الفهرس 
CAESAREAN SECTIONOnly 14 pages are availabe for public view
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Abstract
A
caesarean delivery is a surgical procedure in which a foetus is delivered through an incision in the mother’s abdomen and uterus. It is the most common obstetric operative procedure globally, and the CS rate has been continuously increased.
The origin of the term caesarean delivery is unclear. The beliefs that Julius Cesar was born by this way, and so this procedure became known as the caesarean operation. Several factors weaken this explanation. First, the mother of Julius Cesar lived for many years after his birth in (100 BC.) and as late as the 17th century, the operation was invariably fatal. Second, The operation, whether done on living or dead women, it is not mentioned by any medical writer before the Middle Ages.
CS rates have been rising worldwide over the past decades in both developed and developing countries. In the WHO Global Survey on Maternal and Prenatal Health, which was conducted between 2004 and 2005 in 24 regions of eight countries in Latin America and which obtained data for all women admitted for delivery in 120 randomly selected institutions, the median rate of caesarean delivery was 33%; rates of up to 51% were noted in private hospitals.
The reasons for this increase in CS birth are multifactorial and include the increasing number of women with prior CS delivery, the increase in multifetal gestations, use of intrapartum electronic fetal monitoring, changes in obstetric training, medico legal concerns, alterations in parental and social expectations of pregnancy outcome and maternal autonomy in decision making regarding delivery mode.
Compared with vaginal delivery, maternal mortality and especially morbidity is increased with CS delivery to about twice the rate after a vaginal delivery. The overall maternal mortality rate is 6-22 deaths per 100,000 live births, with approximately one third to one half of maternal deaths after CS delivery being directly attributable to the operative procedure itself. Part of this increase in mortality is that associated with a surgical procedure and, in part, related to the conditions that may have led to needing to perform a CS delivery. Major sources of morbidity and mortality can be related to sequelae of infection, thromboembolic disease, aesthetic complications, and surgical injury.
Women who had previous CS were more likely to have problems with the following births, including increased risk of malpresentations, APH, placenta previa, placenta accreta, prolonged labor, risk of scar dehiscence, uterine rupture, preterm birth.
Women are now four times more likely to have CS birth than 30 years ago. Many programs have been developed to reduce the rate of CS delivery. Approximately one third of CS are performed electively and two third are performed as an emergency procedures. Primary CS have a major contribution in determining the future obstetric course of a woman. Among the primary CS deliveries the most common indication for an elective procedure is breech presentation and for an emergency procedure includes labor dystocia and non-reassuring fetal heart rate tracings.
As primary caesarean deliveries contributed most to the overall CS rate. Wide variation in clinical practice among the obstetricians was identified. Main factor for these inconsistencies in clinical practice was attributed to the lack of adherence to standard guidelines and lack of acceptable benchmarks for the rates of CS, induction of labor and failed inductions. Induced cases contributed most to primary CS.
In order to understand the drivers of increasing CS and to propose effective measures to reduce or increase CS rates when needed, it is necessary to have a tool to monitor and compare CS rates in a same setting over time and between different settings. The 10 group Robson classification of CS has been appreciated by WHO in 2014 and FIGO in 2016.
WHO proposes the Robson classification system as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities over time, and between facilities. In order to assist healthcare facilities in adopting the Robson classification, WHO will develop guidelines for its use, implementation and interpretation, including standardization of terms and definitions.
This classification is simple, robust, reproducible, clinically relevant, and prospective. It allows the comparison and analysis of CS rates within and across these groups of women. The Robson Classification had been rapidly and increasingly used by many countries all over the world.
There are a range of practices used over decades that should be replaced by standardized, evidence-based practices so the rate of CS deliveries may be safely decreased. However, the practice environment that clinicians are facing, the cultural and medico legal pressures, need to be improved. Through such perinatal quality improvement efforts that are health system approach, the environmental changes will allow clinicians to adopt the described practices.
It includes clinical and non-clinical interventions. Clinical interventions tend to target a specific clinical practice for an individual woman like [VBAC] and induction of labor. The non-clinical intervention includes health educational for women and use of evidence-based clinical practice guidelines.
The study was descriptive cross sectional conducted at labor ward of Ain shams university maternity hospital (a tertiary care center) for a 6 months duration, all women delivered by CS were recruited.
The total number of all deliveries were 6260 deliveries, the total number of Cesarean sections were 3430 cesarean deliveries, and CS proportion were (54.79%). group 5 was the most frequent (38.98%), followed by group ten (34.20%) of overall cesarean section rate. While, group three and nine were the least contribution (48 cases, 1.4%) and (17 cases, 0.5%) respectively.
The study assessed the frequency of the subgroups of the modified Robson criteria and revealed that, the most common subgroup contributing to cesarean section rate was group 5C (22.57%), followed by subgroup A of the same group with the second highest frequency (16.41%). On the other hand, subgroup 4A had the least frequency (0.15%) of overall cesarean section rate, followed by subgroup 2A (0.12%).
The study revealed that the most frequent indications for the overall CS rate was previous cesarean section (48.27%), while fetal distress represented 4.43%, mal-presentation 4.05%, multiple pregnancy 3.2%, and only 0.64% mothers had CS due to suspected uterine rupture.
Our study also assessed the prevalence of medical disorders among the participants and found that the majority were without medical disorders (66.73%), while 33.26% had medical disorders. The majority of whom had hypertension (21.22%), followed by patients with DM with pregnancy (9.5%) and only 1.5% had heart disease.
Furthermore, the study assessed the major maternal morbidity and mortality among the participants, which revealed that, there were 9 cases of maternal mortality (0.26%). ICU admission were 129 cases (3.76%), DIC were 14 cases (0.4%), morbidly adherent placenta were 68 cases (1.98%), hysterectomy performed to control PPH in 59 cases (1.72%), intestinal injury complicated 7 cases (0.2%), urinary bladder injury complicated 16 cases (0.46%), ureteric injury complicated 3 cases (0.08%).
The study revealed also neonatal outcome, admission to NICU was 23.14%, RDS (11.48%), Apgar score less than 7 at 5 minutes (7.11%), IUFD and fresh stillbirth (3.55%).
The present study assessed the relationship between the frequency of C.S, placenta previa and morbidly adherent placenta, and found that there was a forward relationship between the number of previous CS & the occurrence of MAP. While no cases of women with no prior CS had MAP, 42 cases (6.30%) of those with previous 3 or more CS, had MAP.
The present study found that, Preterm CS was found to be associated with morbidly adherent placenta, with an odds ratio of 7.30 (95% CI 3.81-13.96). When adjusted for placenta previa, the adjusted OR is 2.18 (95% CI 1.08 – 4.41)
Finally, the Robson classification helps to identify the contributors to the CS rate and to classify the population handled by the hospital to develop strategies for improving the services and interventions to reduce medical unnecessary cesarean sections, but does not provide insight into the reasons or explanation for the observed differences. It has limitation in view of qualitative assessment of comorbidities and their severity.
This classification also does not allow the analysis of C.S on maternal request, indications of caesarean section, or even morbid conditions as placenta previa. Also does not account for pre-existing medical, surgical or fetal disorder, the indication and the used method for induction of labor, degrees of prematurity.