Ministry of Higher Education and Scientific Research

University of Thi-Qar

College of Medicine

Department of Obstetrics and Gynecology

Prevalence of Causes of Primary

Caesarean Section Operation which

did in Al-Habubi Hospital From

January to March at 2017

By

Haider Issa Ahmed Madhi Hasaneen Faisal

Supervised By

Dr. Nadia Al-Asady

2016 – 2017

Abstract

Background : Caesarean section is surgery to deliver a baby. The

baby is taken out through the mother's abdomen , may be is emergency

or elective procedure according to state of mother and her fetus.

Cesarean delivery has become a commonly used measure for delivery of

the fetus. In the recent years incidence of Cesarean section (CS) has

increased dramatically with massive pubic interest. It is called "Primary

Cesarean section" when it is performed for the first time on a pregnant

woman.

Aim : to estimate the causes of 1st C-section in Al-Nasiriyah in Al-

Habubi hospital in 1st 3 months of 2017

Methods : this was across sectional study. The data was taken

from recorded files of patients who were made the operation in

Habubi hospital in Al-Nasiriyah city in the (January , February ,

march ) of 2017

Result : A total of 606 cases the major findings of the study were as

follows: Overall cesarean section rate was 46 per cent and among

them 31 per cent were primary cesarean section. The median age

group of patients being operated was 20 to 25 years. The main

indications were malpresentation fetal distress , pre-eclampsia and

other.

Introduction

History:

There are three theories about the origin of the name.

The name 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 derivation of the name is also often attributed to an ancient

story, told in the first century AD by Pliny the Elder, who claimed

that an ancestor of Caesar was

delivered in this manner.

An alternative etymology suggests that the procedure’s name

derives from the Latin verb caedere, to cut, in which case the term

‘Caesarean section’ is redundant.

The 1st recorded incidence of a woman surviving a C-section was in

1500, in 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 16th century, the procedure had a high

mortality. A C-section was considered an extreme measure, performed

only when the mother was already dead or considered to be beyond

help. In Great Britain and Ireland, the mortality

rate in 1865 was 85 per cent.

Key steps in reducing mortality were:

adherence to principles of asepsis;

• the introduction of uterine suturing by Max Sänger in 1882;

• extraperitoneal C-section and then moving to low transverse incision

(Pfannenstiel)

• anaesthesia advances

• blood transfusion

• antibiotics.

Definition

A Caesarean section, also known as C-section or Caesar, is a surgical

procedure in which incisions are made through a mother’s abdomen

(laparotomy) and uterus (hysterotomy) to deliver one or more babies.

Prevalence

In 2010, there were a total of 128 million births in the world, and of

those 18.5 million (14.45%) were delivered by C-section.

In England, rates of C-section have increased from 9% of births in 1980

to 24.8% in 2010.

In 2014, 32.2% of women who gave birth in the US did so by cesarean

delivery

The incidence of CS varies between 10% and 25% in most developed

countries.

The principal aims must be to ensure that those women and babies who

need delivery by C-section are so delivered and that those who do not

are saved from unnecessary intervention.

Types of Caesarean section

The type of CS is based on the type of incision of the uterus.

Lower uterine segment incision

is used in over 95 per cent of Caesarean deliveries due to ease of repair,

reduced blood loss and low incidence of dehiscence or rupture in

subsequent pregnancies. The loose reflection of vesico-uterine serosa

overlying the uterus is divided laterally, the underlying lower uterine

segment is refl ected with blunt dissection, the developed bladder fl ap

is retracted and the lower uterine segment is opened in a transverse

plane for a distance of 1–2 cm; the incision is extended laterally to allow

delivery of the fetus without extension into the broad ligament or

uterine vessels.

Midline vertical incision

The midline vertical incision could be in the lower or upper segment of

the uterus. Commonly, it starts in the lower segment as a small

buttonhole incision until the uterine cavity is reached and is extended

upwards. The midline incision is reserved for specific indications because

of the difficulty in making the incision, increased blood loss, inadequate

approximation at closure, increased postoperative morbidity, and

inability to offer a trial of vaginal delivery in the next pregnancy due to

possible higher incidence of scar rupture. A midline approach is used

when the lower segment approach is difficult because of fibroids or

anterior placenta praevia with large vessels in the lower segment. Other

indications include preterm breech with poorly formed lower segment,

impacted transverse lie with ruptured membranes or transverse lie with

congenital anomaly of the uterus. An extreme example is peri-mortem

CS.

Factors that may contribute to an increase in the rates

of C-section

1- Inaccurate dating of the pregnancy particularly when the

date of the last menstrual period is uncertain. Such accurate

dating reduces the anxiety experienced by many women when

they pass their ‘expected date of delivery’ and also reduces the

requests for ‘early’ induction of labour.

2- Fetal monitoring. electronic fetal monitoring (EFM) was

universally implemented without the appropriate trials. This has

resulted in an increase

in the incidence of C-section without demonstrable

improvement in perinatal outcome. Current recommendations

are for intermittent auscultation to be performed in all ‘low

risk pregnancies’, with continuous EFM in those pregnancies

deemed to be ‘high risk’.

3- Macrosomia Although there is evidence to suggest that

birthweights are rising in developed countries, the amount (30 g

over 12 years) is unlikely to be of any biological significance.

Unfortunately, both clinical and ultrasonographic estimations of

fetal size are prone to inaccuracy (especially in large term

infants), and unnecessary inductions of labour and Caesarean

deliveries are performed as a consequence.

4- Maternal request. Controversy exists regarding elective

cesarean delivery on maternal request (CDMR). The 2013

American College of Obstetricians and Gynecologists (ACOG)

Committee on Obstetric Practice and 2006 National Institutes of

Health (NIH) consensus committee determined that the

evidence supporting this concept was not conclusive and that

more research is needed.

Both committees provided the following recommendations

regarding CDMR :

Unless there are maternal or fetal indications for cesarean

delivery, vaginal delivery should be recommended

CDMR should not be performed before 39 weeks’ gestation

without verifying fetal lung maturity (due to a potential risk

of respiratory problems for the baby)

CDMR is not recommended for women who want more

children (due to the increased risk for placenta previa/accreta

and gravid hysterectomy with each cesarean delivery)

The inavailability of effective analgesia should not be a

determinant for CDMR

The NIH consensus panel on CDMR also noted the following [10] :

CDMR has a potential benefit of decreased risk of

hemorrhage for the mother and decreased risk of birth

injuries for the baby

CDMR requires individualized counseling by the

practitioner of the potential risks and benefits of both vaginal

and cesarean delivery

Indications

There are many different reasons for performing a delivery by C-section.

The four major indications accounting for greater than 70 per cent of

operations are:

1. Previous C-section

2. Dystocia

3. Malpresentation

4. Suspected acute fetal compromise.

Other indications, such as( multifetal pregnancy, abruptio placenta,

placenta praevia, fetal disease and maternal disease) are less common.

No list can be truly comprehensive and whatever the indication, the

overriding principle is that whenever the risk to the mother and/or the

fetus from vaginal delivery exceeds that from operative intervention, a

C-section should be undertaken

Category 1 or emergency CS

Category 2 or urgent CS.

Category 3 or scheduled CS

Category 4 or elective CS

State threat to the mother or the fetus. , CS should be done within the next 30›min.

maternal or fetal compromise but it is not immediately life-threatening delivery should be completed within 60–75 min

The mother needs early delivery but currently there is no maternal or fetal compromise.

The delivery is timed to suit the mother and staff. These are cases where there is an indication for CS but there is no urgency.

Examples *abruption, *cord prolapse, *scar rupture, * scalp blood pH below 7.20, *prolonged FHR deceleration below 80 bpm.

FHR abnormalities of concern

*failure to progress, *growth-restricted fetus *pre-eclampsia where liver or renal function tests are gradually deteriorating

*placenta praevia *malpresentations )brow, breech), *Hx of previous hysterotomy or vertical incision CS, *Hx of repair of vesico-vaginal or recto-vaginal fistulae or stress incontinence, or HIV infection.

Morbidity and mortality

Confidential Enquiries into Maternal Deaths have enabled the risks

associated with different methods of delivery to be analyzed; case

fatality rate for all Caesarean sections is five times that for vaginal

delivery, although for elective Caesarean section the difference does not

reach statistical significance. Some maternal deaths following Caesarean

section are not attributable to the procedure itself, but rather to medical

or obstetric disorders that lead to the decision to deliver using this

approach. Many women who deliver vaginally encounter the same

problems.

Complications

C-section is a major abdominal surgical procedure and carries significant

risks.

Intraoperative complications

1- Bowel damage may occur during a repeat procedure or if adhesions

are present from previous surgery.

2-Caesarean hysterectomy The most common indication for Caesarean

hysterectomy is uncontrollable maternal haemorrhage; The most

important risk factor for emergency postpartum hysterectomy is a

previous C-section – especially when the placenta overlies the old scar,

increasing the risks of placenta

accrete.

Other indications for hysterectomy are( atony, uterine rupture,

extension of a transverse uterine incision and fibroids preventing uterine

closure and haemostasis).

3-Haemorrhage may be a consequence of damage to the uterine

vessels, or may be incidental as a consequence of uterine atony or

placenta praevia. In patients with an anticipated high risk of

haemorrhage.

4-Placenta praevia The proportion of patients with a placenta praevia

increases almost linearly after each previous C-section, and as the risks

of such a complication increases with increasing parity, future

reproductive intentions are very relevant to any individual decision for

operative delivery.

5-Urinary tract damage The risk of bladder injury is increased after

prolonged labours where the bladder is displaced caudally, after

previous C-section where scarring obliterates the vesicouterine space, or

where a vertical extension to the uterine incision has occurred

Post-operative complications

1-Infection and endometritis

Women undergoing C-section have a 5–20-fold greater risk of an

infectious complication when compared with a vaginal delivery.

Complications include fever, wound infection, endometritis,

bacteraemia and urinary tract infection. Other common causes of

postoperative fever include haematoma, atelectasis and deep vein

thrombosis.

2-Psychological

All difficult deliveries carry increased maternal psychological and

physical morbidity. The compromised postpartum psychological

functioning in women

delivered by C-section may be secondary to delayed contact with the

baby; a factor that in most cases should be amenable to remedy.

Methodology

Data from Habubi hospital in Al-Nasiriyah city Survey were analyzed for

pregnant females did operation in this hospital .

Site and Study Design: A cross-sectional descriptive study was

conducted on a conveniently selected 1st C-section.

Data sources: The data was taken from Habubi hospital in Al-Nasiriyah

city for all patients who did her 1st C-section in this hospital from

(January to march ) of 2017.

The information was taken from files of patients which documented and

recorded in the statistic unite.

Sample size: All cases was taken during these 3 months was 189 case of

1st C-section from 606 case of all type of C-section was do it.

Result From (January to march ) of 2017 , about 1923 case of delivery.

About 1317 case was normal vaginal delivery (68.48 per

cent).

And about 606 case was C-section (31.51 per cent).

The number cases of 1st C-section was 189 case ( 31.18 per

cent from case of C-section , and 9.82 from total delivery) .

Table 1 : Number percentage of each type of delivery in this study.

Normal vaginal delivery Cesearian section 1st C-section Total No.

Count percent Count percent Count percent 1923

1317 68.48% 417 21.68% 189 9.82%

Fig. 1 percentage of each type of delivery.

The causes of primary C-section were variable and contribute between

many reason ; ex. (were malpresentation fetal distress , pre-eclampsia

and other)

Table 2 : percentage of each case from the total number of primary C-

section in this study.

S Cause Count Percentage 1 Malpresentation 39 20.6 %

2 Failure to progress 34 17.9 % 3 cephalopelvic disproportion 33 17.4 %

4 Fetal distress 21 11.11 %

5 Post date 12 6.3 % 6 Sever Oligohydramnios 12 6.3 %

7 Prolong rupture membrane 9 4.7 % 8 Premature labor 9 4.7 %

9 Pre-eclampsia 7 3.7 %

10 Patient preference 4 2.1 % 11 Placenta previa 4 2.1 %

12 Polyhydramnios 3 1.58 % 13 Precious baby 2 1.05 %

Normal vaginal delivery

68%

C-section not 1st

22%

1st C-section 10%

Fig. 2 percentage of each cause for primary C-section.

And when we classified the patients according age groups find

Table 3 : percentage of each age group from the total number of primary

C-section in this study.

S Age group count Percentage 1 17 – 21 y 48 25.39 %

2 22- 26 y 69 36.5 %

3 27 – 31 y 21 11.11 % 4 32 – 36 y 30 15.87 %

5 37 – 41 y 12 6.34 % 6 42 – 46 y 9 4.76 %

0

5

10

15

20

25

percentage of cause

Fig. 3 : percentage of each age group from the total number of primary

C-section in this study.

Discussion The results of this study that do to estimate the percentage of each cause

for the patient did a primary C-section in from Habubi hospital in Al-

Nasiriyah city for all patients who did her 1st C-section in this hospital

from (January to march ) of 2017.

We found the common causes for the primary C-section are

(malpresentation , failure to progress and CPD) and the most age group

of this patients are teenage and 3rd decade reproductive women.

The study compare with same study made in Iran ( A survey on causes of

cesarean sections performed at theuniversity hospitals of Niknafs and

Ali-Ibn Abi Talib of Rafsanjan, Iran, in the second trimester of 2014)

But the percentage of C-section in our study less than it , because the

difference in the economic state and education level.

17-21 y 22-26 y 27-31 y 32-36 y 37-41 y 42-46 y

25.39 1سلسلة 36.5 11.11 15.87 6.34 4.76

0

5

10

15

20

25

30

35

40

per

cen

t o

f gr

ou

ps

Limitation We find many limitation and difficulties in the preparation this stydy

some of these :

1- In adequate information in the files of patients which did operation.

2- The study depend on the diagnosis find it in the file of patients.

3- Difficulty in obtaining information and routine administrative

procedures

4- The cost of financial fees for the purpose of the license in the

preparation of the study

Recommendation 1- Health awareness and education about the advantage of normal vaginal

delivery.

2- Health awareness about the risk and suspected complication of the C-section.

3- Encourage visit to pregnant care centers(antenatal care program).

4- Taxation of Caesarean deliveries without indication for caesarean.

5- Encourage the female and pregnant women to do sport and decrease obesity.

Conclusion Considering drastic causes of caesarean in our country and its upward

procedure on one hand, and its side effects on mothers, infants,

treatment-health system and generally social health, health system

managers, planners and other qualified members of this field, should

design and administrate effective interferes and plans in reducing

caesarean amount and promoting normal vaginal delivery. Considering

the key reasons for caesarean prevalence including: previous caesarean,

fear of pain in normal vaginal delivery and doctors recommendation,

Providing psychological interventions and education, Increase the quality

of vaginal delivery services, appropriate culture, providing solutions and

legislation which are preventing doctors from personal

Reference 1- OBSTETRICS by Ten Teachers 19

th edition

2- Dewhurst’s Textbook of Obstetrics & Gynaecology 8th

edition

3- Open Journal of Obstetrics and Gynecology

Vol.3 No.7(2013), Article ID:37028,9

4- Medscape website

5- BMJ (British medicine journal) website

6- Study: A survey on causes of cesarean sections performed at

theuniversity hospitals of Niknafs and Ali-Ibn Abi Talib of Rafsanjan, Iran, in the second trimester of 2014