risk of mental disorders.

Recognizing Cesarean Delivery on Maternal Request as a Social Problem

Nearly one in three babies in the United States are now born surgically. While many causes for this surge in cesareans have been suggested, the phenomenon of cesarean delivery on maternal request (CDMR) has been the subject of the most controversy. Utilizing Hilgartner and Bosk's public arenas model, this article examines the ways in which CDMR has been framed and a collective definition of the problem established. Recognizing CDMR as a social problem is the first step to creating policies to ensure that the health and safety of mothers and babies are protected.

Intra-amniotic Infection Upregulates Neutrophil Gelatinase-Associated Lipocalin (NGAL) Expression at the Maternal-Fetal Interface at Term

Neutrophil gelatinase-associated lipocalin (NGAL) is a ubiquitous lipocalin that serves as a critical component of innate immunity and a transport shuttle for numerous substances (retinoids, arachidonic acid, prostaglandins, fatty acids, steroids, iron, and MMPs). Despite the well-documented association between intra-amniotic infection/inflammation (IAI) and preterm birth, NGAL expression in the uterus has not previously been examined. This study investigates NGAL expression at the maternal-fetal interface in vivo and in vitro. Neutrophil gelatinase-associated lipocalin expression in term placenta with/without IAI was examined by immunohistochemistry. Trophoblast and decidual stromal cells were retrieved from elective cesarean, purified, and depleted of leukocytes. On days 1 (cytotrophoblast cells) and 4 (syncytiotrophoblast), cells were stimulated with/without interleukin 1β (IL-1β; 1 ng/mL), tumor necrosis factor α (TNF-α; 1 ng/mL), or lipopolysaccharide (LPS; 1 μg/mL). Neutrophil gelatinase-associated lipocalin messenger RNA (mRNA) and protein expression were measured by immunocytochemistry/Western blot and RT-qPCR, respectively. Under basal conditions, NGAL is expressed in trophoblast, but not decidua. Trophoblast NGAL is significantly upregulated in tissues with evidence of IAI vs controls. NGAL expression was increased after stimulation with all 3 pro-inflammatory mediators in day 1 (cytotrophoblast) but not day 4 cells (syncytiotrophoblast). IL-1β and TNF-α (not LPS) upregulated NGAL gene expression in cytotrophoblast (not syncytiotrophoblast) cells. Intra-amniotic infection/inflammation is associated with increased expression of NGAL in trophoblast tissues in vivo. IL-1β, TNF-α, and LPS stimulated NGAL in cytotrophoblast cells (not syncytiotrophoblast and decidua) in vitro. These data suggest that, in keeping with its role as a mediator of innate immunity, NGAL may have a central role to play in IAI-induced preterm birth.

Median effective dose of intrathecal hyperbaric and hypobaric ropivacaine for cesarean section

Objective To determine the median effective dose (ED50) of intrathecal (IT) hyperbaric and hypobaric ropivacaine for elective cesarean section.Methods Forty parturients aged 20-40 yr at full term undergoing elective cesarean section under combined spinal-epidural anesthesia were randomized to receive IT 0.5 ％ hyperbaric (group HR) and hypobaric ropivacaine (group LR) ( n =20 each).The initial dose was 9 mg and the dose was increased/decreased by 1 mg in the next parturient using an up-and-down sequential allocation technique.Analgesia was considered acceptable if adequate analgesia reached T7 or higher in response to pin prick until 20 min after IT ropivacaine and no supplemental epidural analgesic was required during the operation.ED50 and 95％confidence interval (CI) were calculated.Results The ED50 and 95 ％ CI were 9.34 mg (95 ％ CI 8.34-10.46mg) for 0.5％ hyperbaric ropivacaine and 9.64 mg (95％ CI 8.90-10.44 mg) for 0.5％ hypobaric ropivacaine.Conclusion Baricity has no effect on the efficacy of IT ropivacaine for cesarean section. Key words: Amides; Specific gravity; Anesthesia, spinal; Cesarean section; Dose-response relationship, drug

Expression of growth arrest and DNA damage-inducible 45α and p38 mitogen-activated protein kinase in placentas of women complicated with preeclampsia

Objective To evaluate the expression of Gadd45α and p38 MAPK in placentas and the correlations of Gadd45α protein and serum soluble vascular endothelial growth factor receptor-1 (sFlt-1) and soluble endoglin (sEng) in preeclampsia(PE). Methods Fifty-four pregnant women who delivered from September 2009 to March 2010 in the First Affiliated Hospital of Chongqing Medical University were chosen as the subjects. They were classified into mild preeclampsia group (n=20),severe preeclampsia group (n=16) and the control group (normal pregnant women underwent elective cesarean sections at term without labor and perinatal complications, n=18). Western blot and immunohistochemistry were employed to determine the expression and localization of Gadd45α and p-p38 MAPK protein respectively. Gadd45α mRNA level was determined by quantitative real-time PCR. The levels of seum sFlt-1 and sEng were measured by enzyme-linked immunosorbent assay (ELISA). One-way ANOVA and LSD-t test were applied for statistical analysis. Results (1)Immunohistochemistry identified that the positive stained cells were mostly located in trophoblast cells in normotensive placentas, whereas in preeclamptic placentas Gadd45α protein and p-p38 MAPK protein were detected in trophoblast and endothelial cells, as well as a few stromal cells at increased levels.(2)The mRNA levels of Gadd45α was significantly elevated in mild and severe preeclampsia groups compared to the control group (2.10±0.11 and 3.33±0.13 vs 1.01±0.18, P＜0.05), and Gadd45α mRNA level in severe group was significantly higher than in mild group (P＜0.05).(3)The data of Western blot revealed that the Gadd45α protein levels in each group were 0.22±0.11, 0.65±0.15 and 1.34±0.17, respectively, with significant differences between each group(P＜0.05). The p-p38 MAPK protein levels in each group were 0.32±0.08, 0.72±0.12 and 1.45±0.21, respectively, with significant differences between each group (P＜0.05). p38 MAPK protein levels in the total groups showed no difference(P＞0.05).(4)Compared with the control group, sFlt-1 and sEng concentrations in maternal circulation were significantly increasing in mild and severe preeclampsia groups, and concentrations in severe group were significantly higher than those in mild group (P＜0.05).(5) There were positive correlations between Gadd45α protein levels and the concentrations of serum sFlt-1 and sEng in each group( r=0.88 and 0.87, respectively all P＜0.05). Conclusions Upregulation of Gadd45α in preeclampsia placentas may play an important role in the pathogenesis of preeclampsia. It may induce the increased maternal serum levels of sFlt-l and sEng by activating p38 MAPK signaling pathway, leading to deficient cytotrophoblastic invasion and abnormal placental vascular reconstruction during pregnancy. Key words: Pre-eclampsia; Nuclear proteins; Cell cycle proteins; p38 Mitogen-activated protein kinases; Vascular endothelial growth factor receptor-1; Receptors, cell surface; Antigens, CD

Determinants of patient satisfaction after cesarean delivery at a university teaching hospital in Nigeria

Objectives To assess the prevalence of satisfaction, and associated factors, among parturients who had recently delivered by cesarean. Methods In a descriptive cross-sectional study, women who delivered by cesarean at the University of Benin Teaching Hospital, Nigeria, were enrolled between April and July 2010. A simple, qualitative, semi-structured researcher-administered questionnaire was used for data collection. Data analysis was done via SPSS version 16. Results Among 220 women who delivered by cesarean, 211 women were enrolled in the study and were interviewed 2–5 days after delivery. The mean age was 30.8 ± 5.1 years, and the median parity was 1. An initial negative reaction to the decision for cesarean delivery was reported by 76% of respondents, 19% were indifferent, and 5% reported an initial positive reaction. Satisfaction with delivery by cesarean was reported by 80% of the respondents. Satisfaction with cesarean delivery was significantly associated with age, level of education, initial reaction to the decision for cesarean delivery, and elective cesarean. Conclusion Most parturients expressed overall satisfaction after delivery by cesarean. There is a need for in-depth studies in low-income countries to further evaluate satisfaction with regard to various aspects of the cesarean delivery experience.