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  578  JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 101, NO. 6, JUNE 2009 O R I G I N A L   C O M M U N I C A T I O N INTRODUCTION C esarean section still poses a lot of challenges to clinicians in low-resource settings. Fetal out-come after cesarean section is of serious con-cern, especially if part of the reason for surgery was to salvage the fetus. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk, although in recent times it has been also performed upon request  for births that would otherwise have been normal. 1  Cesarean section has been shown to be a safe operation for both the mother and the fetus, 1,3  and in many countries around the world there has been a dra-matic increase in its frequency. 1-5  Previously, the mortal-ity was almost 100% for the mother, especially in devel-oping countries with poor resources, the major causes  being infections, hemorrhage, and poor health care. 6  Improved health care delivery in terms of personnel and facilities have all contributed to the dramatic decrease in mortality seen during the last century. 6,7  In an attempt to reduce the rising trend of cesarean delivery worldwide, obstetricians now offer, among other options, the trial of labor more readily to women even a with previous his-tory of cesarean section. 5-7  Several studies both in devel-oped and developing countries have shown that it is not only feasible but safe. 1-5  This new trend is a welcome development especially in our environment, where there is a strong aversion for cesarean delivery informed by the desire of mothers to have vaginal delivery. 7,8 Despite the improved obstetric practice, considerable care is still required to maintain and improve the rates of maternal and fetal morbidity and mortality. 9-11  We have, therefore, carried out a prospective study to evaluate fetal outcome for the various indications for cesarean section in a teaching hospital in Nigeria. PATIENTS AND METHODS This prospective study was carried out at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria, between January 2006 and April 2007. The hospital has a 500-bed space and an average annual delivery rate of 2500. Ethical approval was obtained from the ethical committee of the teaching hospital  before the study was commenced.All patients that were to have cesarean section within the study period were consecutively recruited into the study. The following information were obtained using a structured questionnaire: maternal sociodemographic variables and obstetric history, fetal gender, fetal birth weight, and gestational age, with emphasis on indica-tions for the cesarean section and perinatal outcome. Author Affiliations:  Departments of Paediatrics (Mr Onankpa) and Obstet-rics and Gynaecology (Mr Ekele), Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto, Sokoto State, Nigeria. Corresponding Author:  Ben Onankpa, MBBS, FWACP, Department of Pae-diatrics, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto, Sokoto State, Nigeria (benonankpa@yahoo.com). Objective:  To evaluate fetal outcome for the various indica-tions for cesarean section.  Methodology:  A review of all cases of cesarean section that were done in the maternity unit at Usmanu Danfodiyo Uni-versity Teaching Hospital, Sokoto, Nigeria, between January 2006 and April 2007, with emphasis on indications and peri-natal outcome. Results:  There were 2562 total deliveries within the study peri-od and 112 perinatal deaths giving a perinatal mortality rate of 43.7 per 1000 live births. Cesarean section accounted for 216 of the deliveries (8.4%) with 24 perinatal deaths (11.1%). Perinatal mortality from Cesarean sections accounted for 21.4% of the total deaths with severe birth asphyxia respon-sible for most perinatal deaths, 17 of 24 (70.8%). There were 174 emergency sections with 22 perinatal deaths, while 42 elective sections had 2 perinatal deaths. The main indica-tions for cesarean section were cephalopelvic dispropor-tion, 86 (39.8%); previous section plus an obstetric abnormal-ity, 39 (18.1%); and prolonged obstructed labor, (10.2%), with perinatal deaths of 3, 2 and 11, respectively. Conclusions:  The perinatal mortality among the cesarean deliveries were 11.1%, and the main cause of death was severe birth asphyxia. Emergency cesarean section was more likely than elective to result in a perinatal loss. The indication with the poorest fetal outcome was prolonged obstructed labor. Keyword:  obstetrics/gynecology  J Natl Med Assoc.  2009;101:578-581 Fetal Outcome Following Cesarean Section in a University Teaching Hospital Ben Onankpa, MBBS, FWACP; Bissallah Ekele, MBBS, FWACS  JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 101, NO. 6, JUNE 2009 579 CAESAREAN SECTION AND FETAL OUTCOME The cadre of obstetrician/pediatricians at every surgery was also documented. The findings are presented as simple percentages and frequencies. c 2  Test, where appropriate, was used for the statistical analysis. Two-sided significance was put at less than .05. RESULTS There were 2562 total deliveries within the study  period. Males were 1,371 (53.5%), while females were 1,191 (46.5%), giving a male-female ratio of 1.2:1. Vag-inal deliveries accounted for 2260 (88.2%), instrumental vaginal deliveries were 86 (3.4%), while cesarean sec-tions were 216 (8.4%) of the total deliveries. Teenage mothers aged less than 16 years who had cesarean sec-tion were 38 (17.6%), those aged 16 to 19 years were 42 (19.4%), 20 to 29 years were 66 (30.6%), 30 to 39 years were 43 (19.9%), while those aged 40 years and above were 27 (12.5%). One hundred twelve babies died giv-ing a perinatal mortality rate of 43.7 per 1000 live births. Of the 216 cesarean sections, males were 128 (59.3%), while females were 88 (40.7%). All the cesarean sec-tions were performed under general anesthesia with a  pediatric team in attendance. Elective and emergency cesarean sections accounted for 42 (19.4%) and 174 (80.6%), respectively. Perinatal mortality from vaginal deliveries was 81 (3.6%), instrumental vaginal deliveries was 7 (8.1%), while that of cesarean sections was 24 (11.1%) of the total deaths. Emergency cesarean sections were 174, with 22 perinatal deaths, while elective cesarean sec-tions were 42 with 2 perinatal deaths (Table 1), c 2  = 2.128, p = .01131, Fisher).The main indication for cesarean section was cepha-lopelvic disproportion. There were 86 (39.8%) cases of cephalopelvic disproportion, previous section plus an obstetric abnormality were 39 (18.1%), prolonged obstructed labor was 36 (16.7%), and hypertensive dis-orders of pregnancy were 22 (10.2%) (Table 2). There were 24 perinatal deaths following the cesar-ean sections (11.1%), males were 15 (62.5%) and females were 9 (37.5%). Cephalopelvic disproportion,  previous section plus an obstetric abnormality, pro-longed obstructed labor and hypertensive disorders of  pregnancy accounted for 3 (12.5%) 2 (8.3%), 11 (45.8%) and 4 (16.7%) perinatal deaths, respectively. Of the 22 perinatal deaths following emergency cesarean sections, 77.3% (17 of 22) of the surgeries were done by trainee obstetricians, while the pediatric team at all surgeries were junior registrars (Table 3). Severe birth asphyxia accounted for 17 (70.8%) mortalities (Table 4). Prolonged obstructed labor with 30.5% (11 of 36) deaths had the poorest fetal outcome. DISCUSSION Globally, obstetric practice has witnessed an increas-ing frequency in cesarean sections with continuing growth in the last decades. 1,5,7,12  The need to curtail this alarming rate has led to increasing pressure being placed on obstetricians to alter practice. In Nigeria and in most other countries of low-resource settings, where cesarean deliveries are not readily accepted by the populace, flex-ibility within the framework of good obstetric practice is the desired goal. 1,7,8 The main indications for cesarean section in our study were cephalopelvic disproportion (39.8%) and  previous cesarean section plus an obstetric abnormality (18.1%). This is in keeping with previous findings from other centers within the country. 2,5,7  This is however, in contrast to findings from developed countries, where the common indications are previous cesarean section and, more recently, increasing maternal choice for a cesarean section for any reason whatever. 1,12-14  In this study cepha-lopelvic disproportion was the cause of prolonged obstructed labor in most of those that had prolonged obstructed labor as the indication for cesarean section. The observed high perinatal mortality rate of 43.7  per 1000 live births for our study was comparable with reports from other developing nations. 4-7  Lower values Table 1.  Caesarean Section Type and Fetal Outcome (n = 216) a,b Type of Surgery n (%) Deaths, n (%) Elective 42 (19.4) 2 (4.8) Emergency 174 (80.6) 22 (12.6) Total 216 (100) 24 (11.1) a   c 2  = 2.128 b   p  = .01131 (Fisher) Table 2.  Maternal Indications for Cesarean Section and Fetal Outcome (n = 216) Maternal Indications n Fetal Mortality, n (%) Cephalopelvic disproportion 86 3 (3.5)Previous cesarean/obstetric abnormality 39 2 (5.1)Prolonged obstructed labor 36 11 (30.6)Hypertensive disorders of pregnancy 22 4 (18.2)Postdatism 16 2 (12.5)Antepartum hemorrhage 12 1 (8.3)Others 5 1 (20.0)Total 216 24 (11.1)  580  JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 101, NO. 6, JUNE 2009CAESAREAN SECTION AND FETAL OUTCOME of less than 10 per 1000 live births have been quoted from advanced countries. 6,10,11  The overall perinatal mortality amongst the cesarean deliveries was 11.1% for the study. This is similar to fig-ures cited from studies from similar settings 2,4,5  but higher than figures from the developed countries. 9-11  Perinatal mortality following emergency cesarean sec-tions accounted for 19.6% (22 of 112) of the total peri-natal deaths within the study period. In this study, although cesarean section was only 8.4% of the total deliveries, it had higher perinatal deaths of 11.1% com- pared to 3.6% and 8.1% from vaginal and instrumental vaginal deliveries, respectively. This pattern was also found in studies from other poor-resource settings. 2,4-7  Emergency cesarean section deliveries continue to form the bulk of abdominal deliveries in our center partly  because most patients come to the hospital after an unsuc-cessful attempt at home delivery, when complications would have arisen. In some cases the fetal head is so impacted into the pelvis that delivery of the head at cesar-ean section poses an extra challenge to the surgeon. 15 Our study has shown that perinatal deaths were higher in surgeries carried out by trainee obstetricians compared to consultants. It was also noted that all the 24  perinatal deaths were attended to by pediatric junior res-idents. These observations could be attributed to the experiences of surgeons rather than operative tech-niques. 6  The type of anesthesia did not differ between the emergency cesarean sections and the elective ones. Both emergency and elective cesarean sections were done under general anesthesia.The indications with poor fetal outcome were pro-longed obstructed labor, hypertensive disorders of preg-nancy, and cephalopelvic disproportion. This pattern is similar to previous works. 2,5,6  The main cause of death was severe birth asphyxia, 17 of 24 (70.8%). Children from the group with the elective cesarean section had also less-frequent asphyxia and considerably less-fre-quent resuscitation than the children from the group with the emergency cesarean sections. The facts from the literature are similar. 6,9  There might be need to review the type of resuscitation in such babies and/or consider other options for delivery, especially in settings where aversion to abdominal delivery already exist. There is also need for more attention/supervision by consultant obstetricians and pediatricians, especially in low-resource settings, where electronic fetal monitoring might not be available to assist in decision making, sur-gery, and resuscitation. The very poor fetal outcomes in those with prolonged obstructed labor need a critical appraisal by obstetricians, probably to consider other options outside abdominal delivery. Fetal outcome for options like symphysiotomy might not be too different,  but the mother would have been spared the uterine scar with all its implications! REFERENCES 1. Treffers P, Pel M. The rising trend for caesarean birth. BMJ .1993;307:1017-1019 2. Okpere EE,Oronsaye AU, Imoedehe DAG. Pregnancy and delivery after caesarean section: a review of 494 cases.  Trop J Obstet Gynecol . 1981;3:45-48. 3. American College of Obstetricians and Gynecologists.Guideline for vaginal delivery after previous caesarean birth. Int J Obstet Gynecol . 1996;52;90-98. 4. Aisien AO, Lawson JO, Adebayo AA. A five year appraisal of caesarean section in a northern Nigeria University Teaching Hospital. Niger Postgrad  Med J. 2002;3:146-150.5. Swende Tz, Agida ET, Jogo AA. Elective caesarean section at Federal Medical Centre Makurdi, North central Nigeria. Niger J Med . 2007;16(4):372-374.6. Elvidi-Gasparovic V, Klepac-Pulanic T, Peter B. Maternal and fetal out-come in elective versus emergency caesarean section in a developing Table 4.  Morbidity/Mortality Following Caesarean Section in 24 Newborns Morbidity n Mortality, n (%) Perinatal asphyxia 26 17 (70.9)Prematurity with sepsis 14 3 (12.5)Neonatal jaundice with neonatal sepsis 11 2 (8.3)Multiple congenital anomaly 2 2 (8.3)Total 53 24 (100) Table 3.  Type of Surgery, Experience of the Surgeon and the Pediatrician at Surgery to Fetal Outcome (n = 216) a,b Type of Surgery n Mortality Surgeon Pediatrician Consultant Resident Consultant Resident Elective 42 2 28 (0) c  14 (2) 0 (0) 42 (2) Emergency 174 22 82 (5) 92 (17) 0 (0) 174 (22) Total 216 24 110 (5) 106 (19) 0 (0) 216 (24) a   c 2  = 0.5742 b   p  = .6196 (Fisher) c  Mortality with respect to the experience of the surgeon/pediatric team in paracentesis  JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 101, NO. 6, JUNE 2009 581 CAESAREAN SECTION AND FETAL OUTCOME country. Coll Antropol. 2006;1:113-118.7. Ezechi OC, Kalu BKE, Njokanma FO, Ndububa V, Nwokoro CA, Okeke GCE. Trial of labour after a previous caesarean section: A private Hospital experience.  Annals of African Medicine . 2005;3:113-117. 8. Oladipo OT, Lamina MA, Sule-Odu AO. Maternal morbidity and mortality associated with elective caesarean delivery at a University teaching hospi-tal in Nigeria.  Aust N Z J Obstet Gynaecol . 2007;2:110-114.9. Gaym A. Perinatal mortality audit at Jimma hospital, south western Ethio-pia. Ethiop. J Health Dev . 2000;14(3):335-343. 10. Joseph KS, Kramer MS. Canadian infant mortality: 1994 update [letter]. Can Med    Assoc J. 1997;156:161-163.11. Howell EM, Blondel B. International infant mortality rates: bias from reporting differences.  Am J Public Health . 1994;84:850-852.12. Lomas J. Holding backs the tide of caesareans. BMJ. 1988;297:569-570. 13. Devendra K Arulkumaran S. Should Doctors Perform an Elective Caesar-ean Section on Request?  Ann Acad Med Singapore .   2003;32:577-582.14. Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Eur J Obstet   Gynecol Reprod Biol . 2001;97:15-16.15. Ekele BA. Impacted head at Caesarean section in obstructed labour: push or pull? Trop Doctor.  2001;31:38-39. n We Welcome Your Comments The  Journal of the National Medical Association  welcomes your Letters to the Editor about articles that appear in the  JNMA  or issues relevant to minority healthcare. Address correspondence to EditorJNMA@nmanet.org.
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