February 2007 - Volume 1, Issue 1

VAGINAL DELIVERY AND CESAREAN SECTION: COMPARITIVE STUDY OF PERSONAL CHARACTRISTICS

1) Simin Taavoni, M. Sc in Medical Education, M. Sc in Midwifery, Faculty member of Iran University of Medical Sciences, Member of Nursing and Midwifery research Center of IUMS, Member of pain research group of ACECR of IUMS. IASP member. 2) Hamid Haghani. PHD student in Statistics and Mathematics, Faculty member - Iran University of Medical Sciences, Tehran, IRAN. 3) Sara Mirzendedel. MD. Iran University of Medical Sciences.

1 Simin Taavoni, staavoni@iums.ac.ir 2) Hamid Haghan, haghani511@yahoo.com

ABSTRACT Introduction: The major duty of the physician and midwife is to identify a normal vaginal delivery from a complicated delivery, because when there is no reason for Cesarean Section, Vaginal Delivery (V/D) is safer than Cesarean Section(C/S). Aims: Identifying the reasons of C/S, and comparing personal characteristics in C/S and V/D groups according to Dystocia, in one of the non-educational hospitals connected to Iran University of Medical Sciences in the year 2000- 2001. Data was finalized in Year 2002. AIMS: Identify the reasons for cesarean section and compare the personal characteristics of client's with Vaginal Delivery and Cesarean Section in the public General Hospital of Karaj city. Methodology: This is a case-control study (retrospective). In this research we compared data from 289 C/S case notes with 301 V/D case notes. These case notes were selected randomly from entire case notes of the only public general hospital of Karaj city, which is near to Tehran, capital of Iran, in the year 2000-2001. (Systematic sampling) The descriptive and inferential statistics (X2, T test, and Mann-Withny) were used. Results: In this study the main reason for C/S was Dystocia (58.1%). 7% of C/S did not have acceptable or clear reasons such as Tubectomy. There were significant differences between mothers' average of: gravidity (P= 0.043), parity (P= 0.007), abortion (P=0.038), and number of children (P= 0.005). Conclusions: Dystocia was more common in this study as a reason for C/S. The most cases were primigravida in young age. Due to performance of this study in one center a definite conclusion from this study is difficult. We recommend a multicenter study for more precise conclusions.

Key words: Cesarean Section, Vaginal Delivery, Personal Characteristics, Dystocia. . INTRODUCTION

One of the special problems in obstetrics is extraordinary increase of the Cesarean Section (C/S) rate! (1) Some of the obstetricians increasingly worry that the fetus will die or be born with a severe handicap unless they intervene. In addition, less experience in operative vaginal delivery has been a side effect of this trend while on the other hand; the skill in performing C/S has possibly become better. Also C/S on demand was the other reason. In one of the private clinics in Brazil, 60-70% of all deliveries are by C/S. This indicates that the operation is no longer done for medical reasons, but instead has become commercialized on demand. (2) Weinsten et al (1996) said that C/S should be performed to protect the mother or the fetus. However there is increasing concern that C/Ss are being performed for maternal or fetal conditions that may not actually require operative delivery. (3), Therefore the major duty of physician and midwife is to identify a Normal vaginal delivery from complicated delivery. The four most frequent indications for Cesarean delivery are: repeat cesarean, Dystocia or failure to progress in labor, Breech presentation, and those performed out of concern for fetal well-being. (4)

A report from a maternity hospital in Riyadh, Saudi Arabia, documented a rise in the C/S rate from 3.9% in 1979 to 9.9% in 1984. (1) Saglamtas et al said the rate of C/S in Zekei Tahir Burak Women's hospital in Turkey was 7.5% between 1980 and 1985, and 16.5% between 1990 and 1992. (5) Weinsten et al said: in the US, C/S has become the most common surgical procedure with 24.7% of all births in 1998, and rising to about 30% in the early 1990s.(3) Cunningham et al said that Labor Dystocia is the most frequent indication for cesarean delivery in the United States. (4) Kambo et al had done a study in 30 medical colleges/teaching hospitals in India. They showed that the overall rate of C/S increased from 21.8% in 1993-1994 to 25.4% in 1998-1999, and among the 7,017 C /S cases, 42.4% were primigravidas and in 18% the surgery was elective. Major indications for cesarean section included Dystocia (37.5%) (6)

According to rises in C/S rates in Iran, and high rates of it in public general hospital of Karaj city (60%) we decided to identify the reasons of cesarean section and compare the personal characteristics of clients with Vaginal Delivery and Cesarean Section in the public General hospital of Karaj city.

Methodology: This is a case-control study (retrospective) and with the aims of identifying the reasons of C/S, also comparing personal characteristics in C/S and V/D groups according to Dystocia, in one of the non-educational public hospitals connected to Iran University of Medical Sciences in the year 2000- 2001. A checklist with two main parts of personal characteristics and reason for C/S were used.

Duration of study: Data collection was in year 2000-2001, and had been finalized in 2002.

Place of study: The study was conducted in the only public general hospital of Karaj city, which is near to the capital of Iran.

Setting: According to other studies and using sample formula (Alpha= 0.05) the number of samples for each group was found to be 280. In this research by systematic sampling we selected case notes randomly from entire case notes of one of the non-educational public hospitals of Iran University of Medical Sciences, in the year 2000-2001. Due to the approximately 15000 cases, who were admitted in the maternity wards of the mentioned hospital for delivering of babies, during 2000-2001, we chose 20 as interval of case notes. For finding the real reason for C/S we excluded the group with the history of previous C/S. From 750 cases, 160 were excluded due to repeat C/S. In some of the cases in this research, multiple reasons were found for C/S, but only the first mentioned reason was indicated in this study. All patient data was extracted from medical records. ANALYSIS

Descriptive (Means and standard division of variables) and inferential statistics (X2, T test, and Mann-Whitny) were used by the SPSS program. P value of 0.05 was considered statistically significant. RESULTS

590 cases were included (289 primary C/S versus 301 V/D). 58.1% of C/S had been performed for dystocia; 7% of C/S had been performed for no clear reason such as request of patients for doing tubal ligation; 6.3% for Post date. The reasons for C/S are shown in Table 1.

The lower C/S rate belongs to ages over 36 years old (6.3%), which is more than V/D in the same age (2.7%). The highest C/S rate belongs to age group 21-25, which is close to control group (34.9%). Average age in the C/S group was 25.4 years (SD: +- 5.6), and in the V/D group were 25 years (SD 5.4). There were no significant differences between averages of age. (Table 2) The highest rate of C/S was in G1 (52.7%) and G2 (2.5%), and in the V/D was in G1 (40.5%) and G2 (25.6%). Average of G in C/S group was 2+- 1.4, and in V/D group was 2.2+-1.4. There were significant differences between averages of Gravidity. (Table 3) There were significant differences between mothers' average of: parity, abortion, number of children and mothers' weight. (Table 4)

The lowest weeks of pregnancy in V/D was 22-28(2.9%), in C/S was 29-36 weeks (1.1%) and highest week was 41-43 in both groups (7.3% in V/D , 11.1% in C/S) There were no significant differences between weeks of pregnancy in the two, groups. (Mann-Whitney tests were used) According to babies' gender, rates of girls and boys were the same in V/D (50%), but in C/S rates of boys was 50.9%. There was no significant difference between two groups (X2 test were used). DISCUSSION

Due to the results of other studies, which showed that the main factor responsible for the increasing rate of C/S was previous C/S (5) (7)(8) in this study, because we wanted to control the effect of this variable; we collected our samples from groups without previous history of C/S. In this study the highest reasons for C/S was Dystocia, like other studies, but its rate in comparison with other studies is so high.469 Cunningham et al said that Labor Dystocia is the most frequent indication for cesarean delivery in the United States. In 1990 rate of C/S was: in Norway 12.8% with 3.6% Dystocia, in Scotland 14.2% with 4% Dystocia, in Sweden 10.7% with 1.7% Dystocia, in Canada 20.3% with 4.5% Dystocia, and in United States 23.6% with 7.1% Dystocia. (4) Also according to the Kambo et al study, which was done in 30 medical colleges/teaching hospitals in India, the overall rate of C/S increased from 21.8% in 1993-1994 to 25.4% in 1998-1999, and among the 7017 C/S cases, 42.4% were primigravidas, and in 18% the surgery was elective. Major indications for cesarean section included Dystocia (37.5%). (6) In Manitoba and Quebec of Canada the overall C/S rate increased from 18.0% in 1994-95 to 22.1% in 2000-01. The primary C/S rate increased from 12.7% to 16.3%. Most of the increase in primary C/S was due to increases for Dystocia, which increased from 6.9% in 1994-95 to 9.2% in2000-01. (10)

In our study, rate of Dystocia was 58.1%, even more than Khawaja et al study in Pakistan (28.2%) (11) and Kambo et al study in India (37.5%) (6)

In our study rate of meconium aspiration was 4.9% and fetal distress rate was 2.8% of entire C/S which was less than the Kambo et al study, in which fetal distress with or without meconium aspiration rates, was 33.4%. (6) It was also less than the Khawaja et al study in Pakistan (22.18%) (10)

We found 7% of C/S did not have acceptable or clear reasons, such as Tubectomy, by demand. This indicates that the operation in some cases is no longer done for medical reasons like the study in Brazil. (2)

In our study there was significant difference due to Gravidity among two groups. Primigravida was more common among the C/S group. In contrast to other studies there was no significant difference according to age of mothers. (Table 2)(4) These results are confusing. We had three suggestions for them. 1) In this city Young mothers are more prone to Dystocia. 2) In some cases Dystocia was diagnosed incorrectly. 3) Due to fear of complication of Dystocia C/S were performed. CONCLUSION

Dystocia was more common in this study as a reason of C/S. The most cases were primigravida in young age. Due to performance of this study in one center, forming definite conclusions from this study, is difficult. We recommend a multicenter study for more precise conclusions.

Table 1: Reasons of C/S and its rates Reasons No. % Dystocia 166 58.1 Postdate 18 6.3 Meconium 14 4.9 Decreasing of Fetal movement 13 4.6 Previous history of infertility for long time 12 4.2 Fetal distress 8 2.8 Abruption Placenta 6 2.1 Placenta prevai 2 0.7 Others + no clear reason 26+20=46 16.2 Total 285* 100

Table 2: Frequency of type of delivery according to age Type of delivery V C/S Age No % No % 15-20 64 21.3 58 35.1 26-30 81 26.9 77 27.0 31-35 43 14.3 32 11.2 +36 8 2.7 18 6.3 Total 301 100 285* 100 X+_SD 25=_5.4 25.4+_5.6 * Missing Data: 3 T test results: 0.92 (NS)

Table 3: Frequency of type of delivery according to Gravidity Type of delivery V C/S Gravidity No % No % 1 122 40.5 149 52.7 2 77 25.6 58 20.5 3 55 18.3 35 12.4 4 24 8.0 30 10.6 5 13 4.3 5 1.8 6 9 3.0 2 0.7 7 1 0.3 0 0 8 0 0 4 1.4 Total 301 100 283* 100 X+_SD 2.2+_1.3 2+_1.4 * Missing Data: 6 T test results: 2.02 Significant (P: 0.043)

Table 4: Variables and significant test results Variable Mean of C/S SD of C/S Mean of VD SD of VD Test Results Gravidity 2 +_1.4 2.2 +_1.3 t = 2.02, P value = 0.043 Parity 0.8 +- 1.2 1.1 +- 1.3 t= 2.70,P value= 0.007 Abortion 0.2 +- 0.5 0.1 +- 0.4 t=2.07,p value= 0.038 No. of children 0.8 +- 1.2 1 +- 1.2 t= 2.82,P value= 0.005 Mothers' weight (Kg) 71.6 +- 11.3 66.2 +- 10 t= 6.024,P value= 0.001

ACKNOWLEDGMENT

Supported by grants from the research deputy Department of Iran University of Medical Sciences. (Code: 309, year 2001) REFERENCES

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