Volume ​Academic Medical Journal of India ​32 II

​ - Issue 1 ​www.medicaljournal.in February 2014

Comparison of Fetal Outcomes of Emergency and

Elective Caesarean Sections in a Teaching Hospital
in Kerala
Suja Daniel, Manjusha Viswanathan, B N Simi, Nazeema A
Department of Obstetrics and Gynecology, Sree Gokulam Medical College and Research Foundation*
Corresponding Author: ​Manjusha Viswanathan, TC 24/179, “RAVIKEDAR”, Near Sastha Temple, Thycaud,
Thiruvananthapuram, Kerala. Pin - 695014. Phone: +91471 2323247, +919349427177, E mail: manjuvishy@yahoo.com
Abstract
The incidence of primary Caesarean Sections (CS) is on the rise
of Emergency Caesarean Sections and 76 cases of Elective Caesarean throughout the world.​1 ​Due to advances in surgical
technology,
Sections. Neonatal outcomes were compared between Elective and anesthesia techniques and better surgical skills, maternal and
neonatal
Emergency Caesarean section babies. Information regarding fetal mortality rates have come down in Cesarean Sections; but the
mor-
morbidity was collected by noting history and clinical examination bidity is still high in comparison to vaginal delivery.​2 ​This
study was
findings. The babies were followed up for 6 weeks postpartum. conducted to compare the fetal outcomes of Elective and
Emergency Caesarean Sections.
Neonatal morbidity was significantly higher in the Emergency Caesarean group than in Elective Caesarean. Hence the decision
for All patients who underwent Emergency and Elective Caesarean Sec-
Emergency Caesarean section has to be taken judiciously. tions in a teaching hospital in Thiruvananthapuram district of Kerala
during a one year period were included in the study. Patients who had definite antenatal complications that would adversely
affect neonatal outcome were excluded from the study. There were a total of 89 cases
Key words: ​Neonatal Outcome, Emergency Caesarean Section, Elective Caesarean Section, Neonatal Morbidity, Teaching
Hospital, Kerala.
​ aniel S, Viswanathan M, Simi BN, Nazeema A. Comparison of Fetal Outcomes of Emergency and Elective
Cite this article as: D
Caesarean Sections in a Teaching Hospital in Kerala. Academic Medical Journal of India. 2014 Feb 23;2(1):32–6.

I​ Introduction ​ncidence veloped and surgical and of Caesarean techniques developing deliveries have

​
countries.advanced, has 3,4,5,6,7 ​
increased Caesarean Though both Medical delivery in de-
is still associated with increased maternal and fetal morbidity.​8
The Social and Medico Legal expectation of a perfect perinatal outcome has influenced obstetric care.
Advancing age at preg- nancy and artificial reproductive techniques have led to rise in number of so called
precious pregnancies and hence the rise in expectations of perinatal outcome. Dramatic advances in neo- natal
care have lowered the gestational age at which CS can be done for indicated cases. According to WHO,
Caesarean rate of more than 15% is not justified.​9 ​With the increase in Caesarean Section rate, there is also
increase in incidence of maternal and neonatal morbidity.
Caesarean Section can be done as an Elective as well as Emergency procedure. The maternal morbidity is
definitely high with Emergency Caesarean Section.​10,11 ​This study was conducted to assess whether there was
significant increase in neonatal morbidity and mortality with Emergency Caesarean Section.
Objectives
To compare fetal outcomes between Elective and Emergency Caesarean Sections in a Tertiary care centre.
*See End Note for complete author details
ORIGINAL RESEARCH
Published on 23th February, 2014
Operational Definitions
Elective Caesarean is a term used when the procedure is done at a pre-arranged time during office hours, to
ensure the best quality of obstetrics, anesthetic, neonatal and nursing services.
The procedure is termed as Emergency Caesarean Section when it is performed due to unforeseen or acute
obstetric or fetal emergencies irrespective of the time of the day.
Office hours was defined as working hours of the hospital, that is 8.00 am to 5.00 pm when the staff manning
the opera- tion theater, Anaesthesia department, Neonatal intensive care unit, and the Surgeons were at the best
of their abilities.
Fetal outcome was studied on the basis of Neonatal complica- tions like still birth, birth asphyxia, transient
tachypnea of new born, respiratory distress syndrome, sepsis, NICU stay > 24 hrs and Neonatal death.
Methodology
This was a Longitudinal Descriptive Study conducted in the Obstetrics and Gynaecology Department of Sree
Gokulam Medical College and Research Foundation, Thiruvanan- thapuram, Kerala, during a period of one
year from December 2011 to November 2012. All patients undergoing Caesarean Sections in the hospital were
included in the study.

​ - Issue 1 ​Since the study aimed at comparing fetal outcomes

Volume ​Academic Medical Journal of India ​33 II
that can be attributed to the type of Caesarean Section chosen, cases with maternal or fetal complications that
could have ad- versely affected the neonatal outcome were excluded from the study. These included
gestational age <32 weeks, meconium stained liquor and severe IUGR with estimated baby weight <3​rd ​centile
for the gestational age. The major indications of Caesarean Sections that were included in the study were failed
induction, fetal distress, CPD and Previous Caesarean Sections. The cases of fetal distress that were included
in Emergency Caesarean Section were those patients who had no complications during the antenatal period
that could affect the fetus adversely, but during the course of labor went in for fetal distress.
There were a total of 89 Emergency Caesarean Sections which were compared to 76 Elective Sections.
Information regarding fetal morbidity was collected by noting history and clinical examination findings. The
babies were followed up for a period of 6 weeks. Informed consent from the participants was obtained prior to
collection of data.
The outcome variables studied were incidence of Elective and Emergency Caesarean Sections, timing of
Caesarean Sections, antenatal complications and neonatal complications includ- ing still birth, Birth Asphyxia,
Transient Tachypnoea of new born, Respiratory Distress Syndrome, Sepsis, NICU stay > 24hrs and Neonatal
death.
The data collected, were coded and fed into MS Excel and analyzed using SPSS v 19 with the assistance of a
statistician. Statistics such as mean, standard deviation and percentage were used to describe the data and Chi
square test was used to find associations.
Results
During the study period there were a total of 575 deliveries. There were 89 (53.9%) cases of Emergency
Caesarean Sec- tions. These were compared with 76 (46.1%) cases of Elective Caesarean Section ​(Figure 1)​.
The rate of Caesarean Section was 28.7%. The youngest woman included in the study was 18 years old and the
oldest was 37 years old.
Of the women who were <20 years of age 1.3% (n=1) had Elective CS and 5.6% (n=5) had Emergency CS. In
the above 30 yrs group 28.9% (n-22) had Elective CS and 10.1% (n=9) had Emergency Caesarean Section.
The majority of patients were between 20 and 30 years of age among whom 69.7% (n=53) and 84.3% (n=75)
had Elective and Emergency Cae- sarean Sections respectively.
In Elective Caesarean group 1.3% were early preterm, 1.3% were late pre term and the rest (97.4%) were term
CS. In the Emergency Caesarean group 1.1% was early pre-term 16.9% late pre-term and the rest (82%) were
term ​(Table 1)​. Mean
Figure 1. Type of Caesarean Section
period of gestation in which Caesarean Section was done was similar in both groups, i.e. 38 weeks.
All cases of Elective Caesarean Sections were done during the office hours, that is between 8.00 am and 5.00
pm. Among the 89 cases of Emergency Caesarean Section, 49 cases were done during office hours, 23 cases
between 5.00 pm and 8.00 pm 11 cases between 8.00 pm and 11.00 pm 4 cases between 11.00 pm and 2.00 am
and 2 cases between 2.00 am and 5.00 am.
Table 1. Caesarean Sections by Period of Gestation
Elective Caesarean Section Emergency Caesarean Section
Period of Gestation ​
Count (%) Count (%)
< 34 weeks 1(1.3) 1(1.1)
34 - 37 weeks 1(1.3) 15(16.9)
> 37 weeks 74(97.4) 73(82.0)
Pearson Chi-square = 11.3 df=2 p = 0.004
Occurrence of antenatal complications was found similar in both groups i.e. 48%. There was no significant
difference between antenatal complications in both the groups ​(Table 2).
Table 2. Antenatal complications
Antenatal complications
Elective Caesarean
Emergency Caesarean Section
Section
Count (Percent) Count (Percent)
GDM 16(21.1) 15(16.9)
Gestational Hypertension 9(11.8) 4(4.5)
Mal Presentation 10(13.2) 6(6.7)
Twins 0(0.0) 5(5.6)
IUGR 4(5.3) 9(10.1)
Oligamnios 3(3.9) 5(5.6)
Obstetric Cholestasis 0(0.0) 4(4.5)
Heart Disease 1(1.3) 0(0.0)
Antepartum Hemorrhage 1(1.3) 3(3.4)
Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala

​ - Issue 1 ​In the Emergency Caesarean group, incidence of

Volume ​Academic Medical Journal of India ​34 II
GDM, Gestational Hypertension and Malpresentation was less than that in the Elective Caesarean group.
In the present study, 40.4% of babies delivered by Emergency Caesarean Section developed neonatal
complications whereas only 9.2% of babies delivered by Elective Caesarean Section developed neonatal
complications ​(Table 3)​. This was in spite of the fact that all antenatal complications that might predispose to
adverse fetal outcomes were excluded from the study. The difference was statistically significant. The odds
ratio 0.15 indicates that there is 85% less risk of neonatal complication among patients who underwent
Elective CS than those who had Emergency CS.
RDS was seen in 7.4% after Emergency Caesarean Section as compared to 0% after Elective Caesarean
Section. Dif- ference was significant (p-0.015). Sepsis was seen in 23.4% after Emergency Caesarean Section
as compared to 3.9% after Elective Caesarean Section. Difference was significant (p-0.001). There were no
cases of still birth ​(Table 4)​.
Table 3. Neonatal Complications
Elective CS ​ Emergency CS
Neonatal Complications ​ Count(%) ​
Count(%)
Yes 7(9.2) 38(40.4)
No 69(90.8) 56(59.6)
Chi-square value - 21.04, p = 0.001 ​Odds ratio 0.15 (95%) confidence interval 0.06-0.38
When we study the time of Caesarean Section and develop- ment of complications, it is seen that the fetal
complications were much higher when the cases were done after the office hours. The further away from office
hours the section was performed, the greater the proportion of fetal complications ​(Figure 2)​.
Table 4. Details of Neonatal Complications
Elective CS ​ Emergency CS ​
Neonatal complications ​ Count Percent ​ Count Percent
χ​2 ​p ​Still birth Yes 0 0.0 0 0.0
Birth Asphyxia Yes 1 1.3 2 2.1 0.16 0.689
TTN Yes 3 3.9 12 12.8 4.06 0.004
RDS Yes 0 0.0 7 7.4 5.9 0.015
Sepsis Yes 3 3.9 22 23.4 12.68 0.001
NICU stay for more than 24hrs was required in 39.4% of Emergency Caesarean Section as compared to 10.5%
of Elective Caesarean Section cases. Difference was significant (p-0.001) ​(Table 5)​.
Table 5. NICU stay more than 24 hrs
Elective CS ​ Emergency CS ​
NICU stay >24Hr ​ Count (Percent) ​ Count (Percent)
χ​2 ​p ​Yes 8(10.5) 37(39.4) 17.95** 0.001
Discussion
Caesarean sections have been long practiced as a lifesaving procedure for the mother and fetus. Though it is
classified as a major procedure, the incidence of Caesarean Section has risen considerably over the years. The
situation now is that Caesarean Section is adopted for even trivial cases. Though advances in the field have
reduced maternal mortality con- siderably, the problem of maternal and fetal morbidity after Caesarean Section
still persists. The present study was on neo- natal morbidities following Caesarean Section, with particular
emphasis on a comparison between Elective and Emergency Caesarean Sections and the timing of the
procedure.
Premature labor, maternal medical illnesses, maternal sepsis, repeated vaginal examination and PROM all
contribute to increase in neonatal morbidity. A common cause of neonatal morbidity and mortality is
Respiratory Distress Syndrome, ​Figure 2. Distribution of cases according to time and neonatal complications
which is a function of gestational age. Inappropriately timed Caesarean delivery (Elective / Emergency) has
been known to The neonatal complications were Birth Asphyxia, TTN,
result in this complication. According to a study by Mor- RDS, and Sepsis. Birth asphyxia was seen in 2.1%
newborns
rison J. J, et al, a significant reduction in neonatal respiratory after Emergency Caesarean Section whereas it
was 1.3% after
morbidity can be obtained if Elective Caesarean Section was Elective Caesarean Section. Difference was not
statistically
performed in the week 39+0 to 39+6 of pregnancy.​12 ​In significant (p-0.689). TTN was seen in 12.8% after
Emer-
another study by Roth-Kleiner M, et al, it was found that gency Caesarean Section as compared to 3.9% after
Elective
severity of respiratory distress was high for babies born after Caesarean Section. Difference was significant
(p-0.004).
Elective Caesarean Section as compared to Emergency Cae-
Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala
13 ​
​ - Issue 1 ​sarean Section,​ probably because of the changes
Volume ​Academic Medical Journal of India ​35 II
occurring to the fetal lungs when the mother gets into labor. The findings do not correlate with the present
study though.
Transient tachypnea of the newborn may also follow Caesarean Section, although debate exists as to whether
operative deliv- ery contributes to the genesis of this disease. Elective repeat Caesarean Section has been
implicated on the development of pulmonary hypertension of the newborn.​14
When anesthesia is given it may affect the neonate directly or indirectly. The Caesarean Section may be done
under general anesthesia or regional anesthesia. The fetal and neonatal mor- bidity due to regional anesthesia
may be because of the maternal hypotension and large doses of local anesthetic agents.
If anesthetic drugs are used in adequate doses the complications encountered are minimum and alterations in
neuro-behavioral scores are subtle and transient. Under normal circumstances there is not much difference in
fetal and neonatal well-being after Caesarean Section, both with general anesthesia or re- gional block.
Subtle and inconsistent neurobehavioral residua may be present for a short period of time following general
anesthe- sia. In a patient when we anticipate neonatal complications namely intra uterine growth restriction, the
neonates may definitely benefit from regional block rather than general anesthesia.​15
Factors that would influence the outcomes of these babies would be duration of fetal distress, leaking
membranes, asphyxia and prematurity. A study by Roberta De Luca compared the newborns delivered by
Elective and Emergency Caesarean Sec- tions. It was seen that neonates of Elective Caesarean had lesser
morbidity compared to those of Emergency Caesarean Section in terms of admission to neonatal facility but
mortality and respiratory morbidity were similar in both groups.​16
In this study the rate of Caesarean Section was 28.7%. This Caesarean Section rate is comparable to the U.S
rate of 32.8% in 2010.​17 ​It is also comparable to the Caesarean Section rate in tertiary hospitals in Raipur, India
(26.2%).​18
In the present study, 40.4% of babies delivered by Emergency Caesarean Section developed neonatal
complications in com- parison to 9.2% of babies delivered by Elective Caesarean Section. The difference was
statistically significant (p-0.001). This was inspite of the fact that all antenatal complications that might
predispose to adverse fetal outcomes were excluded from the study. It was also seen that the neonatal
complica- tions were higher in patients undergoing Caesarean Section after the office hours.
The neonatal complications were birth asphyxia, TTN, RDS, Sepsis and Neonatal Jaundice. Birth asphyxia
was more with Emergency Caesarean Section than with Elective Caesarean Section (2.1% vs 1.3%). A similar
result had been seen in the
study by Elvedi-Gasparović V, et al.​19
Conclusion
Neonatal morbidity was significantly higher in the Emergency Caesarean group than in Elective Caesarean.
The neonatal morbidity was found to be higher when the cases were done after office hours. Emergency
Caesarean Sections are unavoid- able. The selection of patients for Emergency CS should be in such a way that
the benefits should far outweigh the morbid- ity associated with the procedure. The decision for Emergency
Caesarean Section has to be taken judiciously. If during the progress of labor one anticipates Caesarean
Section, it is advisable to take decision regarding the Emergency Caesarean Sections during office hours and
day time to help bring down neonatal morbidity. Factors that contribute to the indications for Emergency
Caesarean Section like failed induction, fetal distress, CPD, repeat Caesarean Section and cervical dystocia
have to be evaluated independently in a further study to assess the contribution of each factor to the neonatal
morbidity and how best these can be avoided.
End Note
Author Information
1. Suja Daniel, Associate professor in Obstetrics and Gy- necology, Sree Gokulam Medical College and
Research Foundation 2. Manjusha Viswanathan, Associate professor in Obstetrics and Gynecology, Sree
Gokulam Medical College and Re- search Foundation 3. Dr B N Simi, Resident in Obstetrics and Gynecology,
Sree Gokulam Medical College and Research Foundation 4. Dr Nazeema A, Professor in Obstetrics and
Gynecology Sree Gokulam Medical College and Research Foundation
Abbreviations
CS - Caesarean Section NICU - Neonatal Intensive Care Unit TTN - Transient Tachypnea of New born RDS -
Respiratory Distress Syndrome WHO - World Health Organisation GDM - Gestational Diabetes Mellitus
IUGR - Intra Uterine Growth Restriction CPD - Cephalo Pelvic Disproportion
Competing Interests​: None declared
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Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala