Cesarean Section Procedure Research Articles

The relationship between amniotic and newborn gastric fluid inflammatory mediators

Objective: To determine whether the levels of inflammatory mediators in gastric fluid (GF) of a premature newborn are associated with those in amniotic fluid (AF) of the newborn’s mother.Patients: Twenty-three pairs of pregnant women and their premature newborns <35 weeks gestation, born by Cesarean sections.Methods: Amniotic fluids and newborn gastric fluids were obtained from women during Cesarean section procedure. The mother-premature newborn dyads were retrospectively assessed to analyze the clinical and laboratory data. Concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-alpha (TNF-α) and mannose-binding lectin (MBL) were compared between amniotic and newborn gastric fluids in each dyad.Results: Premature newborns and their mothers with funisitis had significantly higher median AF IL-6, TNF-α and GF IL-8 concentrations than those without funisitis (p = 0.022 for AF IL-6; p = 0.023 for AF TNF-α; p = 0.022 for GF IL-8). The concentrations of IL-6, IL-8, TNF-α and MBL in newborn GF were significantly correlated with those in AF in each dyad (p < 0.001, r = 0.872 for IL-6; p < 0.001, r = 0.851 for IL-8; p < 0.001, r = 0.768 for TNF-α; p < 0.001, r = 0.845 for MBL, respectively).Conclusion: The levels of inflammatory mediators in GF of a premature newborn immediately after birth are strongly associated with those in AF of the newborn’s mother.

Validation of a Prediction Model for Predicting the Probability of Morbidity Related to a Trial of Labour in Quebec

Between 2000 and 2006, births by cesarean section (CS) increased from 21.2% to 26.3% in Canada and reached greater than 30% in the United States. A prior CS is the primary indication for greater than 30% of all CS procedures in Canada. The number of CSs could be decreased if more women who could undergo a trial of labor after CS (TOLAC) chose this option. The decision to attempt a TOLAC or to have an elective repeat CS (ERCS) is often made by considering the fear of a repeat failed labor or the odds of developing maternal and neonatal complications with either delivery mode. Grobman’s model, which allows an estimation of the probability of vaginal delivery for women with 1 prior CS undergoing a TOLAC, was developed from 9616 American women experiencing a TOLAC and validated using an independent cohort. Maternal and neonatal morbidity decreased as the predicted chance of vaginal birth after cesarean (VBAC) increased. Morbidity was similar between TOLAC and ERCS when the probability of successful VBAC was 70% or greater. Because the Grobman model has not been validated in a Canadian population and because American and Canadian populations and clinical practices may differ, validation is needed before the prediction model can be used in Canada. The present study was performed to determine whether Grobman’s model for predicting TOLAC success in an American population can predict the probability of morbidity associated with TOLAC in a Canadian population. A perinatal database with 185,437 deliveries from 32 obstetric centers in Quebec was used, and women with 1 prior CS who were eligible for a TOLAC were selected. The probability of VBAC was calculated from the Grobman model, using maternal age, body mass index, history of vaginal delivery, timing of vaginal delivery in relation to the CS, and indication for the prior CS. Major and minor maternal morbidities and newborn morbidities were determined. Women were then categorized by deciles of their predicted probability of VBAC, and the frequencies of maternal and neonatal morbidities between those who underwent TOLAC and those who had ERCS were compared using either the Fisher exact or χ2 analysis. Statistical significance was defined as P < 0.05. Of 8508 women with 1 prior CS, 3113 had a TOLAC (36.6%) and 5395 underwent an ERCS (63.4%). Minor and major maternal morbidity occurred in 1.9% and 1.1%, respectively; the frequency of neonatal morbidity was 5.1%. Maternal and neonatal morbidities became less frequent as the predicted chance of VBAC increased among women who underwent TOLAC (P < 0.05). No comparable trend was apparent among women who had ERCS. When the predicted chance of VBAC was less than 60%, women undergoing a TOLAC were more likely to have morbidity than women who underwent an ERCS (P < 0.05). When the probability of VBAC success reached 60%, this difference was not present. Neonatal morbidities showed a similar pattern, but they became equivalent between TOLAC and ERCS only when the probability of VBAC was 70% or greater. All women were grouped according to predicted probabilities of VBAC success of either 60% or 70%. When the predicted chance of VBAC was less than 60%, women undergoing a TOLAC were more likely to have maternal morbidity (RR 2.3; 95% confidence interval [CI], 1.4–4.0) than those who underwent an ERCS. However, when the predicted chance of VBAC was 60% or greater, maternal morbidity did not differ between the groups (RR, 0.8; 95% CI, 0.6–1.1). Neonatal morbidity was similar between groups when the probability of VBAC reached 70% (RR, 1.2; 95% CI, 0.9–1.5). This prediction model for VBAC success as validated in the United States is also predictive for Canadian women in Quebec. Maternal and neonatal morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOLAC. The findings of this study confirm that individual assessment of the probability of VBAC success allows health care providers to refine and improve counseling to inform women with a prior CS about their chance of successful VBAC and their level of risk, to enable them to make an informed choice regarding their mode of delivery.

Objective Structured Assessment of Technical Skill in assessing technical competence to carry out caesarean section with increasing seniority

Since the incorporation of workplace-based assessment within the specialty training programme in obstetrics and gynaecology, the assessment of technical competence to carry out caesarean section has been undertaken by the Objective Structured Assessment of Technical Skill tool. This requirement has been formalised in the Matrix of Educational Progression, ensuring that the tool must assess trainees' technical competence in caesarean section procedures of varying levels of complexity throughout training. Trainee feedback suggests that the effectiveness of the tool diminishes as the seniority of the trainee increases, with technical competence assessed less effectively in more complex procedures. This seems to be a result of the generic design of the tool and insufficient training on the part of assessors. Both of these are due to be addressed within a division of the Objective Structured Assessment of Technical Skill tool into explicitly formative and summative assessments of technical skill, following a General Medical Council-led consultation on the future of workplace-based assessment.

Birth injury after cesarean section at 24 weeks of gestation: a large scalp laceration

Cesarean section (CS), compared with vaginal delivery, has a lower incidence of neonatal birth injury. Previously, we reported a femur fracture after term CS in this journal [1]. In a pregnant woman with chronic abruption oligohydramnios sequence, CS was performed at 24 weeks under general anesthesia due to continued oligohydramnios and elevated C-reactive protein level (4.5 mg/dL). The obstetrician had 20 years of experience. Being in head presentation, lower segment transverse incision was made with surgical knife: the incision was stopped before entering the uterine cavity to avoid direct injury to the fetal scalp. The uterine cavity was entered with a finger and the incision was extended laterally by both index fingers (Fig. 1a). Then the doctor recognized something ‘‘white’’ just beneath the fingers. In retrospect, it was the skull bone: the scalp skin may have been lacerated by the fingers, sliding off from the underlying skull bone (Fig. 1b). This was well reconstructed. Bleeding from the laceration was slight, requiring no blood transfusion. Extra-or-subdural hematoma or intra-ventricular hemorrhage was absent. The infant, weighing 544 g with Apgar score 4/7 (1/5 min), died the next day due to prematurity. Autopsy was not performed. The scalp laceration itself was not considered to have influenced the outcome. Another similar experience: a scalp laceration in an infant after 23 weeks’ CS. Oligohydramnios due to premature rupture of the membranes and signs of intrauterine infection required CS. The fetal head was deeply engaged and thus the hand was put deeply into the uterine cavity, pulling out the fetal head with the fingers. In retrospect, the scalp, being pushed and possibly scratched by the fingers, was lacerated at the parietal area. The infant died next day due to prematurity. The laceration was not considered to have influenced the outcome. There is a close similarity between the two patients: preterm CS, oligohydramnios, and intrauterine infections. A previous report [2] also showed that ruptured membranes and thus oligohydramnios were the risk factors of fetal scalp laceration, in which, however, infants suffering laceration were almost term infants (average of 38.67 weeks), with the earliest and the lightest being 29 weeks and 825 g of birth weight, respectively. Its context was that obstetricians should avoid direct injury to the fetal scalp with the knife or scalpel [2]. The present significance is different: pushing or scratching the scalp skin with fingers was the considered culprit. Skin and the underlying skull bone, especially at the parietal area, are more loosely connected than skin and other body parts such as the extremities or the trunk. This is more exaggerated in preterm infants. Intra-uterine infection, weakening the skin, may also have caused scalp laceration. Oligohydramnios, pushing the fetal head tightly to the uterine wall, obliged the obstetrician to put fingers into the narrow space between the fetal head and the uterine wall, which may also have caused this injury. The CS procedure was performed gently, considering the infant’s prematurity; however, a much gentler maneuver S. Matsubara (&) R. Usui Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

Hématome sous-capsulaire du foie : cas clinique et mise au point actualisée sur la prise en charge

Hepatic subcapsular hematoma (HSH) is a rare complication of pregnancy that keeps a materno-fetal high mortality rate. Given this severity, HSH management requires a prompt diagnosis and an appropriate care. Before focusing on the current management strategy of HSH, we illustrate this article with a clinical case presenting an original method of abdominal exploration, which has not been described to our knowledge. Thus, taking into account the presence of a moderate hemoperitoneum during a caesarean section procedure for HSH, introduction of laparoscopy through the same incision allowed a satisfactory evaluation of the abdominal cavity and hepatic area without performing an invasive midline laparotomy.

Is it true that placenta previa per se is not a risk factor for perinatal mortality?

I read with great interest the article ‘‘Critical analysis of risk factors and outcome of placenta previa’’ by Rosenberg et al. [1], in which two observations were made. First, infertility treatments, prior cesarean section (CS), and advanced maternal age were major risk factors for placenta previa. I agree with these findings. Second, although placenta previa increased the perinatal mortality rate by 5.6 times, placenta previa per se was not the culprit, instead, its associated conditions (preterm birth, growth restriction, and congenital malformation) were the culprits. However, I disagree with the conclusion since it means that placenta previa, in the absence of these conditions, is not a risk factor for perinatal mortality. In other words, placenta previa does not present a risk factor for a term non-malformed normally grown infant. This differs from my clinical impression based on my three decades of experience in obstetrical practice. In my opinion, CS for placenta previa poses three risks to neonates; a view that I believe is shared by many experienced obstetricians. First, CS sometimes induces fetal hemorrhage, leading to neonatal anemia and circulatory collapse. Incision or destruction of the placenta, either accidentally or intentionally, induces hemorrhage, not only maternal but also fetal. Second, ‘‘abdominal dystocia’’ sometimes occurs in CS for placenta previa. The placenta, sometimes being present just adjacent to the incision site and thus bulging, narrows the ‘‘exit’’, preventing a smooth head delivery. Third, resuscitation of the infant, if required, may not be sufficiently provided in a case with unexpectedly severe hemorrhage in an emergent CS setting. General anesthesia may be more frequently employed in CS for placenta previa, especially in an emergent CS. Infant resuscitation may be more frequently required in placenta previa due to the higher possibility of fetal anemia, abdominal dystocia and general anesthesia. CS procedures have been developed to overcome, or at least lessen, the former two problems. First, we perform ultrasound after laparotomy, confirm the placental site and choose the incision site to avoid a transplacental approach as much as possible. If hysterectomy has been decided preoperatively, vertical uterine body incision or transverse uterine fundus incision is employed, which prevents placental incision and thus decreases the amount of hemorrhage [2]. Second, we usually use ‘‘forceps with vacuum’’ to deliver the head, better facilitating delivery than ‘‘manual delivery aided by fundal pressure’’ (Fig. 1). The third problem may be difficult to overcome since it depends on the institutional staffing pattern. Emergent CS at night, when medical staff is limited, may well illustrate the situation. Usually, when an infant is born with asphyxia or circulatory collapse, not only neonatologists but also other staffs on duty, including anesthesiologists or obstetricians, may help resuscitate the infant. However, more medial attention may be required for massive hemorrhage with less attention paid to the infant. Experienced obstetricians may not always be present at emergent CS. Inexperienced and limited staff in emergent CS settings may prevent physicians from performing the procedures described above or cooperating with the infant’s resuscitation. Thus, emergent CS for placenta previa may pose great risks of perinatal mortality. Data from Ananth et al. [3] were in line with this view. Term babies from women with previa, compared with those from women without previa, had a higher neonatal mortality rate, with the mortality rate S. Matsubara (&) Department of Obstetrics and Gynecology and Perinatal Education Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

DO DOCTORS INDUCE DEMAND?

This paper examines supply-induced demand in medicine using an exogenous income shock to obstetricians and gynaecologists caused by a declining number of births in their practice location from 1989 to 1999. The results of the present study indicate some evidence of induced demand. A 4.1 percentage point increase in Caesarean section procedures is found for a one unit decline in the birth rate per 100 population. Interestingly, people commence prenatal care statistically significantly earlier with fertility decline and, subsequently, the total number of prenatal care visits has been increased. However, I found no evidence of declining fertility inducing excessive prenatal care visits.

Maternal Hypotension During Elective Cesarean Section and Short-term Neonatal Outcome

Objective To investigate the extent and risk factors for hypotension among women undergoing elective cesarean section, and whether maternal hypotension has any impact on perinatal infant outcome. Study Design Retrospective analysis of data on 919 mother-infant pairs after elective cesarean section that involved the use of regional anesthetic. Data collection included information on maternal blood pressure during the cesarean section procedure and any infant perinatal complications. Results Nearly one-half of the mothers underwent a decrease in their mean arterial blood pressure by ≥30%. The risk factors for hypotension included preoperative hypertension, older age, type of spinal anesthesia, and a higher infant birthweight. A drop in the maternal mean arterial blood pressure exceeding 30% or even 50% compared with the preoperative value was not found to predict any perinatal complications. Conclusion Despite a very high prevalence of maternal hypotension during cesarean sections, term infants tend to tolerate this placental blood perfusion challenge without any major sequel.

Successful management of a patient with Marfan syndrome complicated with acute aortic dissection using landiolol during Cesarean section

Aortic dissection is a lethal complication in pregnant women with Marfan syndrome. To decrease arterial wall stress, beta-blockers have been used as standard treatment, although uterine contractions caused by beta-2-adrenergic receptor antagonism may result. Herein, we report a patient with Marfan syndrome who was given landiolol, a selective beta-1-adrenergic receptor antagonist with a short half-life, for management during a Cesarean section procedure following development of acute aortic dissection. A 30-year-old pregnant woman with Marfan syndrome in the 38th week of gestation was referred to our department for an emergency Cesarean section because of development of acute aortic dissection. Blood pressure (BP) decreased from 157/70 to 128/64 mmHg after giving nicardipine and nitroglycerin. However, heartrate (HR) increased from 112 to 145 bpm, which was reduced to 105 bpm with landiolol, while BP was maintained. A Cesarean section was performed without complications under combined spinal-epidural anesthesia. Hemodynamic state, uterine contraction, and the extent of aortic dissection remained stable. The postoperative course was uneventful, and the patient and her baby were discharged safely. Landiolol was useful for reduction of HR without affecting BP or uterine contractions during a Cesarean section procedure in our patient with aortic dissection.

The role of instrumental vaginal delivery in low resource settings

This commentary discusses instrumental vaginal delivery (IVD) and the issues experienced with that practice in low resource settings. It states that IVD is a key element of essential obstetric care and the improvement of maternal and neonatal outcomes will require the scaling up of IVD use with the provision of equipment and trained operators to areas where they are currently unavailable.

Maternal hypotension during elective cesarean section and short-term neonatal outcome

To investigate the extent and risk factors for hypotension among women undergoing elective cesarean section, and whether maternal hypotension has any impact on perinatal infant outcome. Retrospective analysis of data on 919 mother-infant pairs after elective cesarean section that involved the use of regional anesthetic. Data collection included information on maternal blood pressure during the cesarean section procedure and any infant perinatal complications. Nearly one-half of the mothers underwent a decrease in their mean arterial blood pressure by > or =30%. The risk factors for hypotension included preoperative hypertension, older age, type of spinal anesthesia, and a higher infant birthweight. A drop in the maternal mean arterial blood pressure exceeding 30% or even 50% compared with the preoperative value was not found to predict any perinatal complications. Despite a very high prevalence of maternal hypotension during cesarean sections, term infants tend to tolerate this placental blood perfusion challenge without any major sequel.

Loss of vision after anaesthesia for nonophthalmic surgery: a persistent problem

Loss of vision after anaesthesia for nonophthalmic surgery: a persistent problem

Born on the first of July: An (un)natural experiment in birth timing

It is well understood that government policies can distort behavior. But what is less often recognized is that the anticipated introduction of a policy can introduce its own distortions. We study one such “introduction effect,” using evidence from a unique policy change in Australia. In 2004, the Australian government announced that children born on or after July 1, 2004 would receive a $3000 “Baby Bonus.” Although the policy was only announced seven weeks before its introduction, parents appear to have behaved strategically in order to receive the benefit, with the number of births dipping sharply before the policy commenced. On July 1, 2004, more Australian children were born than on any other single date in the past thirty years. We estimate that over 1000 births were “moved” so as to ensure that their parents were eligible for the Baby Bonus, with about one quarter being moved by more than one week. Most of the effect was due to changes in the timing of induction and cesarean section procedures. We find evidence to suggest that babies who were shifted into the eligibility period were more likely to be of high birth weight. Two years later, on July 1, 2006, the Baby Bonus was increased, and we find that this again caused births to be moved from June to July. These birth timing events represent an opportunity for health researchers to study the impact of planned birthdays and hospital management issues.

Reducing Cesarean Section Infections in a Tertiary Care Teaching Facility through Standardization of Surgical Processes

ISSUE: Increased readmissions for wound debridement following cesarean section procedures at a tertiary care teaching facility prompted an infection control investigation. Obesity (BMI ≥ 30) is a known risk factor for surgical site infections (SSIs) with obstetric patients particularly at risk due, in part, to skin folds covering the incision site, making skin antisepsis difficult to achieve and maintain. At this institution, obese obstetric patients comprise >60% of the infected cases. Cesarean sections are clean-contaminated procedures further increasing the inherent risk of infection.

First Assisting in Obstetrics

As the cesarean rate rises nationwide, many maternity nurses, certified nurse-midwives, certified midwives, and other women's health nursing professionals are expanding their scope of practice to include first assisting with cesarean delivery. Becoming qualified to assist with cesarean section requires evaluation of facility, state, regulatory, and professional standards related to first assistants. First assisting education programs offer didactic education and clinical experience designed to ensure that surgical assistants are competent. Surgical first assistants for cesarean section are expected to be knowledgeable regarding the procedure, the relevant surgical anatomy, potential complications, and options for treatment. Acquiring clinical skills requires significant intraoperative experience under the tutelage of a knowledgeable mentor. In this article, the cesarean section procedure and the role and expectations of the surgical first assistant are described to provide the women's health nursing professional with the information needed to determine whether to include surgical first assisting with cesarean section as part of their professional practice.

Caesarean section surgical site infection surveillance

Surveillance of surgical site infection (SSI) is an important infection control activity. The Caesarean section procedure was selected, as part of the Scottish Surveillance of Healthcare Associated Infection Programme, to monitor and report upon the incidence of SSI. Data were collected prospectively for 715 patients undergoing a Caesarean section procedure for 35 weeks during the latter months of 2002 and the first quarter of 2003. Of these, 80 (11.2%) patients developed an SSI, 57 (71%) of which were detected by postdischarge surveillance. Risk factors associated with infection were analysed. The choice of subcuticular suture rather than staples to close the surgical site was associated with a significantly lower incidence of infection (P=0.021). Obese women experienced significantly more infections than women with a normal body mass index (P=0.028). Dissemination of the surveillance results has made clinicians aware of the influence of body mass index and choice of skin closure in relation to SSI in this patient population. Analysis of these data has led to a review of local practice. The results also indicate the importance of postdischarge surveillance if SSIs are to be detected in this patient group. Continuous data collection and timely dissemination of the results are important factors acting as the catalyst for a review of practice.

Is inferior dissection of the rectus sheath necessary during Pfannenstiel incision for lower segment Caesarean section? A randomised controlled trial

Objective The objective was to determine the benefit of non-dissection of the rectus sheath inferiorly in a Pfannenstiel incision during an elective Caesarean section with regard to operative blood loss and post-operative pain. Design A randomised controlled trial. Setting The Royal Free Teaching Hospital in London. Population One hundred and twenty women who underwent elective Caesarean section delivery. Method Women were randomised to have dissection or non-dissection of the rectus sheath inferiorly during an elective Caesarean section. Main outcome measures Estimated blood loss during the operation, as well as the difference between pre- and post-operative haemoglobin levels. Post-operative pain was assessed by the visual analogue scale, a verbal rating scale and the use of post-operative analgesia. Patient satisfaction was assessed by a verbal rating scale. Results There was no significant difference in the estimated blood loss during the procedure between the two groups; however, the mean difference between the pre-operative and post-operative haemoglobin was significantly smaller in the study group ( p = 0.05). There was a statistically significant difference in both the visual analogue scale ( p-value = 0.03) and the verbal rating scale scores ( p-value = 0.02) for pain between the two groups, with lower scores for the study group. There was no overall difference in the verbal rating scale scores for patient satisfaction. Conclusion Non-dissection of the rectus sheath inferiorly in Pfannenstiel incisions during Caesarean section procedures is associated with a significant reduction in the post-operative pain as well as a smaller drop in post-operative haemoglobin.

Born on the First of July: An (Un)natural Experiment in Birth Timing

It is well understood that government policies can distort behavior. But what is less often recognized is the anticipated of a policy can introduce its own distortions. We study one such introduction effect, using evidence from a unique policy change in Australia. In 2004, the Australian government announced that children born on or after July 1, 2004 would receive a $3000 Bonus. Although the policy was only announced a few months before its introduction, parents appear to have behaved strategically in order to receive this benefit, with the number of births dipping sharply in the days before the policy commenced. On July 1, 2004, more Australian children were born than on any other single date in the past thirty years. We estimate that over 1000 births were so as to ensure that their parents were eligible for the Baby Bonus, with about one quarter being moved by more than two weeks. Most of the effect was due to changes in the timing of inducement and cesarean section procedures. This birth timing event represents a considerable opportunity for health researchers to study the impact of planned birthdays and hospital management issues.

Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures

To report 11 cases of incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. The diagnostic approaches and therapies for incisional endometriosis are also evaluated. Eleven patients who presented with a painful nodule that was increasing in size during menstruation on the scar of a previous gynecologic procedure were examined retrospectively. All patients presented with a palpable painful lesion, located on the cesarean section incision, perineal episiotomy incision or the vaginal cuff after hysterectomy. All masses were increasing during menstruation and all patients had been having cyclical pain that worsened during menstrual periods. The mean age of the patients was 28.2 years. The onset of symptoms was referred at variable intervals after surgery ranging between 2 and 11 years (mean: 5.72 years). Ultrasound examination confirmed hypoechoic mass septated with cystic and solid components in the abdomen without intra-abdominal communications. All endometriotic masses were completely excised under general anesthesia. The excised masses were sent for microscopic examination which confirmed the diagnosis of endometriosis. Incisional endometriosis seems to be common in women who have had a cesarean section, although it does occur after other procedures and de novo. It is suggested that caution is exercised during gynecologic procedures to avoid transplantation of endometrium to the anterior abdominal wall. The preferred management is to excise the lesion completely even if this necessitates fascial excision.

Obstructed labor: using better technologies to reduce mortality

Objective: To identify, from the best available evidence, underutilized and promising technologies that may reduce maternal mortality from obstructed labor. Methods: The author sought systematic reviews of randomized trials, individual randomized trials, and, in the absence of randomized data, non-randomized studies and clinical consensus. Data were presented according to the level of the evidence. Results: Obstructed labor causes approximately 8% of maternal deaths, and indirectly contributes to a greater percentage. Proven or widely accepted technologies that help reduce mortality from obstructed labor include contraception, external cephalic version, the partogram, augmentation of labor, selective amniotomy, selective episiotomy, vacuum extraction, caesarean section, symphysiotomy, and destructive procedures for non-viable fetuses. Technologies of uncertain usefulness include maternal height and shoe size, vaginal cleansing, upright posture for delivery and vaginal lubrication. Unuseful technologies include pelvimetry, estimating fetal weight, early labor induction, routine amniotomy and augmentation, routine episiotomy, and starvation during labor. Conclusion: Access to well-established technologies, particularly safe caesarean section, can reduce maternal mortality in resource-poor countries.