Caesarean section (some idea from literature and personal experience)

1. Introduction

We are normally called upon to perform cesarean section, with emergency procedure. The indications are often decided by the midwives. Over half a million women and 5.7 million newborns die each year from complications relating to pregnancy and childbirth. Many of these are preventable and timely access to safe and competent obstetrical care, including cesarean section, is lifesaving for both mother and child.

2. Rates of Cesarean Birth

There has been considerable debate over the years as to what represent reasonable rates

of cesarean section. The World Health Organization (WHO) published guidelines in 1985 suggesting that cesarean rates should not exceed 15%, but revised these in 1994, suggesting that rates should be between 5-15%. Debate around these numbers has centered on implications that rates under 5% suggest that perhaps the population does not have sufficient access to life-saving health care. Alternatively, it could be argued that trying to maintain cesarean rates at too low a rate (potentially even as low as 15%) may put pregnant women and their infants in peril. To date, there is no consensus worldwide as to what is an appropriate rate of cesarean section. In Chaaria the rate of C/S is higher then 15%, mainly because we are a referral center for many rural maternities which send us mothers already complicated or with obstetric conditions preventing vaginal delivery

3. Indications for Cesarean Section

- One of the most common indications for cesarean section is prior cesarean section.

Maternal/Fetal Indications:

- Dystocia

The most common indication for cesarean section in primiparous women, accounting for

68% of cesarean sections in one series, is failure to progress in labour or dystocia.

Dystocia, literally meaning “difficult labour”, refers to a disproportion between the fetal

presenting part and the maternal pelvis. Dystocia is typically accompanied by slower than

usual progress in labour (dilation at less than 1cm/hour in a primiparous patient) or

crossing of lines on the partogram, indicating slow progress in labour. Dystocia can be

caused by poor forces of expulsion - either poor contraction forces (in the first or second

stages of labour) or insufficient maternal expulsive effort (in the second stage of labour).

It can also be caused by fetal malpresentation or malposition, such as transverse,

posterior presentations of the fetal occiput, breech or transverse position, by fetal

macrosomia or abnormality (such as hydrocephalus) or by inadequate size of the maternal

pelvis, due to either bony contracture or soft tissue abnormalities .

The most important means of assessing dystocia is through the attendance during labour of a skilled professional who assesses progress via a partogram.

- Malpresentation can be a common cause of dystocia. Accurate vaginal assessment

of the presenting part is required in order to make a diagnosis of malpresentation. Face presentation is rare (0.17%), but it is a recurrent finding in Chaaria. Other important malpresentation is the so called face to pubis.

A transverse lie is also an indication for cesarean section, as there is no direct presenting

part expressing force on the maternal cervix.

A compound presentation (a limb accompanying the fetal head, usually an arm) will

usually resolve spontaneously prior to delivery.

- Breech Presentation. At term approximately 3-4% of infants are in the breech presentation. A breech presentation has been associated with a higher incidence of morbidity for both the mother and the fetus. We put indication for C/s for breech presentation in primigravida, while er deliver vaginally the breech in multipara. We never use induction of labour or even oxytocin augmentation in the case of a breech

presentation.

Similarly, breech presentation of the first twin is for us an indication for cesarean section.

- Failure to progress.

Prior to a diagnosis of dystocia in the first stage of labour, so long as the fetal heart is

reassuring, we try to optimize the contractions by use of oxytocin. We decide on C/S for prolongued labour when the partogram has shown that we have crossed the action line.

- Fetal Distress

The heart rate should be monitored through labour, either intermittently or continuously.

Normal baseline fetal heart rate is between 110 and 160 beats per minute; above 160bpm is considered tachycardic and below 110 bpm is considered bradycardic. Non reassuring fetal heart rates include late decelerations, repetitive prolonged variable decelerations (to less than 60bpm or for more than 60 seconds). In all the cases when fetal heart is not good, with pr without meconium, we go to C/S.

Placental Indications

In placenta previa, the placenta lies over the cervix and below the fetus. This would lead

to detachment of the placenta and maternal hemorrhage in labour as the cervix opens.

Placenta previa must therefore be delivered by cesarean section. Profuse, painless

bleeding and a high presenting part in labour would be clinical findings associated with

placenta previa. Whenever possible, we use ultrasound to confirm the diagnosis.

A low-lying placenta, less than 2.5 cm from the internal os, can also be associated with

hemorrhage and we do cesarean section.

Other Indications

Additional indications for cesarean section include major antepartum hemorrhage such as with significant abruption, severe Pregnancy Induced

Hypertension (PIH). Postmaturity in primigravida, twins with twin A in a noncephalic presentation, cervical cancer and active herpes

Infections, HIV.

Bro Beppe Gaido

Reference list:

1. World Health Organization. 1994. Indicators to Monitor Maternal Health Goals:

Report of a Technical Working Group. WHO/FHE/MSM/94.14. Geneva: WHO.

http://www.who.int/reproductive_health/publications/MSM_94_14/MSM_94_14_table_o

f_contents.en.html (click link)

2. Stanton, Cynthia K.; Holtz, Sara A. Levels and Trends in Cesarean Birth in the

Devloping World. Studies in Family Planning, 2006; 37(1): 41-48.(KB 2621)

3. United Nations Statistics Division. “Progress Towards the Millenium Development

Goals”. http://unstats.un.org/unsd/mdg/default.aspx (click link)

4. Ronsmans, Carine; Holtz, Sara A.; Stanton, Cynthia. Socioeconomic Differentials in

Cesarean Rates in Developing Countries: A Retrospective Analysis. The Lancet, 2006;

368: 1516-1523. (KB 138)

5. Williams Obstetrics. 2005, McGraw-Hill, New York, NY.

6. Hannah, Mary E.; Hannah, Walter J.; Hewson, Sheila A.; et al. Planned Caesarean

Section Versus Planned Vaginal Birth for Breech Presentation at Term: A Randomised

Multicentre Trial. The Lancet, 2000; 356: 1375-1383. (KB 115)

7. SOGC Policy Statement. Attendance at Labour and Delivery Guidelines for Obstetrical

Care. Journal of Obstetrics and Gynecology of Canada, 2000. (KB 23)