Feto-maternal Outcomes of Emergency Caesarean Section following Residential Posting at Dhading District Hospital

ABSTRACT Introduction Caesarean section is a commonly performed major obstetric surgery to deliver baby under certain indications which may be maternal or fetal. If performed timely, it is helpful to save the life of mother and fetus and if not, it increases both maternal and fetal risks. Methods A hospital based descriptive cross-sectional study was conducted at Dhading district hospital from 17th October 2016 to 17th October 2017. Total of 41 patients undergoing emergency caesarean section meeting the selection criteria were included. Results The incidence of emergency caesarean section was 41 (5.5%). Most common indication for caesarean delivery was fetal distress in 12 (29.3%) followed by failed induction and cephalopelvic disproportion each accounting 6 (14.6%) cases. The least common causes being chorioamnionitis and cord prolapse in 1 (2.4%). Regarding perinatal outcomes, 33 (80.5%) babies delivered were of normal weight. Low Apgar score (<7) at one minute was noted in 8 (19.5%) cases. Neonatal resuscitation in the form of oxygen supplementation was required in 2 (4.9%) cases whereas bag and mask ventilation was required in 5 (12.2%) cases. Referral for neonatal intensive care unit admission was done in 6 (14.6%) cases. There were three neonatal deaths. Conclusions Residential posting was fruitful to decrease feto-maternal morbidities and mortalities. Even to minimize the delay of treatment, government should provide adequate equipments and skilled man-power to run neonatal intensive care unit.

Feto-maternal Outcomes of Emergency Caesarean Section following Residential Posting at Dhading District Hospital

INTRODUCTION
Caesarean section (CS) represents the most significant obstetric operative intervention. 1 CS is defined as delivery of fetus through incision in abdominal and uterine wall after fetal viability. [2][3][4] The ideal CS rate is between 10-15%. 5 CS rate in Nepal has increased from 5% in 2011 to 9% in 2016. 6 Rate of CS has increased worldwide in recent years due to increased safety of procedure. 1,4,7 Rise in CS rate has become a public health concern. 3 Caesarean delivery is the marker for availability and use of obstetric services. 8 Globally, CS has markedly improved maternal and fetal outcomes of pregnancy. 1 Gestational age at CS and indications determine perinatal outcomes of emergency CS. 9 This article reflects the improved impact on maternal and fetal outcomes provided by residential posting and their importance in district hospitals to overcome the shortage of skilled man-power.
This study was conducted to evaluate the feto-maternal outcomes of emergency CS following community posting of Doctor of Medicine (MD) -Obstetrics and Gynaecology (OBG) Residents.

METHODS
A hospital based descriptive cross-sectional study was conducted at Dhading district hospital from 17 th October 2016 to 17 th October 2017. Permission for data collection was taken from hospital authority. All 41 patients undergoing CS by the MD-OBG Residents under community posting scheme of National Academy of Medical Sciences (NAMS) during the study period were included in the study. Data were collected by reviewing the hospital records. Operation theatre register and operative notes were checked in addition to admission sheets and out-patient and in-patient registers to get information on maternal age, parity, number of antenatal checkup (ANC) visits, gestational age at CS, indication of CS, maternal complications, presentation of baby, birth weight of baby, sex of baby delivered, interval between accomplishment of CS and start of breastfeeding, Apgar score at one minute, requirement of neonatal resuscitation or not and mode in required cases, need for neonatal intensive care unit (NICU) referral, neonatal injury during CS, neonatal sepsis, neonatal seizure, neonatal death (NND) and its relation to birth and duration following birth. Post-mortem of neonates that died was not done. To describe variables, statistical tools of absolute numbers, percentages, mean, rate and ratio are used. The data obtained were analyzed with statistical package for social sciences (SPSS), version 16 and presented in tables.

RESULTS
The prevalence of emergency CS was 5.5% (41 of 752 deliveries). Almost half that is 19 (46.4%) cases of the CS occurred in maternal age group of 20-25 years with mean age of 23 years. CS in primigravida accounted in 27 (65.9%) cases. Booked cases undergoing CS were 28 (68.3%). The commonest gestational age for CS was 39-41 weeks in 20 (48.7%) with mean gestational age of 40.6 weeks ( Table 1). Most common indication for CS was fetal distress in 12 (29.3%) followed by failed induction and cephalopelvic disproportion (CPD) each accounting for 6 (14.6%) cases. The least common identified causes were chorioamnionitis and umbilical cord prolapse each accounting for 1 (2.4%) case (Table 2). Prolonged II nd stage 2 (4.9%) As many as 37 (90.3%) cases were devoid of maternal complications and only two cases of postpartum haemorrhage (PPH) required blood transfusion (BT) to maintain haemoglobin level >8gm%. One case each was of puerperal pyrexia and wound infection (Table 3). Regarding fetal outcomes, the most common presentation was vertex in 37 (90.3%) cases and 33 babies 33 (80.5%) delivered were of normal weight. In this study, 24 (58.5%) newborns were male. Breast feeding was started within one hour of life in 36 (87.8%) neonates (Table 4). Low Apgar score (<7) at one minute was noted in 8 (19.5%) cases. Neonatal resuscitation in the form of oxygen supplementation was required in 2 (4.9%) cases whereas bag and mask ventilation (BMV) was required in 5 (12.2%) cases. Referral for NICU admission was done in 6 (14.6%) cases. There were three NNDs each accounting for fresh still birth, NND within and after 24 hour of life (Table 5).

DISCUSSION
The prevalence of emergency CS in this study was 5.5% whereas it varied widely in different studies conducted by Onankpa et al (8.4%), 10 Shah et al (8.8%), 8 16 Benzouina et al, 3 Moges et al, 4 and Nnadi et al. 1 Higher CS rate in primigravida is due to common indications like fetal distress/cephalopelvic disproportion, maternal request, risk of medico-legal issues and limited resources/man-power for intrapartum monitoring leading to more liberal use of CS to deliver babies that are at high risk of intra-partum compromise 9 whereas in multipara higher CS rate is due to disproportion from fetal malposition and malpresentation along with high practice of elective repeat caesarean delivery as compared to trial of labour.  1 the major culprit in later one being puerperal sepsis. Prolonged prelabour rupture of membrane (>18 hours), multiple digital vaginal examinations without maintaining asepsis, late referral, restricted and injudicious use of antibiotics in these patients may be some of the many contributing factors for sepsis. Correct use of partograph in the peripheral health centers is of paramount importance as it would have detected labors deviating from the normal course and facilitated early referral even decreasing cases of puerperal sepsis from prolonged labor. 1 In this study, reduced post-operative complications may be attributed to timely use of uterotonics, easy availability of blood and blood products, improved anaesthetic techniques and routine use of prophylactic antibiotics.
The sex ratio of male to female in this study was 1.  1:1). 3 The relatively high number of male child may be attributed to illegal but increased sex selective abortion of female fetus.
In this study, Apgar score of <7 at one minute was noted in 19.5% cases which was comparable to study done by Grace et al 9 13.13%. Another study by Bhandari 14 reported Apgar score of <5 in 10.8% babies which was analogous to this study (9.7%). Apgar score <5 was noted in 52.43% cases by Nnadi et al. 1  There is emerging evidence that in term, appropriately grown babies, the cerebro-umbilical ratio and umbilical venous flow rate 19,20 may be helpful in identifying pregnancies at risk of intra-partum compromise requiring emergency CS for delivery. It has recently been demonstrated that the likelihood of death on the day of birth exceeds that of any other day until the tenth decade of life. 21 This hospital also serves as referral centre for sub-health posts, health post and primary health care centres of Dhading district and it is established fact that overall maternal mortality and stillbirths are high in facilities receiving many referrals. High emergency cesarean delivery rates were associated with increased fresh stillbirths, NNDs and severe neonatal morbidity. Majority of emergency CS performed for labour dystocia and fetal distress resulted in a significant proportion of the perinatal deaths. Severe newborn morbidity was related to birth asphyxia secondary to prolonged labor and late interventions to prevent perinatal morbidity and mortality. Close monitoring of labor, early detection of complications and timely decision for caesarean delivery are crucial. 8 Since it was a hospital based study, all data for long term follow-up could not be presented. The time duration of study was less considering the volume of deliveries and caesarean sections.
The good part of this study is that it has highlighted the status regarding health delivery system of district hospitals of the country in terms of maternal and fetal outcomes and has provided chances for improvement. This study could be prolonged to know the facts and figures better.

CONCLUSIONS
Residential posting was fruitful to decrease maternal and fetal morbidities and mortalities as compared to records of previous years. Emergency CS should be performed uninterruptedly and in liberal way as per valid indications to improve maternal and fetal outcomes. To uplift the figure in terms of maternal and fetal status, it is essential to minimize the delay in treatment by improving transportation facilities and setting up NICU and maternal ICU services with adequate skilled manpower at local level. Residents should be posted at district hospital to supplement the specialist and not to replace them. Government should be aware that residents should work under supervision of seniors and should not be employed as specialist to fill the vacuum. Residential posting should not avoid creating necessary vacancies of specialist doctors.