International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Kuntal N et al. Int J Reprod Contracept Obstet Gynecol. 2018 Jun;7(6):2311-2316

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20182341
Original Research Article

Feto-maternal outcomes following caesarean section: a prospective

comparative study at tertiary care centre in North-Western Rajasthan
Neha Kuntal1, Madhu Patni Bhat1, Amit Nimawat2,
Munmun Yadav3*, Mahendra Kumar Verma4

1
Department of Obstetrics and Gynecology, S.P. Medical College and P.B.M Hospital, Bikaner,
2
Department of Paediatrics, NIMS Medical College Jaipur, Rajasthan, India
3
Department of Obstetrics and Gynecology, SMS Medical College and Hospitals, Jaipur, Rajasthan, India
4
Department of Preventive and Social Medicine, SMS Medical College and Hospitals, Jaipur, Rajasthan, India

Received: 26 March 2018

Accepted: 01 May 2018

*Correspondence:
Dr. Munmun Yadav,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Caesarean section (CS) is employed when vaginal delivery is not feasible or hazardous to the mother
and/or her baby. The procedure, however, is not without risk. We determined the fetomaternal outcomes of CS
conducted at P.B.M Tertiary hospital situated in the North-Western region of Rajasthan.
Methods: This is a Hospital based prospective comparative study of all CSs performed for various indications at the
Dept. of Gynaecology and Obst., S.P. Medical College and P.B.M Hospital, Bikaner, India, from August 01, 2016, to
July 31, 2017. All patients who had CS at any time within the 24 h period were noted and followed up until discharge.
The sociodemographic data, types of CS, indications, and feto-maternal outcomes were documented in a proforma.
Statistical analysis was carried out using the SPSS version 24.
Results: There were 16386 deliveries out of which 4456 (27.1%) were by LSCS. The age range of the group A was
21-25 years while in group B it was 26-30 years. The mean age group A was 22.4, and group B it was 27.9 years.
Total 6572 primigravida patients delivered and 32.1% had LSCS. Total 9814 multigravida patients delivered and
12.6% had primary LSCS. In group A, 119(79.3%) LSCS were elective as compared to group B where only
19(12.7%) were elective and this difference was found statistically highly significant (p<0.001). Indication of LSCS is
different in both the groups. Fetal distress was most common indication in group A (53.3%) while in group B most
common indication was APH (35.9%). Perinatal mortality/morbidity was significantly higher in group B (7.3%) as
compared to group A (2.7%).
Conclusions: The CS rate in this study was 27.1%. Although primary caesarean section in multipara constitutes only
a small percentage of total deliveries and caesarean, they are associated with high maternal and perinatal morbidity.
The reason for these complications is many. Beside obstetrical causes, factors like lack of antenatal care, low
socioeconomic status, anaemia, malnutrition and illiteracy also play a major role obstructed labor and previous CS
among Maternal and perinatal complications were more frequent with emergency CS and in the referred cases.

Keywords: Caesarean section, Fetomaternal-outcome, Parity

INTRODUCTION outcomes of pregnancy globally.1 The origin of CS is lost

in antiquity and mythology.2 The indications and rates of
Caesarean section represents the most significant CS delivery vary from country to country and from
operative intervention in obstetrics practice. This hospital to hospital though the overall incidence of CS
procedure has tremendously improved fetomaternal shows a rising trend worldwide. The increasing, use of

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CS as a mode of delivery is due to improved safety of the the Bikaner. About 16000 deliveries take place annually
procedure as a result of increasing use of antibiotics, in the hospital. The Obstetrics and Gynaecology
blood availability, and improved aesthetic techniques.3 A Department has five labor suites, one each for the booked
sense of false security prevails in most of the multiparous patients and referred cases. There is a functional
women who had previous uneventful labour. As most of obstetrics theatre, and a special care baby unit attached to
the multiparous women have had easy vaginal deliveries the main labor room. The hospital runs residency
they do not pay much attention to the antenatal care they programs in obstetrics and gynaecology, surgery, internal
deserve. Moreover, the socio economic condition of these medicine, paediatrics, public health among other
patients does not permit them to have adequate balanced specialties. The institution is accredited for both the
diet, which the pregnant stage demands. These patients undergraduate and postgraduate medical training. Most of
get expert supervision only when unforeseen emergency the clientele of the hospital belong to the middle‑.and
arises during pregnancy and labour. The relative ease low‑income status.
with which some multiparous women deliver in the
presence of faulty position and presentation may account Study design
for false sense of security. This invites laxity on part of
patients as well as Obstetrician. Due to those factors the Hospital based prospective comparative study carried out
multiparous women pass through the stage of pregnancy over a period of 0ne years (August 2016, to July 2017).
and labour in a subnormal stage of health with a potential All patients who had CS at any time within the 24 h
risk, when caesarean section has to be performed. 4 In period were noted and followed up till discharge. Consent
some countries, medical indications for CS have been for the research was obtained verbally and in written
replaced by mundane reasons such as social reasons, forms. Women who had caesarean hysterectomy
tocophobia, astrological (parents want the child to be following uterine rupture were excluded from the study.
born under favorable heavenly bodies constellations), and Relevant information such as the sociodemographic
on maternal request.5,6 variables, type of CS, indications, type of anaesthesia
given, nature and types of anterior abdominal wall and
Despite the safety of CS, the procedure, especially in low uterine incisions, cadre of surgeon, postpartum blood
‑resource settings still poses challenges to the clinician. loss, fetal and maternal outcomes were extracted from the
In the neonate, CS is associated with increased incidence case notes and operation files and documented in a
of respiratory distress, high incidence of admission to the proforma. The duty residents were informed about the
neonatal Intensive Care Unit, prolonged hospitalization, study and were trained to fill the proforma. Parameters of
low Apgar scores at birth, iatrogenic prematurity, and fetal outcome were determined by Apgar scores at birth,
transient tachypnea of the newborn.7 neonatal intensive care admission, and perinatal
mortality. The adverse maternal outcomewas determined
It is well‑documented that CS carries a much higher by complications of surgery such as hemorrhage, surgical
site wound infections (SSI), sepsis, and anemia among
maternal mortality and morbidity as compared to a
others.
vaginal delivery.8 In India, CS is becoming increasingly
used as a mode of delivery and is a good practice to
perform a periodic clinical audit of the fetal and maternal Data collection
outcomes. The aim of our study is to maternal and fetal
outcome following primary caesarean section in This includes the patients reporting directly to our
primigravida and multigravida and compare various hospital requiring elective or emergency caesarean
indication and incidence for primary caesarean section in section after trial, both primigravida and multigravida.
primigavida and multigravida at tertiary care hospital. It All the patients taken up for study were to be followed up
is envisaged that the information provided may lead to an for 14 days. At the time of discharge, the patients were
improvement on this obstetric service. explained about the importance of spacing, contraception
and immunization.
METHODS
Data analysis
This is a hospital based prospective comparative study of
all CSs performed for various indications at the Dept. of The data were entered and compiled in Microsoft excel
Gynaec and Obst., S.P. Medical College and P.B.M which were further analyzed using SPSS version 24.
Hospital, Bikaner, India, from August 2016, to July 2017. Percentage and proportions were calculated. Chi-square
test used for trend analysis as per data yield. The
Hospital’s Ethical and Research Committee approved the
Study setting
study.
The study was conducted at P.B.M Tertiary Hospital
RESULTS
situated in the North‑Western region of Rajasthan. It
provides tertiary healthcare services to Bikaner states. It
During the study period, total 16386 patients delivered
also acts as a major referral centre for high‑risk obstetric
and out of them 4456 (27.1%) delivered by LSCS. Total
cases from health institutions located within and outside

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 Kuntal N et al. Int J Reprod Contracept Obstet Gynecol. 2018 Jun;7(6):2311-2316

primary LSCS were 3344(20.4%), total repeat LSCS Table 3: Distribution of cases according to degree of
were 1112 (6.78%). anemia.

Table 1: Statistical. Gravida

Degree of anemia Group A Group B
Incidence No. % No. % No. %
Total No. of deliveries 16386 100 Mild (10-11 gm/dl) 101 67.3 23 15.3
Total No. LSCS 4456 27.1 Moderate (7-10 gm/dl) 42 28.0 96 64.0
Total number of primary LSCS 3344 20.4 Severe (5-7 gm/dl) 7 4.7 29 19.3
Total number of repeat LSCS 1112 6.78 Very severe (<5
0 - 2 1.4
gm/dl)
Most common age group in group A was 21-25 years Total 150 100 150 100
(52%) while in group B, most common age group was MeanSD 8.921.42 7.821.40
26-30 years (45.3%). 1.3% cases were found between the P <0.001
age group of 31-35 years in group A and only 1(0.7%)
case presented above the age of 35 years while in group
Table 4: Distribution of cases according to
B 15.3% cases were present between 31-35 years of age
emergency/elective LSCS.
and 4.7% cases were found after the age of 35 years and
this difference was found statistically highly significant Gravida
(p<0.001). Majority of patients came from rural area in
Elective/emergency Group A Group B
both groups (56% in group A and 62% in group B).Most
of patients in group A belongs to lower middle (36%) and No. % No. %
upper lower (26%) class while in group B, most of Elective 119 79.3 19 12.7
patients belonged to upper lower (51.3%) and lower Emergency 31 20.7 131 87.3
(30.7%) class. Total 150 100 150 100
2 134.19
Table 2: Socio-demographic profile of study P <0.001
participants.
In group A, 119 (79.3%) LSCS were elective as
Gravida compared to group B where only 19(12.7%) were
Age group (years) Group A Group B elective and this difference was found statistically highly
No. % No. % significant (p<0.001).
18-20 48 32.0 4 2.7
21-25 78 52.0 48 32.0 In group A, most common emergency indication was
26-30 21 14.0 68 45.3 fetal distress (53.3%) followed by primi breech with good
31-35 2 1.3 23 15.3 size baby (20.7%). In group B, although fetal distress was
>35 1 0.7 7 4.7 there in 30.2% cases but most common indication of
LSCS was APH (35.9%). Beside this other indication like
Total 150 100 150 100
mal-presentation, mal position, obstructed labour,
Residence
impending rupture and cord prolapse were seen with
Rural 84 56.0 93 62.0 higher incidence in group B as compared to group A
Urban 66 44.0 57 38.0 (Table 5).
Total 150 100 150 100
Socioeconomic status Overall postoperative complications rate were higher in
Upper 11 7.3 0 - multies in group A, complications were pyrexia (6.3%),
Upper middle 28 18.7 5 3.3 urinary infection (4.2%), respiratory tract infection and
Lower middle 54 36.0 22 14.7 wound infection was seen in 2.1% and 1.3% of cases
Upper lower 39 26.0 77 51.3 respectively. In group B, most common complication was
Lower 18 12.0 46 30.7 pyrexia (16%) followed by urinary infection (7.3%).
Total 150 100 150 100 Beside this other complications like respiratory tract
infection (6%), wound infection and secondary suturing
(4.7% each), secondary PPH (3.3%) and abdominal
In group A, mild anemia seen in 67.3% of cases while
distension (2.7%) is high in group B as compared to
moderate and severe anemia was seen in 28% and 4.7%
group A (Table 6).
of cases respectively. In group B, mild anemia was seen
in 15.3% of cases, moderate anemia in 64% of cases
Incidence of perinatal complications like early neonatal
while severe and very severe anemia was seen in 19.3%
death were higher in group B (7.3%) as compared to
and 1.4% of cases respectively.
group A (2.7%). There was one still birth case in group A
whereas 3 cases in group B (Table 7).

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Table 5: Distribution of cases according to Indication of LSCS.

Gravida
Total
Indications Group A Group B
No. % No. % No. %
Fetal distress 72 53.3 42 30.2 114 41.6
Abruption 5 3.7 17 12.2 22 8.0
Placenta previa with bout 4 3.0 33 23.7 37 13.4
Impending rupture 0 - 6 4.3 6 2.2
Obstructed labour 2 1.5 9 6.5 11 4.0
Compound presentation 0 - 4 2.8 4 1.5
Cord prolapse 0 - 3 2.2 3 1.1
Transverse lie 0 - 10 7.2 10 3.7
Brow presentation 0 - 3 2.2 3 1.1
PROM with NPOL with breech 7 5.2 3 2.2 10 3.7
PROM with NPOL 17 9.6 9 6.5 26 9.5
Primi breech with good size baby 28 20.7 0 0 28 10.2
Total 135 100 139 100 274 100

Table 6: Distribution of cases according to maternal postoperative complications.

Gravida
Total
Postoperative complications Group A Group B
No. % No. % No. %
Respiratory tract infection 3 2.1 9 6.0 12 4.0
Abdominal distension 0 - 4 2.7 4 1.3
Urinary infection 4 4.2 11 7.3 15 5.0
Pyrexia 6 6.3 24 16.0 30 10.0
Sub involution of uterus 0 - 3 2.0 3 1.0
Wound infection 2 1.3 7 4.7 9 3.0
Secondary PPH 0 - 5 3.3 5 3.3
Secondary suturing 0 - 7 4.7 7 2.3

Table 7: Distribution of cases according to perinatal complications.

Gravida
Perinatal complications Group A Group B
No. % No. %
No mortality 145 96.7 134 89.3
Early neonatal death 4 2.7 11 7.3
IUD 0 - 2 1.4
Still birth 1 0.6 3 2.0
Total 150 100 150 100

DISCUSSION examination which the pregnant stage demands. Due to

these factors, the lady is likely to pass through pregnancy
A sense of false security prevails in most of the pregnant in a sub normal stage of health and reach labour in a state
women who had previous uneventful deliveries, they of potential risk, and undetectable abnormality.
don’t pay much attention to the antenatal care they
deserve. The hazards associated in such labours show that mother
with previous history of eutocia and normal uneventful
Moreover, the socioeconomic condition of the pregnant delivery, may exhibit dystocia and other abnormalities
women, specially in our catchment area do not permit leading to impending bad foeto maternal outcome, and
them to have adequate balanced diet and antenatal primary caesarean section in multies at times. The aim of

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our study is to compare various statistics in primary was seen in 15.3% of cases, moderate anemia was seen in
caesarean section in primi and multies. 64% of cases while severe and very severe anemia was
seen in 19.3% and 1.4% of cases respectively and this
This prospective study of comparing the primary result comparable with the studies of Suresh et al and
caesarean section in primi gravida and multi gravida was Rajput et al indicating the lack of nourishment and
conducted in the Department of Obstetrics & antenatal care in all pregnant women specially
Gynaecology, S.P. Medical College and A.G. of multiparous.4,10
Hospitals, Bikaner which provided health care service
predominantly to the rural population. Three hundred Table 4 shows in group A 10% LSCS were elective as
pregnant women selected for study and divided into 2 compared to group B where only 7.3% were elective.
groups randomly i.e., Group A (primi gravida) and Group This again shows negligence of society towards
B (multigravida), contents of 150 cases each group. multipara. These patients get expert supervision only
when unforeseen emergency arises during pregnancy and
Table 1 shows that total number of deliveries during labour. These results were comparable to study conducted
study period of 1 year was 16386 and out of them by Suresh et al.4
4456(27.1%) delivered by LSCS. Total number of
primary LSCS 20.4% and repeat LSCS 1112(6.78%). Table 5 shows that in group A, most common emergency
This statistical data not comparable with a study indication was fetal distress (53.3%) followed by primi
conducted by Desai et al where total percentage of breech with good size baby (20.7%). In group B,
caesarean section was 45.6%, primary LSCS was 29.05% although fetal distress was there in 30.2% cases but most
and repeat LSCS was 16.55%.9 This can be because in common indication of LSCS was APH (35.9%). Beside
our catchment area, public reluctant for caesarean section this other indication like mal-presentation, mal position,
because they believe that after a scar on body manual obstructed labour, impending rupture and cord prolapse
hard labour is difficult and once a caesarean section is
were seen with higher incidence in group B as compared
always a caesarean section. Secondly our labour room
to group A. Lack of antenatal care and intra-natal
doesn’t have modern methods like continuous electronic
mismanagement by traditional birth attendant in
fetal monitoring or scalp blood sampling for early
multipara are responsible for these variations. Various
detection of fetal distress so early fetal distress delivered
studies, like Himanbindu et al, Rao et al, Desai et al
vaginally.
shows similar results.12-14
In our study incidence of primary LSCS in primigravida
Table 6 shows, overall postoperative complications rate
was 32.1% and in multigravida 12.6%. This incidence
were higher in multies. In group A, complications were
was comparable with study conducted by Rajput et al
pyrexia (6.3%), urinary infection (4.2%), respiratory tract
where incidence of primary caesarean section in primary
infection and wound infection was seen in 2.1% and
gravida was 35.18% and 12.61% in multigravida. 10
1.3% of cases respectively. In group B, most common
complication was pyrexia (16%) followed by urinary
Table 2 shows most common age group in group A was
infection (7.3%). Beside this other complications like
21-25 years (52%) while in group B, most common age
respiratory tract infection (6%), wound infection and
group was 26-30 years (45.3%). 1.3% cases were found
secondary suturing (4.7% each), secondary PPH (3.3%)
between the age group of 31-35 years in group A and
and abdominal distension (2.7%) is high in group B as
only 1(0.7%) case present above the age of 35 years
compared to group A. These results are comparable to
while in group B 15.3% cases were present between 31-
study conducted by Rao et al.13 Table 7 reveals that
35 years of age and 4.7% cases were found after the age
incidence of perinatal complications like early neonatal
of 35 years and this difference was found statistically
death were higher in group B (7.3%) as compared to
highly significant (p<0.001) which is comparable to study
group A (2.7%). There was one still birth case in group A
done by Suresh et al.4 Age distribution in both groups
whereas 3 cases in group B. This result comparable to
revealed an older age profile in multigravida. Majority of
study conducted by Suresh et al and Himanbindu et al. 4,12
patient came from rural area in both groups (56% in
group A and 62% in group B). This shows geographical
CONCLUSION
distribution of our tertiary care hospital these findings
were comparable to study done by Saluja et al.11 Table 2
Although primary caesarean section in multipara
also shows that majority of patients belongs to lower
constitute only a small percentage of total deliveries and
socioeconomic class (62% in group and 82% in group).
This study is comparable with the study done by Rajput caesarean, they are associated with high maternal and
perinatal morbidity.
et al.10

Table 3 shows, in group A, mild anemia seen in 67.3% of The reason for these complications are many. Beside
obstetrical causes, factors like lack of antenatal care, low
cases while moderate and severe anemia was seen in 28%
socioeconomic status, anaemia, malnutrition and
and 4.7% of cases respectively. In group B, mild anemia
illiteracy also play a major role.

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Recommendation caesarean section rate in East Delhi. Indian J

Community Med. 2007;32:222‑4.
Authors recommend that tertiary institutions should have 7. Okeke TC, Onah N, Ikeako LC, Ezenyeaku CC,
an outreach enlightenment program for the community Nwogu‑Ikojo C. Maternal and fetal outcome of
and traditional birth attendants in particular on the elective caesarean section at 37‑38 completed weeks
benefits of hospital supervised delivery and early referral of gestation in Enugu, Southeast Nigeria. Am J Clin
of obstetric cases. Similarly, proper supervision of Med Res. 2013;1:32‑4.
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Conflict of interest: None declared 9. Desai E, Leuva H, Leuva B, Kanani M. A study of
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Institutional Ethics Committee Reprod Contracept Obstet Gynecol. 2013;2(3):320-4.
10. Rajput N, Singh P, Verma YS. Study of primary
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