Characteristics and determinants of caesarean section and cord prolapse at the University Teaching Hospital, Lusaka

Abstract

Caesarean section rates and their indications vary all over the world. Audit of indications and factors affecting infant and maternal outcome remain an important activity in rationalising the use of this major procedure in obstetric practice. Over a period of one year in 1998, 1,880 caesarean sections were performed at the University Teaching Hospital, Lusaka, out of 10,525 total deliveries, giving an institutional caesarean section rate of 17.9%. The eight commonest indications for caesarean sections were: causes related to failure to progress in labour, including CPD (22.0%), previous caesarean section (19.3%), fetal distress or fetal compromise (15.2%), hypertensive disease in pregnancy (8.9%), malpresentation and abnormal lie (8.3%), breech presentation (6.9%), antepartum haemorrhage (APH) (6.3%), cord presentation and prolapse (4.1%). These constituted 91% of all indications. Caesarean section for failure to progress, fetal compromise, severe hypertensive disease and breech presentation were commoner in primiparas. Malpresentation (excluding breech) and cord presentation/prolpase were commoner indications in multiparas. 24.5% of caesareans were in preterm pregnancies. Severe hypertensive disease and APH were commoner in preterm compared to term pregnancies. All but 5 cases (0.3%) were performed under general anaesthesia. 7.0% of infants born at caesarean section were stillborn. After excluding cases of uterine rupture, APH (16.0%) and malpresentation (12.7%) had the higher case fatalities at caesarean section. Prematurity was associated with over 2.5 times the risk of stillbirth (OR 2.59, 95% CI 1.72-3.89). The majority of cases were performed by Registrars (62.7%) and Senior Resident Medical Officers (SRMOs) (26.2%). However Senior Registrars and Consultants who performed fewer but more complicated cases were over two fold more likely to have a stillbirth at caesarean section (OR 2.24, 95% CI 1.43-3.51). Seven cases of maternal mortality due to haemorrhage, post eclampsia and infection were identified having had caesarean section (maternal case fatality of 3.7 per 1000 caesarean sections). It is recommended that: decisions for caesarean section be made at the highest level and at least at the Registrar level); more cases be performed under regional anaesthesia (e.g. spinal) and constant audit be made of management of labour to minimise the number of cases requiring caesarean section for failure to progress in labour. Cord prolapse Cord prolapse frequently leads to caesarean section and is associated with a high perinatal mortality and morbidity rate. Cases presenting to UTH in 1998 were studied in-depth to determine risk factors and outcomes. 63 cases of cord prolapse were identified (0.59% of deliveries at UTH). 58.7% occurred at home or at a local clinic requiring referral to UTH. The risk factors commonly associated with cord prolapse were malpresentation, prematurity, high presenting part and multiple pregnancy. In only 6 cases had there been an ARM. 30.1% were preterm. The majority (63.5%) presented as cephalic although 22.2% of cases were breech. 66.7% were delivered by caesarean section. Cases in which there was already fetal death in-utero were more likely to have a vaginal delivery. 37.5% of all infants were stillborn. A diagnosis-to-delivery interval of <60 minutes, rather than site of rupture of membranes was strongly associated with a liveborn outcome (OR 4.5, 95% CI 1.4-14.89).Early diagnosis, prompt referral to UTH and judicious use of caesarean section in the management of cord prolapse is advocated.