Undergoing Emergency Cesarean Research Articles

Safety of vaginal delivery among dichorionic diamniotic twins over 10years in a UK teaching hospital.

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK. A retrospective study was conducted using data for women with dichorionic diamniotic twin pregnancies who attended a teaching hospital in London, UK, for delivery between January 4, 2000, and December 23, 2010. Among 892 women, 474 (53.1%) attempted vaginal delivery, 220 (46.4%) of whom achieved spontaneous vaginal delivery of both twins. Instrumental vaginal delivery was performed among 89 women (18.8%), and 165 (34.8%) women underwent emergency cesarean delivery. Delivery of the second twin by emergency cesarean (n=31) was predominantly for fetal distress (13 [41.9%]) or abnormal lie (10 [32.3%]). A 5-minute Apgar score of 9 or 10 was recorded for 384 (83.7%) of 459 first twins and 369 (82.9%) of 445second twins, irrespective of the mode of delivery. Vaginal delivery among dichorionic diamniotic twins had a good success rate and a low intrapartum emergency cesarean delivery rate. Training in cardiotocography and intrapartum procedures might further reduce the need for emergency cesarean delivery.

Reciprocal Feedback Between miR-181a and E2/ERα in Myometrium Enhances Inflammation Leading to Labor

The initiation of term and preterm labor is associated with an up-regulated inflammatory response in myometrium; however, the underlying signaling pathways remain incompletely defined. To define the regulatory mechanisms that mediate the increased myometrial inflammatory response leading to labor, we investigated the roles of microRNAs (miRNA/miR). Human myometrial tissues, isolated smooth muscle cells, and animal models were used to study miR-181a regulation of uterine inflammatory pathways and contractility. Myometrial tissues from 15 term pregnant women undergoing elective cesarean section (not in labor) and 10 term pregnant women undergoing emergency cesarean section (in labor) were used. Expression of the highly conserved microRNA, miR-181a, was significantly decreased in mouse and human myometrium during late gestation. By contrast, the putative miR-181a targets, TNF-α, and estrogen receptor (ER)-α, and the validated target, c-Fos, key factors in the inflammatory response leading to parturition, were coordinately up-regulated. In studies using human myometrial cells, overexpression of miR-181a mimics repressed basal as well as IL-1β-induced TNF-α, C-C motif chemokine ligand 2 and 8 expression, whereas the expression of the antiinflammatory cytokine, IL-10, was increased. Overexpression of miR-181a dramatically inhibited both spontaneous and IL-1β-induced contraction of human myometrial cells. Notably, miR-181a directly targeted ERα and decreased its expression, whereas estradiol-17β reciprocally inhibited expression of mature miR-181a in myometrial cells. Thus, increased estradiol-17β/ERα signaling in myometrium near term inhibits miR-181a, resulting in a further increase in ERα and proinflammatory signaling. This escalating feedback loop provides novel targets and therapeutic strategies for the prevention of preterm labor and its consequences.

Gastric Rupture in Pregnancy: Case Series from a Tertiary Institution in Rwanda and Review of the Literature

Background Gastric rupture is a rare, life-threatening condition during pregnancy. Case study We present three cases of gastric perforation during pregnancy and the puerperium. The first patient presented with gastric perforation 4 days following an uncomplicated cesarean delivery for obstetric indications. She initially complained of epigastric pain; however, those symptoms resolved. She later demonstrated worsening abdominal distension, intra-abdominal free fluid, and signs of peritonitis. At laparotomy, an ascariasis-associated gastric rupture was diagnosed. She died from sepsis 4 days following the laparotomy. The second patient presented 19 days following a normal vaginal delivery. She presented with hemodynamic instability and underwent emergent laparotomy due to suspected septic shock peritonitis. Gastric rupture was diagnosed intraoperatively. She improved clinically and was discharged home. The third patient underwent emergency cesarean delivery due to non-reassuring fetal status in the setting of preeclampsia. She was initially diagnosed with ascites and pulmonary edema as a result of preeclampsia. Later in her course, she developed features in favor of acute abdomen and signs of sepsis. At the time of emergent laparotomy, a gastric rupture was identified and repaired. She died 2 days later from sepsis. Conclusion We report the management and outcome of three cases of pregnancy-related gastric rupture. To our knowledge, these three cases represent the largest series of pregnancy-related gastric ruptures from a single institution.

Effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.

PurposeCesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.Patients and methodsThirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively.ResultsElevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively.ConclusionLow-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia.

Carbetocin versus oxytocin to reduce additional uterotonic use at non-elective caesarean section: a double-blind, randomised trial

Objective: We compared the efficacy of Carbetocin (long-acting oxytocin receptor agonist) versus Oxytocin given at non-elective caesarean section.Method: We performed a double-blind, randomised, single-centre study. Eligible women were ≥37 weeks of gestation undergoing emergency caesarean section. Participants received either carbetocin of 100 μg or oxytocin 5 international units. The primary outcome was the need to administer additional uterotonics, as determined by the clinician. Secondary outcomes included estimated blood loss, haemoglobin drop pre–post operation and the need for a blood transfusionResults: From August 2012 to February 2013, 114 women were enroled. Two were excluded from analysis as they received a general anaesthetic. Fifty-nine patients received 100-μg carbetocin; 53 received 5 international units oxytocin. There was no statistically significant difference in the number of women requiring additional uterotonics between the two groups: Carbetocin group 22% and Oxytocin group 13% (p = 0.323). There were no significant differences in the fall in haemoglobin, estimated blood loss, rates of post-partum haemorrhage or blood transfusions.Conclusion: Oxytocin and carbetocin have similar requirements for additional uterotonics, estimated blood loss, haemoglobin drop and blood transfusions. There was a trend towards requiring additional uterotonics in patients receiving Carbetocin which was not statistically significant. This study found no benefits in using carbetocin over oxytocin.

Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise

BackgroundMost studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise. MethodsHealthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100mmHg patients received phenylephrine 100μg or ephedrine 8mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded. ResultsThere was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1–2] and 2 [1–2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60beats/min after vasopressor administration (P=0.001). ConclusionsBoth phenylephrine 100μg and ephedrine 8mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.

Clinical value of color doppler ultrasound in prenatal diagnosis of umbilical cord entry abnormity.

Objective:To study the clinical value of prenatal diagnosis of umbilical cord entry abnormity (UCEA) by means of color Doppler ultrasound (CDUS).Methods:Clinical data of sixty-four cases with confirmed umbilical cord entry abnormity were reviewed and the specific UCEA conditions and the outcomes of perinatal infants were analyzed.Results:Detection rates of marginal umbilical cord entry abnormity and velamentous umbilical cord entry abnormity by means of CDUS at second trimester were 94.1% and 93.8% respecdtively much higher than 80.0% and 68.8% which were those of third trimester. Discrepancy had statistical significance (P<0.05). True positive rate of prenatal diagnosis of UCEA by means of CDUS was 85.9% (55/64), and false negative rate was 14.1% (9/64). Among sixty four patients with UCEA, seventeen patients (26.6%) underwent selective caesarean delivery; twenty-six patients (35.9%) underwent emergency caesarean delivery and twenty-four patients (37.5%) had normal delivery.Conclusion:Prenatal diagnosis of UCEA by means of CDUS is intuitive and accurate. It provides an evidence for determination of the best time to diagnose UCEA, and also offers a proper advice for pregnant women about delivery mode to ensure the fetus survival rate, which is clinically valuable.

Phenomenological study of primiparous mother's experience of emergency cesarean section in Yogyakarta

A phenomenological study of primiparous mothers’ experience of emergency cesarean section in YogyakartaPurposeThe purpose of the study was to explore the experience of primipara mothers when the emergency cesarean section was decided at hospital of Wates Kulon Progo in Yogyakarta.Method A phenomenological study was conducted involving in-depth interviews with 7 post emergency cesarean section mothers at hospital of Wates Kulon Progo in Yogyakarta from April until July 2014. ResultsThe study found three themes in the mothers’ experiences related to emergency cesarean section: the perception of the mothers was associated with emergency cesarean section, the influence of spirituality on positive perceptions of mothers and support for mothers in the face of emergency cesarean section. ConclusionMothers have a specific strategy in dealing with the emergency cesarean section which they will experience. Support for mothers in facing emergency cesarean section, spirituality influences on mother's positive perception and mothers’ perceptions related to emergency cesarean section affect mothers’ readiness to undergo emergency cesarean section. It is necessary to create a policy focusing on FCMC by involving family counselors when the mother has decided for emergency cesarean section.

Sublingual Misoprostol as an Adjunct to Oxytocin During Cesarean Delivery in Women at Risk of Postpartum Hemorrhage

Abstract Objective To evaluate whether a combination of misoprostol and oxytocin more effectively reduces blood loss during and after cesarean delivery than does oxytocin alone among women with known risk factors for postpartum hemorrhage (PPH). Methods A prospective, randomized, double-blind, placebo-controlled trial was performed at a tertiary care center in Kolkata, India, between October 2012 and December 2013. Women were eligible if they were undergoing emergency cesarean under spinal anesthesia and were at high risk for PPH. Participants were randomly assigned (1:1) to receive 400 μg misoprostol or matched placebo sublingually after delivery of the newborn using a computer-generated random number sequence (block size eight). Participants and providers were masked to assignment. All participants received 20 IU oxytocin. The primary outcomes were intraoperative and postoperative blood loss. Results Both groups contained 198 women. Mean intraoperative blood loss was significantly lower in the misoprostol group (505.4 ± 215.5 mL) than in the placebo group (587.3 ± 201.5 mL; P Conclusion Misoprostol as an adjunct to oxytocin seemed to more effectively reduce blood loss than did oxytocin alone. Clinical Trial Registry India: CTRI/2013/05/003645 .

After surgery: the effects of life-saving caesarean sections in Burkina Faso.

BackgroundIn African countries, caesarean sections are usually performed to save mothers and babies’ lives, sometimes in extremis and at considerable costs. Little is known about the health and lives of women once discharged after such surgery. We investigated the long-term effects of life-saving caesarean section on health, economic and social outcomes in Burkina Faso.MethodsWe conducted a 4 year prospective cohort study of women and their babies using mixed methods. The quantitative sample was selected in seven hospitals and included 950 women: 100 women with a caesarean section associated with near-miss complication (life-saving caesareans); 173 women with a vaginal birth associated with near-miss complication; and 677 women with uncomplicated vaginal childbirth. Structured interviews were conducted at 3 months, 6 months, 12 months and 3 and 4 years postpartum. These were supplemented by medical record data on delivery and physical examinations at 6 and 12 months postpartum. The lives and experiences of 21 women were documented ethnographically. Data were analysed with multivariable logistic regressions, using survival analysis and thematic analysis.ResultsThe physical effects of life-saving caesareans appeared to be similar to women who had an uncomplicated childbirth, although 55 % of women with life-saving caesareans had another caesarean in their next pregnancy. The negative effects were generally economic, social and reproductive when compared to vaginal births, including increased debts (AOR = 3.91 (1.46–10.48) and sexual violence (AOR = 4.71 (1.04–21.3)) and lower fertility (AOR = 0.44 (0.24–0.80)) 4 years after life-saving caesareans. In the short and medium term, women with life-saving caesareans appeared to suffer increased psychological distress compared to uncomplicated births. They were more likely to use contraceptives (AOR = 5.95 (1.53–23.06); 3 months). Mortality of the index child was increased in both near-miss groups, independent of delivery mode. Ethnographic data suggest that these consequences are significant for Burkinabe women, whose well-being and social standing are mostly determined by their fertility, marriage strength and family links.ConclusionsLife-saving caesareans have broad consequences beyond clinical sequelae. The recent policy to subsidise emergency obstetric care costs implemented in Burkina Faso should help avoid the majority of catastrophic costs, shown to be problematic for women undergoing emergency caesarean section.

Electronic Poster Presentations, Maternal Fetal Medicine

Electronic Poster Presentations, Maternal Fetal Medicine

Airway management in patients undergoing emergency Cesarean section.

Special care is required for airway management of patients undergoing emergency Cesarean section. Although the incidence of difficult intubation and difficult ventilation is similar between pregnant and non-pregnant women, the severity of complications in pregnant patients would be much greater than in non-pregnant patients, if tracheal intubation is found to be difficult: increased risk of pulmonary aspiration, hypoxia, airway obstruction due to laryngeal edema, and a "sleeping baby" being taken out. Rapid-sequence induction of anesthesia is generally indicated to a patient undergoing emergency Cesarean section under general anesthesia. The technique has been evolving, without losing the key premise of minimizing the period of the airway being not protected from pulmonary aspiration, and of permitting rapid wake up if tracheal intubation fails. In this review, I describe the appropriate airway management, based on the current state of knowledge, in a patient undergoing emergency Cesarean section under general anesthesia.

Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery

Objective: To assess and compare the effectiveness and safety of single IV polus dose of carbetocin, versus IV oxytocin infusion in the prevention of PPH in obese nulliparous women undergoing emergency Cesarean Delivery.Methods: A double-blinded randomized-controlled trial was conducted on 180 pregnant women with BMI >30. Women were randomized to receive either oxytocin or carbetocin during C.S. The primary outcome measure was major primary PPH >1000 ml within 24 h of delivery as per the definition of PPH by the World Health Organization Secondary outcome measures were hemoglobin and hematocrit changes pre- and post-delivery, use of further ecobolics, uterine tone 2 and 12-h postpartum and adverse effects.Results: A significant difference in the amount of estimated blood loss or the incidence of primary postpartum haemorrhage (>1000 ml) in both groups. Haemoglobin levels before and 24-h postpartum was similar. None from the carbetocin group versus 71.5% in oxytocin group needed additional utrotonics (p < 0.01). The uterine contractility was better in the carbetocin group at 2, and 12-h postpartum (p < 0.05).Conclusions: A single 100-µg IV carbetocin is more effective than IV oxytocin infusion for maintaining adequate uterine tone and preventing postpartum bleeding in obese nulliparous women undergoing emergency cesarean delivery, both has similar safety profile and minor hemodynamic effect.

Antibiotic prophylaxis for caesarean section at a Ugandan hospital: a randomised clinical trial evaluating the effect of administration time on the incidence of postoperative infections.

BackgroundProphylactic antibiotics are used to prevent postoperative infections after caesarean section. Studies have suggested that the timing of prophylaxis plays an important role. Over the years, the role of the anaesthesiologist in the administration of prophylactic antibiotics has become prominent. Therefore, there is an increasing need for anaesthesia providers to understand the rationale of antibiotic prophylaxis. We therefore sought to compare the effect of antibiotics prophylaxis within 1 hour before skin incision and after skin incision on the incidence of postoperative infections in patients undergoing caesarean section at Mulago Hospital.MethodsWe conducted a single-blind randomised clinical trial conducted at Mulago Hospital evaluating 464 patients undergoing emergency caesarean section. Patients were randomly assigned a group number that allocated them to either arm of the study. They received the same prophylactic antibiotic according to their allotment, that is, either within 1 hour before skin incision or after skin incision as per current standards of practice in Mulago Hospital. They were followed up to detect infection up to 10 days postoperatively. The primary outcome was postoperative infection. The data collected were analysed with STATA version 12 using univariate and bivariate analysis.ResultsThe risk of overall postoperative infection was significantly lower when prophylaxis was given within an hour before incision (RR O.77, 95% CI 0.62–0.97). We also found endometritis to be significantly reduced in the pre-incision group (RR 0.62; 95% CI 0.39–0.99; P value 0.036).ConclusionsGiving prophylactic antibiotics before skin incision reduces risk of postoperative infection, in particular of endometritis.Trial registrationPan African Clinical Trial Registry PACTR201311000610495.Date of trial registration: 12th August 2013.

The clinical practice of sitting position with pencil point spinal needle for spinal anesthesia in emergency cesarean section

Objective To study the effects of sitting position with pencil point spinal needle in spinal anesthesia for emergency Cesarean-section.Methods Four hundred ASA physical status of Ⅰ or Ⅱ parturients undergoing emergency cesarean section were divided randomly into four groups (100 cases each).Spinal anesthesia was performed with pencil pointed needle in sitting position in group A,or with pencil pointed needle in lateral position in group B,or with ordinary inclined plane needle in sitting position in group C,or with ordinary inclined plane needle in lateral position in group D.Spinal anesthesia was induced with 1.8 ml-2.2 ml of 5％ bupivacaine (9 mg-1 1 mg) following successful puncture.The parturients were escorted to wards when analgesia block level dissipated to T10 after operation.All patients must be in supine position for six hours.Postoperation follow-up lasted for three days.The frequency of puncture,puncture time,the rate of successful puncture,the time from skin incision to delivery.Intraoperation and postoperative complications were recorded.Results Compared with group B and D,the frequency of puncture were declined significantly in group A and C[group B(3.2±0.9) and D(4.1±0.4) vs group A(1.1±0.5) and C(1.2±0.6)],the rate of successful puncture were increased [group B (90％) and group D (92％) vs group A (100％) and group C (98％)],the time of puncture were shorter [group B (5.2±0.6) min and D (4.1±0.9) min vs group A (1.2±0.8) min and C (2.1±0.7) min],the time of performed spinal anesthesia were shorter [group B (7.1±0.5) rmin and D (6.2±0.8) min vs group A (3.4±0.7) min and C (4.3±0.6)min],the time from beginning puncture to skin incision were shorter [group B (15.2±6.3) min and D (17.1±4.4) min vs group A (10.4±0.5) min and C (11.3±0.7) min] (P＜0.05).Compared with group C and D,the rate of intraoperation hypotension were reduced in group A and B [group C(18％) and group D (20％) vs group A (8％) and group B (10％],There were no postdural puncture headache and low back pain in group A and B [group C(3％) and group D(4％) vs group A(0) and group B(0)](P＜0.05).Conclusions Spinal anesthesia with fine needle in sitting position is simple to perform and needs shorter time and fewer puncture times and has higher successful rate and fewer intraoperation and postoperation complications.It can be widely used in emergency cesarean section. Key words: Sitting position; Fine needle; Anesthesia, spinal; Cesarean-section

English

OBJECTIVES: To study the fetal outcome of rural referrals undergoing emergency caesarean delivery versus elective caesarean delivery in a tertiary care hospital METHODOLOGY: This comparative study was done at a rural medical college hospital, Karnataka, from October 2010 to October 2011. 50 patients referred to the hospital and who underwent caesarean delivery are emergency group and 50 patients admitted in our hospital who were posted for elective cesarean delivery were the other group in the study with emphasis on indications and perinatal outcome. RESULTS: obstructed labour (34 %) was the commonest indication in emergency and previous caesarean delivery (36%) being the commonest in elective group. The live birth was 88% in Emergency group as against 100% live births in Elective group. Perinatal mortality from emergency Caesarean sections accounted for 12%, with severe birth asphyxia responsible for most perinatal deaths. There was statistically significant difference in stillbirths, neonatal deaths, and severe neonatal morbidity between emergency and elective caesarean sections-probably related to prolonged labor, asphyxia, and sepsis than in elective caesarean delivery. CONCLUSION: The perinatal mortality was 12%, and the main cause of death was severe birth asphyxia. Emergency caesarean section was more likely than elective to result in a perinatal loss. The indication with the poorest fetal outcome was prolonged obstructed labor. Early diagnosis and timely intervention may result in decrease in incidence of morbidity and mortality. Emergency caesareans, when performed, are often too late to reduce perinatal deaths.

Combined-Spinal-Epidural Anesthesia in a Parturient with Gestational Hypertension with Acute and Extremely Elevated Blood Pressure Undergoing Emergency Caesarean Section

Hypertensive disorder is the most common medical problem encountered in pregnancy. It remains an important cause of maternal, and foetal, morbidity and mortality. Neuraxial anaesthesia techniques are most widely used for caesarean delivery. We describe the anaesthetic management of a 40-year-female with gestational hypertension undergoing caesarean section who presented with acute and extreme rise of blood pressure (BP) (249/116 mmHg). Her BP was controlled quickly and she was successfully managed by combined-spinal-epidural technique. This report shows that carefully conducted neuraxial anaesthesia can be useful for caesarean delivery in parturients with severe elevation of BP where general anaesthesia is normally indicated.

Sublingual misoprostol as an adjunct to oxytocin during cesarean delivery in women at risk of postpartum hemorrhage

ObjectiveTo evaluate whether a combination of misoprostol and oxytocin more effectively reduces blood loss during and after cesarean delivery than does oxytocin alone among women with known risk factors for postpartum hemorrhage (PPH). MethodsA prospective, randomized, double-blind, placebo-controlled trial was performed at a tertiary care center in Kolkata, India, between October 2012 and December 2013. Women were eligible if they were undergoing emergency cesarean under spinal anesthesia and were at high risk for PPH. Participants were randomly assigned (1:1) to receive 400μg misoprostol or matched placebo sublingually after delivery of the newborn using a computer-generated random number sequence (block size eight). Participants and providers were masked to assignment. All participants received 20IU oxytocin. The primary outcomes were intraoperative and postoperative blood loss. ResultsBoth groups contained 198 women. Mean intraoperative blood loss was significantly lower in the misoprostol group (505.4±215.5mL) than in the placebo group (587.3±201.5mL; P<0.001). Mean postoperative blood loss was slightly lower in the misoprostol group (96.9±57.3mL) than in the placebo group (103.4±58.4mL; P=0.07). Shivering and pyrexia were more frequently associated with misoprostol (P<0.05 for both). ConclusionMisoprostol as an adjunct to oxytocin seemed to more effectively reduce blood loss than did oxytocin alone.Clinical Trial Registry India:CTRI/2013/05/003645.

PMM.54 Experience of the management of non-acute low platelets in pregnancy

Thrombocytopenia in pregnancy is defined as a platelet count <100 × 109/l. We undertook a 5-year [2008–2012] retrospective case note review of 34 patients with thrombocytopenia in pregnancy managed in...

Maternal and institutional characteristics associated with the administration of prophylactic antibiotics for caesarean section: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

To illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections. Secondary analysis of a cross-sectional study. Twenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. Three hundred and fifty-nine health facilities with the capacity to perform caesarean section. Descriptive analysis and effect estimates using multilevel logistic regression. Coverage of antibiotic prophylaxis for caesarean section. A total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section. Coverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible.