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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 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 Key words: Neonatal Outcome, Emergency Caesarean Section,
definite antenatal complications that would adversely affect neonatal Elective Caesarean Section, Neonatal Morbidity, Teaching Hospital,
Kerala.
outcome were excluded from the study. There were a total of 89 cases

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

*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 35 Volume II - Issue 1

sarean Section,13 probably because of the changes occurring to study by Elvedi-Gasparović V, et al.19
the fetal lungs when the mother gets into labor. The findings
do not correlate with the present study though. Conclusion
Transient tachypnea of the newborn may also follow Caesarean Neonatal morbidity was significantly higher in the Emergency
Section, although debate exists as to whether operative deliv- Caesarean group than in Elective Caesarean. The neonatal
ery contributes to the genesis of this disease. Elective repeat morbidity was found to be higher when the cases were done
Caesarean Section has been implicated on the development of after office hours. Emergency Caesarean Sections are unavoid-
pulmonary hypertension of the newborn.14 able. The selection of patients for Emergency CS should be in
such a way that the benefits should far outweigh the morbid-
When anesthesia is given it may affect the neonate directly or
ity associated with the procedure. The decision for Emergency
indirectly. The Caesarean Section may be done under general
Caesarean Section has to be taken judiciously. If during the
anesthesia or regional anesthesia. The fetal and neonatal mor-
progress of labor one anticipates Caesarean Section, it is
bidity due to regional anesthesia may be because of the maternal
advisable to take decision regarding the Emergency Caesarean
hypotension and large doses of local anesthetic agents.
Sections during office hours and day time to help bring down
If anesthetic drugs are used in adequate doses the complications neonatal morbidity. Factors that contribute to the indications
encountered are minimum and alterations in neuro-behavioral for Emergency Caesarean Section like failed induction, fetal
scores are subtle and transient. Under normal circumstances distress, CPD, repeat Caesarean Section and cervical dystocia
there is not much difference in fetal and neonatal well-being have to be evaluated independently in a further study to assess
after Caesarean Section, both with general anesthesia or re- the contribution of each factor to the neonatal morbidity and
gional block. how best these can be avoided.
Subtle and inconsistent neurobehavioral residua may be
End Note
present for a short period of time following general anesthe-
sia. In a patient when we anticipate neonatal complications Author Information
namely intra uterine growth restriction, the neonates may 1. Suja Daniel, Associate professor in Obstetrics and Gy-
definitely benefit from regional block rather than general necology, Sree Gokulam Medical College and Research
anesthesia.15 Foundation
Factors that would influence the outcomes of these babies would 2. Manjusha Viswanathan, Associate professor in Obstetrics
be duration of fetal distress, leaking membranes, asphyxia and Gynecology, Sree Gokulam Medical College and Re-
and prematurity. A study by Roberta De Luca compared the search Foundation
newborns delivered by Elective and Emergency Caesarean Sec- 3. Dr B N Simi, Resident in Obstetrics and Gynecology,
tions. It was seen that neonates of Elective Caesarean had lesser Sree Gokulam Medical College and Research Foundation
morbidity compared to those of Emergency Caesarean Section
in terms of admission to neonatal facility but mortality and 4. Dr Nazeema A, Professor in Obstetrics and Gynecology
respiratory morbidity were similar in both groups.16 Sree Gokulam Medical College and Research Foundation

In this study the rate of Caesarean Section was 28.7%. This Abbreviations
Caesarean Section rate is comparable to the U.S rate of 32.8% CS - Caesarean Section
in 2010.17 It is also comparable to the Caesarean Section rate
NICU - Neonatal Intensive Care Unit
in tertiary hospitals in Raipur, India (26.2%).18
TTN - Transient Tachypnea of New born
In the present study, 40.4% of babies delivered by Emergency
RDS - Respiratory Distress Syndrome
Caesarean Section developed neonatal complications in com-
parison to 9.2% of babies delivered by Elective Caesarean WHO - World Health Organisation
Section. The difference was statistically significant (p-0.001). GDM - Gestational Diabetes Mellitus
This was inspite of the fact that all antenatal complications IUGR - Intra Uterine Growth Restriction
that might predispose to adverse fetal outcomes were excluded CPD - Cephalo Pelvic Disproportion
from the study. It was also seen that the neonatal complica-
tions were higher in patients undergoing Caesarean Section Competing Interests: None declared
after the office hours.
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Suja Daniel et al. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala