This is descriptive study was conducted by a group of innovate student including my brother, at the department of Obstetrics and Gynecology (OB and GYN), Erbil Maternity and Paediatrics Teaching Hospital, from 21st of November to 27th of November 2007.
All cases of Cesarean Sections presenting during the study period were recorded in the department using data information sheet prepared for the purpose of this study.
All patients were interviewed post operatively in the wards. For each patient a data information sheet is filled which includes: name, age, parity, gestational age, educational level, type and cause of cesarean section.
Even my brother, Raman, published this study in his own blog, bug I thought it will be good to publish it here too.
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Hawler Medical University
College of Medicine
4th Year Medical Students' Community Medicine Research Projects
Rate and Indications of Caesarean Section in Erbil Maternity Hospital/2007
Conducted by
Muhammed Nizar Khidhir
Rawand Kamaran Hussein
Ibrahim Mussa Ma’roof
Wa’d Jarjis Abdullah
Rebaz Hamza Salih
Dilbrin Mula Muhammed
Raman Sabr Ma’roof
Supervised By
Dr. Lazha Talat
M.B.Ch.B.; M.P.H.
2007-1428-2707
Acknowledgment:
Any accomplishment requires the effort of many people and this work is no different. We thank our supervisor (Dr. Lazha Talat) for her patience and support in accomplishing this research.
Grateful acknowledgement is made to anyone who had role in completing this research.
ABSTRACT
A descriptive study was conducted in Erbil Maternity and paediatric hospital from the (21St of Nov. 2007 to 27th of Nov. 2007). All cases of cesarean deliveries that were done during this period were reviewed. This study aimed to identify the rate and indications for cesarean section in Erbil maternity and paediatric hospital. The total live births in this period were (423); among those, (325) were delivered vaginally and (98) delivered by cesarean section.
The patients have been divided into two groups:
Group 1
Including cases that were referred to the hospital for elective cesarean sections (12).
Group 2
Emergency cesarean section had been conducted from the labour ward (86).
Contents
| Titles | Pages |
| Definition…………………………………………………………… | 1 |
| History……………………………………………………………… | 1-2 |
| Types of uterine incisions………………………………………….. | 3 |
| Elective Cesarean Section………………………………………….. | 4 |
| Emergency Cesarean Section………………………………………. | 4 |
| Incidence……………………………………………………………. | 5 |
| Indications………………………………………………………….. | 5 |
| Risks and complications…………………………………………… | 6-7 |
| Vaginal birth after delivery………………………………………… | 8 |
| Patients and methods………………………………………………. | 9 |
| Sheet of data collection…………………………………………….. | 10 |
| Results……………………………………………………………... | 11-19 |
| Discussion………………………………………………………….. | 20-21 |
| Conclusion and Recommendation…………………………………. | 22 |
| References………………………………………………………….. | 23 |
List of tables
| Titles | Pages |
| Table 1: Total number of deliveries…………………………………….. | 13 |
| Table 2: Indications of cesarean sections in Erbil Maternity Hospital...... | 14 |
| Table 3: Indications of caesarean sections regarding the numbers of previous cesarean sections………………………………………………. | 15 |
List of figures
| Titles | Pages |
| Figure 1: Maternal Diseases as indication of Caesarean sections……….. | 16 |
| Figure 2: Distribution of Caesarean sections according to educational level……………………………………………………………………… | 17 |
| Figure 3: Distribution of Caesarean sections among different age groups | 18 |
| Figure 4: Caesarean section according to gestational age……………….. | 19 |
I- Introduction
I.I Definition
Caesarean section is a form of childbirth in which a surgical incision is made through a mother’s abdomen (laparotomy) and uterus (hysterectomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk.14
I.II History
The earliest attested usages of the made up language in an obstetric context date from the first century. There are three theories about the origin of the name:
1. In the English language, the name for the procedure is said to derive from a Roman legal code called "Lex Caesarea", which allegedly contained a law prescribing that the baby be cut out of its mother's womb in case she dies before giving birth.4 (The Merriam-Webster dictionary is unable to trace any such law; but "Lex Caesarea" might mean simply "imperial law" rather than a specific statute of Julius Caesar.)
2. The derivation of the name is also often attributed to an ancient story, told in the first century A.D. by Pliny the Elder, which claims that Caesar's ancestor was delivered thus.5 Whether or not the story is true, it may have been widely enough believed to give its name to the operation. (The reverse view, that the name "Caesar" was derived from the operation, is clearly indefensible, see below.)
3. An alternative etymology has been proposed, suggesting that the procedure's name derives from the Latin verb caedere (supine stem caesum), "to cut," in which case the term "Caesarean section" is a tautology. Proponents of this view consider the traditional derivation to be a false etymology, though the supposed link with Julius Caesar has clearly influenced the spelling. The merits of this view must be considered separately from the corollary believed by some, that Caesar himself derived his name from the operation. This is certainly false: the cognomen "Caesar" had been used in the Julii family for centuries before Julius Caesar's birth, and the Historia Augusta cites three possible sources for the name Caesar, none of which have to do with Caesarean sections or the root word caedere.
The link with Julius Caesar, or with Roman emperors generally, exists in other languages as well. For example, the modern German & Dutch terms are respectively Kaiserschnitt & keizersnede (literally: "Emperor's section").
Caesarean section to deliver the baby of a mother who has died has been documented in ancient Egypt, Asia and Europe.
Pliny the Elder theorized that Julius Caesar's namesake came from an ancestor who was born by Caesarian section, but the truth of this is debated. The Ancient Roman c-section was first performed to remove a baby from the womb of a mother who died during childbirth. Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility that the Roman Dictator and General was a c-section baby. (In fact, she died 45 years later.) It should be noted that Maimonides, the famous rabbi, philosopher, and doctor, says that it was known in ancient Rome how to perform a c-section without killing the mother, but that the medical knowledge of his day was lacking and it was not performed. Thus it would seem that, according to what Maimonides knew, c-sections were not performed solely on dying women, but also on mothers who would live after the birth of their child.
The Catalan saint, Raymond Nonnatus (1204-1240), received his surname — from the Latin non natus ("not born") — because he was born by C-section. His mother died while giving birth to him.7
In 1316 the future Robert II of Scotland was delivered by caesarean section — his mother, Marjorie Bruce, died. This may have been the inspiration for Macduff in Shakespeare's play Macbeth".
The first caesarean carried out on a live woman is thought to be that of the wife of Jacob Nufer, a sixteenth century Swiss pig-farmer. She was in obstructed labour and her life was saved by the procedure.1
I.III Types of Uterine incision2
v Classical: vertical incision into the upper portion of uterine muscle, which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications.
v Low transverse or Kehr incision:
· It is most common.
· Incision made transversely in the lower uterine segment.
· The uterus is least likely to rupture in subsequent pregnancies.
· Trial of labour acceptable after low transverse Caesarean section.
· Majority of the scar separations are ''windows'' or incomplete.
v Low vertical: Incision made vertically in the lower uterine segment.
I.IV Elective caesarean sections
Caesarean sections are in some cases performed for reasons other than medical necessity. Reasons for elective caesareans vary, with a key distinction being between hospital or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered caesareans worry that caesareans are in some cases performed because they are profitable for the hospital, because a quick caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at 3 a.m:8 for unknown reasons, naturally-occurring labour seems to occur most often between midnight and dawn. Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. For example, the failure to perform a caesarean section has been a central point in numerous lawsuits against obstetricians over incidents of cerebral palsy.
I.V Emergency caesarean section
An emergency caesarean section is a caesarean performed once the labour has commenced.
I.VI Incidence
The World Health Organization estimates the rate of caesarean sections at between 10% and 15% of all births in developed countries. In 2004, the caesarean rate was about 20% in the United Kingdom. In 2005 the caesarean rate was 30.2% in the United States.9 During 2001–2002; the Canadian caesarean section rate was 22.5%.10 In the United States the caesarean rate has risen 46% since 1996.9
Studies have shown that continuity of care with a known care provider may significantly decrease the rate of caesarean delivery11 but that there is also research that appears to show that there is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care.12
I.VII Indications
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Reasons for caesarean delivery include:
v Prolonged labour or a failure to progress (dystocia) 2.
v Fetal distress.1, 2
v Malpresentations. 1, 2
v Placental problems (placenta praevia1, 2, placental abruption or placenta accreta).
v Previous Caesarean section. 1, 2
v Catastrophes such as cord prolapse. 1, 2
v Maternal diseases1
A. Uncontrolled Diabetes Mellitus.
B. Pre-Eclampsia and Eclampsia.
C. Heart diseases.
D. Obstructive tumor.
I.VIII Risks and complications of Caesarean section
When c-sections are done, most women and babies do well. But c-section is a major operation with risks from the surgery itself and from anesthesia.
The National Center for Health Statistics estimates that 1 in 3 babies in the United States are delivered by c-section.3 Over the past few years, the rate of cesarean birth has increased rapidly. Some health care providers believe that many c-sections are medically unnecessary. When a woman has a cesarean, the benefits of the procedure should outweigh the risks.
The Risk of Late Preterm Birth
C-sections may contribute to the growing number of babies who are born “late preterm,” between 34 and 36 weeks gestation. While babies born at this time are usually considered healthy, they are more likely to have medical problems than babies born a few weeks later at full term.3
A baby’s lungs and brain mature late in pregnancy. Compared to a full-term baby, an infant born between 34 and 36 weeks gestation is more likely to have problems with:
- Breathing
- Feeding
- Maintaining his or her temperature
- Jaundice
Other Risks for the Baby
- Anesthesia: Some babies are affected by the drugs given to the mother for anesthesia during surgery. These medications make the woman numb so she can’t feel pain. But they may cause the baby to be inactive or sluggish. 2, 3
- Breathing problems: Even if they are full-term, babies born by c-section are more likely to have breathing problems than are babies who are delivered vaginally. 3
- Breastfeeding
Women who have c-sections are less likely to breastfeed than women who have vaginal deliveries. This may be because they are uncomfortable from the surgery or have less time with the baby in the hospital. - Fetal lacerations
Risks for the Mother
A few women have one or more of these complications after a c-section:
- Increased bleeding, which may require a blood transfusion. 2, 3
- Infections to uterus, urinary tract, or pulmonary system. 2
Ø Use of antibiotics at the time of operation reduces risk
Ø Risk increases if the patient had laboured
- Reactions to medications, including the drugs used for anesthesia
- Injuries to the bladder, bowel, ureters, vessels, nerves and cervix. 2
- Blood clots in the legs, pelvic organs or lungs.3
- Post operative ileus or bowel obstruction. 2
If a woman who has had a caesarean section becomes pregnant again, she is at increased risk of:
- Placenta praevia: The placenta implants very low in the uterus. It covers all or part of the internal opening of the cervix (the birth canal).
- Placenta accreta: The placenta implants too deeply and too firmly into the uterine wall.
Both of these conditions can lead to severe bleeding during labor and delivery, endangering mother and baby. The risk increases with the number of pregnancies.3
I.IX Vaginal birth after caesarean section
Vaginal birth after caesarean (VBAC) is not uncommon today. The medical practice until the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s and early 90s soared, but more recently the rates of VBAC have dramatically dropped due to medico-legal restrictions.
In the past, caesarean sections used a vertical incision which cut the uterine muscle fibres in an up and down direction (a classical caesarean). Modern caesareans typically involve a horizontal incision along the muscle fibres in the lower portion of the uterus (hence the term lower uterine segment caesarean section, LUSCS/LSCS). The uterus then better maintains its integrity and can tolerate the strong contractions of future childbirth. Cosmetically the scar for modern caesareans is below the "bikini line."
Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean section following a caesarean delivery; some still recommend a caesarean routinely, others do not. What should be emphasized in modern obstetric care is that the decision should be a mutual decision between the obstetrician and the mother/birth partner after assessing the risks and benefits of each type of delivery.
Twenty years of medical research on VBAC support a woman's choice to have a vaginal birth after caesarean. Because the consequences of caesareans include a higher chance of re-hospitalization after birth, infertility, and uterine rupture in the next birth, preventing the first caesarean remains the priority. For women with one or more previous caesareans, as an alternative to major abdominal surgery, some claim that VBAC remains a safer option.13
II- Patients and methods
A descriptive study was conducted at the department of obstetrics and gynecology, Erbil maternity and pediatrics hospital, Iraq, from 21st of November to 27th of November 2007.
All cases of cesarean sections presenting during the study period were recorded in the department using data information sheet prepared for the purpose of this study.
All patients were interviewed post operatively in the wards.
For each patient a data information sheet is filled which includes: name, age, parity, gestational age, educational level, type and cause of cesarean section.
Rate and indications of C/S in maternal Teaching Hospital/ Erbil
| | No.: |
city
| Name: | Educational Level: | ||||
| Age: | | Illiterate: | |||
| LMP: | | Elementary: | |||
| Parity (G.P.A.): | | Mid and High School: | |||
| G.A.: | | College: | |||
| Type of C/S: | Elective | Emergency | |||
| Causes of C/S: | |||||
| Previous C/S: | |||||
| Non progressive labour | |||||
| Malpresentation: | |||||
| | Breech | Shoulder | Face | Footling | |
| Fetal distress: | |||||
| Ante partum haemorrhage: | |||||
| | Placenta praevia | Placenta abruption | |||
| Cord Prolapse: | |||||
| Maternal Diseases: | |||||
| | D.M. | ||||
| | Pre-Eclampsia | ||||
| | Elcampsia | ||||
| | Heart disease | ||||
| | Obstructing tumor | ||||
| Fetal Diseases: | |||||
| | Preterm baby | Post-term baby | |||
| | Congenital anomalies | ||||
III- RESULTS
Table 1; shows the total number of deliveries were (423), of these, 325 (76.83%) of cases were delivered by vaginal deliveries and the rest 98 (23.17%) cases by cesarean sections, and of these 12 {12.24%} were delivered by elective cesarean section and 86 {87.75%} were delivered by emergency cesarean section.
Table 2; shows the indications of cesarean sections in Erbil Maternity Hospital. The most common indications were a history of previous cesarean section (52/98) 52.05%, and non-progressive labour (44/98) 44.89%, the other indications were as follows; mal-presentation (17/98) 17.34%, maternal diseases (14/98) 14.28%, antepartum haemorrhage (7/98) 7.14%, and congenital anomalies (4/98) 4.08%.
Note: 33.67% of patients had only one indication, but 45.91% had two indications, and the rest had three and more indications.
Table 3; shows indication for caesarean sections regarding the numbers of previous cesarean sections, women with one previous caesarean sections (33) 64.5%, while previous two caesarean sections (12) 23.5% and more than two previous cesarean sections (6) 12%.
Figure 1; shows Maternal Diseases as indication of cesarean sections .The most common maternal disease was pre-eclampsia (50%), the others were Eclampsia (28.57%) diabetes mellitus (14.28%), Heart diseases (7.14%).
Figure 2; shows the distribution of cesarean sections according to educational level, 34 (34.69%) of the cases were illiterate, while 65 of the cases were educated, among educated cases; 44 (44.89%) of the cases were at elementary level, 11 (11.22%) of the cases were at mid and high school level and the rest of the cases 9 (9.18%) were at college.
Figure 3; shows the distribution of cesarean sections among different age groups; the incidence of cesarean section was most common among 25-29 and 30-34 years, 28 (28.57%) in each age group. While 36 (36.72%) cases were among 20-24 and >=35 age group, 18 (18.36%) cases in each. In those who were <=19 years, 6 (6.12%) cases were present.
Figure 4; shows cesarean section according to gestational age, 54 (55.1%) of the cases were above 40 weeks, 37 (37.75%) of the cases were within 37-39 weeks, and 7 (7.14%) of the cases were below 36 weeks.
III.I
Table 1: Total number of deliveries
| Total No. of deliveries | Vaginal delivery | No. of Cesarean Section = 98 cases | |||
| Elective | % | Emergency | % | ||
| 423 | 325 | 12 | 12.24 | 86 | 87.76 |
III.II
Table 2: Indications of cesarean sections in Erbil Maternity Hospital
| Indications | NO. | % |
| Previous cesarean section | 51 | 52.04 |
| Non-progressive labour | 45 | 45.9 |
| Mal-presentation | 17 | 17.34 |
| Maternal diseases | 14 | 14.28 |
| Fetal distress | 7 | 7.14 |
| Antepartum haemorrhage | 7 | 7.14 |
| Preterm baby | 7 | 7.14 |
| Congenital anomalies | 4 | 4.08 |
Note: (24.98%) of patients had only one indication, but (50%) had two indications, and the rest (25.02%) had three and more indications.
III.III
Table 3: Indication of caesarean sections regarding the numbers of previous cesarean sections
| Previous cesarean sections | No. | Percentage |
| One | 33 | 64.5 |
| Two | 12 | 23.5 |
| More | 6 | 12 |
| Total | 51 | 100 |
III.IV
Figure 1: Maternal Diseases as indication of cesarean sections
III.V
Figure 2: Distribution of cesarean sections according to educational level
III.VI
Figure 3: Distribution of cesarean sections among different age groups.
Figure 4: Cesarean section according to gestational age.
IV- Discussion
In our study which was done in Erbil maternity hospital during 21st Nov. 2007 to 27th Nov. 2007 for determining the rate and indications of Caesarean section, we have found the rate of Caesarean section to the total number of deliveries was 98/423 (23.17%), and it was lower than the vaginal delivery 325/432 (76.83%) as vaginal delivery is preferable way of delivery and it’s associated with low morbidity and mortality rate.
The rate of cesarean delivery was 23.17% and this was in agreement with the study done in Erbil Maternity Hospital at 2002 by Dr. Shahla Hamza Ahmed, in which the rate was (24.7%)6.
The emergency cesarean sections in our study were higher than elective cesarean sections, which was 86/98 and 12/98 respectively, as most of the cases arrived late to hospital and they were not in appointment with doctors, this may be associated with educational level of the patients as our study revealed that the rate of caesarean section was common among those who were illiterate and at elementary level.
Among the cases, those who admitted to hospital for operation, 24.98% of cases have one indication, 50% of cases have tow indications, and 25.02% of cases have 3 and more indications.
In our study the most common indication for Caesarean section was previous Caesarean section (52.04%); (64.5%) included in within this list those who had only one previous Caesarean section, (23.5%) those who had two and (12%) those who had more than two, although we mentioned that medical researches on VBAC support a woman's choice to have a vaginal birth after caesarean, obstetricians and other caregivers have different opinions about VBAC, some still recommend a caesarean routinely, others do not, but in our community most with a previous Caesarean section had undergone another Caesarean section.
The second most common indication was non progressive laobur 45.9%; some of the cases tried vaginal delivery and waited but not adequately as it is obvious that the normal duration of first stage in primigravida and multigravida 12, 8 hours respectively. Some factors influenced this e.g. if a case is presented in afternoon the obstetrician may decide to do the operation instead of doing it later, because the obstetrician usually attends the clinic at this time.
The 3rd most common indication in our study was malpresentation, such as breech, face...etc which was 17 (17.34%).
The other indications of cesarean section were;
§ Maternal diseases 14 (14.28%) and among the diseases pre-eclampsia was the most common one, the other diseases were eclampsia, D.M. (which is usually associated with macrosomic baby), and heart diseases.
§ Fetal distress, ante partum hemorrhage, preterm baby each one 7 (7.14%) and congenital anomalies 4 (4.08%).
V- Conclusion and Recommendation:
We concluded in our study:
1. The rate of vaginal delivery was higher than cesarean section, and the rate of caesarean section in our study as compared to World Health Organization's estimation of rate caesarean section in developed countries is higher.
2. Emergency cesarean sections were higher than elective cesarean section.
3. The most common cause of cesarean section was previous cesarean section.
Some Recommendations:
1. All patients admitted to hospital should be observed closely for progression of labour and recognition of any cause that require operative delivery and use of CTG "cardiotocography" in labour room is strongly recommended.
2. Training and assessment of skills and close supervision of primary health providers.
3. Health education in people in rural areas and improvement in governmental assistance so that ante natal and delivery services will be affordable to all pregnant women of society.
4. Education and promotion of family planning which provide basic ante natal and delivery health services and it also could decreases maternal mortality and morbidity.
5. Building new hospitals and health centers.
6. Training and education for midwives, to know whether it's mandatory to perform caesarean section.
References
1. Stuart Campbell, Christoph Lees. Obstetrics by ten teachers. 17th edition. London. Arnold. 2000
2. Arthur T. Evans. Manual of obstetric. 7th edition. USA. Lippincott Williams and Wilkins.2007
3. Official website of the National Institutes of Health http://www.nih.gov/
4. England, Pam and Rob Horowitz, Birthing From Within, p. 149
5. Pliny the Elder, Historia naturalis 7.47
6. Dr. Shahla???????????????????????????????????????????
7. St. Raymond Nonnatus. Catholic Online. Retrieved on 2006-07-26.
8. Mackenzie IZ, Cooke I, Annan B. Indications for caesarean section in a consultant unit over the decades. J Obstet Gynecol 2003;23:233-8
9. a b Preliminary Births for 2005: Infant and Maternal Health. National Center for Health Statistics. Retrieved on 2006-11-23.
10. "Canada's caesarean section rate highest ever", CTV, April 21, 2004. Retrieved on 2006-07-26.
11. Homer Caroline et al. (2001). "Collaboration in maternity care: a randomized controlled trial comparing community-based continuity of care with standard hospital care." J British Journal of Obstetrics and Gynaecology, 2001 vol. 108 p16-22.
12. Hodnett, E. D. (2000). "Continuity of caregivers for care during pregnancy and childbirth" (PDF, fee may be required). John Wiley & Sons, Ltd. doi:10.1002/14651858.CD000062
13. Vernon, D (2005). Having a Great Birth in Australia. Canberra, Australia: Australian College of Midwives
14. Official website of the Sarasota Memorial Hospital http://www.smh.com.au/
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