DISSERTATION ON
STUDY OF PRIMARY CEASAREAN SECTION IN MULTIPARA
Submitted to
THE TAMILNADU
DR.M.G.R. MEDICAL UNIVERSITY CHENNAI – 600 032
With fulfillment of the Regulations For the Award of the Degree of
M.D. OBSTETRICS AND GYNAECOLOGY (BRANCH-II)
DEPARTMENT OF OBSTETRICS AND GYANECOLOGY KILPAUK MEDICAL COLLEGE
CHENNAI – 600 010
MARCH - 2009
CERTIFICATE
This is to certify that the dissertation work titled “STUDY OF PRIMARY CEASAREAN SECTION IN MULTIPARA” is a bonafide research work of Dr. S. Vishranthi, Enrolment No.………..
Submitted in partial fulfillment of the requirements for the award of Degree of M.D. OBSTETRICS AND GYNAECOLOGY (BRANCH-II) in THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI - 600 032.
Signature of H.O.D Signature of Dean
ACKNOWLEDGEMENT
I start this thesis in the name of almighty God, the most beneficient and forgiving. I thank God that he has given me the privilege to learn from the able teachers in my department.
I express my sincere thanks to Dr. M. DHANAPAL, MD., DM, Dean, Kilpauk Medical College for allowing me to conduct the study using the available facilities.
I express sincere thanks to my professor, Dr. M. MUTHULAKSHMI, M.D., DGO, professor and Head of the
Department of Obstetrics and Gynaecology, for her valuable help and encouragement.
I convey my heartfelt gratitude and sincere thanks to my guide Dr. T.A. SREE DEVI, M.D., DGO, Registrar Department of Obstetrics
and Gynaecology, Kilpauk Medical College, who with her exhaustive knowledge and professional expertise has provided able guidance and constant encouragement throughout the course of my study and in the preparation of this dissertation.
I thank my other professors Dr. H. K. FATHIMA, M.D., D.G.O., Dr. PREMALATHA, M.D. D.G.O., Dr. MEENALOCHINI, M.D., D.G.O., Dr. FAMIDHA, M.D., D.G.O., for their kind help.
I am grateful to my assistant professors, colleagues and my friends for their advice and suggestions.
My heartful thanks to my husband Dr. GUNASEKARAN M.S., my parents and parents in law for instilling me in a sense of commitment and belief in myself, a constant encouragement and immense help.
Also I thank medical records department K.M.C.H, for their grateful help in giving me the statistics and case sheets.
Last but not the least I thank all my PATIENTS, who formed the backbone of this study without this the study would not have been possible.
CONTENTS
CHAPTER TITLE PAGE NO.
1 INTRODUCTION 1
2 REVIEW OF LITERATURE 3
3 AIMS & OBJECTIVES 23 4 MATERIALS AND METHODS 24
5 OBSERVATON & ANALYSIS 25
6 SUMMARY 57
7 CONCLUSION 60
8 ANNEXURE 62 a. BIBLIOGRAPHY
b. MASTER CHART
c. KEY TO MASTER CHART d. PROFORMA
e. LIST OF ABBREVIATIONS USED
DISSERTATION ON
STUDY OF PRIMARY CEASAREAN SECTION IN MULTIPARA
Submitted to
THE TAMILNADU
DR.M.G.R. MEDICAL UNIVERSITY CHENNAI – 600 032
With fulfillment of the Regulations For the Award of the Degree of
M.D. OBSTETRICS AND GYNAECOLOGY (BRANCH-II)
DEPARTMENT OF OBSTETRICS AND GYANECOLOGY KILPAUK MEDICAL COLLEGE
CHENNAI – 600 010
MARCH - 2009
CERTIFICATE
This is to certify that the dissertation work titled “STUDY OF PRIMARY CEASAREAN SECTION IN MULTIPARA” is a bonafide research work of Dr. S. Vishranthi, Enrolment No.………..
Submitted in partial fulfillment of the requirements for the award of Degree of M.D. OBSTETRICS AND GYNAECOLOGY (BRANCH-II) in THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI - 600 032.
Signature of H.O.D Signature of Dean
ACKNOWLEDGEMENT
I start this thesis in the name of almighty God, the most beneficient and forgiving. I thank God that he has given me the privilege to learn from the able teachers in my department.
I express my sincere thanks to Dr. M. DHANAPAL, MD., DM, Dean, Kilpauk Medical College for allowing me to conduct the study using the available facilities.
I express sincere thanks to my professor, Dr. M. MUTHULAKSHMI, M.D., DGO, professor and Head of the
Department of Obstetrics and Gynaecology, for her valuable help and encouragement.
I convey my heartfelt gratitude and sincere thanks to my guide Dr. T.A. SREE DEVI, M.D., DGO, Registrar Department of Obstetrics
and Gynaecology, Kilpauk Medical College, who with her exhaustive knowledge and professional expertise has provided able guidance and constant encouragement throughout the course of my study and in the preparation of this dissertation.
I thank my other professors Dr. H. K. FATHIMA, M.D., D.G.O., Dr. PREMALATHA, M.D. D.G.O., Dr. MEENALOCHINI, M.D., D.G.O., Dr. FAMIDHA, M.D., D.G.O., for their kind help.
I am grateful to my assistant professors, colleagues and my friends for their advice and suggestions.
My heartful thanks to my husband Dr. GUNASEKARAN M.S., my parents and parents in law for instilling me in a sense of commitment and belief in myself, a constant encouragement and immense help.
Also I thank medical records department K.M.C.H, for their grateful help in giving me the statistics and case sheets.
Last but not the least I thank all my PATIENTS, who formed the backbone of this study without this the study would not have been possible.
CONTENTS
CHAPTER TITLE PAGE NO.
1 INTRODUCTION 1
2 REVIEW OF LITERATURE 3
3 AIMS & OBJECTIVES 23 4 MATERIALS AND METHODS 24
5 OBSERVATON & ANALYSIS 25
6 SUMMARY 57
7 CONCLUSION 60
8 ANNEXURE 62 f. BIBLIOGRAPHY
g. MASTER CHART
h. KEY TO MASTER CHART i. PROFORMA
j. LIST OF ABBREVIATIONS USED
INTRODUCTION
INTRODUCTION
Caesarean section is one of the most common surgical intervention in modern obstetrics. Caesarean section is almost centainly one of the oldest operations in surgery, with its origin lost in antiquity and ancient mythology. Originally performed only in interests of the mother, is now used quite freely in the interest of the fetus also. Caesarean section an operation mainly evolved to save a maternal life during difficult childbirth has now increasingly become the procedure of choice in high risk situations to prevent perinatal morbidity and mortality.
Thus an operation initially utilized to save maternal life is today
increasingly employed in the interest of the fetus also. The incidence of the caesarean section has doubled or tripled all over the world in the last 15yrs justification for this trend is the lowering of maternal mortality almost to the point of nil and increasing fetal survival as compared to difficult vaginal deliveries.
The twentieth century has seen many new developments in the field of obstetrics, rendering increased safety to CS which is mainly due to
availability of antibiotics , safe anesthesia, blood transfusion facilities and recent improvement in surgical techniques.
Multipara implies, woman who has previously been delivered vaginally one or more pregnancies, which crossed the period of viability.
This definition is taken for this study purpose. In this study 565 cases of primary CS done over a period of recent two years were compared with past two years.
REVIEW OF
LITERATURE
REVIEW OF LITERATURE
A Caesarean section (or Cesarean section in American English), also known as C- 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, although in recent times it has been also performed upon request for births that would otherwise have been natural.
Etymology
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 the case that she dies before giving birth. (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 in this manner.
3. An alternative etymology suggests that the procedure’s name derives from the Latin verb caedere (Supine stem caesum), “to cut,” in which case the term “caesarean section” is redundant. 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. (A corollary suggesting that Julius Caesar himself derived his name from the operation is refuted by the fact that the Cognomen
“Caesar” had been used in the Julii family for centuries before his 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.)
History
Successful Caesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879.
The Ancient Roman Caesarean 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 born by Caesarean section. (In fact, she died 45 years later.) The Catalan saint, Raymond Nonnatus (1204-1240), received his surname- from the Latin non natus (“not born”) because he was born by caesarean section. His mother died while giving birth to him.
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”.
Caesarean section ususlly resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in 1500, in Sigershauses, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour. For most of
the time since the sixteenth century, the procedure had a high mortality. In Great Britain and Ireland the mortality rate in 1865 was 85%. Key steps in reducing mortality were:
• Adherence to principles of asepsis.
• The introduction of uttering suturing by Max Sanger in 1882.
• Extraperitoneal CS and then moving to low transverse incision (Kronig, 1912)
• Anesthesia advances.
• Blood transfusion.
• Antibiotics.
European travellers in the Great Lakes region. Of Africa during the 19th century observed Caesarean sections being performed on a regular basis the expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. Form the well- developed nature of the procedures employed, European observers concluded that they had been employed for some time.
On March5, 2000, Ines Ramirez performed a caesarean section on herself and survived, as did her son, Orlando Ruiz Ramirez. She is believed
to be the only woman to have performed a successful caesarean section on herself.
Types
There are several types of Caesarean sections (CS). The differences between them primarily lie in the deep incision made on the uterus, below the skin and subcutaneous tissue, and should be differentiated from the skin incision, such as a pfannenstiel incision.
¾ The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complication.
¾ The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.
¾ An emergency Caesarean section is a Caesarean performed once labour has commenced.
¾ A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child (ren) or both.
¾ A caesarean hysterectomy consists of a caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the Placetna cannot be separated from the uterus.
¾ Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section of Porro caesarean section.
¾ A repeat caesarean section is done when a patient had a previous caesarean section. Typically it is performed through the old scar.
In many hospitals, especially in Argentina, the United States, United Kingdom, Canada, Norway, Australia, and New Zealand the mother’s birth partner is encouraged to attend the surgery to support the mother and share the experience. The anaesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.
INCIDENCE
IN WORLD:
For the past 3 decades, the rate of cesarean Births has risen dramatically. The WHO estimates the optimal rate of CS at between 10%
and 15% in developed Countries. In 2004, CS rate was about 20% in U.K while the Canadian rate was 22.5% in 2001-2002.
In the united states the CS rate has risen 46% since 1996 reaching a level of 30.2% in 2005. A 2008 report found that fully one third of babies born in Massachusetts in 2006 were delivered by CS. In response the states secretary of health and human services, Dr.Juddy Ann Bigby, announced the formation of a panel to investigate the reasons for the increase and the implications for public policy.
Among developing countries, Brazil has one of the highest rate of CS in the world. In the public health network, the rate reaches 35% while in private hospitals the rate approaches 80%.
Many European countries like Sweden, Belgium and Ireland Have very low CS rates (5-12%), yet have much better maternal and neonatal
outcome. May countries such as USA (253%) and canada 20%
respectively, as a major health problem.
In India
Over the last 20 years there has been a disturbing increase in the rate of Caesarean sections in India. It used to be a matter of pride to have low caesarean section rates, especially in teaching hospitals. A collaborative study done by the Indian Council of Medical Research (ICMR) in the 1980s showed a Caesarean section rate of 13.8 per cent in teaching hospital .This has risen significantly. A study to examine the escalating rates of Caesarean section in teaching hospitals in India compared the rates between 1993-94 and 1998-99, with data from 30 medical colleges/teaching hospitals. The overall rate showed an increase form 21.88 per cetn in 1993-994 to 25.4 per cent in 1998-99. What was alarming was that 42.4 per cent were primigravidas and 31 per cent had come from rural areas. Because of the rise in primary caesarean sections, there is a proportionate rise in repeat sections as well. Between 1990 and 1992 the repeat rate between 30 and 45 per cent in teaching hospitals in Madurai and Chennai.
In a study over a two-year period in an urban area of India, the total Caesarean section rates even in the public and charitable sectors were 20
16.7
0.79 14.9
0.87 11.3
1.59 4.3
1.95 3.3
4.09
2 4.52
3.5 4.98
1.6 6.7
1.6 7.7
0 2 4 6 8 10 12 14 16 18
Tamil Nadu Kera
la
Andhra P radesh
Karnat aka
Assam Bihar
Madh
ya Pradesh Rajashan
Uttar Prad esh
C section Ratio & MMR/1000. Source CRC India First Periodic Report - DWCD 2001
C Section rate MMR/1000 and 38 per cent respectively. In the private sectors, the rate was an unbelievable 47 per cent A similar study from an affluent part of Chennai showed that almost every other woman (45 per cent) had a Caesarean section These rates cannot be justified.
The rate of Caesarean section is relatively higher in Kerala and Goa. A 1995 study in Tiruvananthapuram, Kerala, found that the Caesarean section rate in the private sector (30 per cent) was three times that of the public sector (10 per cent). In addition, in Andhra Pradesh, Bihar, Gujarat, Karnataka, Punjab and Uttar Pradesh the chance of having a Caesarean is four times higher in private institution as compared to public ones.
In another study, Perinatal mortality increased despite doubling of the Caesarean section rate. These findings suggest that the increase in Caesarean sections did not improve perinatal deaths. A study form a hospital in Mumbai showed that though the Caesarean section rate increase form 1.9 to 16 per cent in 40 years, it did not accompany a corresponding improvement in overall perinatal outcome beyond a Caesarean section rate of 10 per cent.
INCIDENCE OF PRIMARY CAESAREAN SECTION IN MULTIPARA
S. No Author Cs% Incidence 1 Dill, Leonard & sheftray 1.66% 1.02
2 Duck man et al 70 0.74
3 O’ Sullivan - 15.8
4 Palanisamy 11.44 1.6
5 Narendrakumari pinto - 16.9
6 Kasthrilal 4.6 0.85
From the above table o’ Sullivan and Narendrakumari series show higher incidence of Primary CSin Multipara.
INDICATIONS FOR PRIMARY CS IN MULTIPARA 1) CPD.
2) Fetal distress.
3) Obstructed labour.
4) Deep transverse arrest/ malposition.
5) Cervical dystocia.
6) PROM /MRO with failed acceleration.
7) Failed induction/ acceleration.
8) Recurrent Pregnancy loss.
9) APH- antepartum hemorrhage.
10) Cord Prolapse / cord presentation.
11) Failed forceps.
12) Genital warts.
13) Congenital anomaly of the baby.
14) HIV + Ve.
Malpresentations
• Breech.
• Transverse lie.
• compound Presentation.
• Face/ brow presentation.
Multiparty favors’ certain obstetrical difficulties which necessitates special concern for the patients in that group. The spectrum of indications for primary CS change with advancing parity. As parity advances more CS are done for maternal rather from fetal indications.
1. CPD
Dystocia must always be kept in mind especially with respect to fetopelvic disproportion. When it is realized that previous Uncomplicated deliveries of large babies tend to create a false sense of security even to the most experienced obstetrician.
Though the common cause for CPD in multipara is increase in baby size as parity advances, but in rare instances the capacity of the pelvis may be diminished especially in high parity.
Reasons may be
1. Subluxation of sacrum leads to prominent sacral promontory that tends to decrease true conjugate.
2. According to Adams (1957) increasing inclination of pelvic brim due to lumbar lordosis.
CPD in the multipara continued to be recognized after much delay.
INCIDENCE OF PRIMACY CS IN MULTI FOR CPD
Dill 1.62%
Klein 4.1%
Jacob & Barghav 26%
Duchman 4.1%
2. Antepartum Heamorrhage
APH is three times more frequent with multipara than in a primi. A review of the studies done for Primary CS in multi indicates that the APH is more frequent indication for CS. Parikh (1965) found the incidence of placenta previa as 1.2 and 1.4% with the parity group V and above
Incidence of APH Placenta previa Abruptio placenta
Jacob& barghav 17.3% 6.4%
Kasthurilal 19.6% 8.8%
Klein’s 37.6% 7%
O’ Sullivan’s 25.6% 2.6%
3. Malpresentation:
Coyle (1960) stated that the unstable lie was the more harassing problem in high parity malpresentation are favoured by pendulous abdomen, lordosis of the lumbor spine. Transverses lie is the mostcommon Malpresentaiton encountered. Malpresentation are 10 times common in multi than primi.
MATERNAL MORBIDITY & MORTALITY
It is known that unnecessary CS do more harm than good. when all is normal with the mother caesarean section has an eightfold higher mortality than vaginal delivery, 8-12 times more morbidity and a higher incidence of complication in subsequent pregnancies.
Risks
Statistics from the 1990s suggest that less than one woman in 2,500 who has a Caesarean section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the mortality rate for both continues to drop steadily, the Uk National Health service gives the risk of death for the mother as three times that of a vaginal birth. However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries.
Woman with severe medical disease often require a caesarean section which can distort the mortality figures.
A study published in the 13 February 2007 issue of the Canadian Medical Association journal found that women that have planned caesareans had and overall rate of severe morbidity of 27.3 per 1000 deliveries compared to an overall rate of severe morbidity of 9.0 per 1000 planned vaginal deliveries. The planned Caesarean group had increased risks of cardiac arrest, wound haematoma, hysterectomy (alt PPH – post pregnancy Hysterectomy), major puerperal infection, anaesthetic complications, venous thromboembolism, and haemorrhage requiring hysterectomy over those suffered by the planned vaginal delivery group.
these figures can be significantly distorted given that women with severe health conditions are more likely to preschedule births by caesarean.
A study published in the February 2007 issue of the Jouranl obstetrics and Gynecology found that women who had just one previous caesarean section were more likely to have problems with their second birth. Woman who delivered their first child by Caesarean delivery had increased risks for malpresentaiton, placenta previa, antepartum hemorrhage, placenta accrata, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second delivery.
Gynecology found that women who had multiple caesarean sections were more likely to have problems with later pregnancies, and recommended that women who want larger families should not seek Caesarean section as an elective. The risk of placenta accreata, a potentially life- threatening condition, is only 0.13% after two Caesarean sections but increases to 2.13% after four and then to 6.74% after six or more surgeries.
Along with this is a similar rise in the risk of emergency hysterectomies at delivery. The findings were based on outcomes firm 30, 132 caesarean deliveries.
A CS is a major operation, with all that it entrails, including the Risk of post- op adhesions. Pain at the incision can be intense, and full recovery of Morbidity can take several weeks or more. A prior CS increases the risk of uterine rupture during subsequent labour if a CS is preformed emergency situations, the rash of the surgery may be increased due to, number of factor, the pt’s stomach may not be empty increasing the anesthesia risk too.
Since Caesarean sections are of the most frequently performed operations in woman, any attempt to reduce morbidity, even with relatively
modest differences for a particular outcomes, is likely to have significant benefits in terms of costs and health benefits.
In an under- resourced country like India, it is important to look at interventions that will make a difference. The following are evidence- based strategies and interventions that have been shown to reduce morbidity, the cost of the operation and benefit the patient.
The single most important risk factor for postpartum febrile morbidity is a Caesarean section. In developing countries other factors, including malnutrition and poor social conditions, are likely to exacerbate the already higher risk of infectious morbidity and mortality associated with a caesarean section. The high prevalence of poor social and economic conditions, anaemia, blood loss, repeated vaginal examinations, pre-labour rupture of menbranes, and other pathological conditions could account for a stronger protective effect of antibiotic prophylaxis.
A systematic review of published data has shown that use of prophylactic antibiotics in women undergoing caesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, uninary tract infection and serious infection after Caesarean section.
In India, where in some areas one out of two women are delivering by an abdominal route, deciding which antibiotic is most suitable as a prophylactics is very important. The systematic review of the Cochrane Database recommends the use of ampicillin or first- generation cephalosporine (cefazolin). A single dose given just at the start of surgery with a possible one or two doses after the procedure is the recommendation.
The alarming abuse of antibiotics, with woman getting expensive antibiotics on multiple doses over several days, should be abandoned.
Perinatal mortality and Morbidity:
CS result in a highest risk of respiratory distress and prematurity in new born, delayed feeding and at best have only a very small impact n prenatal mortality . That a low perinatal mortality rate can be achieved along with a low CS rate in Indian Setting is evident from data from CMC Vellore India,
CS rate was 12.4%, PNMR 19.8/1000 during 1991 -1995.
It is well established that maternal & perinatal outcome are linked strongly to good obstetric practice rather than CS. This has been confirmed recently in. WHO 2005 global survey done in eight counties. In developing countries with poor infrastructure lack of well qualified manpower and non availability of blood Perinatal morbidity and mortality and the woman’s future reproductive performance are a cause for concern. The dictum to perform a CS must maternity centered and not technology centered.
AIM OF
STUDY
AIMS & OBJECTIVES
1. To study the incidence of primary Caesarean section in multipara.
2. To study the various indications for primary Caesarean section among multiparous woman.
3. To study the influence of various parameters on Primary Caesarean section.
4. To study the maternal morbidity, mortality, fetal outcome among multi parous woman who undergone primary Caesarean section.
5. To compare the above factors of the period of current 2 yrs (2006-2008) with previous 2 yrs (2000-2002).
MATERIALS AND
METHODS USED
MATERIALS AND METHODS
In this study 565cases of primary CS in multipara done over a period of current 2 yrs (2006-2008) were compared with 621 cases of primary cs in mulipara done over a period of previous 2 yrs (2000-2002) at the obstetric department of Kilpauk Medical College, Chennai-10.
INCLUSION CRITERIA
1) Previous one or more vaginal deliveries.
2) Previous instrumental deliveries.
3) Previous assisted breech deliveries, Stillbirths & IUD.
EXCLUSION CRITERIA
1) Previous one or more CS.
2) Previous H/o myomectomy & hysterotomy.
OBSERVATION &
ANALYSIS
OBSERVATION & ANALYSIS
Group I:
Cases of primary CS in multipara done over a period of 2 yrs.
From April 2006 to March 2008.
565 cases.
Group II:
Cases of primary CS in multipara done over a period of 2yrs.
From April 2000 to March 2002.
621 cases.
The result of the study were analyzed between group I & II according to the incidence of primary CS in multipara, age distribution, booked / unbooked status, Obstetric score , previous delivery details, type of LSCS, Indication for LSCS, maternal complications, Operative complications, birth weight of the baby, and the fetal outcome.
INCIDENCE OF PRIMARY CS IN MULTIPARA IN KMCH
TABLE I
S.NO INCIDENCE
GROUP I (2006-2008)
GROUP II (2000-2002) a) Total No. of deliveries 15388 16717
b) Total no. of LSCS 6112 14584
c) Total no. of CS in multipara 2765 1090
d)
Total no. of primary Cs in multipara
565 621
INCIDENCE OF PRIMARY CS / REPEAT CS IN MULTIPARA
TABLE II
PRIMARY CS REPEAT CS GROUPS No. of
Cases
% with total CS in Multi
No. of Cases
% with total CS in Multi
TOTAL
I 565 20.43% 2200 79.5% 2765
II 621 56.97% 469 43% 1090
X2 = 490 = P < 0.0000001
Significant.
INCIDENCE OF PRIMARY CS IN MULTIPARA VS PRIMIPARA
TABLE-III
Groups Primary Cs in multi Pinay Cs in primi No. of cases % with total CS No. of cases % Total CS
I 565 9.2% 3347 54.76%
II 621 13.5% 3494 76.22%
P< 0.000001 Significant
INFERENCE & DISCUSSION
From the above two tables it is clearly seen that both the incidence of primary CS in primi& Multipara were significantly higher in group II as compared to group I.
But interestingly repeat Cs in mulipara were significantly high in group I (ie) 79.56% as compared to group II (43.02%) ,and also incidence of repeat section were contributing the major percentage of CS nowadays as compared to past Years.
More over the increasing incidence of primary sections in primipara in the recent years can be attributed to the greater incidence of repeat caesarean section. In a uterus with a previous scar there is always a risk to the mother and child and also a risk of rupture of uterine scar in labor, it will increase the maternal and fetal morbidity.
AGE DISTRIBUTION
TABLE IV
Groups
No. of Patients
Mean age S.D S.E of mean
I 565 26.0283 4.38 0.18447
II 621 25.9436 5.49 0.22035
T= 0.292 P=0.771 Not significant
Table IVa
Group I Group II Age in Years
No. of cases % No. of cases %
< 20 yrs 45 8.0% 100 16.1%
21-25 yrs 275 48.7% 276 44.4%
26-30 yrs 171 30.3% 13.4 21.6%
31-35 yrs 58 10.3% 67 10.8%
> 35 yrs 16 2.8% 44 7.1%
Total 565 100% 621 100%
Inference& Discussion
There is no significant change in the age distribution between the two groups.
As per the table the peak incidence of primary Caesarean section in multipara is seen in the age group of 21 -25 yrs in both the groups.
The lowest incidence is in the age group >35 yrs. (ie) about 2.8% in group I, 7.1% in group II.
BOOKING STATUS
TABLE-V
Booking status Group I Group II
No. of. Cases %
No. of.
Cases
%
Booked 335 59.3% 381 60.4%
Unbooked 147 26.0% 133 23.6%
Referral 83 14.7% 107 15.9%
Total 565 100% 621 100%
P= 0.142 not significant INFERENCE & DISCUSSION
Booking status for both the groups were not significant.
In the recent years, it is observed that decreasing Number of referral cases to KMC. It is clearly seen from the table in the group I 83 cases of referrals than group II 107 cases, this is because of most of the health posts and corporation hospitals have been improved in the operation theater facilities and anesthetic facility for the past 2 years, since reducing number of referrals nowadays.
OBSTETRIC SCORE
OBSTETRIC SCORE
TABLE - VI
Group I Group II Gravida
Cases % Cases %
G2 290 51.3% 151 24.5%
G3 204 36.1% 413 66.6%
G4 48 8.5% 49 7.7%
>G4 23 4.1% 8 1.3%
Total 565 100% 621 100%
P= 0.000 Signifinant Inference &Discussion
The graph depicts the incidence of primary Caesarean section in multipara in the respect to gravidity.
In group I significant increased incidence of (51.3%) G2 as compared to 24.4% in group II.
Same time in group II G3 were high in number as compared to group I.
The total incidence of Gravida 3 is reducing nowadays, because most of the Gravida 2 were motivated for family planning procedures.
TYPE OF PREVIOUS DELIVERY
TABLE -VII
Group I Group II Type of delivery
Cases % Cases %
Term LN 419 74.2% 404 65.5%
Preterm LN 54 9.6% 49 7.6%
Instrumental 45 8.0% 66 10.4%
Assisted breech delivery
41 7.3% 84 13.6%
Stillbirth/ IUD 6 1.1% 18 2.9%
Total 565 100% 621 100%
P= 0.0000 Significant
INFERENCE &DISCUSSION
The incidence of previous H/o term LN & pretern LN were almost same in two groups.
But incidence of instrumental deliveries (10.4%), assisted brech deliveries (13) ,are significanty higher in group II as compared to group I (8.0% & 7.3% )respectively.
Assisted breech deliveries & instrumental deliveries are showing decreasing trends in recent yrs in order to avoid cord prolaspses, fetal distress and low apgar scores. In modern obstetrics Breech presentation is a indication for CS, most of the primi with breech presentation were taken for caesarean section ;this has contributed significantly as the main factors responsible for the increase in CS rate.
PRESENT PREGNANCY DETAILS
TABLE VIII
Presentation Group I Group II
Cases % Cases %
Vertex 467 82.7% 482 80.0%
Breech 46 8.1% 64 9.3%
Transverse lie 22 3.9% 27 4.1%
Face / brow 8 1.4% 19 2.3%
Compound 10 1.8% 12 1.9%
Twins with malpresentation
12 2.1% 17% 2.4%
Total 565 100% 621 100%
P= 0.253 not significant
INFERENCE& DISCUSSION
From the above table the commonest presentation in both the groups were vertex presentation. The next will be the breech, and also the least common presentation in both the groups were compound presentation. The incidence of the presentation is almost same, statistically not significant in both groups.
GESTATIONAL AGE OF THE PRESENT PREGNANCY
TABLE IX
Gestational age Group I Group II
Cases % Cases %
Term 538 95.2% 586 94.4%
Preterm 19 3.4% 27 4.3%
Extreme preterm 8 1.4% 8 1.3%
Total 565 100.0% 621 100.0%
P= 0.671 not significant.
INFERENCE& DISCUSSION
There was no significant differences in the gestational age of the present pregnancy in both groups. Most of pregnancies taken for CS were term. Preterm about 3.4% in-group II and 4.3% in group II, the common causes would be pregnancy complicated by preeclampsia, abruption, maternal Infections and also in some case of iatrogenic prematurity also play a role.
TYPE OF LSCS
TABLE X
Type of LSCS Group I Group II
Cases % Cases %
Emergency 543 96.1% 586 94.4%
Elective 22 3.9% 35 5.6%
Total 565 100% 621 100%
P = 0.163 not significant
INFERENCE& DISCUSSION
Majority of cases underwent emergency CS in both groups.
The common indication found in the emergency CS were fetal distress, meconium stained liquor, poor progression of Labour, failed induction & acceleration. These indication were more or less same for the two groups.
The common indication for elective LSCS were breech presentation, Transveselie, RPL, long Period of secondary infertility, placenta previa , HIV+Ve , GDM & PIH complicating pregnancies.
CS were in some cases performed for reason other than medical necessity. Reason for elective cs vary, with a key distinction being between hospital or doctor- centric reasons and mother centric reason.
Studies of US women have indicated that married white woman giving birth in private hospitals are more likely to have CS due to considerations of pain and vaginal tone, in contrast to this ,a recent study in the BRITISH MEDICAL JOURNAL retrospectively analysed a large number of CS in England and stratified them by a social class, findings was that CS not more likely in higher classes.
INDICATION FOR LSCS TABLE - XI
Group I GroupII Sl.
No. Indication for LSCS
Cases % Cases %
1. Fetal distress 124 21.9% 128 20.6%
2. CPD 113 20.6% 53 8.5%
3. Obstructed labour 45 8.0% 45 7.2%
4. DTA 21 3.7% 64 10.3%
5. dystocia 28 5.0% 29 4.7%
6. Malpresentations 78 13.8% 100 16.1%
7. PROM/MRO with failed acc.
14 2.5% 35 5.6%
8. Failed Induction 43 7.6% 67 10.8%
9. RPL 35 6.2% 21 3.4%
10. APH 30 5.3% 31 5.0%
11. Cord prolapse 7 1.2% 7 1.1%
12. Failed Forceps 3 0.5% 6 1.0%
13. Genital warts 2 0.4% 1 0.2%
14. Cong.anomaly of fetus,IUD
4 0.7% 2 0.3%
15. HIV +ve 12 2.1% 8 1.3%
16. Long period of secondary infertility
6 1.1% 24 3.9%
INFERENCE& DISCUSSION 1. Fetal distress:
In this study fetal distress forms one of the leading indications in both the series (group I 21.9%, groupII 20.6) though the incidence was not significant statistically. In most of the patients there were also an associated indications (eg) prolonged labor, cord accidents, CPD.
Parameters used for diagnosis.
I. CLINICALLY
i) Abnormalities in fetal heart rate.
ii) Fetal tachycardia or Bradycardia.
iii) Late deceleration on electronic monitoring.
iv) Meconium stained liquor.
USG: In group I apart from clinical parameters, uses of USG and NST have also been utilized for diagnosis than group II, because KMCH is equipped with these instruments for past 3 yrs only.
In the present years (group I)
In high risk pregnancies (eg.) in cases of severe preeclampsia, RPL, GDM, oligohydramnios non stress test was carried out when patients were near term, USG also done for fetal maturity this has reflected in the Perinatal mortality.
Introduction of uninterrupted fetal heart rate monitoring has resulted in increase rate of CS in many hospitals.
2. CPD
Incidence of CPD in group I was 20.6% in group II was 8.5% it is statistically significant.
In this study, in the group I (2006-2008) pts with gross degree of disproportion were taken up for CS with out a trial of labor but such cases were few. Pts with borderline disproportion were given a trial of labor with continuous intrapartum monitoring. Pt who faild to show progress in labor inspite of good contractions and those who developed fetal distress during labor were subjected to CS immediately.
Incidence of DTA was more in group II (10.3%) has group I (3.7%).The deceasing incidence of DTA in group I, may be due to the improvement in continuous intrapartum monitoring, early assessment of fetal weight and CPD, early detection of malpositions (ie) ROP, ROT.
These factors may be contributed to the increased incidence of CPD in group I.
3. Dystocia (prolonged labour)
Prolonged labour complicated 5.0% on group I, 4.7% in group II.
There was not much change in trend as far as this indication concerned.
This group includes the following (eg) failure to progress in labour, mal positions of fetal head, mild degrees of CPD, PROM, in coordinated uterine activity.
4. Malpresentations
Incidence of malpresentation was 13.8% is group I and 16.1% in group II.
Statistically was significant
Out of all malpresentation Breech presentation is the commonest.
Eastman lists three common causes are.
i. Abnormal relaxation of abdominal wall which results from high parity
ii. Pelvic contraction iii. Placenta previa
Brow presentation is due to any factor which promotes extension or prevents flexion of fetal head.
During 2000-2002, 12 pts with twin pregmany was submitted to CS while in 2006-2008, 17 pt were submitted to CS, because of increase in the in the incidence of multiple gestation and to prevent fetal distress in the 2nd twin. It is observed that the apgar score of second twin born vaginally is always significantly lower than that of first where as in CS apgar of both the babies are the same.
Malpresatation Group I Group II
Cases % Cases %
Breech 46 8.1% 64 10.3%
Transverse lie 22 3.9% 27 4.3%
Face / brow 8 1.4% 19 3.1%
Compound 5 0.8% 12 1.9%
Multiple gestation
with malpresentations 17 2.8% 12 2.0%
5. HIV + ve
There were 12 cases of HIV + ve were subjected to CS in 2006 -2008 but in 2000-2002 only 8 cases of HIV +ve were subjected to CS. This is because of increased incidence of detection of HIV+ve pregnancies via screening procedures and Motivated them for safe operative delivery in order to reduce the transmission rate.
ACCELERATION OR INDUCTION
ACCELERATION OR INDUCTION
TABLE – XII
Group I Group II Agents used
Cases % Cases %
PGE2gel 85 42.7% 18 18.5%
Ony +PGe2gel 114 57.2% 32 32.9%
T.misoprostol 25 micro 0 0% 47 48.4%
Total 199 100% 97 100%
P = 0.000 Significant INFERENCE & DISCUSSION
It is clearly seen from the table, group I has signifitity higher rate of induction with PGE2gel (42.7%).
The common indications for inductions post datism,
oligohydramnios,
maternal complications (eg) P1H, GDM, PROM, RH negative.
The indications were almost same in both the groups.
One more important point to note from this study that none of the cases in group I was induced by T-misoprostal. T.misoprost is efficient and also low cost in induction of labor, there are some RCT show significant increased incidence of fetal tachycardia and fetal distress with the use of misoprostal, so it is not practising in KMCH for induction of labour for the recent yrs.
MATERNAL COMPLICATIONS
MATERNAL COMPLICATIONS
TABLE – XIII
Group I Group II Complication
Cases % Cases %
1. Aneamia 67 11.9% 61 9.8%
2. P1H 83 14.7% 68 11.0%
3. Recurrent P1H 39 6.9% 12 1.9%
4. GDM 16 2.8% 7 1.1%
5. Heart disease 15 2.7% 12 1.9%
6. Others (BA, epilepsy, jaundice)
10 10% 17 2.7%
INFERENCE& DISCUSSION
Regarding maternal complications aneamia was the common complication. About in group I 11.9%, group II 9.8%. But incidence of PIH and recurrent PIH were more with group I as compared to group II
Regarding GDM the incidence is found to be more in group I, this because of screening procedures are introduced in K.M.C.H in recent years.
BABY WEIGHT TABLE – XIV
Group I Group II Baby Wt
Cases % Cases %
< 2 kg 31 5.5% 48 6.7%
2.1 – 2.5 kg 199 35.2% 62 22.0%
2.6 – 3.0 kg 181 32% 125 25.8%
3.1 – 3.5 kg 117 20.7% 322 37.0%
3.6 – 4 kg 32 5.7% 46 6.6%
>4 kg 5 0.9% 18 1.9%
Total 565 100% 621 100%
P = 0.000 Significant
INFERENCE& DISCUSSION
In group I maximum no of babies were born with the wt of approximately 2-3 Kg about (380) cases.
In group II maximum no. of babies were belonging to 3-3.5 kg about 322 babies.
In group I only 5 babies were > 4 kgs, but in group II about 18 babies were more than 4 kgs.
In this in group I, 2 babies were born to GDM mothers where as about 6 babies in group II were born to GDM mother.
For the recent years GDM screening is done for all patients, and the complication like macrosomia are prevented by early detection and management.
POST OP MORBIDITY
TABLE – XV
Group I Group II
Post op Morbidity Cases % Cases %
Nil 494 87.4% 544 87.6%
UTI 25 4.4% 33 5.3%
Wound infection 34 6.0% 24 3.9%
Wound resuturing 11 1.9% 13 2.1%
CS hysterectomy 2 0.2% 6 1.1%
Total 565 100% 621 100%
P = 0.122 not significant
INFERENCE & DISCUSSION
Commonly encountered post –op morbidity were infections in both the groups. UTI, wound infections were the leading causes of morbidity.
There were only 2 cases of CS hysterectomy in group I and 6 cases of CS hysterectomy in group II.
The indications for CS hysterectomy included were atonicity of the uterus, postpartum hemorrhage which not responding to other measures and ruptured uterus.
Nowadays availability of prostadin and other medical measures, early detection and timely management of PPH prevents many patients from hysterectomy.
FETAL OUTCOME
TABLE - XVI
Group I Group II
Fetal Cases % Cases %
NICU admission 67 11.9% 84 13.5%
Neonatal death 23 4.1% 42 6.76%
P = 0.164 not significant
INFERENCE& DISCUSSION
Though there was no statistically significant difference in the fetal outcome in the both the groups, Group I have little bit decreased rate of NICU admission and neonatal death.
Recent improvement of neonatal care, neonatal setup, preterm care and availability of medications may be the contributing factor for the decreasing rate of neonatal deaths in recent years.
Intrapartum monitoring with CTG, availability of USG and NST have been also took part in reducing the neonatal morbidity.
STERILIZATION
TABLE – XVII
Group I Group II Sterilization
Cases % Cases %
Not done 357 63.3% 377 61.1%
Done 208 36.7% 244 38.9%
Total 565 1005 621 100%
P = 0.84 not significant
Inference
In group I about 36.7% underwent sterilization and about 38.9% of pts in group II underwent sterilization. It is not significant.
SUMMARY
SUMMARY
1. Incidence of Primary CS in Multipara in KMCH during the period of 2006 to 2008 was about 565 cases, and during 2000 to 2002 was 621 cases.
2. It was found to be that increased incidence of repeat CS were high ( 79.5%) in group I than group II (43%).
3. There is no significant change in age distribution between the two groups, highest incidence of primary cesarean section in multipara is seen in the age group of 21-25 yrs about 48.7% in group I, 44.4% in group II.
4. The Booking status of both the groups were the same, but little more increased number of referral cases were seen in group II.
5. Regarding obstetric score, more number of G2 were seen in group I than group II (51.3%) (24.4%). More number of G3 were seen in group II (66.6%) than group I (36.1).
6. The incidence of previous Term labor naturale and pretern labour, Were not significantly different in both groups. Incidence of Instrumental deliveries (10.4%) assisted breech deliveries (13.6%) are significantly higher in group II.
7. The commonest presentation will be the vertex presentation in both the groups. Least common presentations is compound presentation.
8. There is no significant difference in the GA of present pregnancy, in group I 95.2%, group II 94.4 were term and 3.4% & 4.3% were preterm.
9. Commonest type of CS in both groups were emergency LSCS.
In group I 96.1%
Group II 94.4%
10. Regarding Indications for the CS fetal distress was the common indication in both groups
In-group I- 21.9%
In group II 20.6%
But CPD in me comparatively light in group I 20.6% than group II 8.5%.
11. Regarding malpresentations breech presentation was the common indication in both groups.
Group I 8.1%
Group II 10.3%
12. About 42.7% In group & 18.5% of cases in group II were indiuced by PGE2GEL but non of the cases in group I were induced with T.
misoprostol.
13. Regarding maternal complication aneamia was the common complication about in group I 11.9%, group II 9.8%, But PIH and recurrent PIH were common in group I.
14. It was found that maximum number of babies were born with the wt of 2-3 kgs in group I about 380 cases. in group II maximum to 3-3.5 kgs 322 babies.
15. Reading post op morbidity infection were play a major role in both groups in group I UTI 4.4%
Wound infection 6.0%
In group II UTI 5.3%
Wound infection 3.9%.
CS hysterectomy incidence is decreasing in the recent years because of improvement in the management of PPH.
16. It was found that decreasing rate of NICU admission & Neonatal death in group I.
17. About 36.7% cases were under went sterilization in group I, about 38.9% were underwent sterilization in group II.
CONCLUSION
CONCLUSION
Analyzing and comparing the results between the two groups it was concluded that
i. In previous years there was increased incidence of primary CS in primi & multipara were found, this could be the contributing factor to the increased incidence of repeat CS in recent years.
In the recent years repeat CS were found to be increased in number than the primary sections.
ii. Primary CS in Multipara is seen in the age group of 21-25 yrs in both groups.
iii. Majority of Primary CS in Multipara followed by a full term vaginal deliveries.
iv. The commonest presentation was the vertex presentation in both the groups.
v. Regarding indication for primary CS in multi para in both groups fetal distress were common indication. CPD was significantly higher in recent years because of decreased incidence of instrumental deliveries in concerned with reducing the fetal morbidity following instrumental deliveries, careful intrapartum monitoring and timely
diagnosis of CPD before it going for DTA or obstructed labour in order to prevent both maternal & fetal complications.
vi. More over indication for LSCS for malpresentations were increased since breech presentation itself an indication for CS irrespective of the obstetric score.
vii. Regarding malpresentation breech presentation was the commonest presentation
viii. Majority of the pregnancies were with the gestational age of term in both groups.
ix. More than 90% of CS were done for emergency indication .
x. Infections were played major role in the post op morbidity in both groups. CS hysterectomy incidence were. high in previous years.
xi. In the recent years cs with sterilization was maximally done for G2.
xii. The Overall incidence of macrosomia with GDM is reduced in nowadays because of screening modality available for early detection of GDM & prevention of its complications.
BIBLIOGRAPHY
BIBLIOGRAPHY
1. Fear a factor in surgical births- National –sch.com. au
2. Kiwi caesarean rate continues to rise- New Zealand news on Stuff. Co.nz 3. Finger (2003).”Caesarean section rates skyrocket in Brazil. Many
women are opting for caesareans in the belief that it is a practical solution.” Lancet 362: 628.PMID 12947949
4. From a summary (in German) of an article (also in German ) that deals usefully with many of the relevant historical and linguistic questions raised here, go her
5. Liu, shiliange, Maternal mortality and severe morbidity associated with low risk planned caesarean delivery versus planed vaginal delivery at term Canadian medical Association Journal, 13 February 2007; 176(4) 6. Silver, R.M. Obstertrucs and Gynecology, June 2006: vol 107:PP 1226-
1232
7. Why are Caesareans Done?” Gynaecwould. Retrieved on 2006-07-26 8. Canada’s caesarean section rate highest ever”’ CTV (April 21,2004)
Retrieved on 2006-2007
9. Stephen smith, “C- sections leap to 1 in 3 births is Bay state, to outstrip US” Boston Globe February 14,2008
10. Homer Caroline et al. (2001)” Collaboration in maternity care: a randomized controlled trial comparing community-based continuity of
care with standard hospital care.” JBrithish Jourmal of Obstetrics and Gynaecology, 2001
11. Mackenzie IZ, cooke I, Annan B. Indications for caesarean section in a consultant unit over the decades. J Obstet Gynecol 2003;23:233-8
12. “social class and elective caesareans in the English NHS” British Medical Journal (2004-06-12)Retrieved on 2006-10-01).
13. Rita Rubin.”Battle lines drawn over C-Section”. USA Today. Retrieved on 2008-02-09.
14. Mehta A, Apers L, verstraelen H, and Temmerman M. Trends in Caesarean section rates at a maternity hospital in Mumbai, India, J Health Popul Nutr 2001 Dec; 19(4): 306-12.
15. Petitti DB. Maternal mortality and morbidity in caesarean section. Clin obstet Gynecol 1995 Dec/;28(4):763-9
16. Kabar SG, Narayanan R, Chaturvedi M, Anand P, MathurG. What is happening to caesarean section rates? Lancet 1994 Jan 15;3439(8890) 17. Smail F, Hofmeyr GJ. Antibiotic prophylaxis for Caesarean section. The
Cochrane Database of systematic Reviews lssue.3: 2005. The Cochrane collaboration, publishe by.john software ltd. Oxford; 2007
18. Pattinson R.Audit and feedback; effects on professional practice and health –care outcomes;RHL commentary (last revised: 15 December 2006). The WHO Reproductive Health Library.
19. American college of Obstetricinas and Gynecologists. Task force on cesarean: a meta analysis of morbidity and mortality. Obstet gynecol 1991 Mar;77(3): 465-70
20. Rosen MG, Dickinson JC, westhoff CL. Vaginal birth after cesarean: a meta- analysis of morbidity and mortality. Obstet Gynecol 1991 Mar;
77(3) 465-70
21. Homefyr GJ, Hannah ME. Planned caesarean section for term breech delivery (Cochrane Review). Cochrane Database of systematic Reviews, lssue3.
22. Agustin Conde- Agudelo. Planned caesarean section for term breech delivery: RHL commentary (last revised: 8 september 2003). The WHO Reproductive Health Library
23. Arora R, Oamaguichi A.J Obst and Gyn of India 1991; 41:192 24. Menon MKK. J obstet and Gynaec India 1963;7: 35.
25. Studd. J.lmplication of increasing rates of caesarean section. Progress in obstet and Gynaec., Vol.6: 1990
26. Patwardhan M, Oka M, Mahajan MJ. Obstetrics and Gynaes india 1990;40;210
27. Shy KK, Luthy DA, Bouchtt FC, et al. effects of electronic fetal –heart- rate monitoring, as compared with periodic auscultation, on the neurological development of premature infants. N Engl N Med 1990.
1990: 322 (9).
28. Tahilramaney MP, Boucher M.Eglinton GS, et al. Previous cesarean section and trial of labour . Factors related to uterine dehiscence. J Reprod Med 1984; 29(1)
29. Cunningham FG,MacDonald PC, Gant NF (eds). Williams obstetrics.
19th ed Norwalk, conn: Appleton and Lange: 1993.
30. Cheng M, Hannah M, Breech delivery at term: a critical review of the literature. Obstet Gynaecol 1993.82: 605-18
31. Shama U, SaxenaS, Mittal G, Foetal outcome in lower segment caesarean section, journal of Obstet and Gynaecol India 1980; 30: 69-75 32. Padmadas SS, Kumar, S, Nair SB, Kumari A. Caesarean section delivery
in Kerala, India: evidence from national family health surver. Soc sci Med 2000: 51(4) :511-521
33. McCloskey L, Petitti DB, Hobel CJ. Variations in the use of caesarean delivery for dystocia: lessons about the source of care. Med care 1992:
30(2) : 126-135.
34. Duggal R, Anin S.Cost of health Care- A Household survey in an India District,. Mumbai: Foundation for Research in Community Health, 1989 35. Shelton Brown H. Physician demand for leisure: implication for
caesarean section rates J.Health Econ 1995: 15: 233-242.
36. Estrin D. Hight caesarean section rates in Brazil result in large part from non – clinical factor. Fam plan perspect Dig 2000; 26(1) (march).
37. Petitti DB. Maternal mortality and morbidity in caesarean section clin obstet Gynecol 1985.28(4: 763-769 (December)
38. Indian Council of Medical Research. Collaborative study on high risk pregnancies and maternal mortality (ICMR task force study). New Delhi:
ICMR; 1990.
39. Sreevidya S, Sathiyasekaran BWC. High caesarean rates in Madras (India): a population based cross- section study. BJOG 2003 Feb; 110 (22): 106-11.
KEY TO MASTER CHART
I. AGE
1. < 20 yrs 2. 21 – 25 yrs 3. 26 – 30 yrs 4. 31 – 35 yrs 5. >35 yrs
II. Booking status 1. B – 1
2. UB - 2 3. Ref - 3.
III. Obstetric Score 1 G2 2 G3 3 G4 4 >G4
IV. Previous delivery details a. Type
1 – Term 2 – Preterm 3 – Instrumental 4 – Assisted breech 5 – Still birth / IVD
b. Maternal Complication 1 – Aneamia
2 – P1H 3 – GDM
4 – Heart disease 5 – Others
C. Baby Wt 1. < 2 kg 2. 2.1 – 2.5 3. 2.6 – 3 4. 3.1 – 3.5 5. 3.6-4 6. >4 d. N1CU / ND
Nil
Nicu admission - 1 Neonatal death - 2
V. Present Delivery Details Presentation
1 – Vx
2 – Breech 3 –Transverse lie 4 - Face
5 – Compound / cord
6 – Twins with malpresentation
VI. Gestational Age 1. > 37 wks
2. 37-28 wks 3. <28 wks
VII. – LSCS Type 1 – emergency 2 - Elective
VII – Indication 1. Fetal distress 2. CPD
3. Obstructed labor 4. DTA
5. Cervical dystocia 6. PROM / MRO
7. Failed induction/ failed acceleration 8. RPL
9. APH
10. Cord Prolapse / Cord Presentation 11. Failed forceps
12. Genital watrs
13. Congenital Anomaly of Baby, IUD with Malpresentation 14. HIV + Ve
15. Malpresentation 16. Secondary infertility
VIII . Acceleration / induction Nil – 0 PG E2 - 1 Oxy + PGE2 - 2 Misoprostal - 3
IX. I- D interval 1 - 6-8 hrs 2 – 8-10 hrs 3 > 10 hrs
X - maternal complication 1 - Aneamia
2 P1H 3 Rec. P1H
4 GDM / heartdisease
5 Others (BA, epilepsy, jaundice)
XI. – Baby wt 1 < 2 kg 2 2.1 – 2.5 3 2.6 – 3 4 3.1 – 3.5
5 3.6 – 4 6 > 4 kg
XII . Post op morbidity O - Nil
1 – UTI
2 – wound infection 3 - wound resuturing 4 - CS hysterectomy
XIII. N1CU/ ND Nil – 0 Admi - 1 ND - 2
XIV. Sterilisation No – 0 Yes – 1
XV. Group 1 Group 2
PROFORMA
PROFORMA
STUDY OF PRIMARY CEASAREAN SECTION MULTIPARA Name
1. Age <20Yrs 20-25yrs 25-30Yrs >30Yrs
2. Unit IP No 3. D.O.A
4. D.O.S
5. S.E Status poor LMC UMC High Class Rural/
Urban
6. Litracy Level
7. Booked / Un booked
8. ANC at Ist Trimester II III 9. LMP
10. EDD
11. Admitted for
Safe confinement
Labor Pains
Draining PV
Bleeding PV
Decreased Fetal Movements
Crossed Dates
Others
Referred as From
Gestational Age USG Age Less Than 37 weeks Term
Post Term
Not known
Menstrual History: Regular / Irregular
Obstetric History
G1 G2 G3 G4 No of Abortions
Previous Delivery Labour Naturale Instrumental Delivery Assisted Breech Delivery
Delivery Place : Domiciliary/ Hospital Conducted BY: Untrained / Trained / Doctor Duration Of Labour
Sex of Child
Any History Of NICU admission : Reason Discharged Puerperium
Cong.Anomalies
Any Maternal complications
Present Pregnancy Presentation
Vx Breech
Trensverse lie Face
Position LOA ROP
Maternal complication
Aneamia: Treated with PIH
Mild Severe
Eclampsia Rh Negative Heart Diease GDM
Post Datism Others
Indication for LSCS Malpresetnaion Malposition Fetal Distress PROM
Failed Induction/ Acceleraion Uterine Inertia
Obstructed Labour CPD
Placenta preavia APH
Type of CS
Emergency / Elective: Indication Mode of Induction
Induction Delivery interval Intra op findings
Sex of the baby
Placental site wt NICU admission / observation
Sterilization Blood Loss Post of period
Wound infection / Resuturing Perinatal death
<24hurs 24-72hrs
>72hrs
Cause of death
LIST OF ABBREVIATIONS USED
1. CS - Ceasarean section
2. CPD - Cephalopelvic disproportion 3. PIH - Pregnancy induced hypertension 4. GDM - Gestational Diabetes Mellitus 5. NICU - Neonatal intensive care unit 6. ND - Neonatal death
7. RPL - Recurrent Pregnancy loss
8. PROM - Premature Rupture of membranes 9. IUD - Intra Uterine death
10. BA - Bronchial Asthma 11. VX - Vertex
12. B.Wt - Birth Weight
MASTER CHART
Fetal
NICU admission 67 84
Neonatal death 23 42
Group I Group II
FETAL OUT COME
NICU admission , 67
Neonata death, 23 NICU
admission , 84
Neonata death, 42
0 20 40 60 80 100
0 0.5 1 1.5 2 2.5
ME
Neonatal death, 23 Neonatal death, 42
2.5
Group I Group II
