Academic Medical Journal of India 32 Volume II - Issue 1

www.medicaljournal.in February 2014

ORIGINAL RESEARCH

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 Published on 23th February, 2014

The incidence of primary Caesarean Sections (CS) is on the rise
throughout the world.1 Due to advances in surgical technology,
anesthesia techniques and better surgical skills, maternal and neonatal
mortality rates have come down in Cesarean Sections; but the mor-
bidity is still high in comparison to vaginal delivery.2 This study was
conducted to compare the fetal outcomes of Elective and Emergency
Caesarean Sections.
All patients who underwent Emergency and Elective Caesarean Sec-
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
of Emergency Caesarean Sections and 76 cases of Elective Caesarean
Sections. Neonatal outcomes were compared between Elective and
Emergency Caesarean section babies. Information regarding fetal
morbidity was collected by noting history and clinical examination
findings. The babies were followed up for 6 weeks postpartum.
Neonatal morbidity was significantly higher in the Emergency
Caesarean group than in Elective Caesarean. Hence the decision for
Emergency Caesarean section has to be taken judiciously.
Key words: Neonatal Outcome, Emergency Caesarean Section,
Elective Caesarean Section, Neonatal Morbidity, Teaching Hospital,
Kerala.

Cite this article as: Daniel S, Viswanathan M, Simi BN, Nazeema A. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a
Teaching Hospital in Kerala. Academic Medical Journal of India. 2014 Feb 23;2(1):32–6.

Introduction Operational Definitions

I
ncidence of Caesarean deliveries has increased both in de-
veloped and developing countries.3,4,5,6,7 Though Medical
and surgical techniques have advanced, Caesarean delivery
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.
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.

*See End Note for complete author details

Academic Medical Journal of India 33 Volume II - Issue 1

Since the study aimed at comparing fetal outcomes 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
<3rd 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.
Figure 1. Type of Caesarean Section
There were a total of 89 Emergency Caesarean Sections which
were compared to 76 Elective Sections. Information regarding period of gestation in which Caesarean Section was done was
fetal morbidity was collected by noting history and clinical similar in both groups, i.e. 38 weeks.
examination findings. The babies were followed up for a All cases of Elective Caesarean Sections were done during the
period of 6 weeks. Informed consent from the participants office hours, that is between 8.00 am and 5.00 pm. Among
was obtained prior to collection of data. the 89 cases of Emergency Caesarean Section, 49 cases were
The outcome variables studied were incidence of Elective and done during office hours, 23 cases between 5.00 pm and 8.00
Emergency Caesarean Sections, timing of Caesarean Sections, pm 11 cases between 8.00 pm and 11.00 pm 4 cases between
antenatal complications and neonatal complications includ- 11.00 pm and 2.00 am and 2 cases between 2.00 am and 5.00
ing still birth, Birth Asphyxia, Transient Tachypnoea of new am.
born, Respiratory Distress Syndrome, Sepsis, NICU stay >
24hrs and Neonatal death. Table 1. Caesarean Sections by Period of Gestation
Elective Caesarean Section Emergency Caesarean Section
The data collected, were coded and fed into MS Excel and Period of Gestation
analyzed using SPSS v 19 with the assistance of a statistician. Count (%) Count (%)

Statistics such as mean, standard deviation and percentage < 34 weeks 1(1.3) 1(1.1)
were used to describe the data and Chi square test was used to 34 - 37 weeks 1(1.3) 15(16.9)
find associations. > 37 weeks 74(97.4) 73(82.0)
Pearson Chi-square = 11.3 df=2 p = 0.004
Results
During the study period there were a total of 575 deliveries. Occurrence of antenatal complications was found similar in
There were 89 (53.9%) cases of Emergency Caesarean Sec- both groups i.e. 48%. There was no significant difference
tions. These were compared with 76 (46.1%) cases of Elective between antenatal complications in both the groups (Table 2).
Caesarean Section (Figure 1). The rate of Caesarean Section
was 28.7%. The youngest woman included in the study was Table 2. Antenatal complications
18 years old and the oldest was 37 years old. Elective Caesarean Emergency Caesarean
Antenatal complications Section Section
Of the women who were <20 years of age 1.3% (n=1) had Count (Percent) Count (Percent)
Elective CS and 5.6% (n=5) had Emergency CS. In the above GDM 16(21.1) 15(16.9)
30 yrs group 28.9% (n-22) had Elective CS and 10.1% (n=9)
Gestational Hypertension 9(11.8) 4(4.5)
had Emergency Caesarean Section. The majority of patients
Mal Presentation 10(13.2) 6(6.7)
were between 20 and 30 years of age among whom 69.7%
(n=53) and 84.3% (n=75) had Elective and Emergency Cae- Twins 0(0.0) 5(5.6)
sarean Sections respectively. IUGR 4(5.3) 9(10.1)
Oligamnios 3(3.9) 5(5.6)
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 Obstetric Cholestasis 0(0.0) 4(4.5)

Emergency Caesarean group 1.1% was early pre-term 16.9% Heart Disease 1(1.3) 0(0.0)
late pre-term and the rest (82%) were term (Table 1). Mean 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
Academic Medical Journal of India 34 Volume II - Issue 1

In the Emergency Caesarean group, incidence of GDM, RDS was seen in 7.4% after Emergency Caesarean Section
Gestational Hypertension and Malpresentation was less than as compared to 0% after Elective Caesarean Section. Dif-
that in the Elective Caesarean group. ference was significant (p-0.015). Sepsis was seen in 23.4%
after Emergency Caesarean Section as compared to 3.9%
In the present study, 40.4% of babies delivered by Emergency
after Elective Caesarean Section. Difference was significant
Caesarean Section developed neonatal complications whereas
(p-0.001). There were no cases of still birth (Table 4).
only 9.2% of babies delivered by Elective Caesarean Section
developed neonatal complications (Table 3). This was in Table 4. Details of Neonatal Complications
spite of the fact that all antenatal complications that might
Elective CS Emergency CS
predispose to adverse fetal outcomes were excluded from the Neonatal complications χ2 p
Count Percent Count Percent
study. The difference was statistically significant. The odds
ratio 0.15 indicates that there is 85% less risk of neonatal Still birth Yes 0 0.0 0 0.0
complication among patients who underwent Elective CS Birth Asphyxia Yes 1 1.3 2 2.1 0.16 0.689
than those who had Emergency CS. TTN Yes 3 3.9 12 12.8 4.06 0.004
RDS Yes 0 0.0 7 7.4 5.9 0.015
Table 3. Neonatal Complications Sepsis Yes 3 3.9 22 23.4 12.68 0.001
Elective CS Emergency CS
Neonatal Complications
Count(%) Count(%) NICU stay for more than 24hrs was required in 39.4% of
Yes 7(9.2) 38(40.4) Emergency Caesarean Section as compared to 10.5% of
No 69(90.8) 56(59.6) Elective Caesarean Section cases. Difference was significant
Chi-square value - 21.04, p = 0.001 (p-0.001) (Table 5).
Odds ratio 0.15 (95%) confidence interval 0.06-0.38
Table 5. NICU stay more than 24 hrs
When we study the time of Caesarean Section and develop- Elective CS Emergency CS
NICU stay >24Hr χ2 p
ment of complications, it is seen that the fetal complications Count (Percent) Count (Percent)
were much higher when the cases were done after the office Yes 8(10.5) 37(39.4) 17.95** 0.001
hours. The further away from office hours the section was
performed, the greater the proportion of fetal complications Discussion
(Figure 2).
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
Academic Medical Journal of India
sarean Section,13 probably because of the changes 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
Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala
35 Volume II - Issue 1
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
References
1. Appropriate technology for birth. Lancet. 1985 Aug 24;2(8452):436–7.
2. Rising rate of CS A year review [Internet]. [cited 2013 Dec 18].
Available from: http://nepjol.info/index.php/JoNMC/article/down-
Academic Medical Journal of India
load/7303/5919
3. National Institutes of Health state-of-the-sc... [Obstet Gynecol. 2006]
- PubMed - NCBI FCS 1 [Internet]. [cited 2013 Dec 24]. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/16738168
4. Hamilton B, Martin J, Ventura S. Products - Health E Stats - Preliminary
Birth Data - 2005 FCS 2 [Internet]. CDChome. [cited 2013 Dec 24].
Available from: http://www.cdc.gov/nchs/data/hestat/prelimbirths05/
prelimbirths05.htm
5. Products - Health E Stats - Preliminary Births for 2004 - Infant and
Maternal Health FCS3 [Internet]. [cited 2013 Dec 25]. Available from:
http://www.cdc.gov/nchs/data/hestat/prelimbirths04/prelimbirth-
s04health.htm
6. National Vital Statistics Reports, Vol. 54, No. 2 (9/8/2005) - nvsr54_02.
pdf fcs 4 [Internet]. [cited 2013 Dec 25]. Available from: http://www.
cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_02.pdf
7. Fuglenes D, Oian P, Sombo I. Obstetricians’ choice of cesarean delivery
in ambiguous cases: is it influenced by risk attitude FCS 5 or fear of
complaints and litigation? american journal of obstetrics and gynecol-
ogy. 2008 Jan;200(1):48 e 1–48 e 8.
8. Shiliang L, Robert M L. Maternal mortality and severe morbidity as-
sociated with low-risk planned cesarean delivery FCS 6 versus planned
vaginal delivery at term. Canadian Medical Assosciation Journal. 2007
Feb;176(4):455–60.
9. Purandare C. The Over Roofing Rates of Caesarean Section FCS 7. the-
journal of obstetrics and gynecology of India. 2011 Oct;61(5):501–2.
10. Pomela J, Harmesh bains, Vidhushi B, Annika J. A Comparison of
Maternal and Fetal Outcome in Elective and Emergency Caesarean
FCS 8 Sections - Indian Obstetrics and Gynaecology. [Internet]. 2012
Sep [cited 2013 Dec 20];2(3). Available from: http://iog.org.in/index.
Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala
36 Volume II - Issue 1
php/original-articles-issue-july-september-2012/73-a-comparison-of-
maternal-and-fetal-outcome-in-Elective-and-Emergency-Caesarean-
sections?showall=1&limitstart=
11. Factors affecting The rate and Indications of primary CS FCS 9 [Inter-
net]. [cited 2013 Dec 20]. Available from: http://www.bahrainmedical-
bulletin.com/december_2001/factors.pdf
12. Morrison J, Rennie J, Milton P. Neonatal respiratory morbidity and
mode FCS 11... [Br J Obstet Gynaecol. 1995] - PubMed - NCBI.
British Journal Of Obstetrics and gynecology. 1995 Feb;102(2):101–6.
13. Kleiner R, Wagner B, Bachmann D, Pfeinninger J. Respiratory distress
syndrome in near-term FCS 12 ba... [Swiss Med Wkly. 2003] - PubMed
- NCBI. Swiss Medical Weekly. 2003 May 17;133(19-20):283–8.
14. Ramachandrappa A, Jain L. Elective Cesarean Section: It’s Impact on
Neonatal Respiratory Outcome FCS 13. Clinics in Perinatology. 2008
Jun;35(2):373 vii.
15. Dick W. Anaesthesia for CaesareanFCS17 s... [Eur J Obstet Gynecol
Reprod Biol. 1995] - PubMed - NCBI. European journal of obstetrics
gynecology and reproductive biology. 1995 May;59(supple S 6):1–7.
16. Deluca R, Boulvain M, Irion O, Berber M, Pfister R. Incidence of early
neonatal mortality and FCS 18 morbidi... [Pediatrics. 2009] - PubMed
- NCBI. paediatrics. 2009 Jun;123(6):1064–71.
17. National Vital Statistics Reports Volume 62, Number 3 September 6,
2013 - nvsr62_03.pdfFCS 19 [Internet]. [cited 2013 Dec 19]. Available
from: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_03.pdf
18. A recent way of evaluating CS birthFCS 20 [Internet]. [cited 2013 Dec
25]. Available from: http://medind.nic.in/jaq/t09/i6/jaqt09i6p547.pdf
19. Gasprovic Elvedi, Klepac P, Peter B. Maternal and fetal outcome in
Elective versusFCS 21 ... [Coll Antropol. 2006] - PubMed - NCBI. coll
anthropology. 2006 Mar;1(30):113–8.