Cesarean Section and Maternal

Mortality

Malabika RoyScientist „F‟

INDIAN COUNCIL OF MEDICAL RESEARCH

NAMS 29th August, 2011

Cesarean section (CS)

The term cesarean section derived from „Lex Caesarian‟ or “Caesar's laws”or from the word „caedere‟ which means to cut.

Susruta Samhita and Talmud also refer to

C-Sections

WHO recommends CS rate of 5 -15% (in

women with medical/obstetrical indication) to improve

maternal and perinatal outcome

Changing trends

Madras : 1 to 2% between 1930s and 1960s rose to 3% in 1970,10% in 1980 and 20% in 1992

New Delhi : 1993 : 8.1%

Trivandrum : 1991 : 21.1%

B.Rao(1994) : rates in India varied from 8% to 36% in 33 teaching institutions in India

How common are cesarean-section

deliveries?

9% of live births in the past 5 years were delivered

by c-section

16% of first births are delivered by a c-section

C-sections increase sharply with women‟s education

and wealth

C-sections are almost twice as common for

deliveries in the private sector than in the public

sector: 28 v/s15 percentNFHS-3 India (2005-06)

Comparative Cesarean rates in the

industrialized world

35%

29%

29%

30%

26%

25%

23%

22%

22%

20%

18%

17%

14%

37%

10% 45%

Italy('03)

S. Korea('04)

Portugal('03)

US('04)

Australia('04)

Germany ('04)

Canada('03)

England ('04)

New Zealand('04)

Ireland('02)

Denmark('04)

France('01)

Sweden('03)

Netherlands('04)

Reasons for increasing Cesarean rates

Increase in the number of repeat c-sections

Use of Fetal Heart Rate monitoring

Breech presentations

Rising induction of labour

Decrease in conduct of difficult forceps

Concern for low birth weight (LBW) and

very low birth weight (VLBW) babies

Better maternal and fetal outcome in ante-

partum hemorrhage (APH)

Contd…Reasons for increasing rates

Pregnancy induced hypertension

Ultrasonographic detection of Intrauterine

growth retardation (IUGR)

To avoid malpractice suits especially when

a previous mishap has occurred

Due to economic incentives

Lack of patience on the part of the doctor

or the parturient

Caesarean section- changing

trend in indications

Past Indications for CS Present Indications of CS

• Cephalo-pelvic disproportion

• Shoulder dystocia,

• Mentoposterior presentation

• Brow presentation

• Major degree of Placenta

Praevia

• Dystocia,

• Previous Caesarean,

• Fetal distress

• Breech

• Presentations

Notzon FC et al. Am J obs gyn 1994

A Critical Appraisal of Cesarean section

rates: ICMR study

• Prospective study

• Period of study: 1993-1994

1998-1999

• 30 Human Reproduction Research Centres (HRRCs) of ICMR in OBGY department of Medical colleges.

Kambo et al. Int J Gyn & Obst 2002;79:151

RESULT 1993-1994

(1 yr)

1998-1999

(1 yr)

2005-2006 (8 mths)(unpublished data)

Total Deliveries 172,746 206,164 155,863

Cesarean section

(total-7017)

21.8% 25.4% 28.1%

Indications for CS in the study

• Dystocia :37.5%

• Fetal Distress :33.4%

• Repeat Section :29.0%

• Malpresentation :14.5%

• Pregnancy induced hypertension :12.5%

• Failed induction : 6.2%

• Ante-partum haemorrhage : 6.3%

• Medical causes :2.9%

• Others :19.7%

Kambo et al. Int J Gyn & Obst 2002;79:151

Contd…Maternal and Perinatal Mortality

Maternal Mortality (21): 299/1,00,000 deliveries

Causes: Pulmonary embolism (5)

Severe anaemia (4)

Hemorrhage (4)

Amniotic fluid embolism (3)

Septicemia (2)

Eclampsia (1)

Acute respiratory distress syndrome (1)

Anaesthetic complication (1)

Perinatal Mortality: 493 /1,000 deliveries

Kambo et al. Int J Gyn & Obst 2002;79:151

Methodology: Random selection of country from 24 WHO

regions. State and hospitals randomly selected through

stratified multi-stage cluster sampling as per population

proportion to size

• 120 random hospitals from 8 countries in Latin America

• Information obtained from medical records of all deliveries during 2/3

months of study period

• Total No of deliveries: 106,546

• Median rate for cesarean delivery for Latin America : 33.0% ( 24-43)

contd… Association between proportion of all cesarean

deliveries and maternal and perinatal outcomes

Lancet 2006; 367: 1819-29

Summary findings Highest rates of caesarean delivery noted in private hospitals (51%, range

43–57)

Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity

Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors

Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery.

Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%

Interpretation: higher rates of cesarean delivery donot

necessarily indicate better perinatal care and can be

associated with harm

Lancet 2006; 367: 1819-29

Methodology: Similar to earlier study of 2005. Random selection of

country from WHO region as per the under-5 and adult mortality.

State and hospitals randomly selected through stratified multi-stage

cluster sampling as per population proportion to size

• 122 Facilities from 9 countries in Asia (China,

• Survey through information obtained from medical records

of all deliveries during 2/3 months of study period

• Total No of deliveries: 112,152 (107,950 deliveries analyzed)

• Overall rate of caesarean section for ASIA : 27·3%

India (three states) : 17.8%

WHO- Global survey Asia

Lancet, vol 375, Feb 6, 2010

Number of women by country and method of

delivery

Vaginal Delivery Caesarean Total

Spontaneous Operative

Cambodia 4319 (77.5%) 431 (7.7%) 14.7% 5565 (5.2%)

China 7649 (52.6%) 179 (1.2%) 46.2% 14541 (13.5%)

India 19586 (79.3%) 719 (2.9%) 17.8 % 24682 (22.9%)

Japan 2445 (74.1%) 200 (6.1%) 19.8% 3300 (3.1%)

Nepal 6447 (75.9%) 323 (3.8%) 20.3% 8489 (7.9%)

Phillipines 10427 (78.4%) 372 (2.8%) 18.8% 13295 (12.3%)

Srilanka 9900 (65.9%) 526 (3.5%) 30.6% 15024 (13.9%)

Thailand 6007 (61.6%) 420 (4.3%) 34.1% 9745 (9.0%)

Vietnam 8277 (62.2%) 295 (2.2%) 35.6% 13309 (12.3%)

Total 75057 (69.5%) 3465 (3.2%) 27.3% 107950 (100%)

Lancet, vol 375, Feb 6, 2010

Proportion of caesarean deliveries by four

classifications and countries

Lancet, 375, Feb 6, 2010

Contd…Commonest indication for CS in the study

Previous cesarean delivery (24.2%)

Cephalo-pelvic disproportion (22.6%)

Fetal distress (20.5%)

Breech and other abnormal presentation (12.5%)

Lancet, vol 375, Feb 6, 2010

Summary findings

• All types of CS and operative vaginal delivery was associated with significantly increased risk of maternal mortality and morbidity as compared to spontaneous vaginal delivery

• Intrapartum CS (with or without indication) had higher risk of maternal mortality and morbidity than antepartum CS

• CS without a medical indication is associated with increased risk of maternal mortality and morbidity

• CS for breech presentation was associated with improved perinatal outcome

Interpretation: To improve maternal and perinatal outcomes, CS

should be done only when there is a medical indication.

Suggestive measures to reduce CS

Public and physician education

Recommendations by professional organizations

Peer review of C-Section cases

Second opinion for CS at no extra cost

Extra incentives for vaginal birth after

Cesarean (VBAC)

Elective inductions to be minimized

Monitor fetal distress with scalp blood and cord blood (may not be feasible in all levels of care)

Thank you