Elective Caesarean Section Rates Research Articles

The philosophy of practice governs the rate of obstetric intervention: analysis of 212 units in the United Kingdom

Objective: To investigate the relationship between the practices of obstetric intervention in individual units.Study design: A retrospective analysis of the annual statistical returnsto the Royal College of Obstetricians and Gynaecologists of 222 units in the UK for 1997-98.Results: A total of 212 units that delivered more than 1000 babies were analyzed. A positive correlationwas found between the rates of assisted vaginal delivery and emergency Cesarean section (Spearman's rho = 0.207, p = 0.003) and the rates of emergency and elective Cesarean section (Spearman's rho= 0.205, p < 0.001). There was a significant difference between unit size and the rate of spontaneous vaginal delivery (Kruskall-Wallis χ2 = 14.5, p = 0.002) with largerunits having a lower spontaneous vaginal delivery rate.Conclusion: These results indicate that those units which have a high emergency Cesarean section rate also have a high elective Cesareansection rate and assisted vaginal delivery rate. The philosophy of an individual unit towards intervention is a general philosophy and determines the intervention rates for all procedures.

Maternal age at first birth and obstetric outcome

The objective of this study was to determine the effect of age on women going through their first pregnancy and delivery at extremes of reproductive life. All obstetric records of delivered mothers at the UBTH between January 1995 and December 1999 were extracted for the study. There were 2,658 primiparous birth (27.3%) out of a total of 9,735 deliveries. Teenage mothers were 156 (5.87%), while the elderly primigravidas were 117 (4.4%) and the ideal age primigravidas (Control) were 2,385 (89.73%)The average maternal age at first birth was 27.05±3.04 years. Teenagers registered for their first antenatal visit later than the elderly mothers (23 weeks vs. 18 weeks; P The caesarean section rate for the elderly and the teenage primigravidas was 52.6% and 50.0% respectively compared with 29.2% for the young (idea) mothers. The elective caesarean section rate was significantly higher for the elderly primigravida 21.05%, compared to 0.0% and 1.35% for the teenage and ideal primigravidas respectively. The incidence of low birth weight infants was significantly higher amongst the elderly primigravidas (p =0.000). The number of women having their first birth at the extremes of age is small in our community today. The caesarean section rate is high both for the teenagers and the elderly primigravidas, however their obstetric outcome is good if utilization of antenatal care is adequate and labour properly conducted. KEY WORDS: Primigravida, Age, First Birth, Pregnancy Outcome [Nig J Clinical Practice Vol.5(1) 2002: 20-24]

HIV-infected pregnant women and vertical transmission in Europe since 1986

Objective To describe changes over a 15-year period in characteristics and management of HIV-infected pregnant women in Europe. Design Prospective study. Methods Analysis of prospective data on 2876 pregnant HIV-infected women and their 3076 infants. Factors examined included maternal socio-demographic, immunological and virological characteristics, antiretroviral therapy and pregnancy outcome. Results Among women enrolled, the proportion with heterosexual acquisition of infection has increased significantly from 59% (201/342) in 1985–1987 to 69% (327/471) after 1997 while the proportion acquiring HIV through injecting drug use has declined. Overall median CD4 cell count was 440 × 106/l and 41% of women had undetectable viral load at delivery. In 1995 28% (72/256) of mother–child pairs received the full 076 regimen to reduce risk of vertical transmission, rising significantly to 89% (116/130) by 1999. Use of triple therapy started in pregnancy has increased significantly from < 1% (1/153) in 1997 to 44% (47/107) in 1999. Exposure to antiretroviral therapy was not associated with prevalence or pattern of congenital abnormalities (P = 0.88) but was associated with reversible anaemia in the infant (P < 0.002). The elective cesarean section rate has increased from 10% in 1992 to 71% in 1999/2000. The vertical transmission rate declined from 15.5% by 1994 to 2.6% after 1998. In multivariate analysis, adjusting for maternal CD4 cell count, risk of vertical transmission was reduced by 66% (95% confidence interval, 37–82%) with the full 076 regimen and by 60% (95% confidence interval, 33–73%) with elective cesarean section delivery. Conclusions Changes in treatment of adult HIV disease have affected the management of infected pregnant women. Despite therapeutic and surgical interventions, vertical transmission still occurs.

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

Objectives: To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.Design: Qualitative analysis of audiotaped in-depth...

The changing HIV epidemic in Italian pregnant women

Objective: To describe changes in the characteristics of HIV-pregnant women in Italy and the impact of strategies for prevention of HIV vertical transmission. Study design: Since 1985, HIV-infected women and their children are followed in 23 European centres in the European Collaborative Study (ECS), according to a standard protocol. Eight Italian Obstetric units participating in the ECS enrolled 815 patients. Results: Overall use of zidovudine to reduce HIV vertical transmission has increased significantly since 1994 and between 1995 and 1997, 57% of Italian women were treated. However, 27% of babies received the infant component of the 076 regimen. Over the years, age at delivery has increased and their CD4 count at delivery decreased, most likely reflecting heterosexually infected women with a longer duration of infection. The increasing rate of elective caesarean section (42%) is not related to maternal, foetal or obstetrical indications, but its use as an intervention to reduce HIV vertical transmission. Conclusions: The identification of HIV-infected women during pregnancy or before delivery ensures the appropriate management of the woman and her child, and clinicians should be aware of the increasing number of women with heterosexual acquisition of HIV-infection who may be less easily identified.

Long-term implications of caesarean section

Previous reports have linked caesarean section with subsequent reduced fertility, increased rates of miscarriage/ectopic, time delay to next baby and lower fetal weight. However, most reports studied women delivering before 1980. The aim of this study was to assess whether these findings still apply. Five hundred and seventy-six primiparous women delivered by caesarean section during 1992-93 and 576 controls were identified and followed for five years. No difference was observed for the time (months) to next pregnancy/delivery, proportion suffering miscarriage or ectopic or the number of subsequent children ( P > 0.05, Mann-Whitney U /chi-squared). Subgroup analysis by indication for caesarean section yielded similar results. Subsequent babies in the caesarean section group were statistically smaller and delivered earlier (median 3.4 kg/39 weeks, P <0.01, Mann-Whitney U ) compared with the control group (median 3.5 kg/40 weeks). These differences are probably due to an increased rate of elective caesarean section in the caesarean section group. This study has largely refuted the findings of previous publications. Women delivered by caesarean section in the 1990s can be reassured that future fertility and miscarriage/ectopic risk will not be affected.

Vertical transmission rates for HIV in the British Isles: estimates based on surveillance data

Objective: To estimate and interpret time trends in vertical transmission rates for HIV using data from national obstetric and paediatric surveillance registers.Design: Prospective study of HIV infected women reported through...

Perianal Crohn’s disease and pregnancy: role of the mode of delivery

OBJECTIVE: Elective cesarean section (CS) is a standard recommendation for pregnant women with perianal Crohn’s disease. In this study we examined the mode of delivery for pregnant women with Crohn’s disease and assessed the relationship between perianal disease activity and delivery mode. METHODS: The University of Manitoba’s Inflammatory Bowel Disease Database, a population-based database, was interfaced with a provincial birth database to compare the mode of delivery for women with Crohn’s disease and ulcerative colitis to that of the general population for the years 1985–1995. To describe clinical issues related to perianal Crohn’s disease in relation to mode of delivery, data were obtained from a subset of women with Crohn’s disease who had given birth between 1985 and 1995 using a standardized questionnaire. Data regarding Crohn’s disease and birth history were verified through chart review (93.8%) and corroboration with the personal physician (87.5%). RESULTS: The total and (elective) CS rates were higher for Crohn’s disease 20.9% (9.0%), and for UC 20.8% (9.3%) than the general population 15% (5.4%) ( p < 0.01 for each). Among primiparous women, patients with Crohn’s disease and UC were also significantly more likely to have CS than the general population. In the target group of 281 women, 52 had births in the years in question and were contactable. There were 54 vaginal births and 10 sections. Fifteen of 54 vaginal births were predated by perianal disease; 4 of 15 reported active perianal disease at birth; and all reported worsening of perianal symptoms postpartum. Those with inactive perianal disease (n = 11) had no relapse of perianal disease in 1 yr of follow-up postpartum. Of 39 vaginal deliveries with no known perianal disease, only 1 ultimately developed perianal disease within 1 yr of postpartum follow-up. CONCLUSIONS: Women with inflammatory bowel disease undergo CS more often compared to the general population. For those with either no history of perianal disease or inactive perianal disease at birth, the risk of perianal disease relapse is very low and does not justify CS. Active perianal disease at time of delivery is an indication for CS.

Thickness of the lower uterine segment: its influence in the management of patients with previous cesarean sections

Objective: To determine how ultrasound measurement of the lower uterine segment affects the decision about delivery for patients with previous cesarean sections (CS) and what are the consequences on cesarean section rates and uterine rupture or dehiscence. Design: Prospective open study. Patients: 198 patients: all women with a previous CS who gave birth in our department during 1995 and 1996 to an infant with a gestational age of at least 36 weeks and who underwent ultrasound measurement of their lower uterine segment (95–96 study group), compared with a similar population from 1989 to 1994 whose measurements were not provided to the treating obstetrician. Results: Among the patients with one previous CS, the vaginal delivery rate did not differ significantly during the two periods (70.3% for the 89–94 study period vs. 67.9% for the 95–96 study period, P=0.53), but the 95–96 study group experienced a significant increase in the rate of elective CS, compensated by a reduction in the rate of emergency CS (6.3% and 23.4%, respectively, for the 89–94 study period vs. 11.9% and 20.1% for the 95–96 study period, P=0.01). There was a very significant increase in the rate of vaginal delivery for the 95–96 study period among patients with two previous CS (26.7% vs. 8.0% for the 89–95 study period, P=0.01). The lower uterine segment was significantly thicker among women with a trial of labor than among those with an elective CS (4.5±1.4 mm compared with 3.8±1.5 mm; P=0.006); and the trial of labor group contained significantly fewer women with a lower uterine segment measurement less than 3.5 mm than did the elective CS group (24.0% compared with 56.6%; P<0.001). Two patients (0.8%) were found to have a defect of the uterine scar, a rate significantly lower than that observed in the early group (3.9%, P=0.03). Conclusions: Ultrasound measurement of the lower uterine segment can increase the safe use of trial of labor, because it provides an additional element for assessing the risk of uterine rupture.

The influence of maternal request on the elective caesarean section rate

At a time when there is much criticism of increasing caesarean section rates, as well as an increased emphasis on involving the patient in decisions regarding her care, we decided to assess the effect of maternal request on the elective caesarean section rate. The study was a prospective patient interview and case note review, set at a District General Hospital in Watford, Hertfordshire over a 1-year period. Eligible patients included all women undergoing elective caesarean section, with the main outcome measure being the number of elective caesarean sections performed without obstetric contraindication to vaginal delivery. Out of 3025 deliveries, 570 (18.8%) were delivered by caesarean section, 276 (9.1%) electively and 293 (9.7%) as an emergency procedure. Of the elective procedures (18.2% of the total number of operations), 38% were performed because of maternal request. We conclude that maternal request is a significant factor in the rise in caesarean section rate.

The Medical Management of Gestational Diabetes in Australia Within a Solo Private Practice

This study reports the obstetric and fetal outcomes of 266 consecutive patients with gestational diabetes managed by a solo practitioner in private practice. Labour was spontaneous in 75.6% and 93.2% had a gestational age of delivery between 37 and 41 weeks. The elective Caesarean section rate of 14.7% was slightly higher than the rate for the overall obstetric population. Insulin therapy was required in 12.8% of the patients with a mean daily dose of 35.3 units. The rate of insulin use increased to 23.8% during 1993 when the criteria for its use was revised. This was associated with a significantly lower macrosomic rate of 3.6%. Overall there was a significant reduction in the number of babies weighing ≤ 2500 g and no increase in the number of babies weighing ≥ 4000 g. One patient only was admitted to hospital during this 30-month period and there was 1 neonatal death. These results indicate that successful medical management of gestational diabetes, with obstetric and fetal results similar to the overall obstetric population, is possible outside of tertiary institutions and specialized clinics.

Caesarean Section Rate Reduced

The Caesarean section rate in consecutive years was decreased from 20.5% to 11.1% of total public deliveries (p < 0.0001). On retrospective analysis the emergency Caesarean section rate decreased from 10.9% to 6.0% (p < 0.0001) and elective Caesarean section rate from 9.6% to 5.1% (p < 0.0001) in consecutive years. Interventions which have accounted for the decrease were 3-fold. Firstly, vaginal birth after Caesarean delivery was encouraged, secondly, the active management of labour and thirdly, extensive, regular peer review were introduced as unit policy. The decrease in the Caesarean section rate was not achieved at the expense of the fetus as judged by perinatal mortality rates and 5-minute Apgar scores of less than 7.

The medical management of gestational diabetes in Australia within a solo private practice.

This study reports the obstetric and fetal outcomes of 266 consecutive patients with gestational diabetes managed by a solo practitioner in private practice. Labour was spontaneous in 75.6% and 93.2% had a gestational age of delivery between 37 and 41 weeks. The elective Caesarean section rate of 14.7% was slightly higher than the rate for the overall obstetric population. Insulin therapy was required in 12.8% of the patients with a mean daily dose of 35.3 units. The rate of insulin use increased to 23.8% during 1993 when the criteria for its use was revised. This was associated with a significantly lower macrosomic rate of 3.6%. Overall there was a significant reduction in the number of babies weighing < or = 2500 g and no increase in the number of babies weighing > or = 4000 g. One patient only was admitted to hospital during this 30-month period and there was 1 neonatal death. These results indicate that successful medical management of gestational diabetes, with obstetric and fetal results similar to the overall obstetric population, is possible outside of tertiary institutions and specialized clinics.

Consequences of misdiagnosis of intrauterine growth retardation for preterm elective cesarean section.

We studied the consequences of misdiagnosis of intrauterine growth retardation (IUGR) for preterm elective cesarean section among live singleton newborns in two teaching hospitals in Paris between 1978 and 1983. The population studied comprised the 16,540 babies who were normal for date, according to the 10th percentile of the reference curve established in this population. For 118 of these infants, IUGR had been diagnosed during pregnancy. The preterm elective cesarean section rate was 12.7% among newborns for whom IUGR was erroneously diagnosed, compared to 1.2% among those for whom IUGR was not diagnosed. The relationship between preterm cesarean section and misdiagnosis of IUGR still existed (odds ratio: 5.2, 95% CI: 2.1-12.9) after taking into account obstetric history and hypertension during pregnancy. Our results show that after diagnosis of IUGR, supplementary tests are essential to confirm fetal distress and consequently avoid unnecessary interventions.

The timing of delivery in diabetic pregnancy: a 10-year review.

The approach of term in the pregnancy of a diabetic woman is a time of anxiety for patient and physician alike. The impact of a conservative approach to the timing of delivery is outlined in this review of the clinical course and outcome of 276 pregnancies of diabetic women, delivered at the National Maternity Hospital, Dublin between 1981 and 1990. The mean gestation at delivery was 39 weeks, 229 patients (83%) delivered at or beyond 38 weeks and 112 patients (41%) delivered at or beyond 40 weeks. The overall induction of labour rate was 27% and the elective Caesarean section rate was 19%. Sixty seven percent of patients achieved a normal delivery, the forceps rate was 5%, and 28% of patients were delivered by Caesarean section. There were 16 perinatal deaths in the series, with 7 due to lethal malformations. There were 5 deaths of normally formed infants occurring at or beyond 38 weeks' gestation. All of these 5 deaths had been preceded by clinically apparent polyhydramnios or macrosomia and recognized poor control. This study stresses the value of strict diabetic control in the management of diabetic pregnancy and highlights the significance of polyhydramnios and macrosomia as indicators of risk approaching term in diabetic pregnancy.

Psychosocial indications for cesarean section: A retrospective study of 43 cases

At Helsingborg Maternity Clinic the rate of elective cesarean section on psychosocial indications has increased. The purpose of this study was to identify and characterize those women requiring cesarean section despite the absence of obstetrical complications of pregnancy and childbirth and their reasons for doing so. Hospital case records from 1983 to 1987 were examined retrospectively. Nine women (20%) were primiparae, who for different reasons refused vaginal delivery; 34 (80%) were multiparae, half of whom (n = 17) had been delivered previously by an unanticipated cesarean section and 4 women by elective cesarean. Seven women had experienced obstetrical complications during vaginal delivery. Five had a diagnosis of other serious medical conditions during the previous or the present pregnancy. The final parous woman demanded a cesarean in spite of perfect health and a normal previous delivery. The patients' reasons for demanding a cesarean, as understood from hospital records, were primarily a very serious fear of childbirth. A psychotherapeutically trained member of the obstetrical staff is well equipped to offer help. The impact of previous complicated birth is obvious in this study. Hopefully, we can avoid some future cesarean sections by means of better care for patients in crisis resulting from complicated childbirth.

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation.

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.

OUTCOME OF TERM BREECH DELIVERY IN PRIMIGRAVIDAE. A FETO-PELVIC BREECH INDEX

Analysis of 340 term breech presentations in primigravidas showed a corrected perinatal mortality of 1.5%; the elective cesarean section rate was 15%. The incidence of complicated labour, defined in the study, was analyzed with regard to different parameters, e.g. X-ray pelvimetry data in all 340 cases. Complicated labour in vaginal deliveries markedly increased with increasing fetal weight (p>0.001) and decreasing pelvic capacity (p>0.001). In each case the fetal weight and smallest pelvimetry data were given score points and the sum of these was called the Feto Pelvic Breech Index, which was correlated to the incidence of complicated labour. By using this index the mortality and morbidity probably can be markedly reduced without the routine use of elective cesarean section. The prognostic methods available to detect feto-pelvic disproportion are discussed.

Outcome of term breech delivery in primigravidae. a feto peivicbreech index.

Analysis of 340 term breech presentations in primigravidas showed a corrected perinatal mortality of 1.5%; the elective cesarean section rate was 15%. The incidence of complicated labour, defined in the study, was analyzed with regard to different parameters, e.g. X-ray pelvimetry data in all 340 cases. Complicated labour in vaginal deliveries markedly increased with increasing fetal weight (p less than 0.001) and decreasing pelvic capacity (p less than 0.001). In each case the fetal weight and smallest pelvimetry data were given score points and the sum of these was called the Feto Pelvic Breech Index, which was correlated to the incidence of complicated labour. By using this index the mortality and the routine use of elective cesarean section. The prognostic methods available to detect feto-pelvic disproportion are discussed.