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Caesarean
section has become a relatively safer procedure in the practice of modern
obstetrics. Audit plays an important role in the analysis of changing
trends in caesarean delivery.
In the present study carried out at a tertiary care institute it was
found that the leading cause of caesarean section followed by foetal
distress.
Individualization of every case, meticulous clinical examination, use
of intrapartum foeto-maternal surveillance along with regular use of
partogram would limit the practice of caesarean section.
Obstetric audits, following standardized guidelines and practice of
evidenced-based medicine will help us a lot in reducing the rate of
caesarean section. |
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| INTRODUCTION |
The
advent of better anaesthesia, availability. of improvised surgical techniques
and prophylactic antibiotics have made caesarean section a relatively
safer procedure in the practice of modern obstetrics. The decision whether
to perform a caesarean section or not, is based on the individualized
judgement of the obstetrician, the hospital where the caesarean would
be performed. Economic factors and fear of litigation are other considerations.
Which may indirectly influence such decisions. Audit plays an important
role in the analysis of changing trends in caesarean delivery rates,
the needs and benefits of such changes and to modify the
obstetricians towards the use of caesarean delivery. The present cross-sectional
study attempts to critically analyze one hundred cases of caesarean
deliveries performed in tertiary hospital over a span of four months. |
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| MATERIAL
AND METHODS |
The
LTMG hospital is a tertiary referral institute, which cares for over
6000 deliveries per year. In the present cross sectional study, 100
cases of caesarean delivery were analyzed regarding the indication,
morbidity, mortality, anaesthesia complication and the possibility of
a repeat caesarean delivery in the next pregnancy. The decision to perform
a caesarean section in each of these patients was made by a qualified
lecturer on duty in consultation with the unit head telephonically. |
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| Observation |
The correlation between APGAR score at 1 min and 5 min as compared to
the cardiotocographic results prior to delivery are shown in Table 4.
As shown in Table 5 a cardiotocography was done in 83% of cases and
41% were reactive and 42% were non-reactive. |
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| DISCUSSION. |
There
has been a steady increase in the rate of caesarean section in both
developed and developing countries. Although the WHO recommends that
there is no justification to increase a caesarean rate in excess of
10 to 15%, it may be difficult to contain the rates in tertiary institutes,
catering to a large population of transferred cases.1
Previous caesarean section was the leading indication for a caesarean
delivery in the study group. Therefore a careful individualization of
every case, meticulous clinical examination and use of intensive intrapartum
foetomaternal surveillance could probably reduce the rates of caesarean
section.2
Foetal distress was the next leading indication for performance of a
caesarean section in the present study series. Foetal distress refers
to foetal hypoxia, but often no efforts are taken to document this condition
which would be desirable for medicolegal purposes later. Also a significant
rise in caesarean section could be attributed to electronic foetal monitoring.
A study by Levens et al published in the New England Journal of Medicine
confirms, higher caesarean section rates for foetal distress with no
significant difference in the perinatal mortality rates in the caesarean
versus vaginal route of delivery.3
13% of caesarean section in our series was done for non progress of
labour. Failure to progress or non-progress of labour is an ill-defined
terminology. Lack of dilatation or descent of the presenting part are
often over diagnosed without monitoring the partogram. Thus in every
case it would be ideal to monitor the progress of labour according to
the graphical representation by partogram, thus decreasing the rates
of caesarean section.4 It would be equally important to provide adequate
labour analgesia and a constant caring companion whenever possible.
Also maintenance of hydration and nutrition is crucial during labour.
For malpresentations like breech or transverse lie it would be worthwhile
attempting an external cephalic version at 36 weeks using cardiotocographic
monitoring to reduce the need for caesarean section.5 For breech babies
every case should be individualized and an informed parental discussion
would be most appropriate. Adoption of stringent criteria for vaginal
birth could help in balancing the ratio between caesarean section and
vaginal delivery.
Six patients in this cross-sectional study had undergone a caesarean
section for antepartum haemorrhage. For most cases of placenta previa
caesarean sections optimize the neonatal outcome depending on the foetal
maturity. In abruptio placentae, a higher caesarean rate of 50% may
help to reduce foeto-maternal morbidity.6
Early recourse to caesarean section occurs in 10-20% of cases of severe
PIH or eclampsia. However a multidisciplinary tertiary care and ventilatory
support in intensive care units is equally vital for a safe maternal
outcome.7
In conclusion, it would be ideal to initiate obstetric audits by interdepartmental
meetings, to assess the intrinsic role of caesarean section in influencing
the foetomaternal outcome. Use of standardized management guidelines
and practice of evidence based obstetrics would definitely go a long
way in balancing the rates of caesarean section. |
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| REFERENCES |
| 1 |
Asha
Oumachigui : Changing Trends in Caesarean section. Obs and
Gynaec Today 2002; VII. |
| 2 |
ACOG committee opinion : Vaginal delivery after caesarean birth.
Vol. No. 143 - Oct 1994. Committee on obstetric practice. Int
J Obstet Gynecol 1995; 48 : 127. |
| 3 |
Levens KJ, Cunningham FG, Nelson S, Roark M, et al. A prospective
comparison of selective and universal electronic foetal monitoring
in 34, 995 pregnancies. N Engl J Med 1986; 315 : 615-19.
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| 4 |
O’Driscoll K, Foley M. Correlation of decrease in perinatal
mortality and increase in caesarean section notes. Obstetrics
and Gynaecology 1983; 61 : 1. |
| 5 |
Lancet editorial. External Cephalic Version. Lancet 1984;
385. |
| 6 |
Bhatt
RV. Antepartum haemorrhage; Menon MKK, Devi PK, Rao KB. Post graduate
obstetrics and Gynaecology, 4th edition, Madras; Orient Longman
1999; 19 : 106-20. |
| 7 |
Varawalla
NV, Jhanande S. A five year analysis of Eclamptic Cases. J
Obstet Gynaecol India 1989; 39 : 513-515. |
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DEEP
VEIN THROMBOSIS IS MOST LIKELY WITHIN TWO WEEKS OF LONG FLIGHTS
Only in the first two weeks after a long haul flight. Thromboembolism
after a long haul flight is small and that the average risk of
death from flight related venous thromboembolism is around 1 per
2 million flights.
BMJ 2003; 327 : 1072 |
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