Outcome in Elective and Emergency Cesarean Sections: A Comparative Study
1996; King Faisal Specialist Hospital and Research Centre; Volume: 16; Issue: 6 Linguagem: Inglês
10.5144/0256-4947.1996.645
ISSN0975-4466
AutoresLulu Al Nuaim, Mohammed H. Soltan, Tariq Khashoggi, Mohammed H. Addar, Noori Chowdhury, B Adelusi,
Tópico(s)Hospital Admissions and Outcomes
ResumoOriginal ArticlesOutcome in Elective and Emergency Cesarean Sections: A Comparative Study Lulu Al Nuaim, MB, MRCOG Mohammed H. Soltan, PhD, FRCOG Tariq Khashoggi, MB, MMED Mohammed Addar, MB Noori Chowdhury, and MSc, MPH Babatunde AdelusiMD, PhD, FRCOG Lulu Al Nuaim From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author , Mohammed H. Soltan Address reprint requests and correspondence to Dr. Soltan: Department of Obstetrics and Gynecology, King Khalid University Hospital, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia. From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author , Tariq Khashoggi From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author , Mohammed Addar From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author , Noori Chowdhury From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author , and Babatunde Adelusi From the Department of Obstetrics and Gynecology, King Khalid University Hospital, Riyadh Search for more papers by this author Published Online::1 Nov 1996https://doi.org/10.5144/0256-4947.1996.645SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractTo study the obstetric outcome of cesarean sections (CS) in relation to the elective or emergency nature of this procedure, a comparative study was conducted on 1426 females whose deliveries were by CS in King Khalid University Hospital (KKUH). Of the various factors analyzed in relation to the two types of CS, statistically significant associations were found between emergency CS and younger patients, low parity, irregular attendance at antenatal clinics, complications in labor, postoperative morbidity and low Apgar score (<6). It was concluded that every effort should be directed to effect-planned CS, as determined during the antenatal period, if possible, so as to reduce the various problems associated with emergency CS. The chances are that this approach is unlikely to influence the overall CS rate in either way.IntroductionFor the patient who is about to give birth, cesarean section (CS) carries considerable disadvantages when compared with normal vaginal delivery. This is not only in terms of the pain and trauma of an abdominal operation, but also because of the complications that may be associated with it.1,2 CS is also expensive, because of the cost of the operation itself, as well as the longer postpartum stay in the hospital that is required of the newly delivered mother.Most often, the nature of CS, in terms of whether it is performed as an elective surgical procedure or an emergency, is predicated on the indication for the CS.4 When the need for a CS arises, it is often much better for the patient if adequate time is allowed to prepare for the procedure. Thus, when the CS is performed electively, the chances of morbidity complicating the operation would be much less than when it is performed as an emergency.5However, in spite of all attempts to electively deliver the pregnancy by CS, many times emergency CS may have to be resorted to for fetal or maternal salvage, even if there may be problems associated with it. The present study was therefore undertaken to compare the obstetric outcome in patients delivered by elective CS with those delivered by emergency CS in the obstetric unit in King Khalid University Hospital, Riyadh.MATERIAL AND METHODSThe study group included 1426 pregnant patients who had CS performed in the Obstetric Unit of the King Khalid University Hospital (KKUH), Riyadh, over the five-year period from 1989 to 1993. All the patients were of similar sociodemographic background in terms of age, parity, height, weight, education and occupation. Of these CS, 528 (37.0%) procedures were performed electively, while 898 (63.0%) were performed as emergency sections.Pertinent data were collected from each patient's medical record, with regard to age and parity of the patients, and whether these patients had antenatal care (ANC) or not. Adequate (regular) antenatal clinic attendance was considered to be those who booked early (<16 weeks) and attended clinics regularly until term, or had more than five (≥6) clinic attendances during the pregnancy. Irregular clinic attendance consisted of those who had fewer than four (<4) clinic visits during the course of the pregnancy. The indications for the CS, the types of abdominal and uterine incisions, the intraoperative and postoperative complications, the duration of postoperative hospital stay and fetal outcome were also recorded.The data were analyzed with the chi-squared test to determine the association between the various factors under investigation. A probability value of <0.05 was considered statistically significant.RESULTSThe CS rate in the unit during the study period was 10.3%. Table 1 shows the relationship between age of the patient and the type of CS. Overall, 257 (28.6%) cases of emergency CS were carried out in the younger age groups (<25 years) as compared with 188 (21.0%) in older patients (≥35 years). On the other hand, only 69 (13.1%) elective CS were performed in the younger patients (<25 years), as compared with 136 (25.7%) in the older patients (≥35 years). The association between age and type of CS was found to be statistically significant (P<0.001).Table 1. Type of cesarean section in relation to the age of the patient.Table 2 shows the relationship between parity and the type of CS. There were 230 (25.6%) emergency CS performed on primiparas, while 462 (51.5%) were performed on those who were para 1 to 4. In contrast, only 45 (8.5%) of the primiparas had elective cesarean sections, compared with 358 (67.8%) of the para 1 to 4 group. The percentage of both types of CS were about equal among the grand multiparas. The association between low parity and the emergency CS was statistically significant (P<0.001).Table 2. Effect of parity on the type of cesarean section.There was a statistically significant relationship between antenatal clinic attendance and the type of CS. Of those who attended the clinic irregularly, which was about 10% of the hospital patients, 93 (10.4%) had emergency CS, as compared with 27 (5.1%) cases of elective CS among irregular attendants. On the other hand, 501 (94.9%) elective CS were performed among regular ANC attendants as compared with 805 (89.6%) cases of emergeny CS in this group.The indications for CS in relation to the type of CS are shown in Table 3. The major indication for elective CS was previous CS (69.5%). On the other hand, failure to progress accounted for the highest number (41.5%) of emergency CS. Other indications for emergency CS include breech presentation (16.0%), fetal distress (15.9%), antepartum hemorrhage (9.3%) and multiple pregnancy (2.8%), as compared with 14.6%, 0.4%, 2.8% and 1.7% respectively in elective CS. Other indications, including transverse lie, macrosomia, pre-eclampsia, IUGR, and bad obstetric history, were in the proportion of 11.0% and 14.5% for elective and emergency CS respectively. There was a statistically significant association between the major indications and the type of operation (P<0.001).Table 3. Indications for cesarean section and the type of operation.The type of abdominal incision performed is shown in Table 4. Of the 1426 operations performed, 1093 (76.6%) were performed through transverse incisions and 333 (23.4%) were by midline incisions. Among women who had elective CS, 346 (65.5%) cases were performed by transverse incisions, as compared with 182 (34.5%) through midline incisions. On the other hand, 747 (83.2%) of the emergency sections were performed by transverse incision, as compared with only 151 (16.8%) of those who had midline incisions. The difference between the type of abdominal incision and type of CS was statistically significant (P<0.001).Table 4. Types of abdominal incision in relation to the type of cesarean section.When the type of uterine incisions were compared with the type of CS, 10 (1.9%) of the elective CS patients had classical incisions, as compared with two (0.4%) who had T-shape incisions. On the other hand, only two (0.2%) of those who had emergency CS had the classical incisions, compared with six (0.7%) of them who had the T-shape incisions. The difference was statistically significant (P=0.003). However, there was little difference between the two types of CS in relation to the use of lower segment incisions.At operation, there were more hemorrhages (4.7%), extension of incision (1.2%), and scar windows (0.7%) among the emergency CS, as compared with 1.9%, 0.6% and 0.2%, respectively, among the patients who had elective CS. Table 5 shows the postoperative morbidity in the two groups of patients. Postoperative morbidity was more marked among the patients who had emergency CS compared with those who were sectioned electively. Indeed, all the postoperative complications of fever, wound infection or both were higher in the emergency CS cases. The difference was statistically significant (P<0.001).Table 5. Incidence of postoperative complications in patients with elective and emergency cesarean section.The state of fetal hypoxia in the two groups is shown in Table 6. The Apgar score of <6 at five minutes was generally much higher in the emergency group. For example, while 77 (8.5%) of the emergency CS group had Apgar scores of <6, only 15 (2.9%) of the elective group had Apgar scores of <6. On the other hand, 513 (97.1%) of the elective CS group had Apgar scores of ≥7, compared with 821 (91.4%) of the emergency CS group. The difference was statistically significant (P<0.001).Table 6. Apgar score at five minutes in the babies delivered by elective and emergency cesarean section.When the duration of postoperative stay in hospital was analyzed, it was found that 328 (36.5%) of the emergency group stayed more than seven days, while 570 (63.5%) stayed for six days or less. On the other hand, 318 (60.2%) of the elective cases stayed for less than six days, compared with 210 (39.8%) who stayed for more than seven days. However, the difference was not statistically significant (P=0.294).DISCUSSIONIt is generally accepted that a planned operation often does better in terms of morbidity than one performed as an emergency.5 Yet in spite of all attempts to electively deliver patients by cesarean section when this is indicated, many times this has to be carried out as an emergency, for reasons beyond the control of the attendant. It is uncommon, but therefore essential, to compare the outcome of the deliveries in both situations.The relationship of age with the type of CS is difficult to decipher. However, the increased frequency of emergency CS in the young patients (<30 years) in this environment is rather remarkable. This may indicate the tendency of the attending obstetrician to allow vaginal deliveries in younger patients as long as this is feasible, with a view to preserving their future reproductive performances and only resorting to CS when there is a threat of danger to either the patient or her baby. On the other hand, it is accepted that the older patients tend to have more previous CS, which may automatically necessitate elective CS.3,6,7One of the goals of ANC is to reduce pregnancy complications which may warrant emergency CS. The finding of a significantly greater incidence of emergency CS in patients with irregular ANC attendance (10.4%), as compared with only 5.1% elective CS among the same group of patients, is in consonance with this concept. In the same manner, the correlation between most of the indications and the incidence of emergency CS is not surprising, especially since most of these indications are the same factors that warrant emergency CS in the first instance.In an emergency, the easiest and fastest route to shorten the operative time is always considered first.8,9 It is therefore surprising to see that there were more emergency CS than elective operations performed through transverse incisions than through the midline. This obviously may have to do with the experience of the operators rather than the need for a quick end to the operation.10 Furthermore, several of the abdominal incisions were determined in line with previous abdominal scars. The high incidence of T-shaped uterine incisions in emergency CS, on the other hand, may be due to the difficulty in the delivery of the baby in these cases. Unfortunately, we are unaware of any other studies with which to compare these findings.The intraoperative complications encountered in emergency CS tend to be more of hemorrhage, scar window and the need to extend the uterine incisions. Postoperatively, however, there is a greater incidence of fever, urinary tract infection and wound infections in emergency CS than with elective CS. This is as expected,11–13 even if other investigators have reported no differences at all in their studies.14 It is common for emergency operations to be undertaken when the patient has been in labor, membranes have been ruptured over a period of time, and several vaginal examinations have been performed, thereby introducing potent sources of postoperative sepsis.12 On the other hand, increased hemorrhage in emergency CS may be due to the stretching of the lower segment and the impaction of the presenting part into the pelvic cavity,15 thereby making the operation bloody.The rate of wound dehiscence or scar window in this study is much less than those reported in other studies,12,16,17 even if these studies did not indicate in which type of previous CS the window had occurred. Since most of the studies were for trial of vaginal delivery after CS, however, it might be appropriate to assume that these were previous emergency CS. This will tend to justify the belief that emergency CS is more likely to produce scar window in subsequent deliveries because of the weaker wound healing that may be associated with emergency operations.18 It is no wonder that use of prophylactic antibiotics has been recommended for all patients undergoing emergency CS.15,19The fetal outcome in the form of Apgar score at five minutes was shown to be less favorable in emergency CS, with more cases with Apgar score of <6 in this study, as compared with elective CS. This is contrary to the findings of Miller and Leader.20 This is difficult to explain except for the small figures in their study, since emergency CS are often carried out to salvage the fetus in most cases. It might be a good idea, therefore, to look into this aspect again, with a view to determining the role of elective and emergency CS in the fetal outcome.Even though the incidence of postoperative complications may be higher in emergency than in elective CS,12,13 these may not necessarily prolong the patient's stay in hospital, as was found in our study. Unless it is absolutely necessary, patients' stay in hospital should be as short as possible, since prolonged stay only increases their misery and financial burden.As much as is practical, everything points to the advantages that can be derived from a planned CS as compared to one that is undertaken as an emergency. Antenatal care should be directed to effect-planned CS operations, so as to reduce the problems associated with emergency CS. Every effort should be made in the antenatal clinic to pick up the cases that are likely to result in difficult labor, such as large babies, small pelvis, previous obstetric history, etc., that may indicate the need for CS, in order to reduce the incidence of failed labor that will end up in emergency CS. It is possible, however, that this approach may neither increase nor decrease our CS rates.ARTICLE REFERENCES:1. Cunningham FG, Hanth VC, Strong VD, Kappus SS. "Infections' morbidity following cesarean section" . Obstet Gynecol. 1978: 52: 65661. Google Scholar2. Minkoff HL, Schwarz RH. "The rising cesarean rate: can it safely be reversed?" Obstet Gynecol. 1980; 56: 135–43. Google Scholar3. Yudkin PL, Redman CWG. "Cesarean section dissected, 1978-1983" . Brit J Obstet Gynecol. 1986; 93: 135–44. Google Scholar4. Toffel S, Placek P, Kosary CVS. "Cesarean sections rates 1990: an update" . Birth. 1992; 19: 21–2. Google Scholar5. Choate JW, Lund CJ. 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Soltan MH, Al-Nuaim L, Khashoggi T, Chowdhury N, Addar M, Adelusi B. "Trial of vaginal delivery following cesarean section" . Obstetric outcome, Saudi Med J. 1996; 17: 63–7. Google Scholar19. Rosen MG, Dickson JC, Westhoff CL. "Vaginal birth after cesarean: a meta analysis of morbidity and mortality" . Obstet Gynecol. 1991; 77: 465–70. Google Scholar20. Miller M, Leader LR. "Vaginal delivery after cesarean section" . Aust NZJ Obstet Gynecol. 1992; 32: 213–6. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 16, Issue 6November 1996 Metrics History Received31 January 1996Accepted27 May 1996Published online1 November 1996 ACKNOWLEDGMENTSWe are thankful to Professor Abdulaziz Al-Meshari, head of the Department, and the consultants for allowing us to use their patients in this study.InformationCopyright © 1996, Annals of Saudi MedicinePDF download
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