International Journal of Reproduction, Contraception, Obstetrics and Gynecology Singh N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Mar;9(3):975-980 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20200577 Original Research Article Are we operating unnecessarily?: caesarean audit in a single unit of a private tertiary care hospital in North India Nidhi Singh1*, Manjusha2 1Department of Obstetrics and Gynecology, Prasad Institute of Medical Sciences, Lucknow, Uttar Pradesh, India 2Department of Obstetrics and Gynecology, Sahara Hospital, Lucknow, Uttar Pradesh, India Received: 05 February 2020 Accepted: 11 February 2020 *Correspondence: Dr. Nidhi Singh, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Caesarean section emerged as a lifesaving surgery in situations where vaginal delivery could put the mother and fetus at risk. Over the years global rise in caesarean delivery rate has been alarming and may be attributed to changes in medical practice and societal expectations, especially in urban areas and developing countries. Rising caesarean rate is worrisome as it increases maternal morbidity, exposes the mother to future obstetric risks, besides increasing financial burden on the health care system. Caesarean audits could be an effective tool to analyse, understand and propose solutions to reduce caesarean rates. Hence, this retrospective study was conducted to audit caesarean sections done over a period of 5 years (2011 to 2015) in a single unit of a tertiary care private hospital in North India. Methods: The case records of all caesarean deliveries from January 2011 to December 2015 were analysed retrospectively for demographic profile, clinical parameters and recorded indication of caesarean section on the basis of Robson’s classification. Results: The caesarean section rate in the study was 61.8%. According to Robson’s 10 system classification, Group 2, 5 and 10 were the largest contributors. The commonest indication was previous LSCS (18.7%) followed closely by fetal distress (15.4%) and prolonged labor/failed induction (13.3%). Maternal request contributed 10.6% of the Caesarean deliveries. Conclusions: The caesarean section rate in our study is way higher than the national average. We need to re-duce caesareans in primigravidae and consider VBAC where appropriate. Use of Electronic fetal monitoring during labor needs to be optimized. Appropriate use of oxytocics, proper monitoring and using robust criterion to infer non progress of labor are important. Appropriate counselling and assured pain management during labor may help reduce caesareans on maternal request. Keywords: Caesarean section, Caesarean audit, Robson’s classification, Tertiary hospital INTRODUCTION third world countries is alarming. There is a need to audit the indications in order to find reasons for uncalled for Caesarean section (Cs) is a commonly performed surgical caesarean deliveries and devise new strategies to curb the procedure aimed to reduce maternal and perinatal trend. morbidity- mortality. Although WHO has stated that there is no benefit of Cs beyond 10-15% at community METHODS level, every fifth woman undergoes the procedure.1 The incidence of Cs has been steadily rising globally. Rise in The study was conducted at Sahara Hospital, Lucknow caesarean section rates, especially in urban set-ups in which is a state of art tertiary care and referral center. It March 2020 · Volume 9 · Issue 3 Page 975 Singh N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Mar;9(3):975-980 was a retrospective observational study conducted in a women (52.3%) were post-graduates and 36.8% were single consultant unit of obstetrics and gynecology skilled professionals (Table 2). Most women in our department of the hospital. The study period was from 1st cohort (95%) had singleton cephalic pregnancies while January 2011 to 31st December 2015. All patients who only about 5% had fetal malpresentations/ multiple delivered during this period were identified from the birth pregnancies. register and the case records of all caesarean deliveries conducted in the unit during the study period were Table 1: Year-wise CS rate. analysed. Total no. of Number of Year % CS Data was collected to include the demographic profile of deliveries CS patients (age, educational qualification, profession, 2011 97 52 53.6% religion), details of pregnancy (parity, gestational age, 2012 107 64 59.8% singleton or multiple pregnancy, lie and presentation, 2013 142 95 66.9% previous caesareans, high risk factors), intrapartum 2014 135 87 64.4% events, mode of delivery and indications of caesarean 2015 116 71 61.2% section. Total 597 369 61.8% Indications were then classified using Robson’s ten group Table 2: Demographic profile of women delivering by classification system as follows. caesarean section during the study period. • Group 1: Nulliparous, single cephalic, >= 37 weeks, Number Percentage in spontaneous labour. Age • Group 2: Nulliparous, single cephalic, >= 37 weeks, 15-20 2 0.5% induced (including pre-labour CS). 21-25 71 19.2% • Group 3: Multiparous (excluding previous CS), single cephalic, >= 37 weeks, spontaneous labour. 26-30 200 54.2% Group 4: Multiparous (excluding previous CS), 31-35 85 23.1% single cephalic, >= 37 weeks, induced labour 36-40 11 3% (including pre labour CS). Parity • Group 5: Previous CS, single cephalic, ≥ 37 weeks. Primigravida 192 52.2% • Group 6: All Nulliparous breeches. P1 118 31.9% • Group 7: All multiparous breeches (including >= P2 59 15.9% previous CS). Education • Group 8: All multiple pregnancy (including previous Post-grad 193 52.3% CS). Graduate 154 41.8% • Group 9: All transverse/ oblique lies (including <= 12 grade 22 5.9% previous CS). Profession • Group 10: All preterm single cephalic, < 37 weeks Homemaker 233 63.2% including previous CS. Working profession 136 36.8% Religion Robson’s Classification was used firstly to identify the Hindu 313 84.8% group of patients with increased rate of caesarean delivery. Secondly, to help in the audit process so that Muslim 51 13.8% trends in caesarean section rates can be monitored over Sikh 3 0.8% time and lastly to identify the low risk cohort of women Christian 1 0.2% who could be targeted to reduce caesarean section rate by Buddhist 1 0.2% changing intrapartum protocols. The commonest indication of Cs was previous LSCS RESULTS (18.7%), followed by fetal distress (15.4%) and prolonged labor/ failed induction (13.3%). Maternal The number of deliveries conducted in our unit from 1st request was the reason for 10.6% of the Caesareans in the January 2011 till 31st December 2015 were 597. Out of study period. Around 18.9% caesareans were contributed these, 369 were caesarean deliveries for various reasons, by other indications like PPROM with severe making the overall Cs rate as 61.8%. The Cs rate oligohydramnios or impending chorioamnionitis, IUGR increased from 53.6% (in 2011), to peak at 66.9% (in with absent diastolic umbilical flow, precious pregnancy 2013) and then decreased to 61.2% (in 2015) (Table 1). and large babies. Few special cases included pregnancy with bilateral ovarian masses, metastatic disease, The majority of women were in the age group 26-30 maternal heart failure (Table 3). years (55%) and were primigravidae (52.3%). Majority of International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 9 · Issue 3 Page 976 Singh N et al. Int J Reprod Contracept Obstet Gynecol. 2020 Mar;9(3):975-980 The data collected was then analyzed using Robson’s ten were due to non-progress of labour, 16.9% for fetal group classification system to enable scientific distress, 13.8% were due to maternal request to convert, evaluation, identify shortcomings and devise strategies to 10.8% were due to nuchal cord related issues, 10% due to improve practices (Table 4). The single largest cephalo-pelvic disproportion, 5.4% were hastened due to contributor of Cs in our study was Group 2 i.e. impending eclampsia and 11.5% due to miscellaneous nulliparous women with single-ton cephalic fetus, reasons. induced at term (35.3%). Within this group, 31.5% cases Table 3: Year-wise caesarean section rate according to indications. All five years Indications for 2011 n = 52 2012 n = 64 2013 n = 95 2014 n = 87 2015 n = 71 (2011-2015) n = caesarean section (%) (%) (%) (%) (%) 369 (%) Fetal distress 9 (17.3%) 11 (17.1%) 7 (7.36%) 24 (27.5%) 6 (8.5%) 57 (15.4%) Previous LSCS 13 (25%) 10 (15.6%) 18 (18.9%) 10 (11.4%) 18 (11.3%) 69 (18.69%) Malposition or 2 (3.8%) 2 (3.1 %) 6 (6.3%) 3 (3.44%) 4 (5.63%) 17 (4.6%) malpresentation Prolonged labour/failed 7 (13.4%) 12 (18.7%) 14 (14.7%) 7 (8.04%) 9 (12.6%) 49 (13.3%) induction Maternal request 8 (15.3%) 9 (14.1%) 10 (10.5%) 9 (10.3%) 6 (8.5%) 39 (10.6%) Cephalopelvic 3 (5.7%) 3 (4.6%) 6 (6.3%) 6 (6.9%) 6 (8.5%) 24 (6.5%) disproportion Hypertensive disorders 4 (7.6%) 5 (7.8%) 11 (11.6%) 8 (9.2%) 5 (7.04%) 33 (8.9%) of pregnancy Antepartum 1 (1.9%) 4 (6.2%) 2 (2.1%) 1 (1.5%) 2 (2.8%) 10 (2.7%) haemorrhage (APH) Bad obstetric history 4 (7.6%) 1 (1.5%) 1 (1.1%) 1 (1.5%) 1 (1.4%) 8 (2.1%) (BOH) Others 1 (1.9%) 12 (18.7%) 20 (21.1%) 18 (20.6%) 14 (19.7%) 70 (18.9%) Table 4: Robson’s ten system classification with contribution of each group in the overall caesarean section rate.