|Year : 2018 | Volume
| Issue : 1 | Page : 14-17
A five-year survey of cesarean delivery at a Nigerian tertiary hospital
Isah AD, Adewole N, Zaman J
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, PMB 228, Abuja, Nigeria
|Date of Web Publication||12-Apr-2018|
Dr. Isah AD
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, PMB 228, Abuja
Source of Support: None, Conflict of Interest: None
Background: Caesarean section is one of the most commonly performed surgical procedures in obstetrics and certainly one of the oldest operations in surgery; the incidence of caesarean section is steadily rising. The increasing use of CS as a mode of delivery is due to improved safety of the procedure because of increasing use of antibiotics, blood availability, and improved anesthetic techniques. Despite all these, problems of safety and cost still pose some concern, particularly in resource-poor countries.
Objective: To evaluate the incidence, indications, and outcomes of caesarean section in this hospital during the period under review.
Materials and Methods: This is a retrospective descriptive analysis of all the caesarean sections carried out at the University of Abuja Teaching Hospital, Gwagwalada from 1st January 2012 to 31st December 2016. The labor ward delivery register and theatre operation register were also reviewed. The nature and indications for the procedure were analyzed. Other parameters reviewed included booking status of the patient, parity, and fetal outcome. Results were presented using simple percentages and ratios.
Results: Out of 9,604 deliveries during the study period, 2,053 cases were by caesarean section, giving a caesarean section rate of 21.4%. Most cases 1647 (80.2%) were by emergency caesarean sections and elective caesarean section accounted for 406 (19.8%) cases. The rate of caesarean section was higher among unbooked patients 1304 (63.5%) than booked patients 749 (36.5%). Cephalopelvic disproportion was the most common indication 633 (30.8%) followed by fetal distress 484 (23.6%) and severe pre-eclampsia/eclampsia 224 (10.9%). Anemia was the most common postpartum morbidity and there were 17 maternal deaths and the maternal case fatality rate was 0.8%, and there were 62 (2.9%) perinatal deaths due to birth asphyxia following emergency caesarean section.
Conclusion: The rate of caesarean section has been increasing gradually and is associated with maternal and perinatal morbidity and mortality. There is need for education of the populace to reduce late presentation.
Keywords: Cesarean section; incidence; indications; outcomes
|How to cite this article:|
AD I, Adewole, Zaman. A five-year survey of cesarean delivery at a Nigerian tertiary hospital. Trop J Obstet Gynaecol 2018;35:14-7
| Introduction|| |
Caesarean section refers to the delivery of the fetus, placenta, and membranes through an abdominal and uterine incision. The first documented caesarean section on a living person was performed in 1610. The high rate of caesarean section in the United States is related to the small family size and probably the fear of medicolegal repercussion if not performed. The incidence is about 15% to 21% in most West African countries and would have been higher if there had not been acceptance of vaginal birth after caesarean section and some types of breech presentations. However, the incidence is about 20 to 30% in most teaching hospitals in Nigeria. The high rate of caesarean section in the tropics is due to fetopelvic disproportion and obstructed labor. The Teaching hospitals, for example in Nigeria, have a higher caesarean section rate because they serve as referral centres, and therefore, have higher risk patients concentrated in them. In Midland Province of Zimbabwe, variation has been shown as well, where they found that interhospital differences in caesarean section rate ranges from 2.2% to 16.8% per 100 deliveries, which could not be accounted for by differing numbers of high-risk pregnancies.
The incidence of caesarean section is steadily rising. Apart from the increased safety of the operation due to improved anesthesia, availability of blood transfusion and antibiotics, the other responsible factors are decline in operative vaginal delivery, decline in vaginal breech delivery, fear of litigation in Obstetric practice, identification of at risk mothers, and wider use of repeat caesarean section in cases with previous caesarean delivery. Also elective caesarean deliveries are increasingly being performed for a variety of indications including for pelvic floor injuries associated with birth, medically indicated preterm birth, to reduce the risk of fetal injury and for patient request. Other reasons are malpractice litigation, the use of electronic fetal monitoring, prevalence of obesity has risen dramatically and obesity increases the risk of caesarean delivery. The rate of labor induction continues to rise, and induced labor, especially among nulliparas, also increases the risk of caesarean delivery.
Aim of the study
The aim of this study is to evaluate the incidence, indications, and outcomes of caesarean section in this hospital during the period under review.
| Materials and Methods|| |
The case records of patients delivered by caesarean section between 1st January 2012 and 31st December 2016 were reviewed. The labor ward delivery register and theatre operation register were also reviewed. The nature and indications for the procedure were analyzed. Other parameters reviewed were the booking status of the patients, parity, and fetal outcome. Results were presented using simple percentages and ratios.
| Results|| |
During the period under review, [Table 1] shows different methods of delivery that were employed. Spontaneous vertex vaginal delivery was the most common (73.8%) while caesarean section was next (21.4%) of the total deliveries. Other methods of delivery were assisted breech (2.8%), vacuum (1.4%), forceps (0.7%), and destructive (0.05%). [Table 2] shows the age distribution of patients who had caesarean deliveries. The age group 25–29 had the highest caesarean section rate of 37.1% follow by the age group of 30–34 (28.2%) and 20–24 (17.4%). Other age group 15–19 accounted for 2.9%, 35–39 (10.4%), and 40+ (4.0%). Primigravida had the highest rate of 37.1%. There appears to be a fall in caesarean section rate with increasing parity, as showed in [Table 3].
There was a gradual increase in caesarean section rate from 24.2% in 2012 to 24.3% in 2013 with a drop in 2014 (19.9%) to 2015 (19.6%) and an increase in 2016 (20.2%), as showed in [Table 4]. The overall caesarean sectionrate for the period studied was 21.4%. Emergency caesarean section formed the bulk of the procedure 80.2% while 19.8% accounted for elective cases as seen in [Table 5]. From [Table 6] it can be seen that, out of a total of 2,053 patients who had C/S, 63.5% were unbooked which comprised cases referred from other hospitals/clinics or from traditional birth attendants (TBA) or from churches while the remaining 36.5% were booked.
Cephalopelvic disproportion was the most common indication for caesarean section 686 (33.4%), followed by fetal distress 484 (23.6%), severe pre-eclampsia/eclampsia 224 (10.9%), prolonged obstructed labor 201 (9.8%), and antepartum hemorrhage 180 (8.8%). Others include breech presentation 94 (4.6%), 2 previous caesarean sections 72 (3.5%), multiple gestation 32 (1.6%), and others 30 (1.5%), as seen in [Table 7].
Majority of the babies 1667 (79.9%) were delivered by emergency procedure. Five hundred and eighty-eight (28.2%) had birth asphyxia and there were 62 (2.9%) perinatal deaths. All the perinatal deaths and 550 (93.5%) of birth asphyxia were following emergency procedure [Table 8].
Anemia was the most common maternal morbidity occurring in 416 (20.3%) women followed by pyrexia 380 (18.5%) and wound infection 118 (5.7%) [Table 9]. There were 17 cases of maternal deaths recorded in the study period giving a case fatality rate of 0.8%. All the cases of maternal deaths were referred cases. Twelve died of postpartum hemorrhage, and the remaining 4 died of eclampsia.
| Discussion|| |
The overall caesarean section rate of 21.4% in this study is consistent with data from other Teaching Hospitals in Nigeria. However, the incidence is about 20 to 30% in most teaching hospitals in Nigeria, it varies between under 5% and upto 75% around the world. However, there seemed to be decrease in the yearly rates of the procedure from 2012 to 2016, with a slight increase in 2016. The current figure of 21.4% is lower than the 23.1% and 27.6% obtained in a similar study in Shagamu in 2004 and in Enugu in 2011, respectively., Also the rate is much higher than the one obtained in lle-lfe 12.2% in 1983 and 18.0% in Jos in 2002, respectively. These are variations within the same country.
The increasing incidence of caesarean section in this center (though with slight drop between the years) is not far from what obtains in different parts of the world. The high rate of caesarean section in the United States is related to the small family size and probably the fear of litigation if not performed. The high rate of caesarean section in the tropics is due to cephalopelvic disproportion and obstructed labor. The teaching hospitals in Nigeria, including ours, have a higher caesarean section rate because they serve as referral centre, and therefore, have higher risk patients concentrated in them. Therefore, the increase in caesarean section rate in our environment may be due to other factors. For example, it was observed in this study that the increasing number of caesarean sections were due to cephalopelvic disproportion (33.4%). Although cephalopelvic disproportion has always been the foremost indication for caesarean deliveries in developing countries, it is becoming obvious that its contribution to the procedure is on the rise. A possible explanation is that mothers who because they were malnourished, had smaller pelvics, or even normal pelvic now live in a relatively more affluent era and therefore give birth to bigger babies. Other possible reasons which can be advanced for the steadily increasing caesarean deliveries in our hospitals include the specialist nature of Teaching Hospital. There is a shift of high risk deliveries from the General Hospital, private clinics and maternity homes, traditional birth attendants  and churches to teaching hospitals.
The emergency caesarean section accounted for 80.2% of the total caesarean sections in this study which is low when compared with 91.5% obtained in llorin 2001 and the 93% reported in Zaire in 1996. The possible explanation for this would be that they serve as referral centres for other health facilities.
The post operative complications recorded were seen in the unbooked cases. This may explain why there were more deaths in that group; many of them only presented in labor with complications or were referred from General hospitals and private hospitals after complications had set in. Lack of antenatal care and late presentation in labor have been identified by many authors as being among the major predisposing factors to maternal death.
From this study, there were more caesarean sections in primigravida and low parity women than the grandmultiparous women, probably because labor is usually faster and smoother in the latter. Cephalopelvic disproportion (33.4%) was the most common indication higher than the finding in Gombe (20.8%).
Also from this study, perinatal outcome and complications associated with elective and emergency caesarean section was examined. The perinatal outcome was poorer with emergency caesarean section as most emergency cases were referred and there would have been development of severe fetal distress from prolonged labor before referral.
The post-operative complication of caesarean section in this study agreed with study from Enugu. Anemia in our study accounted for 20.3% while in Enugu it accounted for 32.5% followed by pyrexia 18.5% (in Enugu 24%) and wound infection 5.7% (in Enugu 9%). There were seventeen maternal deaths recorded during this study. The high case fatality rate following caesarean sections were due to emergency cases that were referred from other hospitals and unbooked cases.
| Conclusion|| |
This study demonstrated that Cephalopelvic disproportion, Fetal distress, Severe preeclampsia/eclampsia, prolonged obstructed labor and antepartum hemorrhage were the most common indications for caesarean section. Emergency caesarean section accounted for most of the cases and is associated with increased maternal and perinatal morbidity and mortality. Late presentation is associated with poor fetal outcome. Education of the populace about supervised pregnancy and delivery will reduce maternal and perinatal morbidity and mortality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Incerpi MH. Caesarean section. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, editors. Current diagnosis and treatment Obstetrics and Gynaecology. 10th
ed. New York: McGraw Hill; 2007. pp 469-75
Kwawukume EY. Caesarean section. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive obstetrics in the tropics. 1st
ed. Asante and Hittscher printing press; 2002. pp 321-9.
Broadhead TJ, James DK. Worldwide utilization of caesarean section. Fetal Maternal Med Rev 1995;7:99-108.
Agboola A. Caeserean section. Textbook of Obstetrics and Gynaecology for Medical Students. 2nd
ed. Heinemann Educational Books Nig. Plc; 2006. pp 495-503.
Muylder XD, Amy JJ. Caesarean section rates in an African country. Paediatr Perinat Epidemiol 1993;7:234-44.
Dutta DC. Operative Obstetrics. In: Textbook of Obstetrics. 6th
ed. New central book Agency (P) Ltd: Calcutta, India; 2004. pp 36:588-97.
Ananth CV, Joseph KS, Oyeles Y. Trends in preterm births and perinatal mortality among singletons: United States 1989 through 2000. Obstet Gynecol 2005;105:1084.
Willams JL, Barry SS, Feizal W. Caesarean section. In: Stromme D, editor. Operative Obstetrics. 4th
ed. New York; 1982. pp 15: 599-658.
Oladipo OT, Sotunsa JO, Sule-Odu AO. The rise in caesarean birth in Sagamu, Nigeria: Reflection of changes in obstetric practice. J Obstet Gynecol 2004;24:377-81.
Ugwu EOV, Obioha KCE, Okezie OA, Ugwu AOA. Five-year Survey of Caesarean Delivery at University of Nigeria Teaching Hospital, Enugu, Nigeria. Ann Med Health Sci Res 2011;1:77-84.
] [Full text]
Makinde OO. A review of caesarean section at University of Ife Teaching Hospital, Ile-Ife (1982–1983). Trop J Obstet Gynaecol 1987;6:26-30.
Aisian AO, Lawson JO, Adebaya AA. A five-year appraisal of caesarean section in a Northern Nigeria University Teaching Hospital. Niger Postgrad Med J 2002;9:146-50.
Adewumi OA. Maternal mortality in Ibadan city 1982. West Afr J Med 1986;5:12-27.
Etuk SJ, Itam IH, Asuquo EEJ. Role of spiritual churches and antenatal clinic default in Calabar, Nigeria. East Afr J 1999;76:639-42.
Ijaiya MA, Aboyeji AP. Caesarean Delivery: The trend over a Ten-year period at Ilorin, Nigeria. Nig J Surg Res 2001;3:11-8.
Onsrud L, Onsrud M. Increasing use of caesarean section even in developing countries. Tidssk Nor Loegen foen (English translator from Medline search) 1996;116:67-71.
Adetoro OO. Maternal mortality-A twelve year survey at the University of Ilorin Teaching Hospital (U.I.T.H) Ilorin, Nigeria. Int J Gynecol Obstet 1987;25:93-8.
Bukar M, Audu BM, Massa AA. Caesarean Delivery at the Federal Medical Centre Gombe: A 3-yearexperience. Niger J Med 2009;18:179-83.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]