Total Cesarean Section Rate Research Articles

High caesarean rates in Madras (India): a population‐based cross sectional study

To estimate the population caesarean section rate in urban India. Population-based cross sectional study. Madras City (Chennai), India. Seven hundred and eighty resident women who delivered in Madras between June 1997 and May 1999. Cluster sampling was done using streets as cluster units. Thirty clusters were selected from 1255 clusters by the probability proportion to size method and 26 women were selected randomly from each cluster. Total and primary caesarean rates. Total population caesarean section rate was 32.6% (95% CI 27-38) and primary caesarean section rate was 25% (95% CI 20-30). Total caesarean section rates in the public, charitable and private sectors were 20%, 38% and 47%, respectively. Private sector deliveries had an odds ratio of 2.4 (95% CI 1.5, 3.8) of a primary caesarean section delivery in comparison with the public sector after adjustment for parity, age at delivery of mother and educational status. Forty-seven percent of births by caesarean section in the private sector is alarming and could implicate private sector care as the main contributing factor behind the high population caesarean section rates. Policymakers should urgently institute systems for accountability and ethical practice and regularly monitor all medical interventions, before large scale exploitation of the rural markets begins.

High caesarean rates in Madras (India): a population-based cross sectional study

Objective To estimate the population caesarean section rate in urban India. Design Population-based cross sectional study. Setting Madras City (Chennai), India. Sample Seven hundred and eighty resident women who delivered in Madras between June 1997 and May 1999. Methods Cluster sampling was done using streets as cluster units. Thirty clusters were selected from 1255 clusters by the probability proportion to size method and 26 women were selected randomly from each cluster. Main outcome measures Total and primary caesarean rates. Results Total population caesarean section rate was 32.6% (95% CI 27–38) and primary caesarean section rate was 25% (95% CI 20–30). Total caesarean section rates in the public, charitable and private sectors were 20%, 38% and 47%, respectively. Private sector deliveries had an odds ratio of 2.4 (95% CI 1.5, 3.8) of a primary caesarean section delivery in comparison with the public sector after adjustment for parity, age at delivery of mother and educational status. Conclusions Forty-seven percent of births by caesarean section in the private sector is alarming and could implicate private sector care as the main contributing factor behind the high population caesarean section rates. Policymakers should urgently institute systems for accountability and ethical practice and regularly monitor all medical interventions, before large scale exploitation of the rural markets begins.

Evaluation of emergency caesarean sections--completion of the audit cycle in a Central London teaching hospital

We set out to complete the audit cycle of caesarean deliveries in order to determine if improvements could be achieved. This was a prospective review of clinical notes in a Central London Teaching Hospital. The study involved 152 women delivering between 18 May and 23 August 1998, and 226 women over the same time period in 1999. For each case, a proforma was completed within 72 hours of delivery. We recorded the total and emergency section rate; indications; decision-to-delivery times; reasons for delay; prescription of ranitidine and heparin; fetal blood samples and cord pH values. The total caesarean section rate decreased from 20·9% to 19·2%. The emergency section rate was unchanged at 14·8% in 1998 (70·9% of total) and 13·6% in 1999 (70·8% of total). Main reasons for emergency sections were failure to progress (59% in 1998, 47% in 1999) and fetal distress (27% in 1998, 34% in 1999). For failure to progress 76% of cases were performed within 1 hour in 1998 vs. 64% of cases in 1999. For fetal distress 39% of cases were delivered within 30 minutes in both years. Fetal blood samples were taken in 41% of fetal distress cases in 1998 and 34% in 1999. Cord pH was documented in 60% of emergency cases in 1998 (96% in 1999). Prescription of ranitidine rose from 53% to 81%. Heparin was well prescribed in both years (88% vs. 87%). Following the initial audit, the total caesarean section rate was significantly lower but there was no difference in the emergency section rate. The implementations had no effect on decision-to-delivery times or use of fetal blood sampling. Improvements were seen in obtaining cord pH values and ranitidine prescription.

Active management of labor: is it suitable for a developing country?

Objective: To evaluate the effectiveness of active management of labor in the setting of a developing country. Methods: This historical cohort study compared the labor characteristics and outcome of all anti-HIV positive nulliparous pregnant women ( n=96), who delivered between January 1991 and March 1999, treated with traditional labor management to all anti-HIV negative nulliparous pregnant women ( n=1856), who delivered in 1998, treated with active management of labor in the tertiary center of a developing country. The year 1998 was chosen by using the total cesarean section rate of nulliparous patients from 1991 to 1998 to find the mean, then selected the year with cesarean section rate nearest to the mean as a control. Data were analyzed by the chi-square and t-tests. Results: The length of labor was significantly shortened in the active management group (6.3±3.3 h vs. 8.9±6 h, P<0.001). A significantly greater proportion of the traditional management group had prolonged labor (29.3% vs. 4.9%, P<0.001). However, the cesarean section rate was not different between the two groups (active vs. traditional=17% vs. 14.6%, P=0.7) with dystocia as a major indication in both groups. Maternal and fetal complications were not different. Conclusion: The active management of labor shortened the duration of labor and reduced prolonged labor; however, it did not decrease the cesarean section rate.

Excessive Use of Cesarean Section for the Second Twin?

Background: In Sweden, the frequency of cesarean section of the second twin after vaginal birth of the first twin has increased in recent years. Methods: To investigate the indications for second twin cesarean sections, all twin deliveries at Huddinge University Hospital from 1995 to 1997 were reviewed retrospectively. The rates of cesarean section for the second twin were compared with figures from the whole country, based on the Swedish medical birth register. Results: Thirty-one percent of all twin deliveries had a spontaneous onset and spontaneous vaginal delivery. The total twin cesarean section rate, including cesarean section for the second twin, was 45% at Huddinge University Hospital in 1995–1997 and 44% in Sweden in 1995. Cesarean section for the second twin after vaginal delivery of the first twin occurred in 11%. On review, 2/3 of the cesarean sections for the second twin were considered potentially avoidable. Conclusion: In normal twin pregnancies with vertex/nonvertex presentation, the favorable fetal outcome and also the maternal risks associated with cesarean section support vaginal delivery as the recommended delivery route. Extraction or version of a second nonvertex twin should be attempted before cesarean section for this twin is performed.

Diagnostische und klinische Wertigkeit der Dopplersonographie in der Geburtshilfe

The diagnostic value (efficiency) of Doppler ultrasound in obstetrics is assessed by studying the association or correlation between Doppler measurement parameters and pregnancy outcome parameters, without influencing the clinical management. The clinical value (efficacy) is however assessed by studying the ability to improve the outcome of pregnancy if Doppler ultrasound is used in obstetrical management for the purpose of possible intervention. The accepted method for assessment of the diagnostic value is the observational study, and the best method for the assessment of the clinical value is the randomised controlled management study (clinical trial). Observational studies concerning the diagnostic value have been widely reported in the literature. According to these studies significant relationships between abnormal Doppler findings and the following obstetrical problems were found: intrauterine growth retardation, preterm delivery, acidosis determined by fetal blood sampling, abnormal intrapartum fetal heart rate, neonatal depression and acidosis, and admission to neonatal intensive care unit. However from these studies it cannot be concluded that pregnancy outcome will be improved by using this information clinically. This problem can only be properly addressed by appropriate clinical management studies. The majority of the published randomised controlled trials showed beneficial effect from Doppler ultrasound application in high-risk pregnancy management. These effects included a significant decrease in the duration of antenatal and neonatal hospital stay, the rate of labour induction, and the rate of emergency Caesarean section. At the same time there was no difference in the gestational age at delivery or in the total Caesarean section rate. None of these trials alone was large enough to demonstrate a statistically significant reduction in perinatal mortality. However cumulative meta-analysis allows pooling to evaluate the results from separate but similar studies. The results from such an analysis showed that in high-risk pregnancies managed with Doppler there is a significant decrease of 50 per cent in perinatal mortality and in stillbirths of anatomically normal fetuses. It is important to note that there was no increase in neonatal or maternal morbidity associated with the use of Doppler ultrasound, and that the reduction in perinatal mortality was not the result of a delay in timing fetal death.

Cesarean Section

OBJECTIVE: To examine the effect of recommendations to reduce the cesarean section rate issued by the National Consensus Conference on Aspects of Cesarean Birth in 1986 on obstetric practices and to identify current patient factors that predict cesarean section. DESIGN: Descriptive retrospective cross-sectional study. SETTING: A tertiary care perinatal referral centre and a general teaching hospital with a level 2 nursery in Hamilton, Ont. PATIENTS: All patients who gave birth at the two hospitals in 1982 (4121 women) and 1990 (4431). MAIN OUTCOME MEASURES: Cesarean section rates and indications and predictors of cesarean section. RESULTS: Although a trial of vaginal delivery after cesarean section was offered 93% more often in 1990 than in 1982 (p = 0.0002), the rate of vaginal delivery increased only 2.6%, for a reduction of 8.7% in the total cesarean section rate and of 15% in the repeat cesarean section rate. The incidence rate and treatment of dystocia did not change. The rate of cesarean section for breech presentation remained unchanged, and fetal distress was rarely confirmed with pH measurement in scalp blood before cesarean section. The most important predictors of cesarean section in 1990 were previous cesarean section and labour induction. For the nulliparous women and the multiparous women with no previous cesarean section labour induction was the most important predictor. CONCLUSIONS: The rate at which patients with previous cesarean section are offered a trial of vaginal delivery has increased significantly since 1982; however, the total and repeat cesarean section rates have not decreased proportionally. Induction of labour is currently the most important correctable predictor of cesarean section. The active management of dystocia, efforts to increase the rate of vaginal breech delivery and appropriate methods to diagnose fetal distress need to be improved; such improvements should reduce the cesarean section rate further.

The benefit of external cephalic version with tocolysis as a routine procedure in late pregnancy

The effectiveness of external cephalic version with tocolysis when routinely used in the 37th week of gestation is reported. The procedure had earlier been ruled out in our department, was found effective in a prospective study, and afterwards settled as a routine. Among 1038 women with single breech presentation, 882 could be offered an attempt of external cephalic version during the period 1982–1988. Attempt of version was carried out in 316 women resulting in a vertex presentation at delivery in 100. The success rate on average was 35%. The estimated reduction of breech deliveries was 100 1038 = 9.6% . As the mean caesarean section rate in women with breech presentation was 81% during the period studied, the estimated reduction in the number of caesarean sections during those seven years was 81. Thus the total caesarean section rate (11.3%) was estimated to be reduced by 0.4%. No immediate serious complications were associated with the procedure. Two cases of intra-uterine fetal death occurred 2 and 5 weeks, respectively, after successful, uncomplicated version to vertex presentation. No obvious connection with the external cephalic version could be demonstrated. The effectiveness of version as a routine procedure is less than expected from reports of prospective trials of external cephalic version carried out by a few investigators, but the results may realistically illustrate what is achieved in the long term.

1983-1989 Yılları Arasında Sezeryan Oranlarındaki Değişmeler

The rates of cesarean section between 1983-1989 ✓The distribution of the rates of cesarean section made between 1983-1989 and their indica¬tions was investigated retrospectively according to the years at Ondokuzmayis University, Medical School, Department of Gynecology and Obstetrics. The total cesarean section rate between these years was found 20.15 %, by a progressive increase, it was found to rise to 29.89 % in 1989. Repated cesarean sections were found that they constitued the first indication. Our findings were seen consistend with the literature findings.

Cesarean section and perinatal mortality: A nine-year experience in a city/county hospital

Presented is an analysis of experience from July, 1973, through June, 1982, in a teaching institution that served a high-risk urban population. The suggestion is made that improvement in perinatal mortality does not necessarily rely upon an ever-increasing cesarean section rate. During the 9 years encompassed by the study, the total cesarean section rate ranged from a low of 5.8% to a high of 8.2%. The primary cesarean section rate was first recorded separately in 1976, and stayed between 3.2% and 4.9%. During the same span of time, the uncorrected Perinatal Group II mortality rate dropped from 35/1,000 to 18/1,000. An attempt is made to interpret the various factors involved in accomplishing these results.

Trial of labor following cesarean section: A two-year experience

Elective repeat cesarean section is one of the major factors responsible for the increase in the total cesarean section rate observed since 1970. Beginning in January 1980, a voluntary program encouraging a trial of labor for patients with a documented previous low-transverse cesarean section and no apparent recurring indication was instituted. Two hundred seven patients were managed with an adequate trial of labor, and 84.5% were delivered vaginally over a 2-year period. There were no deaths associated with a trial of labor, and maternal and fetal morbidity was negligible. This voluntary program resulted in a 27.9% decrease in the repeat cesarean section rate over the 2 years reported. Patient and physician acceptance of such a program was evaluated by follow-up questionnaires. Current recommendations include a mandatory trial of labor in patients with only one previous low-transverse cesarean section and no current indication for cesarean delivery. A more liberal management policy regarding patients with two or more previous low-transverse cesarean sections also seems warranted.

Physician Bias in Cesarean Sections

Various aspects of physician bias in the decision to perform a cesarean section were investigated by comparing indications for cesarean sections for 1979 and 1980 and investigating the distribution of indications according to the day of the week. The contention that obstetricians may perform cesarean sections on weekends for secondary gain was refuted by showing no difference in the distribution of nonelective cesarean section indications between weekdays and weekends. Statistically significant changes in cesarean section indications were, however, observed between the two investigated years, which may be attributed to an organizational change within the department toward more sophisticated obstetric care. These changes included a significant increase in cesarean sections for dystocia and breech presentation and a decrease for fetal distress and "other" indications. Because the total cesarean section rate did not change during the study periods, it is suggested that modern obstetric practice per se does not increase cesarean section rates, but may shift the distribution of indications for cesarean section.

Modern indications for cesarean section

Total cesarean section rates and rates of various indications for primary cesarean section were reviewed for four yearly periods during the past decade. The time periods studied were chosen to follow the introduction of new obstetric practices and technologic advances in monitoring fetal condition. The total cesarean section rate increased from 6.8% to 17.1% during this time. The most common indication for primary cesarean section was cephalopelvic disproportion, which represented approximately 40% of cases during each study period. Primary cesarean section for fetal distress increased to 28.2% but has decreased over the past 2 years to a present rate of 11.7%. Primary cesarean section for breech presentation increased from 12.3% to 21%. From the perspective of this review a total cesarean section rate of 15% is predicted for the future.