Women’s Health & Gynecology
ISSN: 2369-307X
Review Article
Pulling Down the Curtain on Un-necessary Cesarean Section:
Shatby Maternity University Hospital Experience in Alexandria with
Systematic Literature Review
This article was published in the following Scient Open Access Journal:
Abd El-Moneim Fawzy1, Manal Sweilam1,
Ahmed Samy El-Agwany1*, Esraa Hassan1,
Azza A. Moustafa2 and Dina Abd El-Moneim
Fawzy2
Members of El-Shatby Maternity University Hospital,
Alexandria University, Alexandria, Egypt
2
Members of El-Shatby Pediatric University Hospital,
Alexandria University, Alexandria, Egypt
1
Women’s Health & Gynecology
Received February 02, 2016; Accepted February 17, 2016; Published February 24, 2016
Abstract
Introduction: Cesarean section (CS) was introduced in clinical practice as a life
saving procedure both for the mother and the baby. The rising rate of Caesarean sections
has been a concern for over two decades. Bearing in mind that in 1985 the World Health
Organization (WHO) stated: “There is no justification for any region to have CS rates higher
than 10-15%”. Data indicate that the maternal mortality rate associated with caesarean
delivery is 3-7 times greater than that associated with vaginal delivery. The overall mortality
rate from cesarean delivery alone is 6 per 100,000 procedures. There are many potential
intraoperative and postoperative complications associated with cesarean delivery for the
mother and the fetus. If the cesarean delivery rate continues to remain high, institutions
must be prepared to manage the potential complication of severe hemorrhage associated
with higher rates of placenta accreta. Current research on pelvic floor injury from vaginal
delivery does not offer sufficient evidence to mandate a change in standard clinical
management of labor and birth towards CS. Numerous factors as medical and nonmedical
ones affect rates of CS, which may provide ways to decrease the cesarean delivery rate.
So the aim of our work is to provide best practice to the management of pregnancy, labour
and delivery that will achieve a Caesarean section rate consistently below 20% and will
have aspirations to reduce that rate to 15% according to the WHO. This should have an
impact on admissions to neonatal units, adverse incidents, health outcomes for mothers in
this and future pregnancies, successful breastfeeding, hospital stay, birth experience and
productivity (cost savings).
Aim: To show the impact of cesarean section on mother and fetus and to review the
indications and strategies for cesarean section reduction.
Methods and Analysis: The 2008 EDHS obtained information on the frequency of
caesarean sections in Egypt showed that more than one-quarter of deliveries in the fiveyear period before the 2008 EDHS survey were by caesarean section. The EDHS survey in
2014 revealed that 52% of deliveries in Egypt were by CS. Our hospital data showed that
Vaginal delivery in the first six months of year 2014 occurred in 45.3% of women with 63%
in multipara and 37% in primigravida versus CS delivery in 54.7% of women with 33% in
primigravida and 67% in patients with previous CS. Nearly 50 % of primigravida delivered
by CS in El-shatby Maternity Hospital. Less than 2% underwent VBAC. Statistics in ElShatby maternity university hospital, a tertiary care center in Alexandria (250 beds) showed
that cesarean section represented 60.7% (5376 of 8846) of all deliveries in 2012, 58.4%
(5799 of 9929) in 2013 and 53.5% (5475 of 11779) of all deliveries in 2014.
*Corresponding author: Ahmed Samy El-agwany,
El-shatby Maternity University Hospital, Faculty of
Medicine, Alexandria University, Alexandria, Egypt,
Tel: 00201228254247,
Email: ahmedsamyagwany@gmail.com
Volume 2 • Issue 2 • 021
Conclusions: The indications for CS have been clinical factors for years, such as
previous CS, dystocia, fetal distress, breech presentation, and mal presentation. Recent
temporal trends in maternal characteristics that might help explain rising CS rates include
increasing maternal age and higher rates of hypertension, diabetes, obesity, and multiple
gestations. However, many other factors have contributed to the increasing rate of CS in
recent years, including improved surgical techniques, providers and patient’s perception of
the safety of the procedure, patient demand, physician non acceptance of guidelines, money
earning and pressures on caregivers to practice “defensive medicine.” The strategies should
include the following: The Robson 10-group Caesarean section classification system is a
simple, standard tool to identify groups making the most significant contribution to the overall
rate of CS, so we can work upon it. Review nurses responsibilities and student nurse training
with incorporation in doula or midwifery programs. Reduction in the total cesarean delivery
rate would require a reduction in the primary caesarean delivery rate and recurrent CS with
implementations of the guidelines of normal labour and vaginal birth after CS (VBAC).
Keywords: Cesarean section, Labor, vaginal birth, Robson criteria
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Womens Health Gynecol
Citation: Abd El-Moneim Fawzy, Manal Sweilam, Ahmed Samy El-Agwany, Esraa Hassan, Azza A. Moustafa, Dina Abd El-Moneim Fawzy (2016).
Pulling Down the Curtain on Un-necessary Cesarean Section: Shatby Maternity University Hospital Experience in Alexandria with
Page 2 of 6
Systematic Literature Review
Introduction
Bearing in mind that in 1985 the World Health Organization
(WHO) stated: “There is no justification for any region to have
CS rates higher than 10-15%”, the recommended minimum
necessary CS rate at population level to avoid death and severe
morbidity in the mother lays between 1-5%, according to WHO
and others. Regarding neonatal outcomes, studies evaluating the
association of CS rates with neonatal death have shown outcome
improvements up to a CS rate of 10%. Thus the minimum
threshold for a population level CS rate could be considered to lay
between 5-10% [1-6].
The rising rate of Caesarean sections has been a concern for
over two decades. Between 2004 and 2008, the World Health
Organization conducted the Global Survey on Maternal and
Perinatal Health, and this showed that 25.7% of all deliveries
worldwide were by CS. Approximately 18.5 million cesarean
sections are performed yearly worldwide. About 40% of the
countries have CS rates <10%, about 10% have CS rates between
10 and 15%, and approximately 50% have CS rates >15%. The
cost of global ‘excess’ CS in 2008 was estimated to amount to
approximately US$ 2.32 billion, while the cost of the global
‘needed’ CS in 2008 was estimated to amount to approximately
US$ 432 million. In countries with ‘needed’ CS, the average cost of
a C-section was estimated to be approximately US$ 135; whereas
in countries with excess CS, the average cost of the procedure
was estimated at approximately US$ 373. The lowest cost per
(‘needed’) procedure was found to be in Nepal (US$ 97), whereas
the highest cost per (‘excess’) procedure was found to be in
Iceland (US$ 2 18,040). ‘Excess’ CS could thus potentially finance
the ‘needed’ ones. ‘Excess’ CS can therefore have important
negative implications for health equity both within and across
countries [4-6].
The indications for CS have been clinical factors, such as
previous CS, dystocia, fetal distress, breech presentation, and
mal presentation [7,8]. Recent maternal characteristics might
help explain rising CS rates include increasing maternal age and
higher rates of hypertension, diabetes, obesity, and multiple
gestations [9]. However, many other factors have contributed to
the increasing rate of CS including improved surgical providers
and patients’ perception of the safety of the procedure, patient
demand, physician non acceptance of guidelines money earning
and pressures on caregivers to practise “defensive medicine.”
EFM : No Standard definitions, Additive effect of mild changes ,
Overreaction of variable deceleration in the second stage of labor
and No high quality recording of uterine activity (25%) [1012]. The four most common medical indications for caesarean
delivery according to the international literature account for
approximately 80 percent of these deliveries: [13] 1. Failure to
progress during labor (30 percent), Previous hysterotomy (usually
related to caesarean delivery, but also related to myomectomy or
other uterine surgery) (30 percent), none reassuring fetal status
(10 percent) and Fetal mal presentation (11 percent).
Egyptian Data
The 2005 EDHS obtained information on the frequency of
caesarean sections shows that one-fifth of deliveries in the fiveyear period before the 2005 EDHS survey were by caesarean
section. Women delivering in a private health facility were more
Volume 2 • Issue 2 • 021
likely than women delivering in a government facility to have
a caesarean delivery. The likelihood of a caesarean delivery
increased with the age of the mother and decreased with the
child’s birth order. Caesarean deliveries were twice as common
in urban areas as in rural areas. Around one-third of births in
urban Lower Egypt and the Urban Governorates were caesarean
deliveries. The likelihood of a caesarean delivery increased
with both the mother’s educational status and with the wealth
status and was greater among women working for cash than
among other women. The 2008 EDHS obtained information on
the frequency of caesarean sections shows that more than onequarter of deliveries in the five-year period before the 2008
EDHS survey were by caesarean section. Women delivering in a
private health facility were more likely than women delivering in
a government facility to have a Caesarean delivery. The likelihood
of a Caesarean delivery increased with the age of the mother and
decreased with the child’s birth order. Thirty-seven percent of
urban births were Caesarean deliveries compared to 22 percent
of rural births. Considering place of residence, urban Lower Egypt
had the highest proportion of Caesarean deliveries (43 percent)
followed by the Urban Governorates (39 percent). The likelihood
of a Caesarean delivery increased with both the mother’s
educational status and was greater among women working for
cash than among other women. The rate of Caesarean deliveries
peaked at 45 percent among women in the highest wealth
compared to 14 percent among women in the lowest wealth. CS
in this year consumes not less than 250 million pound a year .The
DHS survey in 2014 revealed that 52% of deliveries in Egypt were
by CS from survey in the previous six years before 2014 [14].
Statistics in El-Shatby maternity university hospital, a tertiary
care center in Alexandria (250 beds) showed that cesarean
section represented 60.7% (5376 of 8846) of all deliveries in
2012, 58.4% (5799 of 9929) in 2013 and 53.5% (5475 of 11779)
of all deliveries in 2014. Most common causes in primigravida in
our hospital: Dystocia, PET, Drained liquor and Breech.
Discussion
A study was conducted in Egypt that evaluated some variables
representing the determinants for cesarean delivery namely the
age at first birth, parity, near birth problems, previous termination
of pregnancy, previous fetal death, residence and utilization
of antenatal care. They found out that increased maternal age,
more utilization of antenatal care (due to early detection of high
risk pregnancies), urban rather than rural areas, history of fetal
death, previous termination of pregnancy, nulliparity and women
with more than three live births, near birth complications (as
prolonged labour and eclapmsia) are more commonly associated
with cesarean delivery [15]. An important cause of cesarean
section increased rate is fear; fear of the unknown, fear of
labour pains, fear of the episiotomy, fear of complications, fear
of impairment of sexual function or fear of loss of the baby e.g.
old age at first pregnancy, continuous fetal monitoring or many
years of infertility. Fear of childbirth is still an important factor
that increases the rate of cesarean section. A longitudinal cohort
study was conducted gathering 6,422 pregnant women from
different countries including Belgium, Iceland, Denmark, Estonia,
Norway, and Sweden. Severe fear of childbirth increased the
incidence of elective cesarean section among both primiparous
(OR, 1.66 [95% CI 1.05-2.61]) and multiparous women (OR 1.87
[95% CI 1.30-2.69]) [16]. Fear is indeed a cause of CS on request,
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Womens Health Gynecol
Citation: Abd El-Moneim Fawzy, Manal Sweilam, Ahmed Samy El-Agwany, Esraa Hassan, Azza A. Moustafa, Dina Abd El-Moneim Fawzy (2016).
Pulling Down the Curtain on Un-necessary Cesarean Section: Shatby Maternity University Hospital Experience in Alexandria with
Page 3 of 6
Systematic Literature Review
however, the reason for persistence fear not only include past bad
experience during delivery of the women herself or relative, but
also poor counselling from care providers. To tighten the raised
issue of fear, as mentioned for both care provider and women
fear , medical legal concerns, ethical issue-automony, and poorly
set audits should be highlighted as contributors of unnecessary
CS. Poor timing and care providers skills of counselling also
contributed to women unjustified fear hence opting for CS.
Data indicate that the maternal mortality rate associated with
caesarean delivery is 3-7 times greater than that associated with
vaginal delivery [17]. The overall mortality rate from cesarean
delivery alone is 6 per 100,000 procedures [18]. Many authors have
studied potential intraoperative and postoperative complications
associated with cesarean delivery [19-21]. Intraoperatively,
uterine hemorrhage may develop from atony, extension of
the incision, uterine rupture, the presence of leiomyomata, or
placenta accreta [22]. Urinary tract injury, which may include
cystotomy or ureteral injury. Vaginal or broad ligament extension
of the lower-segment uterine incision increases the risk of
ureteral involvement. Injuries to the gastrointestinal tract are rare
and are estimated to occur in 1 in 1,300 cesarean deliveries [23].
The history of previous infection or surgery, which may cause
intraperitoneal adhesions, increases the risk of enterotomy. The
leading causes of maternal mortality associated with cesarean
delivery are deep vein thrombosis and pulmonary embolism.
Infection is the most common postoperative sequela of cesarean
delivery. The observed incidence of endomyometritis varies
greatly, with estimates ranging from 10% to 50%, compared
with 1-3% of vaginal deliveries [24]. Factors that contribute
to this infection rate include the length of labor and rupture of
membranes, the number of vaginal examinations, the use of
internal monitors, and the patient’s socioeconomic status [25].
In addition, the presence of chorioamnionitis and the
duration of the surgical procedure may influence the rate of
endomyometritis [26]. Maternal factors of obesity and diabetes
mellitus also may increase the risk of infection [27]. Other; less
frequent postoperative complications include wound and urinary
tract infections, ileus, and atelectasis.
The frequency of placenta previa in women who previously
delivered vaginally is estimated at 0.3% [28,29]. A recent metaanalysis demonstrated that women with at least one prior
cesarean delivery were 2.6 times more likely to develop placenta
previa in a subsequent pregnancy [30]. Placenta accreta occurs
frequently in patients 7 with placenta previa and previous
uterine scars. Patients without uterine scars face only a 4.5%
risk of accrete [31,32] versus an estimated risk from 24% (30)
to 38% (31) in patients with placenta previa and uterine scars. If
the cesarean delivery rate continues to remain high, institutions
must be prepared to manage the potential complication of severe
hemorrhage associated with higher rates of placenta accreta [33].
The mortality rate of infants delivered by caesarean birth in
1997 was 10.1 per 1,000 deliveries [34]. This rate may be partly
accounted for by risk factors that lead to the cesarean birth.
Iatrogenic prematurity may be prevented by adhering to accurate
pregnancy dating parameters. In addition to respiratory distress
syndrome, elective surgical delivery without labor may contribute
to transient tachypnea of the newborn, a condition that often
requires intensive care treatment [35]. Lastly, approximately
Volume 2 • Issue 2 • 021
0.4% of infants delivered by cesarean birth experience accidental
lacerations.
A retrospective study was conducted over a period of 10
years to assess the changes in postpartum hemorrhage (19982007) and to identify the risk factors. The results showed that
the risk of severe postpartum hemorrhage, diagnosed as blood
loss of >1000 cc, after cesarean section was twice the risk after
vaginal delivery (5.9%; 95% CI 5.3-6.6 vs. 2.8%; 95% CI 2.62.9). Risk factors were identified in order as twin pregnancy,
retained placenta and induction of labour for vaginal delivery
and twin pregnancy followed by general anesthesia for cesarean
delivery; that is to say obstetric intervention increases the risk of
postpartum hemorrhage [15].
A dehiscent scar following cesarean section may be
symptomatic in the form of postmenstrual spotting, dysparunia
and/or secondary infertility. When suspected, diagnosis can be
made by prompt history taking, transvaginal ultrasonography and
diagnostic hysteroscopy. On ultrasonography, the scar appears
as a hypoechoic fluid V- or U-shaped accumulation at the site
of uterine scar. A retrospective study assessed 13 non-pregnant
women with suggestive symptoms; 12 out of the 13 patients
were diagnosed as having a dehiscent scar by transvaginal
ultrasonography while all were diagnosed by hysteroscopy.
Reconstructive surgery was performed and this caused relief of
bleeding disorders in all patients and 3 out of 5 patients with
secondary infertility got pregnant [16].
Studies show that women whose babies are born by cesarean
surgery are just as successful at breastfeeding as mothers who
deliver vaginally, as long as their commitment to breastfeeding
remains high. It may, however, take a bit longer for mothers
and babies to begin breastfeeding after cesarean surgery, and
mothers’ milk tends to come in a bit later following a surgical
birth. This may be a direct result of the surgery, or it may be
because mothers who have cesareans have fewer opportunities
for early and frequent breastfeeding. Neonatal growth can be
affected by the mode of delivery. A cohort study was conducted
in Shiraz including 92 exclusively breastfed neonates who were
followed longitudinally from July 10 to August 10, 2007 and data
were collected at three occasions during the first month after
delivery; 3 to 7 days, 10 to 21 days and 24 to 31 days postpartum.
35 mothers were delivered by cesarean section (38%). Results
showed that neonatal weight gain was affected by the mode of
delivery, the receipt of advice regarding breastfeeding and the
gestational age at delivery. Neonatal weight gain was lower
in babies delivered by cesarean section than those delivered
vaginally till 25 days postpartum then it becomes higher among
cesarean section babies. Since babies delivered by cesarean
section can catch-up their normal growth at the end of the first
month after delivery therefore mothers with cesarean section can
exclusively breastfeed successfully [36].
Birth trauma which may not be just physical, but also
impact psychologically as well can occur. The following list
shows some of the more common psychological effects that
can result from caesarean sections: Mind/body splits, Bonding
deficiencies, Invasion issues, Tactile defensiveness, Difficulties
with pacing and tempo, Bonding disturbances, Control issues,
Directional confusion and Difficulty starting and/or completing
things. C-section is a trauma because of its abrupt and sudden
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Citation: Abd El-Moneim Fawzy, Manal Sweilam, Ahmed Samy El-Agwany, Esraa Hassan, Azza A. Moustafa, Dina Abd El-Moneim Fawzy (2016).
Pulling Down the Curtain on Un-necessary Cesarean Section: Shatby Maternity University Hospital Experience in Alexandria with
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Systematic Literature Review
interruption of the biologically programmed vaginal birth
process. Shock, bonding deficiencies and invasion/control
complex are the major symptoms of the trauma [37]. A cohort
study was conducted in England including 13,141 children to
assess if there was any impact of the mode of delivery especially
cesarean section and induction of labour on the psychological
behavior of children at the age of 7 mainly autism and ADHD
(attention-deficit-hyperactivity disorder). Results showed that
there was no association between the mode of delivery and
autism or ADHD [38].
A study recruited 1,011 women in a retrospective cohort
study to assess the effect of the mode of delivery on the risk of
pelvic floor disorders. 5-10 years after the first delivery, each
birth was classified as cesarean with labour, section during active
labour, cesarean after full cervical dilatation, spontaneous vaginal
delivery or operative vaginal birth. Then anal incontinence, stress
incontinence, overactive bladder and pelvic organ prolapsed
were assessed and the results showed that spontaneous labour
was associated with higher risk of stress incontinence (odds ratio
[OR] 2.9, 95% confidence interval [CI] 1.5-5.5) and prolapsed
(OR 5.6, 95% CI 2.2-14.7) when compared with cesarean section
while operative delivery had significantly increased risk for all
pelvic floor disorders [32,33,38-44].
Normally, the sexual function is inversely affected by
the progress of pregnancy becoming the worst at the end of
pregnancy including loss of desire, dysparunia and decreased
orgasm. These improve gradually through the first 6 months after
delivery. Factors influencing this include: Social background, Age,
Parity, Lactation, Depression, Sexual inactivity in early pregnancy
and Fear of postpartum body image [45]. A prospective study
included 16 women who delivered vaginally without episiotomy,
14 who delivered vaginally with an episiotomy, 16 who delivered
instrumentally, 19 who delivered by emergent CS and 17 who
delivered by elective CS. The female sexual function index
questionnaire (FSFI) was used at 6, 12 and 24 weeks after delivery
to assess their sexual behavior which was helped by determining
the timing of resumption of coitus. The results showed that the
mode of delivery didn’t affect the resumption of sexual function
especially that elective cesarean section doesn’t guard against
sexual dysfunction postpartum [46].
Maternity units applying best practice to the management of
pregnancy, labour and delivery will achieve a Caesarean section
rate consistently below 20% and will have aspirations to reduce
that rate to 15% according to the WHO, With specific targets
of 12 % in primigravida and 60 % in females with previous CS
according to ACOG with evaluation of the following : Admissions
to neonatal units , Adverse incidents, Hospital stay duration and
Cost savings.
ACOG and Cochrane collaboration 2010 recommendations for
reduction: The most important focus is to reduce primary CS and
recurrent CS. 1.Before Labor: Social support for at-risk women,
Turning breech fetuses, Planned out of hospital birth, Delay
admission until active labor has started, Planned VBAC and Avoid
unnecessary induction of labor. 2. During Labor: Continuous
support in labor, Intermittent auscultation for fetal heart rate
monitoring, Pain management alternatives, Amnioinfusion for
suspected cord compression, Giving labor more time, Use higher
dose oxytocin protocol for labor augmentation if fetomaternal
Volume 2 • Issue 2 • 021
condition suits, Second opinion for making the decision about
Cesarean delivery, Improve diagnosis and treatment of labor
dystocia, Standardize diagnosis and treatment of fetal heart rate
abnormalities and Encourage operative vaginal delivery when
appropriate. 3. Systems Level Interventions: Audit and feedback,
Guideline implementation and create will for change [47].
Maternal request: Discuss the overall benefits and risks of CS
and vaginal birth , Facilitate a discussion with other members of
the obstetric team if necessary, to ensure the woman has accurate
information, For women requesting a CS, if after discussion and
offer of support, a vaginal birth is still not acceptable, offer a
planned CS. An obstetrician can decline a woman’s request for
a CS and refer the woman to an obstetrician who will carry out
the CS, Not recommended before 39 weeks, Not recommended
in women desiring several children because of fear of increasing
risk for placenta accrete. (ACOG 2013) and Not recommended
because of unavailability of effective pain management (ACOG
2013) [48].
To address concerns over rising rates of CS and to provide
a mechanism for audit and feedback, a 10-group classification
system to examine CS within groups of women with particular
obstetric characteristics was proposed by Robson in 2001 to
decrease the rising CS in Canada. The Robson classification
system groups women in the obstetric population according to
plurality, fetal presentation, parity, obstetric history (i.e. previous
CS), course of labour and delivery, and gestational age, providing
clinically relevant categories for analyzing and reporting rates
of CS. The Robson 10-group Caesarean section classification
system is a simple, standard tool to identify groups making the
most signification contribution to the overall rate of CS. These
classification findings will allow us to determine which target
groups to investigate further to help us learn more about the
underlying reasons for the differences in CS rates over time and
between units, both nationally and internationally. (SOGC, grade
B recommendation) [49].
Conclusions
The obstetric community should educate clinicians and
patients that cesarean delivery based on nonclinical factors is
not associated with improved maternal or neonatal outcomes.
Strategies to reduce the cesarean delivery rate should focused
primarily on efforts to alter physician practice. Education through
handouts dispersed in the hospital, hospital website, medical
journals and lectures as regards indications and risks of CS.
Reform of medical liability laws and legal procedures to decrease
defensive medicine. In order to reduce non-medically indicated
caesarean sections, the reasons for use of the operation should be
audited and monitored and, where necessary, appropriate health
education and behavior-change strategies should be developed
and implemented. The Robson 10-group Caesarean section
classification system is a simple, standard tool to identify groups
making the most signification contribution to CS. Implementation
of international guidelines and evidence based medicine until
reconstruct ours. We should use comparative outside data on
cesarean delivery rates to evaluate our cesarean delivery rates.
Hospitals or practitioner groups with high cesarean delivery
rates can consider establishing separate 24-hour, in-house
obstetric coverage by physicians who are solely responsible
for the management of the intrapartum patient. Review nurses
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Citation: Abd El-Moneim Fawzy, Manal Sweilam, Ahmed Samy El-Agwany, Esraa Hassan, Azza A. Moustafa, Dina Abd El-Moneim Fawzy (2016).
Pulling Down the Curtain on Un-necessary Cesarean Section: Shatby Maternity University Hospital Experience in Alexandria with
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Systematic Literature Review
responsibilities and student nurse training with incorporation
in doula or midwifery programs. Obstetric practitioners should
not perform cesarean delivery for the sole indication of maternal
age with review of our practice. The practice of VBAC may play
a role in reducing the repeat cesarean delivery rate. Reduction
in the total cesarean delivery rate would require a reduction in
the primary caesarean delivery rate. When feasible, obstetric
practitioners should delay the administration of epidural
anesthesia in nulliparous women until the cervical dilatation
reaches at least 4-5 cm. Practitioners should recommend using
other forms of analgesia instead of an epidural prior to cervical
dilatation of 4-5 cm. External cephalic version of the term fetus
with breech presentation may significantly reduce the rate
of cesarean deliveries for breech presentation if there are no
contraindications. There is no evidence to support cesarean
delivery of the preterm fetus on the basis of gestational age alone.
Review CS with preterm babies. Vaginal delivery of appropriately
selected twin pregnancies may be considered. Hospitals with a
high cesarean delivery rate should consider introducing training
during and after residency in the appropriate use of forceps and
the vacuum (KIWI vaccum).
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Copyright: © 2016 Ahmed Samy El-Agwany, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
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