Cesarean Section Indications in Private Facility In Kenya

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A REVIEW OF CAESAREAN SECTION RATES,
INDICATIONS AND OUTCOMES AT MP SHAH
HOSPITAL – NAIROBI
STUDY PROPOSAL
SUBMITTED BY DR JAHONGA
2000
1
TABLE OF CONTENTS
2
1.
2.
3.
4.
5.
6.
Title
3
List of abbreviations and definitions ..................................................................................... 4
Abstract 5
Introduction and literature review ......................................................................................... 6
Rationale .................................................................................................................................... 15
Objectives .................................................................................................................................. 16
6.1 Broad objective
6.2 Specific objectives
7. Methodology ............................................................................................................................. 16
a.
Variables .............................................................................................................. 16
1.1
Study design ....................................................................................................... 16
1.2
Study area
1.3
Study population
1.4
Inclusion and Exclusion Criteria Sampling and
sample size determination
7.5.1
Data collection .................................................................................................... 18
7.6.1
Data Management .............................................................................................. 18
7.6.2
Study period
7.6.3
Anticipated Study Constraints .......................................................................... 19
7.7 Ethical Considerations .................................................................................................... 19
7.8 Work Plan Budget estimate ............................................................................................ 20
7. References ............................................................................................................................... 21
8. APPENDIX 1: Questionnaire................................................................................................ 27
9. Appendix 2: Dummy tables .................................................................................................... 30
10. Appendix 3: Consent to participate ....................................................................................... 37
2
TITLE:
A REVIEW OF CAESAREAN SECTION RATES, INDICATIONS AND OUTCOMES AT
MP SHAH HOSPITAL - NAIROBI.
PRINCIPAL INVESTIGATOR:
Signed…………………………………Date……………………………..
DR. JAHONGA K.R., MBCHB
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
UNIVERSITY OF NAIROBI.
SUPERVISORS
DR. OYIEKE J.B.,
MB. CHB; MMED O/G NBI
DIP. FERTIL. CONTROL
SENIOR LECTURER AND CONSULTANT
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
UNIVERSITY OF NAIROBI.
Signed……………………………….Date………………………………
DR. NDAVI P.,
MBCHB; MMED O/G NBI
MSC. EPID (LOND.) DLSHTM
SENIOR LECTURER AND CONSULTANT
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
UNIVERSITY OF NAIROBI.
Signed……………………………..Date…………………………………...
PROF. C.S. KIGONDU,
PhD., F.I.R.S.T.
SENIOR RESEARCH FELLOW
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
UNIVERSITY OF NAIROBI.
Signed……………………………..Date……………………………………
PART FULLFILMENT OF THE DEGREE OF MMED IN
OBSTETRICS AND GYNAECOLOGY.
3
LIST OF ABBREVIATIONS
Definition of study concepts:
1.
Still births:
None of the signs of life are present at death, delivery
2.
Neonatal death:
Death of a live-born infant during the first 28 days after birth. This term is used in reference to
the deaths that occurred before discharge from hospital since patients were not followed up after
discharge.
Perinatal deaths:
Sum of still births plus 7 day neonatal deaths.
3.
4.
Early perinatal death is the sum of still births plus neonatal deaths occurring 1st 24 hours.
5.
Perinatal case fatality rate:
Perinatal deaths per 1000 cesarean sections.
6.
Maternal case fatality rate:
Number of mothers who died having been delivered by caesarean section per 1000 caesarean
section deliveries.
7.
Perinatal morbidity will be defined as chart reference to 5 minute Apgar score of less than 7,
incubation of infant, incubator care.
A Correct 5 minute Apgar score will exclude fetus with gross malformations and extreme
prematurity.
8.
Gestational age at time of delivery will be defined by the number of completed weeks, based on
Magael's rule.
9.
Indication for caesarean section will be defined as chart reference to the indication/diagnosis:
these will later be classified.
10.
Caesarean section will be defined as delivery of an infant of 500gms or more through an incision
of the anterior abdominal wall and the uterus.
11.
Fetal distress will be diagnosed if only "fetal distress will be diagnosed if only "fetal distress"
appears on the chart and validated by presence of meconium and FHR patterns
12.
All multiple diagnosis deliveries in which one of the diagnosis is a previous caesarean section
birth will be classified as "previous cesarean birth".
13.
Cases having breech presentation with any other diagnosis will be assigned "breech".
14.
Cases having diagnosis of dystocia and fetal distress will be assigned the class of "dystocia". This
recognizes that dystocia can cause fetal distress.
4
Definition of study concepts:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Still births:
None of the signs of life are present at delivery
Neonatal death will be defined as death of a live-born infant during the first 28 days after birth.
This term will be used in reference to the deaths that occurred before discharge from hospital
since patients were not followed up after discharge.
Perinatal deaths will be defined as sum of stillbirths plus 7-day neonatal deaths.
Early perinatal death is the sum of stillbirths plus neonatal deaths occurring 1st 24 hours.
Perinatal case fatality rate will be defined as perinatal deaths per 1000 cesarean sections.
Maternal case fatality rate will be defined as number of mothers who died having been delivered
by caesarean section per 1000 caesarean section deliveries.
Perinatal morbidity will be defined as chart reference to 5 minute Apgar score of less than 7,
incubation of infant, incubator care. A Correct 5 minute Apgar score will exclude fetus with
gross malformations and extreme prematurity.
Gestational age at time of delivery will be defined by the number of completed weeks, based on
Nagael's rule.
< 999 extremely low birth weight
1000 – 1499 very low birth weight
1500 – 2499 low birth weight
Indication for caesarean section will be defined as chart reference to the
indication/diagnosis: these will later be classified.
Caesarean section will be defined as delivery of an infant of 500 grammes or more through an
incision of the anterior abdominal wall and the uterus.
Fetal distress will be diagnosed if only "fetal distress will be diagnosed if only "fetal distress"
appears on the chart and validated by presence of meconium and FHR patterns
All multiple diagnosis deliveries in which one of the diagnoses is a previous caesarean section
birth will be classified as "previous cesarean birth".
Cases having breech presentation with any other diagnosis will be assigned "breech".
Cases having diagnosis of dystocia and fetal distress will be assigned the class of "dystocia". This
recognizes that dystocia can cause fetal distress.
5
ABSTRACT
This will be a descriptive retrospective cross-sectional study.
The overall objective is to determine the caesarean section rates, indications and outcomes of cesarean
section deliveries, in relation to demographic, obstetric and intrapartum factors.
The study will involve all women delivered by caesarean section at M.P. Shah Hospital, a private hospital
in Nairobi for the period 1st January 1998 and 31st December 1998. Most studies in Kenya have
involved government hospitals.
A structured questionnaire will be used in data collection.
The investigator will seek a room from the hospital administration in order to facilitate the study.
Apart form presenting the work as dissertation for M.Med thesis by the principle investigator, data
obtained will be used to give recommendations on health care to policy makers.
The study intends to compare findings with those of similar studies done locally.
6
BACKGROUND AND LITERATURE REVIEW
Cesarean section is one of the commonest hospital based surgical procedures and its rate has been rising
worldwide. it has been defined as the delivery of a fetus, placental and membranes through an incision
in the abdominal and uterine walls (1). This term does not derive from the birth of Julius Caesar, as is
popularly thought.
From the inception as a postmortem procedure under the Roman law, Lex Cesarean (2) it has undergone
refinements in technique aimed at modifying the risk of maternal morbidity and mortality which was
pervasive.
The low transverse incision by Kerr (9) is now popularly used as it also allows the possibility of vaginal
birth after cesarean section in contrast to the classical incision which only allowed a repeat caesarean
section delivery. The concept of vaginal birth after cesarean was proposed in the early 60s; however, it is
only in the mid 1980s that it become popular; thus curtailing the upward spiral in cesarean section rates.
Infact it is safe and has a high success rate of more than 60Valid %% of the trials of labour (10,23,24).
Patients' role in demand for cesarean section is recognized to affect gains achieved by practise of trials of
labour in previous cesarean. However, such an indication has not been documented in local studies.
TRENDS IN CESAREAN SECTION RATES
The trend world wide is that caesarean section rates are rising. Data summarizes the changes from 1965
to 1985 indicate an increase in the overall caesarean birth rate from 4.5Valid %% to 23Valid %% (10).
However, some centres maintained a stable rate at less than 5Valid %% over the same period of time,
without adverse perinatal or maternal outcome (12).
Mati found a rate of 6Valid %% for Nairobi in the Nairobi birth survey (59). This study showed a
higher rate of 13Valid %% for private hospitals, compared to the teaching hospital 6Valid %%.
Currently, the cesarean section rate in the USA, Brazil and Chile is 25Valid %%, 40Valid %% and
37Valid %% respectively (39).
In Kenya, caesarean section rate has varied with time, place and type of institution.
Kenyatta National Teaching and Referral Hospital handling mainly high risk cases has maintained a rate
of about 20Valid %% over a period of 17 years between 1975 and 1992 (13,14,15,72). However, this
rate has almost doubled to about 42Valid %% currently (77). Pumwani Maternity Hospital, Nairobi, has
had a rate of 4.3Valid %% 1983 (16) and 6.8Valid %% 1990 (17). Latest reports show it is currently at
10Valid %% (84).
Similarly, low rates have been found in other centres. Kericho District Hospital, 1991 had a rate of
8.23Valid %% (18), Coast General Hospital has had a rate of 7.1Valid %% 1990 (19) and recently
6.7Valid %% 1996 (81). Nairobi Hospital has had a relatively high rate of 28.2Valid %% for the period
1995-1997 (20).
Reasons for rise in caesarean section deliveries as
As demonstrated by Henens et al (21) different factors have contributed to the rise in caesarean section
deliveries and have varied with time, place, type of institution, policy of institution, technological
advancement, qualification of personnel, mode of management of labour, social, demographic and
economic factors, while consumer pressure, fear of litigation are increasingly becoming more important
(24). The latter apply more so in private institutions. Availability of effective antibiotics, safe blood
banking services, anaesthesia and improved technique and materials for performing caesarean section.
Limited family size as a result of family planning methods has given way to demand for quality survival.
The impact of demographic shifts has seen more women having their first birth at advanced maternal
7
age, which has been shown to be associated with antenatal and intrapartum complications necessitating
caesarean section delivery (19,21,22). In the U.S.A, the number of patients having their first birth at age
of at least 30 years has risen from 20 to 25 percent (22).
The socio-economic status of the patient has had a significant role. Patients who have medical insurance
compared to non-insured; cared for by obstetricians compared to low cadre health provider; private
compared to clinic patient is more likely to have a cesarean delivery (14b). Hence, poor economic
incentive to the obstetrician is associated with low cesarean section rate (40b). It has been found that
the informed patient and or her spouse are likely to discuss labour with their physician and request or
demand for cesarean section (74). `Fear' of undergoing natural birth or fear of perineal disruption with
consequent impaired sexual function is known to be prevalent in Brazil, accounting for its high caesarean
section rate (39).
The role of litigation in caesarean delivery had not been documented locally. In the U.S.A. 70Valid %%
of obstetricians have had litigation against them. It is thought that these are more likely to deliver by
caesarean section (74) impacting on such chart diagnosis as fetal distress or dystocia.
The role of HIV is likely to impact on caesarean section rates. It is estimated that worldwide, about 2.3
million HIV infected women give birth yearly. It is thought that elective caesarean section can reduce
perinatal vertical transmission (80).
CLINICAL INDICATIONS
There is hardly any obstetrical condition that has not been managed by cesarean section. Common
indications include repeat caesarean section, fetal distress, malpresentation, dystocia and obstetrical
hemorrhage (13-24).
Mati et al (59) demonstrated that breech vaginal delivery was associated with very high perinatal
mortality rate. In this study, 80Valid %% breeches were delivered vaginally and only 20Valid %% by
caesarean section. This led to the policy of caesarean section for all breeches, except for selected cases,
hence accounting for increase in caesarean births. In the Nairobi Hospital study, only 3Valid %% of
breeches had vaginal birth (20). In his study, Mati showed that breech delivery accounted for 2.7Valid
%%, Karanja (13) and Rupani (19) found it to be significant.
Repeat caesarean section delivery has been shown to contribute to high caesarean section rate of more
than 50Valid %% (13,16,20,59,72) with dystocia and fetal distress as its major complications. Before the
advent of vaginal birth after caesarean section, the rates were even higher.
Dystocia encompasses multiple diagnosis such as cephalopelvic disproportion, failure to progress, failed
induction, prolonged second stage, cervical dystocia and primary uterine inertia. Ojo et al demonstrated
that Africans have a disadvantageous narrow pelvis and CPD is significantly a feature (45). In the
absence of CPD, active management of labour by early amniotomy and use of syntocinon is an
alternative to caesarean section (12).
Other proposed alternatives to caesarean section include vaginal birth after caesarean section. Walton
reported a success rate of 68Valid %% for Kenyatta National Hospital (72). In some center, use of
prostaglandin and syntocinon augmentation have raised success rates. Most caesarean sections are
performed as emergency procedures with an elective rate of less than 4Valid %% (15,18,19,81).
However, Nairobi Hospital had an elective procedure rate of about 40Valid %%. Elective, compare to
emergency cesarean section is associated with lower maternal mortality; however, latrogenic prematurity
can be an outward effect.
The low transverse incision is commonly used (13,18,19). It allows possibility of subsequent vaginal
birth. However, the Kronig (8) incision has been used in conditions where the lower segment is not well
8
formed such as preterm breech delivery. Other types of incision include the classical incision. Karanja
(13) and Rupani (19) reported a classical rate of 4Valid %% mainly for extensive adhesions from
previous caesarean section delivery.
General anesthesia is more commonly used in caesarean section deliveries (13,18,19,76), compared to
regional anesthesia; it is associated with more complications. In his study, Kaihura (76) demonstrated
that there was less morbidity associated with on of spinal anesthesia compared to general anesthesia.
Benefits of caesarean section in reducing perinatal, maternal morbidity and mortality are well
documented (10,11,12). Kenya has a maternal mortality ratio of 365/100,000 births (82) and it is
thought that cesarean section could have prevented 25Valid %% of such deaths especially in rural areas
where the procedure is underutilized (83).
However, it has been argued that a decrease in perinatal mortality is still possible in spite of low
caesarean section rate if active management of labour is practiced (12) and when there is an overall
improvement in obstetrical and perinatal care. Other workers have also shown that in spite of rise in
rates for fetal distress, there has been no noticeable decrease in cerebral palsy (41) while in 50Valid %%
of cerebral palsy cases there is no evidence of birth asphyxia (42) and there is considerable evidence that
the majority of damaged new born are injured prior to labour (43).
Maternal morbidity and mortality following caesarean section vary greatly from series to series, but are
consistency high than following vaginal delivery (26,44) both in developed and developing countries
(45,48,49). This is partly due to the surgical procedure itself and other complications that require the
operation. Risk factors for morbidity and mortality include unbooked status, emergency compared to
elective procedure, use of GA, anemia, dehydration, duration of labour, repeated vaginal examinations.
RATIONALE
Cesarean section is a common hospital based procedure whose rate is rising worldwide, causing concern.
There is need to periodically determine the rates, trends, indications, fetal and maternal outcomes as they
relate to socio-demographic changes and institutional policies and to have a national consensus and audit
system, which evaluate patient management and make contribution to national policy guidelines. This is
particularly needful in Kenya to assess quality of health care and improve on it; the young population in
Kenya with its high dependency ratio and HIV prevalence will impact much cesarean section as a
service.
Caesarean section is an instrument that is useful in halting vertical HIV transmission. The government is
putting in place measures to alleviate poverty; it would be interesting to see how this impacts on cesarean
section in Kenya. Low caesarean section rates in some parts of Kenya are not necessarily associated with
good perinatal outcome. Hence the need for periodic evaluation of cesarean section rates with regard to
demographic shifts, education, and family size among others. This will go a long way to assist policy
makers to make effective health management systems.
The safe motherhood programme advocates that each hospital publish its vital statistics, which include
cesarean birth rates, maternal mortality and morbidity.
There is need to understand complications that arise in regard to cesarean section delivery even in "good
settings" like private hospitals in Kenya. This can help create a basis of standards. So far, few studies
have been done in private institutions (which are of higher socio-economic status) and it is of interest to
compare performance in these institutions with teaching and public hospitals (of generally low socioeconomic status). Private hospital patients are likely to be managed by obstetricians, have a high
proportion of old nulliparous mothers, be of high education and socio-economic status, and are better
informed and likely to request caesarean section.
9
OBJECTIVES
BROAD OBJECTIVES
To determine the caesarean section rates, indications, maternal and fetal outcomes at a private hospital in
Nairobi.
SPECIFIC OBJECTIVES
1. To determine the sociodemographic characteristics of patients who underwent caesarean section
at MP Shah
2. To determine caesarean section rate at MP Shah Hospital over a period of one year
3. To determine the indications for caesarean section
4. To determine proportion of mothers who request for cesarean section
5. To determine the perinatal and maternal outcomes among patients who underwent caesarean
section
6. To determine the relationship between indications for caesarean section and sociodemographic
characteristics
7. To determine proportion of mothers who underwent BTL
8. To determine the proportion of mothers who are HIV
9. To recommend ways of reducing cesarean section rates, maternal and fetal morbidity and
mortality.
10. To determine decision to incision time
METHODOLOGY
Study Design.
This will be a retrospective descriptive study.
Study area.
The study will be conducted at MP Shah Hospital.
Study period.
1st January 1998 to 31st December 1998 inclusive. However, this will depend on the duration it takes to
achieve the desired sample size of 400 caesarean section cases.
Study population.
This will comprise all patients delivered by cesarean section at MP Shah Hospital during the period 1st
January 1998 to 31st December 1998.
Sample size determination
The expected repeat caesarean section rate is approximately 50Valid %%. Accuracy is desired at 0.05
level. Z statistic is 1.96.
The desired sample size n, will be calculated as follows
N = Z2P(1 – P)/D2
Where
N = minimum sample size to be determined
P = expected caesarean section rate at 50Valid %%
D = precision / reliability with which to determine P taken as 0.05 for 95Valid %% confidence limit
Z = standard errors from the mean corresponding to 95Valid %% confidence level taken 1.96
The calculated sample size was therefore
N = [(1.96)2x 0.5 (1- 0.5)]/0.052
10
N = 384
Therefore 400 cases will be used. This will be a convenient sampling procedure involving all women
delivered by caesarean section during study period.
Inclusion criteria
1.
2.
For the purpose of calculating the caesarean section rates, all women who delivered during the
study period will be included in the study to get the denominator.
All women who delivered by caesarean section during the study period will be analysed.
Exclusion criteria
Laparotomies for rupture uterus and abdominal pregnancies; and pregnancies less than 28 weeks.
Study instruments.
This will consist of a questionnaire which will have closed and open-ended questions. It will have
several parts.
A.
Demographic and general data
B.
Past obstetrical history
C.
History of index pregnancy
D.
Labour and operative
E.
Indication for cesarean section
F.
Fetal outcome
G.
Maternal outcome.
DATA COLLECTION
All patients admitted in the maternity ward of MP Shah Hospital and subsequently delivered by cesarean
section during the study period (1st January 1998 to 31st December 1998) will form the study
population.
The names and file numbers of all the patients who delivered at the unit during the study period will be
sought by use of the hospital birth register. This will be retrieved with the help of the records clerk. The
files will be coded according to sequence of occurrence in register. Data will be extracted from the files
and filled in precoded questionnaire by the principle investigator. Pretesting of questionnaire will be
done to determine the suitability. An office will be sought for data collection from the administration.
A clerical officer from the hospital will help in file retrieval. The names and file numbers of all patients
who delivered at MP Shah Hospital for the period 1st January 1998 to 31st December 1998 will be
sought from the birth register in the Maternity Unit, to determine their ages and mode of delivery.
The proportion of those who delivered by caesarean section will give he caesarean section rate for the
hospital. The age specific cesarian section rate will be calculated by determining the proportion of
cesarean births for any specific age group. However, for this study, the files of all mothers who
delivered by caesarean section will be sought and coded. A prepared questionnaire will be filled by the
principal investigator using data extracted from the files. This will include maternal age, parity,
indication of caesarean section, gestational age (completed weeks) calculated from LMP using Magaele's
rule). Apgar score, weight in grammes at delivery, sex, maternal morbidity. Study concepts have been
defined (see appendix on page 16). Pretesting of the questionnaire will be done on 20 files to determine
the suitability and modification made accordingly. A retrieval rate of 95Valid %% is expected.
Data management
Data from the precoded questionnaire will be cleaned and entered into a computer program with the
help of a qualified statistician.
Data analysis
11
Frequency tables will be used to look for outliers. Cross tabulation will be done in accordance to the
specific objectives in order to determine relationships. Differences will be tested using chi-square
method at 95Valid %% confidence limit. A P value of < 0.05 will be considered statistically significant.
Ethical considerations
Approval to conduct the study will be sought from my the M.P. Shah hospital Board and Ethical
Committee. Information obtained will be held in confidence.
Study period
Study constraints.
It is anticipated that file retrieval may not be 100 percent. Clinical documents of a diagnosis may be
vague. A single delivery may be associated with two or more indications for example one previous scar
and fetal distress. Multiple diagnosis for example previous caesarean delivery and fetal distress will be
classified under "previous scar" according to the model of Anderson et al (10).
12
COMPARISON OF RATES AND OUTCOME IN DIFFERENT REGIONS IN KENYA
Nairobi
hospital
28.2
35.5
40.5
-12.7%
13.5
--
Kenyatta
Pumwani
Chogoria
Coast
Kericho
18
50
49.5
4.3
10.3
46.1
25.5
7.1
27.5
3
8.2
20.5
6.25
--
12.5
15/1000
76.8/1000
36.4
91.8
142
0.00/
1.4
6.1
4.83
9.6
Maternal
morbidity -(febrile)
Primigravida
37.8
17.3
20.4
13
26.8
--
26.3
30.8
36.6
Elective sterilization
22
--
10.6
11.6
7.5
--
19
74
10
Age ≥ 35
Age specific C/S rate for 28.9
primigravida
Breech C/S
10
--
9.1
6
6
--
--
7.4
--
6.8
15.2
--
5.4
Classical C/S
--
4
4
3.6
Commonest indication
Repeat C/S Repeat
FD
FD
C/S rate
Repeat C/S
Elective C/S
Prematurity
Low birth wt
Asphyxia
Perinatal
Mortality
Maternal
mortality
Hospital duration ≥
days
8 Not clear
10.4
10.4
8.9
C/S
13
28.65
Repeat C/S Dystocia
FD
FD
2.4
6.7
Dystocia
Repeat CS
Coast 79
C/S rate
Repeat C/S
Elective
6.7
4.9
4.7
Pumwani
S.K.
6.8
36
--
Prematurity
Low birth wt
Asphyxia
----
----
Perinatal
mortality/1000
Maternal
mortality/1000
89
118
8.3
6.3
MP Shah
Muriu
Nairobi Birth Survey
20
42
--
6.6
26
-14.3
16.9*1 minute
Maternal
morbidity 18
(febrile)
Primigravida
50.6
19
36
25
Elective sterilization
6.5
--
--
6.0
5.5
8.7
--
--
--
60
30
1.1
0.6
11.9
Classical
18
--
1
Commonest indication
Dystocia
FD
Dystocia
Repeat
FD
Age specific C/S rate for -days
Breech C/S
28.9
14
13
C/S
WORK PLAN
TIME FRAME (MONTHS)
ACTIVITIES
1
2
3
4
5
6
Proposal writing and
Submission to ERB 2000
Data
collection,
entry,
analysis and Report writing
2005
BUDGET
Item
1. Literatures search, stationery, duplicating, photocopies
2. Proposal, typing and duplicating
3. Questionnaires, typing and duplicating
4. Payments to ethical committee for proposal reading
5. Traveling and lunch
6. Communication cost (mobile, telephone)
7. Payments to assistants for data collection
8. Data management, Cleaning, Entry, Analysis
9. Report typing and duplicating
10. Report binding
11. Sub-total
12. Contingency at 10 Valid %%.
13. TOTAL
14. Average cost
15. FUNDING:
15
Amount (Kshs)
10 000
5 000
10, 000
1 000
10000
5,000
10 000
6 000
4 000
2 000
75 000
7,500
82,000
85,000
MOH
APPENDIX 1: QUESTIONNAIRE FOR CAESAREAN SECTION STUDY
1. Patient’s study number:
2. Patient file number
SOCIODEMORGRAPHIC CHARACTERISTICS
3. Nationality............................................................................
4. Age (in completed years)
5. Marital status
1. = Single
2. = Married
3. = Cohabiting
4. = Divorced/separated
5. = Widow
6. Occupation..........................................................................
7. Religion
1. = Protestant
2. = Catholic
3. = Islam
4 = Hindu
5 = Other
6 = Missing
PAST OBSTETRIC HISTORY
8. Parity
9. Abortions
10. Number of living children
11. Any still births?
1. Yes
2. No
12. Any neonatal deaths?
1. Yes
2. No
13. Previous caesarean section delivery stating number
1. None
2. 1
3. 2
4. 3
5. 4 or more
FOR INDEX PREGNANCY
14. LMP
day
month
16
year
15. Gestation at delivery (include ultrasound dating whose LMP is not known)
16. Any antenatal complications?
1. None
2. Hypertensive disease
3. Diabetes mellitus
4. Anaemia
5. Infection e.g. malaria
6. Multiple Pg
7. APH
8. Malpresentation
9. Cervical incompetence
10. Others (specify)
-------------------------------------------------------------------------------------------------LABOUR AND OPERATIVE
17. Date of admission
18. Date of discharge
19. Duration of stay in hospital (days)
20. Was she in labour?
1. Yes
2. No
21. If not in labour, was she induced?
1. Yes
2. No
22. If yes to question 21, what was the reason for induction?
.......................................................................................................................................................................................
23. Indication for caesarean section
1. Repeat C/S
2. Malpresentation/malposition
3. Fetal distress
4. Dystocia
5. APH
6. PET
7. Myomectomy/fibroids
8. BOH
9. Other (specify).......................................................................................................................................
17
MATERNAL OUTCOME
1. Maternal death
2. PPH
3. hysterectomy
4. DIC
5. UTI
6. DVT
7. wound infection
8. foreign body
9. burst abdomen
10. febrile illness
11. Others (specify)..................................................................................
FETAL OUTCOME
24. Single or multiple births?
1. Single
2. Multiple
25. Outcome of delivery
1. Live birth
2. FSB
3. MSB
4. Neonatal death
26. Neonatal Sex
1. Male
2. Female
27. Apgar score at 5 minutes
1. ≥ 7
2. 1 – 6
3. 0
28. If neonatal death, what was the cause of death?
...................................................................................................................................................................................
29. If neonatal death, what was the age at death
1. 0 – 24 hrs
2. 1 – 6 days
3. 1 – 4 weeks
30. Any congenital malformation
1. Yes
2. No
31. If yes to Q30, state type of malformation
-------------------------------------------------------------------------------------------------------
18
APPENDIX 2: DUMMY TABLES
Table 1: Sociodemographic characteristics
Characteristic
1. Nationality
 Kenyan
 Non Kenyan
2. Age
 15 - 19
 20 - 24
 25 - 29
 30 - 34
 35 - 39
 ≥ 40
3. Marital status
 Single
 Married
 Widow
 Divorced
4. Religion
 Protestant
 Catholic
 Muslim
 Hindu
 Other
5. Occupation
 Professional
 Business
 Housewife
 Student
Booking status
 Yes
 No
Freq
Valid %
Table 2: Distribution by mode of delivery
Mode of delivery
Freq
Valid %
SVD
C/S
Vacuum
Breech vaginal delivery
Total number of births
Caesarean section rate***
Cesarean section rate = (Total number of caesarean section deliveries x 100)/total number of
births
Therefore caesarean section rate is _________________________
19
Table 3: Summary of Means
Characteristic
Birth weight
Age(years)
Gestational age in weeks
Duration of hospital stay (days)
Duration decision-incision(hrs)
Mean
3085.595
30.360
38.218
5.818
88.472
SD
680.728
5.111
2.358
3.160
125.924
median
3150.00
30.000
39.000
5.000
60.000
Max
5250.000
45.000
44.000
30.000
1200.000
Table 4: Previous obstetric performance
Characteristic
1. Parity
 0
 1–2
 3–4
 ≥5
2. Still births
 None
 1
 2 or more
3. Neonatal deaths
 None
 1
 2 or more
4. Previous abortion
 None
 1
 2 or more
5. Previous c/s
 None
 1
 2
 3
 4 or more
Freq
Valid %
Table 5: Antenatal complications
Characteristics
Freq.
None
Hypertensive disease
Diabetes mellitus
Anemia
Infections e.g. malaria
Multiple pregnancy
APH
Malpresentation/malposition
Cervical incompetence
Others
Valid %
20
Minimum
450.000
16.000
26.000
0.000
0.200
Mode
3200.000
30.000
38.000
5.000
60.000
Table 6: HIV status
Characteristics
Negative
Positive
Frequency
66
9
Valid percent
88.0
12.0
Table 7: Timing of caesarean section
Characteristics
Elective
Emergency
Frequency
218
270
Valid Percent
44.7
55.3
Frequency
295
144
48
11
1
Valid Percent
59.1
28.9
9.6
2.2
0.2
Table 8: Rank of C/section
Characteristics
0
1
2
3
4
Table 9: Time between decisions to incision
Characteristics
<= 30 min
>= 30 min – 1 hr
>1 hr – 1.5 hr
>1.5 hr – 2 hr
>2 hr – 3 hr
>3 hr – 4 hr
> 4 hr
Elective
Frequency
19
97
61
25
8
5
7
183
valid percent
4.7
24.0
15.1
6.2
2.0
1.2
1.7
45.2
Table 10: Overall indication of caesarean section
Indication
Freq
Repeat caesarean section
Malpresentation/malposition
Fetal distress
Dystocia
APH
PET
Myomectomy/fibroids
BOH
HIV
other
**request for caesarean section
21
Valid %
Table 11: Commonest indications for primary caesarean section
Freq
Percentage
Dystocia
Fetal distress
Breech
APH
Request
BOH
Others
Table 12: Indications for repeat caesarean section (one previous scar)
Indication
Elective
Freq
Emergency
Valid %
Freq
Dystocia
Fetal distress
Breech presentation
APH
BOH
Request
HIV
Other
Table 13: Proportion of BTL between elective and emergency procedure
Characteristic
Freq
Valid %
Elective C/S+BTL
Emergency C/S+BTL
22
Valid %
Table 14: Caesarean section indication by timing: elective or emergency.
Indications
Elective
Freq
Emergency
Valid %
Repeat cesarean
Dystocia
Fetal distress
Breech
APH
BOH
Request
Other
OUTCOME OF DELIVERY
DISTRIBUTION BY BIRTHWEIGHT
Table 15: Distribution by Gestational age
Gestational age
Freq
Valid %
< 31
31-36
37-42
> 42
Proportion of prematurity =
Table 16: Distribution by Birth weight
Birth weight
Freq
Valid %
<1000
1000 – 1499
1500 – 2499
2500-3999
> 4000
Total
Proportion of term low birth weight =
23
Freq
Valid %
Table 17: Sex distribution
Sex
Freq
Valid %
Male
Female
Male: Female ratio =
Table 18: Distribution of Apgar score at 5 min
Apgar score
Freq
Valid %
≥ 7
1–6
0
Table 19: Outcome of delivery
Outcome
Live
FSB
MSB
Table 20: Causes of neonatal morbidity
Cause
Freq
Asphyxia
prematurity
Congenital malformation
Malpresentation
Iatrogenic
Neonatal sepsis
Jaundice
Other
Total
Valid %
Table 21: Type of congenital malformation
Type
Cardiac
Neural tubes
Downs syndrome
Limb defects
GIT
Genito urinary
Other
Total
Table 22: Causes of neonatal death
Asphyxia
Prematurity
LBW
RDS
Lung malformations
Other
24
Table 23: Distribution of perinatal deaths by indication and gestational age
Characteristic
NND
FSB
MSB
Gestational age (wks)
<31
31 – 36
37 – 41
≥ 42
Birth weight
<1000
1000 – 1499
1500 – 2499
2500 – 3599
≥ 4000
Timing of C/S
Elective
Emergency
Indication of C/S
Primary C/S
Repeat C/S
HIV status
Negative
Positive
Medical
illness
pregnancy (PET)
Yes
No
in
Cesarean section perinatal mortality rate =
Timing of C/S Alive
Freq
Valid%
NND
Freq
Valid%
Elective
Emergency
25
SB
Freq
Valid%
Table 24: Neonatal
Outcome
versus
timing of caesarean
section
Table 25: Maternal morbidity (non febrile)
Morbidity
Elective
Freq
Emergency
Valid %
Freq
Valid%
Blood transfusion
ICU/HDU admission
Cesarean hysterectomy
Post C/S laparotomy
Burst abdomen
Other
Table 26: Analysis of indications associated with major (non febrile) morbidity.
Cause
death
of
maternal Indications Parity Age
of C/S
Elective
Table 27: Duration in hospital following cesarean section
Number of days
Freq
Valid %
≤7
8-10
11-14
≥ 15
26
Emergency
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Appendix 3: Letter of Approval from Ethical Committee
34
04.05 05 crude results
Sociodemorgraphic.
Nationality
 Kenyan
 Foreigners
Number
%
459
38
Total 497
92.3
7.6
3
56
153
171
82
21
Total 486
0.6
11.5
31.4
35.1
16.8
4.3
311
26
162
62.3
5.2
32.4
332
149
12
3
66.9
30
2.4
0.6
Age






15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 and above
Marital status
 Married
 Single
 Unknown
Occupation
 Professional
 Housewife
 Auxiliary
 Student
Religion
35
Distribution by parity
Para 0
Para 1
Para 2
Para 3
Para 4
Para 5
Para 6
Para 11
Total
Number
145
153
107
48
11
5
4
1
474
%
30.5
32.2
22.5
10.1
2.3
1
0.8
0.2
Caesarean section rate by primary report
Number
Primary caesarean section
283
Repeat caesarean section
191
Total
474
%
59.7
40.2
100
Distribution of caesarean section by timing
Number
Emergency caesarean section
215
Elective caesarean section
263
Total
478
%
44.98
53.02
55.02
Distribution of caesarean section by rank
Number
No previous primary caesarean 283
section
1 previous scar
136
2 previous scar
40
3 previous scar
10
4 previous scars
1
Total
474
%
59.7
28.6
9.2
2.1
0.2
100
36
Overall indication of caesarean section
n = 478
Number
Repeat caesarean section
191
Malpresentation / malposition
61
Fetal distress
58
Dystocia
65
Obstetric hemorrhage
29
PET/IUGR
24
Myomectomy / fibroids
9
BOH
5
Reduced fetal movements
17
Request
1
ROV
1
Previous uterine perforation
2
Elderly prigravida
2
HIV +
1
Congenital mal
2
HSIL
1
Vaginal cept
1
Spinal injury
1
Indication for primary caesarean section n = 283
Malpresentation/malposition
 Breech
29
 OPP
20
 Transverse lie
5
 Fake topubes
4
 Unstable lie
1
 Shoulder
 Compound
2
Fetal distress
21.56%
58
20.50%
Dystocia







Contracted pelvis
CPP
Poor progress
Cervical dystocia
Failed vacuum
Prolonged labor
Obstructed labor
4
53
4
2
2
22.97
Obstetric hemorrhage
 Abruptio placenta
 Placenta previa
 Placenta increta
 APH
16
2
1
1
37
%
40.2
12.76
12.13
13.6
6.07
5.02
1.88
1.05
3.56
0.21
0.21
0.41
0.41
0.21
0.41
0.21
0.21
0.21

ROV
10.25%
PET/IUGR
 eclampsia
12+8+4
Myomectomy/ fibroids
8.48%
5+4
3.18%
BOH, reduced FM
IPS: Indications n = 136
Malpresentation/ malposition
 breech
 OPP
 Obline
 Transverse
 Placenta topuses
 Unstable lie
Fetal distress
7
1
1
1
7.35%
4
2.94%
Dystocia
 CPD
 Poor progress
 Dystocia
 Failed vacuum/forceps
 Failed trial
 Contracted pelvis
36
2
1
5
33.83%
Obstetric hemorrhage
 Abruptio
 Placenta previa
 Placenta increta
 ROV
 Cord prolapse
PET /Hypertensive disease
 Eclampsia
 IUGR
5
1
1
1
1
5.88%
10
6
2
2
7.35%
Myomectomy
Fibroid
Previous uterine perforation
1
1
1
38
BOH
2.21
4
Reduced FM
2.94%
9
Others prom
6.62%
5
Unstated
3.68%
3
22.79%
IPS (unqualified) Number = 30
IPS (unqualified) + BTL = 6
39
Time between decision to incision
Characteristics
<= 30 min
>= 30 min – 1 hr
>1 hr – 1.5 hr
>1.5 hr – 2 hr
>2 hr – 3 hr
>3 hr – 4 hr
> 4 hr
Elective
Frequency
19
97
61
25
8
5
7
183
valid percent
4.7
24.0
15.1
6.2
2.0
1.2
1.7
45.2
Frequency
443
47
3
Valid percent
89.9
9.5
0.6
Frequency
299
200
Valid percent
59.9
40.1
Apgar score at 5 minutes
Characteristics
>7
1–7
0
Ever had C/section?
Characteristics
No
Yes
Number of previous C/section
Characteristics
0
1
2
3
4
Frequency
295
144
48
11
1
Valid Percent
59.1
28.9
9.6
2.2
0.2
Frequency
218
270
Valid Percent
44.7
55.3
Percent
459
1
3
17
2
Valid percent
92.4
0.2
0.6
3.4
0.4
Elective / emergency
Characteristics
Elective
Emergency
Nationality
Characteristics
Kenyan
Ugandan
Pakistani
Indian
DR Congo
40
British
Somali
French
Sudanese
Zambian
Japanese
Ethiopian
Rwandese
3
6
1
1
1
1
1
1
0.6
1.2
0.2
0.2
0.2
0.2
0.2
0.2
Frequency
311
26
Valid percent
92.3
7.7
Frequency
149
6
16
5
41
12
20
24
15
33
12
14
4
11
73
1
1
3
9
3
3
1
4
1
5
2
4
11
5
3
2
1
Valid percent
30.1
1.2
3.2
1.0
8.3
2.4
4.0
4.8
3.0
6.7
2.4
2.8
0.8
2.2
14.7
0.2
0.2
0.6
1.8
0.6
0.6
0.2
0.8
0.2
1.0
0.4
0.8
2.2
1.0
0.6
0.4
0.2
Marital status
Characteristics
Married
Single
Occupation
Characteristics
Housewife
Hair dresser
Accountant
Sales lady
Teacher
Doctor
Clerk
Banker
Telephonist
Business
Scientist
Administrator
Lecturer
Nurse
Secretary
Insurance broker
Librarian
Sub. Staff
Computer assistant
Preacher
TV/video producer
Loan officer
Travel agent
Driver
Student
Valuer
Lawyer
Operational officer
Cashier
Textile designer
Editor
Social worker
41
Cateress
1
0.2
Frequency
256
87
50
21
6
17
1
Valid percent
58.4
19.9
11.4
4.8
1.4
3.9
0.2
Frequency
1
3
Valid percent
0.2
0.6
Frequency
1
2
35
105
141
97
49
23
18
5
4
4
3
1
1
1
4
Valid percent
0.2
0.4
7.1
21.3
28.5
19.6
9.9
4.7
3.6
1.0
0.8
0.8
0.6
0.2
0.2
0.2
0.8
Frequency
4
5
451
3
Valid percent
0.9
1.1
97.4
0.6
Religion
Characteristics
Protestant
Catholic
Muslim
Hindu
Other
Christian
Orthodox
Education
Characteristics
Primary
Tertiary
Duration of hospital stay
Characteristics
0
1
3
4
5
6
7
8
9
10
11
12
14
18
21
28
30
What was the state?
Characteristics
Fresh
Macerated
N/A
Not indicated
42
Missing cases
Characteristics
No
Yes
Frequency
372
125
Valid percent
74.8
25.2
Frequency
447
52
Valid percent
89.6
10.4
Frequency
498
1
Valid percent
99.8
0.2
Frequency
31
407
Valid percent
7.1
92.9
Frequency
61
424
Valid percent
12.6
87.4
Frequency
240
222
Valid percent
51.9
48.1
Frequency
472
13
Valid percent
97.3
2.7
CSMORE
Characteristics
No
Yes
Request
Characteristics
No
Yes
Single birth
Characteristics
No
Yes
Live birth
Characteristics
No
Yes
Sex of child
Characteristics
Male
Female
Neonatal death
Characteristics
No
Yes
43
Cause of death
Characteristics
Apnoec attach
Severe asphyxia
Perforated uterus
Respiratory failure
N/A
Frequency
1
1
1
1
472
Valid percent
0.2
0.2
0.2
0.2
99.0
Frequency
8
1
473
Valid percent
1.7
0.2
98.1
Frequency
424
65
Valid percent
86.7
13.3
Age at death
Characteristics
0 -24 hrs
1 – 4 wks
N/A
Congenital malformations
Characteristics
No
Yes
44
Congenital malformation specified
Characteristics
N/A
Neural
Genitourinary
Musculoskeletal
Other
Circumcised
Nauroria
Meconium aspiration
Jaundice
Premature
Neural, musculoskeletal
Jaundice, sepsis
Asphyxia
Frequency
424
3
1
8
31
2
1
1
13
1
1
1
1
Valid percent
86.9
0.6
0.2
1.6
6.4
0.4
0.2
0.2
2.7
0.2
0.2
0.2
0.2
Frequency
66
9
Valid percent
88.0
12.0
Frequency
6
15
4
Valid percent
24.0
60.0
16.0
Frequency
13
439
Valid percent
2.9
97.1
Frequency
8
63
380
4
Valid percent
1.8
13.8
83.5
0.9
HIV status if done
Characteristics
Negative
Positive
Baby transferred
Characteristics
Transferred
Left behind
Intubation
Was a patient booked?
Characteristics
No
Yes
Gestational age in weeks
Characteristics
< 31
31 – 36
37 – 42
> 42
45
Table of Means
Characteristic
Birth weight
Age(years)
Gestational age in weeks
Duration of hospital stay
(days)
Duration
decisionincision(hrs)
Mean
3085.595
30.360
38.218
5.818
SD
680.728
5.111
2.358
3.160
median
3150.00
30.000
39.000
5.000
Max
5250.000
45.000
44.000
30.000
88.472
125.924
60.000
1200.000 0.200
46
Minimum
450.000
16.000
26.000
0.000
Mode
3200.000
30.000
38.000
5.000
60.000
wanyonyi
RESULTS
Duration the period studied were 126,000 deliveries and 276 cases of ruptured giving an incidence of
276:126,000 which is 1:219. The number of cases was obtained from theatre registers. Out of 276 cases
only 103 clinical case records could be retrieved for analysis.
Table 1: Age distribution of patients with uterine rapture
Age
15 – 19
20 – 24
25 – 29
30 – 34
35 – 40
Total
Number
5
28
25
19
16
93
Percentage
5.5
30.2
26.9
20.5
17.4
100
The majority of these patients were between 20 – 29 years who accounted for 50% the study subjects.
The mean is 27.1 ± 5.9 with minimum being 17 years and maximum being 40 years.
Table 2: Parity of patients with uterine rapture
Parity
Number
0
16
1
30
2–4
52
F5
5
Percentage
15.5
29.1
50.5
4.9
The majority of patients were multiparous with parity ranging between 2 – 4 children who accounted for
50.5%. Para 1+0 accounted for 29.1 and primipara 15.5% while grand multipara was only 4.9%.
Table 3: antenatal care attendance and place
attendance
Number
Yes
Yes 100(97.1%)
Rural health centre
2
City council clinic/PMH
98
Private
1
None
2
Total
103
Percentage
No 3 (2.9%)
2.0
97.0
1.0
1.9
100
Antenatal care attendance was 97.1%. Most of them attended Nairobi Council health facilities or PMH
antenatal clinic accounting for 97%. Rural health centre 2% and private 1% while those who didn’t
attend any were 2 (1.9%)
Table 4: Indication for previous scars
47
Indication
N/I
CPD
FD
Transverse lie
Twins
Malpresenation
APH
Breech
Prolonged
Big baby
BOH
Number
16
16
7
4
1
4
1
1
2
4
1
Percentage
28.0
28.0
12.0
7.0
1.7
7.0
1.7
1.7
3.5
7.0
1.7
NI – not indicated, CPD –cephalopelvic disproportion, FD – fetal distress, APH – antepartum
hemorrhage, BOH – bad obstetric history.
From the results above, it’s clear that most of the cesarean scars done previously were not clearly
indicated on the maternal antenatal card and in the file. However, CPD accounted for 18.4% with fetal
distress 8.0%, transverse lie 4.6% some with malpresentation and big baby. Twins, APH, Breech and
BOH had one each.
From the study, it was noted that vaginal operative deliveries were not common in Pumwani Maternity
Hospital. There were 2 (2.0%) of two vacuum extraction only. It was also noted that most referrals came
from home in labour with 97.8% of patients.
Table 5: No of Previous cesarean scars
No. of scars
Number
0
46
1
44
2
10
3 & over
2
Percentage
45.1
43.1
9.8
2.0
In this study one previous scar accounted for 43%. Two previous scars about 10% while 3 and more had
2%
Table 6: Use of Syntocinon
Syntocinon
Yes
No
Total
Number
36
10
46
Percentage
78.0
22.0
100
46 cases were reviewed, 36 (78%) had been on syntocinon while 10 (22%) didn’t use.
Table 7: signs of obstructed labour
Signs
Yes (%)
No (%)
48
Dehydration
Vulval oedema
Caput
Moulding
Meconium stained liquor
Oedema of bladder
46(50.5)
35(38.5)
73(80.2)
56(61.5)
59(4.8)
70(77.0)
45(49.5)
56(61.5)
18(19.8)
35(38.5)
32(35.2)
21(23.0)
Dehydration of the mother was present in 46(50.5). Vulval oedeme was present in 35 (28.5%), marked
caput in 73(80.2%), moulding was in 56(61.5%) and meconium stained liquor 59(64.8%), while oedema
of the bladder at operation was present in (77.0%) of the cases.
Table 8: Symptom/Signs
Symptom/signs
Lower abdominal pain
Vaginal bleeding
Tachycardia
Hypotension
Tenderness lower abdomen
Yes (%)
94 (97.9)
63(65.6)
58(60.4)
62(64.4)
94(97.7)
No (%)
2 (2.1)
33(34.4)
38(39.6)
34(35.4)
2(2.1)
Symptoms and signs for impending or uterine rapture were lower abdominal pain which was present in
94(97.9%), tenderness in lower abdomen (97.9%) vaginal bleeding 63(65.6%) and tachaycardia was
62(64.6%). The fetal heart was present in 61(62.9%) of the patients.
Table 9: Type of rapture of uterus
Type of rapture
Number
Impending
1
Spontaneous
46
Previous scar
55
Percentage
1.1
46.1
52.9
The type of rapture involved spontaneous and rapture of previous scar were 46(45.1%) cases of
spontaneous rapture and 55(54%) had previous scar. There was one case of impending rapture.
Table 10: Site of rapture at operation.
Anterior
8
Anterior low segment
81
Posterior
5
Lateral aspect
1
Anterior & Low segment
3
Anterior low segment & 1
posterior
Not recorded
3
7.8
79.4
4.9
1.0
2.9
1.0
2.9
The site of rapture had anterior lower segment accounting for the largest number of cases about 80%.
Table 11: Extension of uterine ruptures to other structures
Extension
Number
Percentage
None
74
72.5
Broad ligament
8
7.8
49
Bladder
Cervix & vagina
Bladder, cervix & vagina
Total
4
15
1
102
3.9
14.7
1.0
100
27.5% of ruptures had tears which extended to neighboring structures. The cervix and vagina was more
common accounting for 15%. It was noted one patient had tears involving the bladder, cervix and
vagina.
Table 12: Type of operation done
Operation
Number
Repair
94
Subtotal hysterectomy
5
Total hysterectomy
2
Repair /subtotal
1
Died
1
Percentage
91.3
4.9
1.1
1.0
1.0
91.3% of patients had repair of uterine rupture while subtotal hysterectomy was about 5% and total
hysterectomy was done in 2 patients. One patient died intraoperatively.
Table 13 maternal and fetal outcome
Maternal/fetal outcome
No
Mother survived
96
Mother died
7
Still births
42
Neonatal death
4
Alive & Discharge
57
%
93.2
6.8
40.8
3.9
55.3
The maternal outcome at operation found 96(93.2%) survived and 7 (6.8%) died intraoperatively
thereafter.
The fetal outcome, the number of still births were 42(40.8%), neonatal death 4(3.9%) and alive and
discharged 57(55.3%). The duration of stay in hospital was as follows;
Table 14: duration of hospital stay in weeks
Weeks
No
<1
7
1- 2
66
2–3
13
>3
10
N/A
7
%
6.8
64.4
12.1
9.7
6.8
73 (70.9%) had a hospital stay of 1 – 2 weeks in hospital. 12.1% had hospital stay of between 2 – 3
weeks while more than 3 weeks were about 10%.
50
Mp shah Objective I
During the study period of Jan 1998 –March 2000 a total of 494 cesarean section files were reviewed.
There were a total of 2067 deliveries as shown in table 1
Table 1: type of deliveries
Type of delivery
SVD
CS
VE
Breech
Forceps
No
1292
596
152
25
2
Percentage (%)
62.5
28.8
7.4
1.2
0.1
There were 596 caesarean section deliveries over the study period, thus the cesarean section rate was
calculated as 596/2067 multiplied by 100, giving a rate of 28.83%
494 files were retrieved, thus the file retrieval rate was calculated as 494/596 multiplied by 100, giving a
retrieval rate of 82.86%.
Booking status
439 patients were booked
Not booked 55
Booking rate = 439/494 x 100
= 88.87%
Type of CS
Elective 153 (30.66%)
Emergency 346 (69.34%)
Rank of CS
Primary CS
I Ps
More than I Ps
Objective 2
Indications for CS?
Indication
Repeat CS
CPP
Fetal distress
Malpresentation
PET
Reduced FM
APH
IUGR
No
177
80
80
43
35
21
21
15
%
1% CS 327 (64.53%)
Repeat CS 177 (35.47%)
Objective 3
There were two CS done on request (case file No.)
51
Objective 4
There were 25 women who had BTL at CS.
No
Elective
Emergency
%
Objective 6
HIV status among CS patients. In 75 patients, HIV status stated. In 424 patients, status not stated.
Of the 75, 66 were negative, 9 were positive. HIV infection rate 9/25 x 100 = 12% (approximately)
Indications of CS among positive: janet.
Fetal outcomes
Single wins
Live
FSB
MSB
Apgar score at 5 minutes:
>7
388
1–6
41
0
7
Birth weight:
<999
1000-1499
1500-1999
2000-2499
2500-2999
3000-3499
3500-3999
3
8
21
40
117
155
52
REPORT WRITING
53
OBSTETRICS LONG COMMENTARY
PROJECT TITLE:
A REVIEW OF CAESAREAN SECTION RATES
INDICATIONS AND OUTCOMES AT MP SHAH
HOSPITAL - NAIROBI
54
LIST OF ABBREVIATIONS
Definition of study concepts:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Still births:
None of the signs of life are present at delivery
Neonatal death will be defined as death of a live-born infant during the first 28 days after birth.
This term will be used in reference to the deaths that occurred before discharge from hospital
since patients were not followed up after discharge.
Perinatal deaths will be defined as sum of stillbirths plus 7-day neonatal deaths.
Early perinatal death is the sum of stillbirths plus neonatal deaths occurring 1st 24 hours.
Perinatal case fatality rate will be defined as perinatal deaths per 1000 cesarean sections.
Maternal case fatality rate will be defined as number of mothers who died having been delivered
by caesarean section per 1000 caesarean section deliveries.
Perinatal morbidity will be defined as chart reference to 5 minute Apgar score of less than 7,
incubation of infant, incubator care. A Correct 5 minute Apgar score will exclude fetus with
gross malformations and extreme prematurity.
Gestational age at time of delivery will be defined by the number of completed weeks, based on
Nagael's rule.
< 999 extremely low birth weight
1000 – 1499 very low birth weight
1500 – 2499 low birth weight
Indication for caesarean section will be defined as chart reference to the
indication/diagnosis: these will later be classified.
Caesarean section will be defined as delivery of an infant of 500 grammes or more through an
incision of the anterior abdominal wall and the uterus.
Fetal distress will be diagnosed if only "fetal distress will be diagnosed if only "fetal distress"
appears on the chart and validated by presence of meconium and FHR patterns
All multiple diagnosis deliveries in which one of the diagnoses is a previous caesarean section
birth will be classified as "previous cesarean birth".
Cases having breech presentation with any other diagnosis will be assigned "breech".
Cases having diagnosis of dystocia and fetal distress will be assigned the class of "dystocia". This
recognizes that dystocia can cause fetal distress.
55
ABSTRACT
Background:
Cesarean section is the commonest hospital based-operation whose rate is rising worldwide. The rates
and trends depend on medical, socioeconomic factors, education and indications such as request for
cesarean section, even in the absence of a medical indication. MP Shah Hospital is private hospital in
Nairobi, where socioeconomic status of the population is high, and that patients are more informed and
are likely to demand for cesarean section. The study involved all women delivered by caesarean section
at M.P. Shah Hospital, for the period 1st January 1998 and March 2000. Most studies in Kenya have
involved government hospitals.
Objective: to determine the cesarean rates, indications and outcomes in a private hospital
Study site: MP Shah Hospital
Study design: This was descriptive cross- sectional retrospective analytical study.
Study methodology: A pre- tested structured questionnaire was used by the principle investigator to
abstract information from case files. Results were computed and analyzed using SPSS version 10.0
Results
The majority (92.3%) was Kenyans and 97% had booked to deliver at the hospital. The mean age of the
population was 30.4± 5 years, adolescents comprising 12%. 62.3% were married and 66% were in
professional employment. The cesarean section rate was 28%, of which 55.3% were emergencies. For
emergencies the decision- to-incision time was less than an hour in 52% of the cases. The commonest
indications were repeat cesarean section (40%), dystocia 13.6% malposition or malpresentation 12.8%
and fetal distress 12.1%. Only two cases requested for cesarean section. 36% had antenatal
complications with PET comprising 60% of the complications. The HIV status was documented in only
66 (13.2%) cases, of which 9 (12%) were positive. One HIV case had an elective cesarean section. 13.2%
of the population had surgical sterilization. 15 (3%) were multiple births. The mean gestational age at
cesarean section was 38.2 weeks± 2.6 weeks with 15.6% being preterm infants. The mean birth weight
was 3086 gm ±680 gm with 15% being low birth weight. There were 8 stillbirths and 7 neonatal deaths.
Asphyxia occurred in 44 (8.9%) of the cases, of whom 6 were transferred to another hospital for
intensive care. There was one term neonatal death with multiple congenital anomalies, the rest were due
to extreme prematurity. During the study period there were no maternal deaths. Maternal morbidity
occurred in 18.8% with prolonged hospital duration being commonest cause. Two cases were admitted
to ICU with DIC associated with eclampsia, and two were admitted in HDU due to poor reversal. Most
cases (87%) were discharged within one week of admission.
Conclusion
Caesarean section rate is high. Cases of request for CS are negligible.
Recommendation
56
INTRODUCTION
BACKGROUND AND LITERATURE REVIEW
Cesarean section is one of the commonest hospital based surgical procedures and its rate has been rising
worldwide. it has been defined as the delivery of a fetus, placental and membranes through an incision
in the abdominal and uterine walls (1). This term does not derive from the birth of Julius Caesar, as is
popularly thought.
From the inception as a postmortem procedure under the Roman law, Lex Cesarean (2) it has undergone
refinements in technique aimed at modifying the risk of maternal morbidity and mortality which was
pervasive.
The low transverse incision by Kerr (9) is now popularly used as it also allows the possibility of vaginal
birth after cesarean section in contrast to the classical incision which only allowed a repeat caesarean
section delivery. The concept of vaginal birth after cesarean was proposed in the early 60s, however, it is
only in the mid 1980s that it become popular; thus curtailing the upward spiral in cesarean section rates.
In fact it is safe and has a high success rate of more than 60% of the trials of labour (10,23,24).
Patients' role in demand for cesarean section is recognized to affect gains achieved by practise of trials of
labour in previous cesarean. However, such an indication has not been documented in local studies.
TRENDS IN CESAREAN SECTION RATES
The trend worldwide is that caesarean section rates are raising. Data summarizes the changes from 1965
to 1985 indicate an increase in the overall caesarean birth rate from 4.5% to 23% (10). However, some
centers maintained a stable rate at less than 5% over the same period of time, without adverse perinatal
or maternal outcome (12).
Mati found a rate of 6% for Nairobi in the Nairobi birth survey (59). This study showed a higher rate of
13% for private hospitals, compared to the teaching hospital 6%. Currently, the cesarean section rate in
the USA, Brazil and Chile is 25%, 40% and 37% respectively (39).
In Kenya, caesarean section rate has varied with time, place and type of institution.
Kenyatta National Teaching and Referral Hospital handling mainly high risk cases has maintained a rate
of about 20% over a period of 17 years between 1975 and 1992 (13,14,15,72). However, this rate has
almost doubled to about 42% currently (77). Pumwani Maternity Hospital, Nairobi, has had a rate of
4.3% 1983 (16) and 6.8% 1990 (17). Latest reports show it is currently at 10% (84).
Similarly, low rates have been found in other centers. Kericho District Hospital, 1991 had a rate of
8.23% (18), Coast General Hospital has had a rate of 7.1% 1990 (19) and recently 6.7% 1996 (81).
Nairobi Hospital has had a relatively high rate of 28.2% for the period 1995-1997 (20).
Reasons for rise in caesarean section deliveries as
As demonstrated by Henens et al (21) different factors have contributed to the rise in caesarean section
deliveries and have varied with time, place, type of institution, policy of institution, technological
advancement, qualification of personnel, mode of management of labour, social, demographic and
economic factors, while consumer pressure, fear of litigation are increasingly becoming more important
(24). The latter apply more so in private institutions.
Availability of effective antibiotics, safe blood banking services, anesthesia, improved technique and
materials for performing caesarean section all contribute to make caesarean section a safe procedure.
Limited family rise as a result of family planning methods has given way to demand for quality survival.
The impact of demographic shifts has seen more women having their first birth at advanced maternal
age, which has been shown to be associated with antenatal and intrapartum complications necessitating
57
caesarean section delivery (19,21,22). In the USA. the number of patients having their first birth at age
of at least 30 years has risen from 20 to 25 percent (22).
The socio-economic status of the patient has had a significant role. Patients who have medical insurance
compared to non-insured; cared for by obstetricians compared to low cadre health provider; private
compared to clinic patient is more likely to have a cesarean delivery (14b). Hence, poor economic
incentive to the obstetrician is associated with low cesarean section rate (40b). It has been found that
the informed patient and or her spouse are likely to discuss labour with their physician and request or
demand for cesarean section (74). `Fear' of undergoing natural birth or fear of perineal disruption with
consequent impaired sexual function is known to be prevalent in Brazil, accounting for its high caesarean
section rate (39).
The role of litigation in caesarean delivery had not been documented locally. In the U.S.A 70% of
obstetricians have had litigation against them. It is thought that these are more likely to deliver their
patients by caesarean section (74) impacting on such chart diagnosis as fetal distress or dystocia.
The role of HIV is likely to impact on caesarean section rates. It is estimated that worldwide, about 2.3
million HIV infected women give birth yearly. It is thought that elective caesarean section can reduce
perinatal vertical transmission (80).
CLINICAL INDICATIONS
There is hardly any obstetrical condition that has not been managed by cesarean section. Common
indications include repeat caesarean section, fetal distress, malpresentation, dystocia and obstetrical
haemorrhage (13-24).
Mati et al (59) demonstrated that breech vaginal delivery was associated with very high perinatal
mortality rate. In this study, 80% breeches were delivered vaginally and only 20% by caesarean section.
This led to the policy of caesarean section for all breeches, except for selected cases, hence accounting
for increase in caesarean births. In the Nairobi Hospital study, only 3% of breeches had vaginal birth
(20).
Prematurity which is often associated with breech presentation comparends the use of caesarean section.
In his study, Mati showed that breech delivery accounted for 2.7%, Karanja (13) and Rupani (19) found
it to be significant.
Repeat caesarean section delivery has been shown to contribute to high caesarean section rate of more
than 50% (13,16,20,59,72) with dystocia and fetal distress as its major complications. Before the advent
of vaginal birth after caesarean section, the rates were even higher.
Dystocia encompasses multiple diagnoses such as cephalopelvic disproportion, failure to progress, failed
induction, prolonged second stage, cervical dystocia and primary uterine inertia. Ojo et al demonstrated
that Africans have a disadvantageous narrow pelvis and CPD is significantly a feature (45). In the
absence of CPD, active management of labour by early amniotomy and use of syntocinon is an
alternative to caesarean section (12).
Other proposed alternatives to caesarean section include vaginal birth after caesarean section. Walton
reported a success rate of 68% for Kenyatta National Hospital (72). In some center, use of
prostaglandin and syntocinon has raised success rates. Most caesarean sections are performed as
emergency procedures with an elective rate of less than 4% (15,18,19,81). However, Nairobi Hospital
had an elective procedure rate of about 40%. The latter is associated with lower maternal mortality,
however, latrogenic prematurity can be an outward effect.
The low transverse incision is commonly used (13,18,19). It allows possibility of subsequent vaginal
birth. However, the Kronig (8) incision has been used in conditions where the lower segment is not well
58
formed such as preterm breech delivery. Other types of incision include the classical. Karanja (13) and
Rupani (19) reported a classical rate of 4% mainly for extensive adhesions from previous caesarean
section delivery.
General anaesthesia is more commonly used in caesarean section deliveries (13,18,19,76), compared to
regional anaesthesia, it is associated with more complications. In his study, Kaihura (76) demonstrated
that there was less morbidity associated with on of spinal anaesthesia compared to general anaesthesia.
Benefits of caesarean section in reducing perinatal, maternal morbidity and mortality are well
documented (10,11,12). Kenya has a maternal mortality ratio of 365/100,000 births (82) and it is
thought that cesarean section could have prevented 25% of such deaths especially in rural areas where
the procedure is underutilised (83).
However, it has been argued that a decrease in perinatal mortality is still possible in spite of low
caesarean section rate if active management of labour is practised (12) and when there is an overall
improvement in obstetrical and perinatal care. Other workers have also shown that inspite of rise in
rates for fetal distress, there has been no noticeable decrease in cerebral palsy (41) while in 50% of
cerebral palsy cases there is no evidence of birth asphyxia (42) and there is considerable evidence that the
majority of damaged new borns are injured prior to labour (43).
Maternal morbidity and mortality following caesarean section vary greatly from series to series, but are
consistency high than following vaginal delivery (26,44) both in developed and developing countries
(45,48,49). This is partly due to the surgical procedure itself and other complications that require the
operation. Risk factors for morbidity and mortality include unbooked status, emergency compared to
elective procedure, use of GA, anaemia, dehydration, duration of labour, repeated vaginal examinations.
RATIONALE
Cesarean section is a common hospital based procedure whose rate is rising worldwide causing concern.
There is need to periodically determine the rates, trends, indications, fetal and maternal outcomes as they
relate to socio-demographic changes and institutional policies and to have a national consensus and audit
system, which evaluate patient management and make contribution to national policy guidelines. This is
particularly needful in Kenya to assess quality of health care and improve on it; the young population in
Kenya with its high dependency ratio and HIV prevalence will impact much cesarean section as a
service.
Caesarean section is an instrument that is useful in halting vertical HIV transmission. The government is
putting in place measures to alleviate poverty; it would be interesting to see how this impacts on cesarean
section in Kenya. Low caesarean section rates in some parts of Kenya are not necessarily associated with
good perinatal outcome. Hence the need for periodic evaluation of cesarean section with regard to
demographic shifts, education, family size among others. This will go a long way to assist policy makers
to make effective health management systems.
The safe motherhood programme advocates that each hospital publish its vital statistics, which include
cesarean birth rates, maternal mortality and morbidity.
There is need to understand complications that arise in regard to cesarean section delivery even in "good
settings" like private hospitals in Kenya. This can help create a basis of standards.
So far, few studies have been done in private institutions (which are of higher socio-economic status)
and it is of interest to compare performance in these institutions with teaching and public hospitals (of
generally low socio-economic status).
59
Private hospital patients are likely to be managed by obstetricians, have a high proportion of old
nulliparous mothers, be of high education and socio-economic status, be better informed and likely to
request caesarean section.
OBJECTIVES
BROAD OBJECTIVES
To determine the caesarean section rates, indications, maternal and fetal outcomes at a private hospital in
Nairobi.
SPECIFIC OBJECTIVES
11. To determine the sociodemographic characteristics of patients who underwent caesarean section
at MP Shah
12. To determine caesarean section rate at MP Shah Hospital over a period of one year
13. To determine the indications for caesarean section
14. To determine proportion of mothers who request for cesarean section
15. To determine the perinatal and maternal outcomes among patients who underwent caesarean
section
16. To determine the relationship between indications for caesarean section and sociodemographic
characteristics
17. To determine proportion of mothers who underwent BTL
18. To determine the proportion of mothers who are HIV
19. To recommend ways of reducing cesarean section rates, maternal and fetal morbidity and
mortality.
20. To determine decision to incision time
METHODOLOGY
Study Design.
This will be a retrospective descriptive study.
Study area.
The study will be conducted at MP Shah Hospital.
Study period.
1st January 1998 to 31st December 1998 inclusive. However, this will depend on the duration it takes to
achieve the desired sample size of 400 caesarean section cases.
Study population.
This will comprise all patients delivered by cesarean section at MP Shah Hospital during the period 1st
January 1998 to 31st December 1998.
Sample size determination
The expected repeat caesarean section rate is approximately 50%. Accuracy is desired at 0.05 level. Z
statistic is 1.96.
The desired sample size n, will be calculated as follows
N = Z2P(1 – P)/D2
Where
N = minimum sample size to be determined
P = expected caesarean section rate at 50%
60
D = precision / reliability with which to determine P taken as 0.05 for 95% confidence limit
Z = standard errors from the mean corresponding to 95% confidence level taken 1.96
The calculated sample size was therefore
N = [(1.96)2x 0.5 (1- 0.5)]/0.052
N = 384
Therefore 400 cases will be used. This will be a convenient sampling procedure involving all women
delivered by caesarean section during study period.
Inclusion criteria
1.
2.
For the purpose of calculating the caesarean section rates, all women who delivered during the
study period will be included in the study to get the denominator.
All women who delivered by caesarean section during the study period will be analysed.
Exclusion criteria
Cases of ruptured uterus and abdominal pregnancies; and pregnancies less than 28 weeks will be
excluded.
DATA COLLECTION
All patients admitted in the maternity ward of MP Shah Hospital and subsequently delivered by cesarean
section during the study period (1st January 1998 to 31st December 1998) will form the study
population.
The names and file numbers of all the patients who delivered at the unit during the study period will be
sought by use of the hospital birth register. This will be retrieved with the help of the records clerk. The
files will be coded according to sequence of occurrence in register. Data will be extracted from the files
and filled in pre-coded questionnaire by the principle investigator. Pre-testing of questionnaire will be
done to determine the suitability. An office will be sought for data collection from the administration.
A clerical officer from the hospital will help in file retrieval. The names and file numbers of all patients
who delivered at MP Shah Hospital for the period 1st January 1998 to 31st December 1998 will be
sought from the birth register in the Maternity Unit, to determine their ages and mode of delivery.
The proportion of those who delivered by caesarean section will give he caesarean section rate for the
hospital. The age specific cesarian section rate will be calculated by determining the proportion of
cesarean births for any specific age group. However, for this study, the files of all mothers who
delivered by caesarean section will be sought and coded. A prepared questionnaire will be filled by the
principal investigator using data extracted from the files. This will include maternal age, parity,
indication of caesarean section, gestational age (completed weeks) calculated from LMP using Magaele's
rule). Apgar score, weight in grammes at delivery, sex, maternal morbidity. Study concepts have been
defined (see appendix on page 16). Pretesting of the questionnaire will be done on 20 files to determine
the suitability and modification made accordingly. A retrieval rate of 95% is expected.
Data management.
Data from the precoded questionnaire will be cleaned and entered into a computer program with the
help of a qualified statistician.
Data analysis
Frequency tables will be used to look for outliers. Cross tabulation will be done in accordance to the
specific objectives in order to determine relationships. Differences will be tested using chi-square
method at 95% confidence limit. A P value of < 0.05 will be considered statistically significant.
Ethical considerations
61
Approval to conduct the study will be sought from my the M.P. Shah hospital Board and Ethical
Committee. Information obtained will be held in confidence.
Study period
Study constraints.
It is anticipated that file retrieval may not be 100 percent. Clinical documents of a diagnosis may be
vague. A single delivery may be associated with two or more indications for example one previous scar
and fetal distress. Multiple diagnosis for example previous caesarean delivery and fetal distress will be
classified under "previous scar" according to the model of Anderson et al (10).
62
RESULTS
Table 1: Sociodemographic characteristics
Characteristic
1. Nationality
 Kenyan
 Non Kenyan
2. Age
 15 - 19
 20 - 24
 25 - 29
 30 - 34
 35 - 39
 ≥ 40
3. Marital status**
 Single
 Married
4. Religion
 Protestant
 Catholic
 Muslim
 Hindu
 Other
5. Occupation
 Professional
 Business
 Housewife
 Student
Booking status
 Yes
 No
Education
 Primary
 Tertiary
File retrieval rate
Freq
Valid %
459
38
92.3
7.6
3
56
153
171
82
21
0.6
11.5
31.4
35.1
16.8
4.3
311
26
62.3
5.2
273
87
50
21
7
62.3
19.9
11.4
4.8
1.8
332
149
12
3
66.9
30
2.4
0.6
439
13
97.1
2.9
1
3
494 x 100/596
25
75
82.9
63
Table 2: Distribution by mode of delivery
Mode of delivery
Freq
Valid %
SVD
1292
62.5
C/S
596
28.8
Vacuum delivery
152
7.4
Breech vaginal delivery
25
1.2
Forceps
2
0.1
Total number of deliveries
2067
Caesarean section rate
596 x 100/2067
28.3
Table 3: Summary of Means
Characteristic
Birth weight
Age(years)
Gestational age in weeks
Duration of hospital stay
(days)
Duration
decisionincision(hrs)
Mean
3085.595
30.360
38.218
5.818
SD
680.728
5.111
2.358
3.160
median
3150.00
30.000
39.000
5.000
Max
5250.000
45.000
44.000
30.000
Minimum
450.000
16.000
26.000
0.000
88.472
125.924
60.000
1200.000 0.200
Table 4: Previous obstetric performance
Characteristic
1. Parity***
 0
 1–2
 3–4
 ≥5
2. Still births
 Yes
 No
3. Neonatal deaths
 Yes
 No
4. Previous abortion
 Yes
 No
Freq
Valid %
145
260
59
10
30.5
54.7
12.4
2
17
482
3.4
96.4
36
463
7.2
92.8
Table 5: Antenatal complications
Characteristics
Freq.
None
Valid %
64
Mode
3200.000
30.000
38.000
5.000
60.000
Hypertensive disease
Diabetes mellitus
Anemia
UTI
Infections e.g. malaria
Multiple pregnancy
APH
Malpresentation/malposition
Cervical incompetence
Fibroids/ infertility
Cardiac disease in pregnancy
Trauma/burns
Elderly primigravida
Asthma
HIV infected
108
1
8
6
4
15
3
4
7
4
1
6
Muniu
4
9 (66)
12
Table 6: Timing of caesarean section
Characteristics
Frequency
Elective
218
Emergency
270
Valid Percent
44.7
55.3
Table 7: Rank of C/section
Characteristics
0
1
2
3
4
Frequency
295
144
48
11
1
Valid Percent
59.1
28.9
9.6
2.2
0.2
Table 10: Time between decisions to incision
Characteristics
Frequency (n= 222)
<= 30 min
19
>= 30 min – 1 hr
97
>1 hr – 1.5 hr
61
>1.5 hr – 2 hr
25
>2 hr – 3 hr
8
>3 hr – 4 hr
5
> 4 hr
7
valid percent
8.6
43.7
27.5
11.3
3.6
2.3
3.1
Table 11: Overall indication of caesarean section
Freq
Repeat caesarean section
204
Malpresentation / malposition 61
Fetal distress
58
Dystocia
65
Obstetric hemorrhage
29
PET/IUGR
24
Valid %
40.2
12.76
12.13
13.6
6.07
5.02
65
Myomectomy / fibroids
BOH
Reduced fetal movements
Request for C/S
ROV
Previous uterine perforation
Elderly primigravida
HIV +
Congenital mal
HSIL
Vaginal septum
Spinal injury
9
5
17
2
1
2
2
1
2
1
1
1
1.88
1.05
3.56
0.42
0.21
0.41
0.41
0.21
0.41
0.21
0.21
0.21
One patient who was a primigravida requested for C/S. The second patient was one previous
scar with an adequate pelvis (ELP).
Table 12: Commonest indications for primary caesarean section
Malpresentation/malposition
 Breech
29
 OPP
20
 Transverse lie
5
 Face to pubes
4
 Unstable lie
1
 Shoulder
 Compound
2
Fetal distress
21.56%
58
20.50%
Dystocia







Contracted pelvis
CPP
Poor progress
Cervical dystocia
Failed vacuum
Prolonged labor
Obstructed labor
4
53
4
2
2
22.97
Obstetric hemorrhage
 Abruptio placenta
 Placenta previa
 Placenta increta
 APH
 ROV
16
2
1
1
10.25%
PET/IUGR
 eclampsia
12+8+4
66
8.48%
5+4
Myomectomy/ fibroids
3.18%
BOH, reduced FM
Table 13: Indications for repeat caesarean section (one previous scar)
Indication
Elective
Freq
Emergency
Valid %
Freq
Valid %
Dystocia
Fetal distress
Breech presentation
APH
BOH
Request
HIV
Other
Table 13: Proportion of BTL between elective and emergency procedure
Characteristic
Freq
Valid %
Elective C/S+BTL
Emergency C/S+BTL
44 patients underwent BTL at caesarean section.
Table 15: Caesarean section indication by timing: elective or emergency.
Indications
Elective
Freq
Emergency
Valid %
Repeat cesarean
Dystocia
Fetal distress
Breech
APH
BOH
67
Freq
Valid %
Request
Other
OUTCOME OF DELIVERY
DISTRIBUTION BY BIRTHWEIGHT
Table 16: Distribution by Gestational age
Characteristics
Frequency
< 31
8
31 – 36
63
37 – 42
380
> 42
4
Valid percent
1.8
13.8
83.5
0.9
Proportion of prematurity = 71 x 100/455 = 15.6%
Table 17: Distribution by Birth weight
Birth weight
Freq (n = 485)
Valid %
<1000
3
0.7
1000 – 1499
9
1.7
1500 – 2499
61
12.6
2500-3999
379
78.6
> 4000
33
6.3
Proportion of low birth weight = 15 %
Table 18: Sex distribution
Sex
Freq
Valid %
Male
240
51.9
Female
222
48.1
Male: Female ratio =
68
Table 19: Distribution of Apgar score at 5 min
Apgar score
Freq (n = 492)
≥7
441
1–6
44
0
7
Table 20: Outcome of delivery
Outcome
Freq (n=508)
Live
500
FSB
7
MSB
1
Valid %
89.6
8.9
1.4
Valid %
98.4
1.4
0.2
Table 21: severe neonatal morbidity
Characteristics
Transferred
Left behind
Intubated
Frequency
6
15
4
Valid percent
24.0
60.0
16.0
Table 21: Causes of neonatal morbidity
Cause
Freq
Asphyxia
prematurity
Congenital malformation
Malpresentation
Iatrogenic
Neonatal sepsis
Jaundice
Other
Total
Valid %
Table 22: Type of congenital malformation
Characteristics
Frequency
N/A
424
Neural
3
Genitourinary
1
Musculoskeletal
8
Other
31
Circumcised
2
Nauroria
1
Meconium aspiration
1
Jaundice
13
Premature
1
Neural, musculoskeletal
1
Jaundice, sepsis
1
Asphyxia
1
Valid percent
86.9
0.6
0.2
1.6
6.4
0.4
0.2
0.2
2.7
0.2
0.2
0.2
0.2
69
Table 23: Causes of neonatal death
Asphyxia
Prematurity
Apnoec attack
RDS
Lung malformations
Severe-congenital malformation.
Other
Freq (n = 7)
1
1
1
1
1
1
1
Valid %
Table 24: Distribution of perinatal deaths by indication and gestational age
Characteristic
NND
FSB
MSB
Gestational age (wks)
<31
31 – 36
37 – 41
≥42
Birth weight
<1000
1000 – 1499
1500 – 2499
2500 – 3599
≥ 4000
Timing of C/S
Elective
Emergency
Indication of C/S
Primary C/S
Repeat C/S
HIV status
Negative
Positive
Medical
illness
in
pregnancy (PET)
Yes
No
Cesarean section perinatal mortality rate =
70
Table 25: Neonatal Outcome versus timing of caesarean section
Table 26: Maternal morbidity and mortality
Freq
Blood transfusion
ICU/HDU admission
Febrile morbidity
PPH
Pueperal infection
Prolonged hospital stay (more than 7 days)
Left baby behind**
Grief
Dissatisfied with care
Discharged against medical advice
ARF
DVT
UTI
2
4
13
7
5
35
1
1
1
1
2
2
Table 27: Duration in hospital following cesarean section
Number of days
Freq
Valid %
≤7
478
87
8-10
46
9.2
11-14
11
1.6
≥15
14
2.2
71
Valid%
COMPARISON OF RATES AND OUTCOME IN DIFFERENT REGIONS IN KENYA
Nairobi
hospital
28.2
35.5
40.5
-12.7%
13.5
--
Kenyatta
Pumwani
Chogoria
Coast
Kericho
18
50
49.5
4.3
10.3
46.1
25.5
7.1
27.5
3
8.2
20.5
6.25
--
12.5
15/1000
76.8/1000
36.4
91.8
142
0.00/
1.4
6.1
4.83
9.6
Maternal
morbidity -(febrile)
Primigravida
37.8
17.3
20.4
13
26.8
--
26.3
30.8
36.6
Elective sterilization
22
--
10.6
11.6
Hospital duration ≥ 8 Not clear
days
Age ≥ 35
10
7.5
--
19
74
--
9.1
6
6
Age specific C/S rate for 28.9
primigravida
Breech C/S
10
--
--
7.4
--
6.8
15.2
--
5.4
Classical C/S
--
4
4
3.6
Commonest indication
Repeat C/S Repeat
FD
FD
C/S rate
Repeat C/S
Elective C/S
Prematurity
Low birth wt
Asphyxia
Perinatal
mortality
Maternal
mortality
10.4
10.4
8.9
C/S
72
28.65
Repeat C/S Dystocia
FD
FD
2.4
6.7
Dystocia
Repeat CS
Coast 79
C/S rate
Repeat C/S
Elective
6.7
4.9
4.7
Pumwani
S.K.
6.8
36
--
Prematurity
Low birth wt
Asphyxia
----
----
Perinatal
mortality/1000
Maternal
mortality/1000
89
118
8.3
6.3
MP Shah
Muriu
Nairobi Birth Survey
20
42
--
6.6
26
-14.3
16.9*1 minute
Maternal
morbidity 18
(febrile)
Primigravida
50.6
19
36
25
Elective sterilization
6.5
--
--
6.0
5.5
8.7
--
--
--
60
30
1.1
0.6
11.9
Classical
18
--
1
Commonest indication
Dystocia
FD
Dystocia
Repeat
FD
Age specific C/S rate for -days
Breech C/S
28.9
73
13
C/S
Discussion
ABSTRACT
Background:
Cesarean section is the commonest hospital based-operation whose rate is rising worldwide. The rates
and trends depend on medical, socioeconomic factors, education and indications such as request for
cesarean section, even in the absence of a medical indication. MP Shah Hospital is private hospital in
Nairobi, where socioeconomic status of the population is high, and that patients are more informed and
are likely to demand for cesarean section. The study involved all women delivered by caesarean section
at M.P. Shah Hospital, for the period 1st January 1998 and March 2000. Most studies in Kenya have
involved government hospitals.
Objective: to determine the cesarean rates, indications and outcomes in a private hospital
Study site: MP Shah Hospital
Study design: This was descriptive cross- sectional retrospective analytical study.
Study methodology: A pre- tested structured questionnaire was used by the principle investigator to
abstract information from case files. Results were computed and analyzed using SPSS version 10.0
Results
The majority (92.3%) was Kenyans and 97% had booked to deliver at the hospital. The mean age of the
population was 30.4± 5 years, adolescents comprising 12%. 62.3% were married and 66% were in
professional employment. The cesarean section rate was 28%, of which 55.3% were emergencies. For
emergencies the decision- to-incision time was less than an hour in 52% of the cases. The commonest
indications were repeat cesarean section (40%), dystocia 13.6% malposition or malpresentation 12.8%
and fetal distress 12.1%. Only two cases requested for cesarean section. 36% had antenatal
complications with PET comprising 60% of the complications. The HIV status was documented in only
66 (13.2%) cases, of which 9 (12%) were positive. One HIV case had an elective cesarean section. 13.2%
of the population had surgical sterilization. 15 (3%) were multiple births. The mean gestational age at
cesarean section was 38.2 weeks± 2.6 weeks with 15.6% being preterm infants. The mean birth weight
was 3086 gm ±680 gm with 15% being low birth weight. There were 8 stillbirths and 7 neonatal deaths.
Asphyxia occurred in 44 (8.9%) of the cases, of whom 6 were transferred to another hospital for
intensive care. There was one term neonatal death with multiple congenital anomalies, the rest were due
to extreme prematurity. During the study period there were no maternal deaths. Maternal morbidity
occurred in 18.8% with prolonged hospital duration being commonest cause. Two cases were admitted
to ICU with DIC associated with eclampsia, and two were admitted in HDU due to poor reversal. Most
cases (87%) were discharged within one week of admission.
Conclusion
Caesarean section rate is high. Cases of documented request for CS are negligible.
Recommendation
INTRODUCTION
BACKGROUND AND LITERATURE REVIEW
Cesarean section is one of the commonest hospital based surgical procedures and its rate has been rising
worldwide. it has been defined as the delivery of a fetus, placental and membranes through an incision
in the abdominal and uterine walls (1). This term does not derive from the birth of Julius Caesar, as is
popularly thought.
From the inception as a postmortem procedure under the Roman law, Lex Cesarean (2) it has undergone
refinements in technique aimed at modifying the risk of maternal morbidity and mortality which was
pervasive.
The low transverse incision by Kerr (9) is now popularly used as it also allows the possibility of vaginal
birth after cesarean section in contrast to the classical incision which only allowed a repeat caesarean
section delivery. The concept of vaginal birth after cesarean was proposed in the early 60s, however, it is
74
only in the mid 1980s that it become popular; thus curtailing the upward spiral in cesarean section rates.
In fact it is safe and has a high success rate of more than 60% of the trials of labour (10,23,24).
Patients' role in demand for cesarean section is recognized to affect gains achieved by practise of trials of
labour in previous cesarean. However, such an indication has not been documented in local studies.
TRENDS IN CESAREAN SECTION RATES
The trend worldwide is that caesarean section rates are raising. Data summarizes the changes from 1965
to 1985 indicate an increase in the overall caesarean birth rate from 4.5% to 23% (10). However, some
centers maintained a stable rate at less than 5% over the same period of time, without adverse perinatal
or maternal outcome (12).
Mati found a rate of 6% for Nairobi in the Nairobi birth survey (59). This study showed a higher rate of
13% for private hospitals, compared to the teaching hospital 6%. Currently, the cesarean section rate in
the USA, Brazil and Chile is 25%, 40% and 37% respectively (39).
In Kenya, caesarean section rate has varied with time, place and type of institution.
Kenyatta National Teaching and Referral Hospital handling mainly high risk cases has maintained a rate
of about 20% over a period of 17 years between 1975 and 1992 (13,14,15,72). However, this rate has
almost doubled to about 42% currently (77). Pumwani Maternity Hospital, Nairobi, has had a rate of
4.3% 1983 (16) and 6.8% 1990 (17). Latest reports show it is currently at 10% (84).
Similarly, low rates have been found in other centers. Kericho District Hospital, 1991 had a rate of
8.23% (18), Coast General Hospital has had a rate of 7.1% 1990 (19) and recently 6.7% 1996 (81).
Nairobi Hospital has had a relatively high rate of 28.2% for the period 1995-1997 (20).
Reasons for rise in caesarean section deliveries as
As demonstrated by Henens et al (21) different factors have contributed to the rise in caesarean section
deliveries and have varied with time, place, type of institution, policy of institution, technological
advancement, qualification of personnel, mode of management of labour, social, demographic and
economic factors, while consumer pressure, fear of litigation are increasingly becoming more important
(24). The latter apply more so in private institutions.
Availability of effective antibiotics, safe blood banking services, anesthesia, improved technique and
materials for performing caesarean section all contribute to make caesarean section a safe procedure.
Limited family rise as a result of family planning methods has given way to demand for quality survival.
The impact of demographic shifts has seen more women having their first birth at advanced maternal
age, which has been shown to be associated with antenatal and intrapartum complications necessitating
caesarean section delivery (19,21,22). In the USA. the number of patients having their first birth at age
of at least 30 years has risen from 20 to 25 percent (22).
The socio-economic status of the patient has had a significant role. Patients who have medical insurance
compared to non-insured; cared for by obstetricians compared to low cadre health provider; private
compared to clinic patient is more likely to have a cesarean delivery (14b). Hence, poor economic
incentive to the obstetrician is associated with low cesarean section rate (40b). It has been found that
the informed patient and or her spouse are likely to discuss labour with their physician and request or
demand for cesarean section (74). `Fear' of undergoing natural birth or fear of perineal disruption with
consequent impaired sexual function is known to be prevalent in Brazil, accounting for its high caesarean
section rate (39).
The role of litigation in caesarean delivery had not been documented locally. In the U.S.A 70% of
obstetricians have had litigation against them. It is thought that these are more likely to deliver their
patients by caesarean section (74) impacting on such chart diagnosis as fetal distress or dystocia.
75
The role of HIV is likely to impact on caesarean section rates. It is estimated that worldwide, about 2.3
million HIV infected women give birth yearly. It is thought that elective caesarean section can reduce
perinatal vertical transmission (80).
CLINICAL INDICATIONS
There is hardly any obstetrical condition that has not been managed by cesarean section. Common
indications include repeat caesarean section, fetal distress, malpresentation, dystocia and obstetrical
haemorrhage (13-24).
Mati et al (59) demonstrated that breech vaginal delivery was associated with very high perinatal
mortality rate. In this study, 80% breeches were delivered vaginally and only 20% by caesarean section.
This led to the policy of caesarean section for all breeches, except for selected cases, hence accounting
for increase in caesarean births. In the Nairobi Hospital study, only 3% of breeches had vaginal birth
(20).
Prematurity which is often associated with breech presentation comparends the use of caesarean section.
In his study, Mati showed that breech delivery accounted for 2.7%, Karanja (13) and Rupani (19) found
it to be significant.
Repeat caesarean section delivery has been shown to contribute to high caesarean section rate of more
than 50% (13,16,20,59,72) with dystocia and fetal distress as its major complications. Before the advent
of vaginal birth after caesarean section, the rates were even higher.
Dystocia encompasses multiple diagnoses such as cephalopelvic disproportion, failure to progress, failed
induction, prolonged second stage, cervical dystocia and primary uterine inertia. Ojo et al demonstrated
that Africans have a disadvantageous narrow pelvis and CPD is significantly a feature (45). In the
absence of CPD, active management of labour by early amniotomy and use of syntocinon is an
alternative to caesarean section (12).
Other proposed alternatives to caesarean section include vaginal birth after caesarean section. Walton
reported a success rate of 68% for Kenyatta National Hospital (72). In some center, use of
prostaglandin and syntocinon has raised success rates. Most caesarean sections are performed as
emergency procedures with an elective rate of less than 4% (15,18,19,81). However, Nairobi Hospital
had an elective procedure rate of about 40%. The latter is associated with lower maternal mortality;
however, latrogenic prematurity can be an outward effect.
The low transverse incision is commonly used (13,18,19). It allows possibility of subsequent vaginal
birth. However, the Kronig (8) incision has been used in conditions where the lower segment is not well
formed such as preterm breech delivery. Other types of incision include the classical. Karanja (13) and
Rupani (19) reported a classical rate of 4% mainly for extensive adhesions from previous caesarean
section delivery.
General anesthesia is more commonly used in caesarean section deliveries (13,18,19,76), compared to
regional anesthesia, it is associated with more complications. In his study, Kaihura (76) demonstrated
that there was less morbidity associated with on of spinal anesthesia compared to general anesthesia.
Benefits of caesarean section in reducing perinatal, maternal morbidity and mortality are well
documented (10,11,12). Kenya has a maternal mortality ratio of 365/100,000 births (82) and it is
thought that cesarean section could have prevented 25% of such deaths especially in rural areas where
the procedure is underutilized (83).
However, it has been argued that a decrease in perinatal mortality is still possible in spite of low
caesarean section rate if active management of labour is practiced (12) and when there is an overall
improvement in obstetrical and perinatal care. Other workers have also shown that in spite of rise in
76
rates for fetal distress, there has been no noticeable decrease in cerebral palsy (41) while in 50% of
cerebral palsy cases there is no evidence of birth asphyxia (42) and there is considerable evidence that the
majority of damaged newborns are injured prior to labour (43).
Maternal morbidity and mortality following caesarean section vary greatly from series to series, but are
consistency high than following vaginal delivery (26,44) both in developed and developing countries
(45,48,49). This is partly due to the surgical procedure itself and other complications that require the
operation. Risk factors for morbidity and mortality include unbooked status, emergency compared to
elective procedure, use of GA, anaemia, dehydration, duration of labour, repeated vaginal examinations.
77
NAIROBI HOSPITAL WORK 1996
A RETROSPECTIVE STUDY OF CAESAREAN SECTION
INDICATIONS AND OUTCOME AT NAIROBI HOSPITAL FOR
THE PERIOD 1ST JANUARY TO 31ST DECEMBER 1996
PRINCIPAL INVESTIGATOR
DR. JAHONGA
CO-INVESTIGATORS
DR. WANJIHIA
DR. WANJALA
DR. KAGIA
DR. THAGANA
REPORT PRESENTED AT THE DIVISIONAL MEETING OF
OBSTETRICS AND GYNAECOLOGY, THE NAIROBI HOSPITAL
BOARD ROOM, ON 12TH FEBRUARY 1997 BY DR. JAHONGA
78
SUMMARY
A retrospective study of caesarean section and outcome was carried out at Nairobi Hospital.
A total of 654 deliveries were conducted over the same period of which 190 were caesarean section
giving a caesarean section of 29.05Valid %%. The commonest indications for caesarean sections were
 Repeat caesarean section (34.74Valid %%)
 Malpresentation /malposition (16.8Valid %%)
 Fetal distress (15.63Valid %%)
There was only one case of caesarean section on request.
There were 6 perinatal deaths associated with caesarean section giving a perinatal mortality rate of 30.3
per one thousand.
Antenatal care for the patients was provided for by 50 obstetricians and 4 midwives.
On average there were about 110 deliveries per month giving approximately 4 deliveries per day
MATERIALS AND METHODS
The names and file numbers of all patients who delivered by caesarean section at Nairobi Hospital
Maternity Unit from 1st January to 30th June 1996 both inclusive were obtained from the Nairobi
Hospital labour ward register of deliveries. A prepared questionnaire was filled using data extracted from
these records. This data included maternal age, parity, and indications for caesarean section, gestational
age, and weight of baby at birth and mode of delivery. Analysis of caesarean section showed that 195
patients had lower uterine section transverse incisions and one had a classical due to extensive adhesions
from two previous scars. One patient in advanced labour with compound presentation underwent
emergency hysteromy, but was included in the study.
Most elective procedures took place on Mondays and Fridays; and the least on Tuesdays.
Seventy nine (41,6Valid %%) operations were performed as elective, 111 (58.4Valid %%) as
emergencies. All operations were performed under general anesthesia. Of the dead babies, only one had
a post mortem report which indicated cause of death as hyaline membrane disease.
79
RESULTS
During the study period, there were 654 deliveries of which 190 were caesarean sections.
Table 1: Distribution by mode of delivery.
Mode of delivery
SVD
caesarean section
Vacuum delivery
Breech delivery
Total
381
190
56
8
Percentage
58.26
29.05
8.56
1.22
Table 1 shows mode of delivery giving caesarean section rate of 29.05Valid %%.
There were 6 sets of twins delivered by caesarean section and 2 sets by vaginal delivery. It would be of
interest to know what number of those who had spontaneous vertex deliveries had a previous caesarean
section. One set of twins was delivered by hysterectomy. There was one twin pregnancy with one fetus
mummified.
Amongst those who underwent caesarean section, only 4 cases had a vaginal delivery following a
previous caesarean section.
Table 2: Age distribution of patients at time of caesarean section.
Age group (years)
15 – 20
21 -25
26 – 30
31 – 35
36 – 40
41 – 50
Total
Frequency
3
20
73
61
31
3
Percentage
1.3
10.55
38.42
32.11
16.31
1.3
The maternal age distribution is shown in table 2 and it shows that 73 (38.42Valid %%) of the cases
were in the age group 26 – 30. there were 3 (1.3Valid %%) cases in the age group 15 – 20 years, and 3
cases in the age group 41 – 45 years old. The mean age was 31.8 years.
Table 3: Parity distribution of patients at time of caesarean section.
Parity
0
1
2
3
4
5
6
Frequency
75
62
36
15
5
3
1
Percentage
38.1
31.5
18.3
7.6
2.5
1.5
0.6
Table 3 shows the parity distribution in the study. The highest number of cases 75 (38.1Valid %%) was
recorded in the primigravida and the last 1 (0.6Valid %%) was recorded in the grand multiparous. There
were 5 (2.5Valid %%) elderly primigravidas.
80
Plan of action on admission
Plan of action on admission
Elective caesarean section
Emergency caesarean section
Trial of scar
Induction of labour
Monitor labour
79
39
13
33
26
Previous perinatal loss in the population.
There were 11 mothers associated with stillbirths, 7 of whom this occurred in their first pregnancy and
was associated with PET. Two had ruptured uterus with FSB and two had neonatal deaths.
Antenatal complications in the population (n = 71)
Complication
Hypertensive disease in pregnancy
Bleeding
Cervical stitch
Multiple pregnancy
Chronic renal disease
Asthma
Diabetes mellitus
Neurological disease (stroke with paralysis)
Trauma (RTA)
Hyperemesisgravidum
UTI
Malaria
Ovarian cystectomy in pregnancy
Sickle cell
Rhesus negative
Number
36
5
5
6
2
2
1
1
1
2
2
1
1
2
2
Those who did not have a complication were 62.4Valid %%. Those associated with complications were
37.6Valid %%.
Table 4: Rank of caesarean section by mode of delivery (n = 190)
Rank
1
2
3
4
Elective caesarean Emergency
section
caesarean section
32
92
28
16
18
2
1
1
Total
Percentage
124
44
20
2
66.26
23.15
10.52
1.0
Table 4 shows the distribution by rank of caesarean sections. One hundred and twenty four (66.26Valid
%%) were primary caesarean sections, 66(33.74Valid %%) were repeats.
81
Table 5: Overall indications for caesarean section
Indication of caesarean section
Repeat caesarean section
Malpresentation/malposition
Fetal distress
Dystocia
Obstetrical haemorrhage
PET/IUGR
Myomectomy/fibroids
BOH
Reduced fetal movements
Others
Freq
66
32
29
23
12
10
5
4
4
5
Percentage
34.74
16.84
15.63
12.11
6.16
5.26
2.63
2.10
2.10
5.26
Table 6: Primary caesarean section indications (n = 124)
Primary
caesarean
section Freq
indication
Malpresentation/ malposition 32
 Breech
17
 OPP
10
 Oblique
3
 Face pubes
1
 Unstable lie
1
Fetal distress
29
Dystocia
22
 CPD
15
 Poor progress
3
 DTA
1
 Cervical dystocia
1
 Failed forceps
1
 prolonged labour
1
Obstetrical hemorrhage
12
 abruptio placenta
8
 placenta previa
2
 placenta increta
1
 APH (Unknown cause)
1
PET/IUGR
10
Myomectomy /fibroid
5
BOH
4
Reduced fetal movements
4
Others
6
Percentage
16.84
15.26
6.31
6.31
5.26
2.63
2.10
2.10
3.15
Table 7: One previous scar indications ( n = 44)
Indications
CPD
Failed trial
Diagnosis unstated
Malpresentation
PET
Myomectomy
Freq
12
7
7*
6
2
2
Percentage
12.27
15.91
15.91
13.63
4.54
4.54
82
BOH
2
APH
1
Others
5
Others include: postdatism,
previous uterine rapture, reduced
fetal movements, scheduled for
elective
4.54
2.27
11.36
* All were elective procedures.
Of all the 111 emergency caesarean sections, 39 (35Valid %%) underwent the operation on admission
while 72 (65Valid %%) laboured prior to the caesarean section.
Outcome of delivery
Table 8: Distribution of birthweight (grams)
Birthweight (grams)
≤ 2499
2500 – 3999
≥ 4000
Frequency
21
148
14
Percentage
12.4
80
7.6
Table 8 shows the distribution of birthweights. The range was 1390 – 4442 with a mean of 3109 grams.
Low birth weights were 21 (12.4Valid %%).
Table 9: Distribution of gestational age
Gestational age
31 – 36
37 – 42
> 42
Total
Frequency
21
165
4
Percentage
12.8
86.6
2.1
Table 7 shows the distribution by gestational age in complete weeks. The range was 31 to 42 weeks, with
a mean of 38 weeks.
83
Table 10: Distribution of perinatal deaths by gestational age and indications
Type of perinatal death
Noenatal death
1
Gestational age
Indication
Comment
41
PET + abruptio
Patient admitted for
induction and noted to
have severe bradycardia
2
33
PET/IUGR
3
Fresh still birth
1
40
PET/ induction
39
Abruptio
bradicardia
2
Macerated still birth
33
39
PET + abruptio
Presented with APH
IUFD + 2 previous Admitted with labour
scars
pains & loss of fetal
movements for two
days
Patient
electively
delivered due to severe
IUGR
Had previous FSB due
to PET
placenta, Loss
of
fetal
movements for one day
Congenital malformations
There were 7 cases of clinically identified congenital malformations as follows:
Malformation
Mongal
Meningocele
Deformity of the right upper limb
Extra digits
Hypospadia
Cord abnormality
Frequency
1
1
1
2
1
1
Neonatal morbidity
There were 7 babies with severe asphyxia requiring intubation, 1 baby with iatrogenic injury from scapel
nick.
Maternity morbidity
There were 4 cases (1.58Valid %%) of maternity morbidity. Two cases of febrile morbidity; 1 urinary
tract infection, and the other no pathogen was isolated from urine and high vaginal swab specimens.
There was 1 case of hemorrhage due to placenta increta who underwent emergency hysterectomy and
was transfused 2 unis of blood. There was no maternal mortality.
84
Hospital duration
The average hospital duration was 5 days with a range of 4 to 19 days. One mother stayed for 14 days
after hysterectomy and another who presented as an emergency with 3 previous scars in labour stayed
for 19 days.
Contraception
Nineteen patients underwent bilateral tubal ligation with the caesarean section giving a BTL rate of
10Valid %%.
Table 1:
Place
Nairobi Hospital
Kenyatta
National
Hospital
Pumwani Maternity
Period
1996
1980
Rate
29.05
17.8
1983
4.3
Coast General
1990
7.1
Kericho
1990
8.22
Nairobi birth survey
Ethiopian
1983
1992-1993
6.6
8
Italy
Zaire
1980 – 1983
1. public
2. private
1992
11.8
13.3
12.0
Czech Republic
1986 – 1994
10
USA
85
Reference
Karanja J.G., Mmed
thesis UON 1981
Bausai Y.P. et al
E.A.M.J 64(11) 741-4,
1987
Rupani M.P, Mmed
thesis, UON 1991
Kudoyi W.O
M.Med thesis UON
1993
EMJ 1983
EMJ 1995 vol. 72 pp
6660 – 63
Perazzini F. et al
Br. J.Obst.Gyn 99 p
203, 1992
Tidsskr nor laegforen
(Norway) 1996 116(1)
p67 – 71
Ceskagynekol
(Czech
Republic) 1995, 60(6)
p283 – 9
Table 2: Comparison of findings by other studies
Nairobi Hospital
Karanja
Kudoyi
Rupani
Bausai
Muriu
Nairobi birth survey
Rank of caesarean section
Primary
66.26
48.8
77.68
72.5
69
56.6
-
Repeat
33.74
51.2
22.32
27.5
31
43.5
-
Table 3: Overall indications for caesarean section
Nairobi Hospital
Repeat
caesarean
section,
malpresenation/malposition, fetal distress, dystocia
CPD, repeat c caesarean section, fetal distress
Dystocia, repeat caesarean section, malpresentation
/ malposition
CPD, repeat caesarean section, prolonged labour,
fetal distress
-
Karanja
Kudoyi
Rupani
Bausai
Muriu
Sociodemorgraphic.
Freq
Valid %%
86
Nationality
 Kenyan
 Foreigners
Age






15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 and above
Marital status
 Married
 Single
 Unknown
Occupation
 Professional
 Housewife
 Auxiliary
 Student
Religion
459
38
Total 497
92.3
7.6
3
56
153
171
82
21
Total 486
0.6
11.5
31.4
35.1
16.8
4.3
311
26
162
62.3
5.2
32.4
332
149
12
3
66.9
30
2.4
0.6
Freq
145
153
107
48
11
5
4
1
474
Valid %%
30.5
32.2
22.5
10.1
2.3
1
0.8
0.2
Distribution by parity
Para 0
Para 1
Para 2
Para 3
Para 4
Para 5
Para 6
Para 11
Total
Caesarean section rate by primary report
Primary caesarean section
Repeat caesarean section
Total
Freq
283
191
474
Valid %%
59.7
40.2
100
Distribution of caesarean section by timing
Emergency caesarean section
Freq
215
Valid %%
44.98
87
Elective caesarean section
Total
263
478
53.02
55.02
Distribution of caesarean section by rank
Freq
No previous primary caesarean 283
section
1 previous scar
136
2 previous scar
40
3 previous scar
10
4 previous scars
1
Total
474
Overall indication of caesarean section
Repeat caesarean section
Malpresentation / malposition
Fetal distress
Dystocia
Obstetric hemorrhage
PET/IUGR
Myomectomy / fibroids
BOH
Reduced fetal movements
Request
ROV
Previous uterine perforation
Elderly prigravida
HIV +
Congenital mal
HSIL
Vaginal cept
Spinal injury
Valid %%
59.7
28.6
9.2
2.1
0.2
100
n = 478
Freq
191
61
58
65
29
24
9
5
17
1
1
2
2
1
2
1
1
1
Valid %%
40.2
12.76
12.13
13.6
6.07
5.02
1.88
1.05
3.56
0.21
0.21
0.41
0.41
0.21
0.41
0.21
0.21
0.21
Indication for primary caesarean section n = 283
Malpresentation/malposition
 Breech
 OPP
 Transverse lie
 Fake topubes
 Unstable lie
 Shoulder
 Compound
Fetal distress
29
20
5
4
1
2
21.56Valid %%
58
88
20.50Valid %%
Dystocia







Contracted pelvis
CPP
Poor progress
Cervical dystocia
Failed vacuum
Prolonged labor
Obstructed labor
4
53
4
2
2
22.97
Obstetric hemorrhage
 Abruptio placenta
 Placenta previa
 Placenta increta
 APH
 ROV
16
2
1
1
10.25Valid %%
PET/IUGR
 eclampsia
12+8+4
Myomectomy/ fibroids
8.48Valid %%
5+4
3.18Valid %%
BOH, reduced FM
IPS: Indications n = 136
Malpresentation/ malposition
 breech
 OPP
 Obline
 Transverse
 Placenta topuses
 Unstable lie
Fetal distress
7
1
1
1
7.35Valid %%
4
2.94Valid %%
Dystocia
 CPD
 Poor progress
 Dystocia
 Failed vacuum/forceps
 Failed trial
 Contracted pelvis
36
2
1
5
89
33.83Valid %%
Obstetric hemorrhage
 Abruptio
 Placenta previa
 Placenta increta
 ROV
 Cord prolapse
PET /Hypertensive disease
 Eclampsia
 IUGR
5
1
1
1
1
5.88Valid %%
10
6
2
2
7.35Valid %%
Myomectomy
Fibroid
Previous uterine perforation
1
1
1
BOH
2.21
4
Reduced FM
2.94Valid %%
9
Others prom
6.62Valid %%
5
Unstated
3.68Valid %%
3
22.79Valid %%
IPS (unqualified) Number = 30
IPS (unqualified) + BTL = 6
90
CORRECTIONS FORR ALLAN
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