Indications and Determinants of Cesarean Section: A Cross-Sectional Study

Impact of 'decision-to-delivery' interval on maternal and perinatal outcomes: a retrospective study of emergency caesarean section from 2017 to 2021 at a secondary health facility in Nigeria

BACKGROUND

The decision-to-delivery interval (DDI) for a caesarean section is among the factors that reflect the quality of care a pregnant woman receives and the impact on maternal and foetal outcomes and should not exceed 30 min especially for Category 1 National Institute for Health and Care Excellence (NICE) guidelines. Herein, we evaluated the effect of decision-to-delivery interval on the maternal and perinatal outcomes among emergency caesarean deliveries at a secondary health facility in north-central Nigeria.

METHODS

We conducted a four-year retrospective descriptive analysis of all emergency caesarean sections at a secondary health facility in north-central Nigeria. We included pregnant mothers who had emergency caesarean delivery at the study site from February 10, 2017, to February 9, 2021.

RESULTS

Out of 582 who underwent an emergency caesarean section, 550 (94.5%) had a delayed decision-to-delivery interval. The factors associated with delayed decision-to-delivery interval included educational levels (both parents), maternal occupation, and booking status. The delayed decision-to-delivery interval was associated with an increase in perinatal deaths with an odds ratio (OR) of 6.9 (95% CI, 3.166 to 15.040), and increased odds of Special Care Baby Unit (SCBU) admissions (OR 9.8, 95% CI 2.417 to 39.333). Among the maternal outcomes, delayed decision-to-delivery interval was associated with increased odds of sepsis (OR 4.2, 95% CI 1.960 to 8.933), hypotension (OR 3.8, 95% 1.626 TO 9.035), and cardiac arrest (OR 19.5, 95% CI 4.634 to 82.059).

CONCLUSION

This study shows a very low optimum DDI, which was associated with educational levels, maternal occupation, and booking status. The delayed DDI increased the odds of perinatal deaths, SCBU admission, and maternal-related complications.

Factors Affecting Elective and Non-elective Cesarean Sections: A Multinomial Regression Analysis Using Robson's Classification in a Southeast European Country

BACKGROUND

Albania, a middle-income Southeast European country, is experiencing an increase in cesarean section rates. This study aims to analyze cesarean section practices in Albania using the Robson classification to identify patterns and provide insights into elective and non-elective cesarean trends.

METHODS

This retrospective cohort study was conducted at the University Hospital of Obstetrics and Gynecology "Koco Gliozheni" in Albania, a leading tertiary hospital, from January to May 2023, involving 5,315 consecutive women who delivered during this period, including both live births and stillbirths, with a gestational age minimum of 28 weeks to align with standards of viability. We defined a function to systematically evaluate each case based on multiple criteria: parity, fetal presentation, onset of labor, previous deliveries, number of fetuses, and gestational age according to the Robson classification. Multinomial multiple regression was used to estimate the relationship between each of the above-mentioned variables and the likelihood of each type of cesarean delivery compared to normal births.

RESULTS

The participants' mean age was 28.2 years (59.6% <30 years vs. 40.4% ≥30 years), while gestational age varied (12.1% before 37 weeks, the majority (72.3%) between 37 and 40 weeks, and 15.6% > 40 weeks). In elective cesarean sections, maternal age (odds ratio (OR) = 1.06) and gestational age (OR = 1.13) were associated with increased odds, with women with previous cesarean deliveries showing significantly higher odds (OR = 20.6), breech position (OR = 15.7), and multiple pregnancies elevating odds (OR = 7.3), whereas in non-elective cesarean sections, similar associations were observed with slightly different odds ratios which were maternal age (OR = 1.07), gestational age (OR = 1.16), previous cesarean delivery (OR = 6.3), breech position (OR = 8.5), and multiple pregnancies (OR = 5.1). Significant disparities in cesarean section rates were observed across various groups, with rates ranging from as low as 0.74% in Group 1 to as high as 89.24% in Group 5, and notable contributions from Group 2 with a rate of 69.95% and Group 6 with a rate of 81.29%.

CONCLUSION

In conclusion, this study emphasizes the significance of factors such as maternal age, gestational age, previous cesarean deliveries, fetal presentation, number of fetuses, and multiple pregnancies in impacting the rates of elective, non-elective, and overall cesarean sections in Albania, highlighting the need for targeted strategies to improve maternal and fetal health outcomes.

Impact of COVID-19 pandemic on the circadian rhythm of cesarean section deliveries

Circadian rhythms synchronize all biological functions, enabling humans to foresee and respond better to periodic environmental changes. The coronavirus disease (COVID-19) lockdown regulations significantly changed the lighting conditions in pregnant women, leading to chronological disruption. This study aimed to investigate the impact of the COVID-19 on the circadian rhythm of cesarean deliveries. We investigated whether the circadian rhythm of cesarean section deliveries changed during the first year of the COVID-19 pandemic at a tertiary hospital in Van Province, eastern Turkey. We analyzed the distribution of birth times for 1476 cesarean deliveries performed between March 01, 2020 and January 20, 2021 (1st year of the COVID-19 pandemic) and compared this information with data from 1194 cesarean deliveries performed during a similar period in the previous year. The primary outcome was the change in the circadian rhythm of cesarean deliveries. Secondary outcomes included cesarean section (CS) delivery rates, indications for CS, 1st and 5th minutes Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration scores, and anesthesia technique use rates. Regarding the time distribution of CS deliveries in the first year of the COVID-19 pandemic, the maximum number of cesarean deliveries (n = 234, 16%) occurred between 14:00 and 16:00 (P = .112). Cesarean deliveries in pre-COVID-19 group were most frequently performed between 10:00 and 12:00, at a rate of 18% (n = 216) (P = .001). In both groups, the time point at which CS deliveries were the least performed was 04:00 to 06:00, and the rates were different (n = 35, 2% and n = 14, 1%, respectively) (P = .022). A 4-hour phase shift was detected at the peak of the birth time in the first year of the COVID-19 pandemic compared to the previous year. These results suggest that the circadian rhythm of cesarean deliveries is affected by the pandemic.

The utero-tonic effects of low dose intravenous ketamine in cesarean section under spinal anesthesia; A randomized double-blind clinical trial

Background

Recently, the prevalence of cesarean section (CS) has been on the rise and the proper uterine tone is an important issue. We investigated the effects of intravenous (IV) ketamine on intraoperative bleeding and the need for oxytocin in CS under spinal anesthesia (SA).

Methods

This study, took place at Alzahra hospital during 2020. Pregnant women candidate for elective CS under SA were divided into two groups of ketamine and placebo. In group K, after umbilical cord clamping, 0.25 mg/kg ketamine and in group P 2ccs normal saline was injected. Mean arterial pressure and heart rate were recorded at baseline, before and 5 minutes after cord clamping and at the end of the surgery. The drop in hemoglobin values, the administrated units of oxytocin and side effects were also recorded.

Results

No significant difference was found in terms of patients' demographic data (P ≥ 0.05). The mean units of administrated oxytocin in group K was 34.61±6.63 and in group P; 48.47±12.15, which was significantly different (P=0.0001). The drop in Hb was less in group K, however not statistically significant (P=0.094). The need for methergine was significantly higher in group P (P=0.0001). The mean HR was significantly higher in group P (P=0.027), however, no significant difference was observed regarding the MAP (P=0.064). The incidence of hallucination (4.8%) and nystagmus (21%) was significantly higher in group K (P= 0.0001), but nausea and vomiting were more significant in group P (P= 0.027).

Conclusion

Prophylactic administration of low-dose ketamine in CS under S.A could significantly reduce the administrated oxytocin units and the need for additional utero-tonics and was associated with less drop in Hb values.

Multilevel analysis to identify the factors associated with caesarean section in Bangladesh: evidence from a nationally representative survey

BACKGROUND

Caesarean delivery has a significant role in reducing maternal and child death. However, unnecessary utilization has adverse health effects. This study aimed to assess the prevalence and associated factors of caesarean delivery in Bangladesh.

METHODS

Data from the latest Bangladesh Multiple Indicator Cluster Survey (MICS, 2019) was used in this study. Since MICS data are hierarchical in nature, multilevel modelling was used.

RESULTS

The prevalence of caesarean section (CS) was 67.4% among Bangladeshi women. Multilevel analysis suggests the age of the women, household wealth status, utilization of antenatal care (ANC) , delivery at a health facility and division were significantly associated with CS. Women who delivered in a private health facility had the highest odds for CS (odds ratio [OR] 10.35 [95% confidence interval {CI} 8.55 to 12.54]). Women 30-34 y of age had a 36% higher likelihood of CS compared with women 15-19 y of age (OR 1.36 [95% CI 1.03 to 1.79]). The odds of CS positively increased with household wealth status. Women who had at least one ANC visit had a 1.7 times higher possibility of CS (OR 1.70 [95% CI 1.26 to 2.30]).

CONCLUSIONS

Policy guidelines on caesarean deliveries are urgently needed in Bangladesh to avoid unnecessary caesarean deliveries and protect mothers from the consequences.

Smoke or smokeless moxibustion treatment for breech presentation: A three-arm pilot trial

AIMS

We conducted a pilot trial to compare the effects of smoke and smokeless moxibustion with a control as a possible supplement to external cephalic version (ECV) for converting breech to cephalic presentation and increasing adherence to cephalic position, and to assess their effects on the well-being of the mother and child.

METHODS

We used a quasi-experimental design with 3 arms: a smoke moxibustion (SM) (n = 20) and smokeless moxibustion (SLM) (n = 20) groups (20-min acupoint BL67 stimulation once or twice daily for 10-14 days), and a control group (n = 20). The participants had singleton breech presentations between 33 and 35 gestation weeks. The primary outcome was cephalic presentation at the conclusion of intervention. The secondary outcomes were cephalic presentation at birth and effects on mother and child well-being.

RESULTS

At the conclusion of intervention, cephalic presentation was higher in the SLM (60.0%) than the control groups (25.0%), Relative Risk 2.40, 95% Confidence Interval [1.04-5.56]; there was no significant difference for SM. At birth, there were no significant differences in cephalic presentation or well-being.

CONCLUSION

SLM treatment showed an increasing trend towards cephalic presentation at the conclusion of intervention. Although significant differences were not observed at birth possibly due to the small samples and non-randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. A randomized controlled trial with a larger sample is warranted to ascertain SLM treatment as a possible ECV supplement for converting and increasing adherence to cephalic position.