Introduction:
Caesarean delivery is most commonly performed obstetric surgeries and the number of women having babies born by caesarean section (CS) is rapidly growing in both the developed and developing countries.(1) Cesarean delivery can be life saving intervention for both mother and fetus in several cases like multiple gestation, fetal malpresentation, placenta abruptio etc. World Health Organization (WHO) states that 15% should be the maximum and that no region in the world is justified with having a ceasarean rate greater than 10% to 15%.(2) According to Nepal Demographic Health Survey (NDHS) 2011, the percentage of cesarean section is 5%, and out of them 12% were planned.(3)
Induction of labor is an important aspect of obstetrics practice and is needed in cases where continuing pregnancy may adversely affect the fetus, mother or both and after 40 weeks to prevent complications of post maturity. WHO recommends induction be performed with a clear medical indication and when expected benefits outweigh potential harms.(4,5) Prostaglandins are most commonly being used for medical induction of labor and are in use since 1987 and has a better outcome as it ripens the cervix along with stimulating myometrial contractility.(4) The Royal College of Obstetricians and Gynaecologists (RCOG)/National Institute for Health and Clinical Excellence (NICE) guidelines recommend that women should be offered induction after 41 weeks to avoid the risks of post-term pregnancy, primarily, increased intrauterine fetal death.(6) One recent systematic review showed that a policy of labour induction for women with post-term pregnancy compared with expectant management is associated with fewer perinatal deaths and fewer cesarean sections.(7)
There are limited number of studies which assess the CS pattern and its major indications. This study aims to study the patterns of CS and medical induction of labor in district hospital and its associated perinatal outcomes.
Methods
Hospital based cross-sectional study was done where all hospital deliveries for the period of 6 months (15th May- 15th Nov, 2013) were recorded and analysed. Study was conducted on Comprehensive Emergency Obstetric and Neonatal Care Centre of Khandbari Hospital, Sankhuwasava. Secondary data was collected from the hospital registers. The data included types of delivery, age at delivery, gestational weeks at delivery, medical induction, neonatal and maternal outcomes, complication associated with caesarean, major indications of CS etc. Cases with severe oligohydramnios [with Amniotic Fluid Volume (AFV) < 3cm] were electively operated and cases with AFV > 3cm without any other contraindication were medically induced. Medical Induction of Labor was done among those pregnant women who were not in labor, but needed termination of pregnancy at the earliest possible times. According to NICE Guidelines, Tablet Misoprostol 50mcg PO q6hour x 6 doses (max.) was used for the induction of the labour.
All data were entered in the master chart prepared in MS Excel and descriptive statistics like mean, proportion etc were used to describe the characteristics of recorded deliveries. Data were analysed using Epi Info 7. Bivariate association between several independent variables and types of delivery and medical induction of labor was assessed using chi- square test at 95% confidence interval (p value <0.05 was considered statistically significant). Ethical clearance for study was obtained from Hospital Ethical Review Board. Confidentiality and anonymity was maintained throughout the study process.
Results
Deliveries conducted in the hospital for the period of six months were analysed. Out of 369 total deliveries, nearly one in every five cases (18.5%) were delivered by cesarean section. Very less number of deliveries (1.6%) was assisted through the use of vaccum.
Table 1 Distribution of types of deliveries in study period (n=369) |
| Types of delivery |
Frequency |
Percent |
Vaginal Delivery |
295 |
80 |
Spontaneous Vaginal Delivery |
103 |
34.9 |
Vaginal Delivery with Episiotomy |
138 |
46.8 |
Vaginal Delivery with Tear |
54 |
18.3 |
Assisted Vaginal Delivery (Vaccum) |
6 |
1.6 |
Cesarean Section |
68 |
18.4 |
Elective CS |
25 |
37.8 |
Emergency CS |
43 |
63.2 |
Table 2: Indication of Cesarean Section (n=68) |
| Indications |
Emergency CS |
Elective CS |
Total |
Spontaneous Labor |
Medical Induction |
Oligohydramnios |
1(1.5) |
0 |
18(26.5) |
19 (27.9) |
CPD |
16 (23.5) |
3 (4.4) |
2(2.9) |
21 (30.9) |
Placenta Previa |
1(1.5) |
0 |
0 |
1(1.5) |
SPOL |
5 (7.5) |
2(2.9) |
0 |
7 (10.3) |
Failed induction |
0 |
0 |
2(2.9) |
2(2.9) |
Mat. Distress |
0 |
1(1.5) |
0 |
1(1.5) |
Previous Caesarean |
1(1.5) |
0 |
1(1.5) |
2(2.9) |
PROM |
0 |
0 |
1(1.5) |
1(1.5) |
Malpresentation/Malposition |
5 (7.5) |
0 |
3(4.4) |
8 (11.8) |
Meconium- stained Liquor |
17 (25.0) |
5 (7.5) |
0 |
22 (32.4) |
(Figures in parenthesis indicates percentages)
(Total percent exceeds hundred as single case may have multiple indications) |
Above table illustrates that major indication for CS was meconium stained liquor accounting for 32.4% (22) and while considering the mother related factors, oligohydramnios (27.9%) was found to be the most common indication for cesarean. In case of medically induced cases, the major indication for CS was meconium stained liquor (7.5%) which was followed by CPD (4.4%).
Table 3: Types of labor according to gestational age (n=369) |
| Types of labour |
Gestational Age in weeks |
<32 weeks |
32-36 weeks |
37-41 weeks |
>41weeks |
Total |
Spontaneous Labour |
7(1.9) |
16 (4.3) |
220 (59.6) |
55 (14.9) |
298 (80.8) |
Medical Induction |
1(0.3) |
1(0.3) |
12 (3.3) |
32(8.7) |
46 (12.5) |
Elective CS |
0 |
0 |
8 (2.2) |
17(4.6) |
25 (6.7) |
Most of the cases (240, 65.1%) delivered at term (37-41 weeks) while just above the quarter of total deliveries (104, 28.2%) were post dated i.e. greater than 41 weeks. Out of total deliveries, significantly large proportion of women (80.8%) were found to enter into spontaneous labor while 46 (12.5%) of cases were medically induced with oral misoprostol. There were two IUFD cases which were medically induced and delivered before reaching to term i.e. 36 weeks. It was found that major indication for medical induction was postdated pregnancies and out of 46 medically induced cases, nearly a quarter (11, 23.9%) was delivered by cesarean section.
Table 4: Bivariate analysis |
| Independent variables |
Dependent Variable |
p- value |
COR (95% CI) |
Meconium stained liquor |
Types of Delivery |
<0.001 |
3.39 (1.82-6.33) |
Cesarean Section |
Vaginal Delivery |
Yes |
21 (30.9) |
35 (11.6) |
No |
47 (69.1) |
266 (88.4) |
Gestational Weeks at Delivery |
Types of labor |
|
|
Non-Spontaneous# |
Spontaneous |
<0.001 |
9.84 (5.50-17.61) |
>= 41 weeks |
49 (69.0) |
55 (18.5) |
<41 weeks |
22 (31.0) |
243 (81.5) |
Numbers in bold indicates significant.
** p value significant at <0. 01
# Non-spontaneous labour includes medical induction and elective cesarean section. |
Chi-square test was used to see the association. It can be seen from above table that pregnancy with meconium stained liquor are more likely to end up in cesarean section (COR= 3.39, 95% CI: 1.82-6.33). There is higher risk of non spontaneous labour (medical induction or elective cesarean) in case of post dated pregnancies (COR: 9.84, 95% CI: 5.50- 17.61).
Table 5: Bivariate analysis of medical induction and its associated factors (n=344) |
| Independent variables |
Dependent variables |
p- value |
COR (95% CI) |
Types of labor |
Meconium stained liquor |
|
Yes |
No |
|
Medical Induction of Labor |
3 (6.5) |
43 (93.5) |
0.05 |
0.322 (0.01-1.07) |
Spontaneous Labor |
53 (17.8) |
245 (82.2) |
Types of labor |
Types of delivery |
|
Emergency CS |
Vaginal Delivery |
Medical Induction of Labor |
11 (25.6) |
32 (74.4) |
0.01 |
2.61 (1.21-5.64) |
Spontaneous Labor |
35 (11.6) |
266 (88.4) |
Numbers in bold indicates significant.
** p value significant at <0.01 |
Medically induced cases were less likely to have meconium stained liquor (COR=0.32, 95%CI: 0.01-1.07). However, medically induced cases are at higher odds of cesarean section (COR= 0.01, 95% CI: 2.61 (1.21-5.64).
Discussion
There has been a sustained increase in cesarean section rates around the world in the last 25 years and WHO has said that it is justified to have CS rate between 10 to 15%. (8) However, in our study, CS rate was found to be slightly higher than the recommended percentage and it was consistent with several other studies. (9, 10) Most common reason for CS was meconium stained liquor which was in agreement with several other studies. (9) It might be due to the increase in public concern about CS and Cesarean Delivery at Maternal Request (CDMR) Despite of this, in developing countries like Nepal where resources are scarce, CS if done in large numbers represent a serious resource drain and thus, it needs to be limited to the cases with absolute indications. (11)
Medical induction accounted for 12.1% of total deliveries of Asia which was similar to finding of this study.(5) The primary reason for induction of labor was found to be post dated pregnancies which was contradictory to the study from India where major indication was PROM. (12) It might be due to unbooked pregnancies and women arriving at health facilities only after crossing the expected date of delivery. Moreover, it can be hypothesized that most of the PROM cases end up in still birth in local health centers and only pregnant women with viable fetus are referred to the CEONC centre. Post dated pregnancies are more likely to end up in either medical induction or cesarean section.
Women who have medical induction of labour are at higher risk of having emergency CS which was in accordance with the study done by Arthur et. al and Seyb et al. (13,14) Consistent to our findings, induction of labor beyond forty one weeks leads to small reduction in perinatal deaths and meconium aspiration syndrome.(15, 16) There might be several possible reason for this like post dated cases with adequate liquor are timely intervened with medical induction and are closely observed by trained health professionals. In addition to this, those who enter into spontaneous labour, if found to have meconium stained liquor after rupture of membrane, they are immediately delivered with emergency cesarean section. Furthermore, those who appeared hospital beyond their EDD and with severe oligohydramnios are electively operated providing less room for fetal distress. However, studies have shown that elective induction of labor resulted in higher direct costs per patient due to requirement for more labour, delivery resources and more frequent cesarean delivery. Hence, medical induction needs to be discouraged unless benefits outweigh risks. This contradictory finding needs to be explored in detail with larger sample and longitudinal design.
Conclusion
This study can’t be generalized to all over the Nepal, however it represents the CEONC centers of rural setting and findings are applicable to the similar settings. Despite of this limitation, this study contributes to the stock of literatures highlighting the fact that CS is in increasing trend and timely medical induction might lead to either vaginal delivery or cesarean section but definitely good fetal outcome. The meconium-stained amniotic fluid was less likely to be in medically induced cases than in women having spontaneous delivery but this needs further exploration with larger extensive studies or randomized controlled trial.
Acknowledgements
Author would like to extend sincere thanks to Khandbari Hospital and staffs for providing permission and necessary support to conduct the study. Similarly, author is thankful to Ms. Anju Acharya and Mr. Khadananda Regmi for their support in data collection.
Conflict of Interest: The author reported no conflict of interest and no funding was received in this work.
Abbreviations
AFV: Amniotic Fluid Volume
CDMR: Cesarean Delivery at Maternal Request
CEONC: Comprehensive Emergency Obstetric and Neonatal Care
CPD: Cephalo-pelvic Disproportion
CS: Cesarean Section
EDD: Expected Date of Delivery
IUFD: Intrauterine Fetal Death
NDHS: Nepal Demographic Health Survey
NICE: National Institute for Health and Clinical Excellence
NPOL: Non progression of Labour
PO: Per Oral
PROM: Premature Rupture of Membrane
RCOG: Royal College of Obstetricians and Gynaecologists
WHO: World Health Organization
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