Indications and Outcomes of Cesarean Section in Labasa Hospital, Fiji

Objective: To examine trends for indications and outcomes of caesarean deliveries at Labasa Hospital; this is a tertiary care hospital in a developing country. Method: A retrospective review of the caesarean deliveries performed at Labasa Hospital from September 2006 to August 2009 inclusive. Results: During the study period there were 6,128 deliveries and 803 caesarean sections giving an overall caesarean section rate of 13.1%. The major maternal indic~tions were previous caesarean section (47%), failure to progress (16%), cephalopelvic disproportion (11%), failed induction (8%) eclampsia and severe pregnancy induced hypertension (3%) and placenta praevia «1%). The major fetal indications include fetal distress (44%), breech presentation (39%), pregnancy complicated by multiple fetus and transverse lie (4% each), postdatism (1 %) and macrosomia «1 %). Demographic analysis showed a steady increase in teenage pregnancy (from 5% in 151 study period to 8 % in third study period) as well as an increase in the caesarean sections performed on ethnic Fijians (increasing from 60% to 64%). Emergency caesarean sections were performed in 609 patients (76%) while 194 patients (24%) were booked. The caesarean section rate showed a steady decrease (14.8% in 151 study period, 13.4% in 2nd study period and 12.2% in the third study period). This was also accompanied by an improvement in the perinatal mortality rate (from 16.1 per lOOO births in the 1 sl study period to 12.2 per lOOO births in the 3rd study period). Conclusion: Caesarean section rates at Labasa Hospital are within WHO guidelines and it should be ensured that the current rate of caesarean sections continues to be maintained at acceptable levels without compromising perinatal outcomes. Perinatal outcome is satisfactory but more prospective research needs to be done to accurately measure perinatal outcomes.
Keywords: Caesarean section, indications, outcomes
Background
Cesarean delivery is defined I as the birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy). This definition does not include removal of the fetus from the abdominal cavity in the case of rupture of the uterus or in the case of an abdominal pregnancy. A caesarean section is medically indicated when a significant risk of adverse outcome for mother or baby is present if the operation is not performed at a given time. However, the use of caesarean section for more vague medical indications (failure to progress, presumed fetal compromise) and non-medical reasons (for example, maternal request) is increasing for developed countries.
Caesarean section rates are progressively rising in many parts of the world2. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity.
Moreover, for a countty like Fiji, which is a developing country with relatively poor neonatal intensive care (NJCU) facilities the threshold for caesarean sections is relatively low to reduce neonatal morbidity and mortality.