COMPARISON OF MATERNAL AND PERINATAL OUTCOME IN ELECTIVE AND EMERGENCY CESAREAN SECTION IN A TERTIARY CARE CENTRE

There were total 1254 deliveries in the study dura on, out of which 461(36.76%) were cesarean sec on (cs). The incidence of emergency cs was 86.5% and elec ve cs was 13.5%. Majority of women (75.7%) undergoing cs had no any antenatal visit. Around 81% of cases undergoing emergency cs were unbooked whereas only 48.4% of unbooked cases underwent elec ve cs (P-value 0.000). The most common indica on for cs in both elec ve and emergency category was previous cs. There was no maternal complica on in elec ve cs group but there were 8 cases (2%) in emergency cs (P value-0.293). In emergency cs group, 7 babies had poor Apgar score whereas all babies had good Apgar score in elec ve group (P-value-0.057). There was increased rate of NICU admission in emergency group than in elec ve group (3% vs 0%, P value-0.166).


Methodology
It was a prospec ve compara ve study conducted in the department of obstetrics and gynecology, Manipal Teaching Hospital from March, 2018 to September, 2018. All the pa ents undergoing cesarean sec on either elec ve or emergency were enrolled in the study a er their consent. A er collec ng data from pa ents, maternal and perinatal outcomes were analyzed by using SPSS so ware.

Results
There were total 1254 deliveries in the study dura on, out of which 461(36.76%) were cesarean sec on (cs). The incidence of emergency cs was 86.5% and elec ve cs was 13.5%. Majority of women (75.7%) undergoing cs had no any antenatal visit. Around 81% of cases undergoing emergency cs were unbooked whereas only 48.4% of unbooked cases underwent elec ve cs (P-value 0.000). The most common indica on for cs in both elec ve and emergency category was previous cs. There was no maternal complica on in elec ve cs group but there were 8 cases (2%) in emergency cs (P value-0.293). In emergency cs group, 7 babies had poor Apgar score whereas all babies had good Apgar score in elec ve group (P-value-0.057). There was increased rate of NICU admission in emergency group than in elec ve group (3% vs 0%, P value-0.166).

Conclusion
The study showed that the incidence of cesarean sec on was high in our centre. The maternal and fetal risks were higher in emergency cs than in elec ve cs, but these were not sta s cally significant.

INTRODUCTION
Cesarean delivery is the birth of a fetus via laparotomy and 1 then hysterotomy. Depending upon the me of opera on, it is divided into elec ve and emergency cesarean sec on (cs). Cesarean sec on is associated with increased risk of maternal and perinatal morbidity and mortality in 2 comparison to vaginal delivery. It is seen that morbidity and mortality are associated more with emergency cesarean 3,4 sec ons than with elec ve ones. According to WHO, the cs rate should be in between 10-15% as rate above this has not shown any improvement in the 5 maternal and perinatal outcomes. Recently, there has been an alarming increase in the rate of cesarean sec on globally, predisposing women to increased risk and cost of the surgery. According to the latest data from 150 countries, currently 18.6% of all births occur by cesarean route, ranging from 6% to 27.2% in the least and most developed regions, respec vely. Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average cs rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of 6 increase of 4.4%. In our centre, the cesarean rate is around 40% from the annual records and ll now no studies have been done to evaluate the maternal and perinatal outcome. So this study aims to compare maternal and perinatal morbidi es in elec ve and emergency cesarean sec ons in a ter ary care centre.

METHODOLOGY
It was a hospital based compara ve study which was conducted in the Department of Obstetrics and Gynecology, Manipal Teaching Hospital, Pokhara. The study was conducted from March, 2018 to September, 2018. A er taking approval from Ins tu onal Review Commi ee, all the pa ents undergoing cesarean sec on either elec ve or emergency cesarean sec ons were enrolled in the study a er their consent. A er the cases were enrolled, detailed history regarding age, parity, booking status, previous obstetric outcome, any significant past, family and personal history were taken and noted in a predesigned proforma. Booking status of the pa ent was defined as women having at least 3 antenatal visits in our centre. Indica ons for cesarean sec on, intra opera ve complica ons were noted. The cases were followed for 7 days postpartum and any puerperal complica ons like puerperal pyrexia, secondary postpartum hemorrhage (PPH), wound infec on or maternal mortality were noted. In cases of maternal mortality, further details were taken from the records of the deceased pa ents. For evalua on of perinatal outcome, Apgar score at 5 minute, need of NICU admission, s ll birth and early neonatal death were recorded. The data were entered and analyzed using SPSS so ware and results were expressed in terms of percentage, categorical data were compared using Chi square and means were compared using unpaired t test and P value <.05 was taken significant.

RESULTS
There were total 1254 deliveries in the study period. Total number of cesarean sec on was 461, the incidence being 36.76% of total deliveries. Among 461 cesarean sec on, 399 (86.5%) were emergency and 62 (13.5%) were elec ve cs.
The mean age in elec ve cs was 27.98±4.083 and emergency cs was 25.71±4.809 and this difference in mean age was sta s cally significant (P value-0.000) ( Table 1). In elec ve cs group, 56.5% were booked and 43.5% were unbooked cases. In emergency cs, majority of cases (80.7%) were unbooked and only 19.3% cases were booked. So unbooked cases underwent more emergency cs than elec ve cs and this was sta s cally significant ( Table 2). In the study, the most common indica on for cesarean sec on in both elec ve and emergency cesarean groups was previous cs, accoun ng 43.54% in elec ve cases and 19.29% in emergency cases. The other common indica ons for cs in elec ve and emergency groups were cephalopelvic dispropor on (CPD) (22.58% vs 11.58%) and breech (19.39% vs 5.26%). In emergency cases, the other common indica ons were oligohydraminos (17.54%), meconium stained liquor (17.04%), fetal heart rate abnormality (11.02%), non progress of labor (7.76%) and hypertensive disorders in pregnancy (5.76%). The mean blood loss in elec ve cs was 236.29 ±74.2 ml and in emergency cs was 228.92±78.85 ml. The study showed higher blood loss in elec ve cases than in emergency ones; however this was not sta s cally significant (Table 4).

Table 4: Mean blood loss
There were no maternal complica ons in elec ve cesarean group. However, there were 8 cases of maternal complica ons in emergency cs , the incidence being 2%. The complica ons seen in emergency cs were 3(37.5%) cases of postpartum hemorrhage and 1(12.5%) case each of high spinal block, postpartum eclampsia, puerperal pyrexia, rectus sheath hematoma and wound infec on. There were increased maternal complica ons in emergency group but it was not sta s cally significant (Table 5).
There were no cases of maternal mortality during the study period. There were 7 cases of poor Apgar score in emergency cs. There were no cases of poor Apgar score in elec ve group. However this difference was not sta s cally significant (Table 6) .  Regarding NICU admission, there were 12 cases of NICU admission in emergency cesarean sec on, the rate of admission being 3%. No newborn were admi ed in NICU in elec ve group. And this difference in the rate of admission was not sta s cally significant (Table 7).
There was no case of perinatal mortality during the study period.

DISCUSSION
Cesarean sec on is the most commonly performed life saving procedure in obstetrics; however it is associated with 7 increased maternal and fetal complica ons.
In our study, the rate of cesarean sec on was 36.76% of total 8 deliveries. In the study conducted by Suwal A in ter ary level centre in Kathmandu, the incidence of cs was 22.3%. A retrospec ve study was conducted in Zambia by Sichundu et 9 al in which cs rate was 26.72% and in a study at India by 10 Daniel S et al, the rate of cs was 28.7%. The average global 6 rate of cs is 18.6%. The higher rate of cs in our centre can be explained by the fact that it is the referral centre of Province no. 4 where we get a great ordeal of maternal and fetal complica ons , where usually the mode of delivery required is cesarean sec on.
The mean age in emergency group was less than in elec ve group in our study and this difference was sta s cally significant, and the result was similar to the studies done by 11 1 2 13 Vesna Elvei-Gasparovic et al, Renuka P and Thakur V et al.
Regarding booking status in our study, unbooked cases underwent emergency cs more than elec ve cs and this 10 finding was sta s cally significant. The study by Diana V also showed that women with no antenatal care were supposed to have more chance of emergency cs. With no proper supervision during pregnancy, women tend to seek advice only when complica ons arise. Hence we may conclude that regular antenatal visit may play a significant role in lowering the emergency cesarean rate.
The most common indica on of cs in both groups was previous cs. The other indica ons for emergency cs were mainly fetal indica ons like oligohydraminos, meconium stained liquor, cephalopelvic dispropor on and fetal heart rate abnormali es in our study. Various other studies [14][15][16][17] support our findings. So, we should all focus on reducing the primary cesarean rate to decrease the overall cesarean rate globally by revising our indica ons and standardizing instrumental delivery, which has become obsolete these days.
Maternal complica ons were seen in 2% of emergency cs whereas no complica on was seen in elec ve group. However this difference was not sta s cally significant. 18 Burshan et al also stated that emergency cs was associated with increased maternal morbidi es and it was sta s cally significant in their study. This sta s cal insignificance in our study may be due to less number of pa ents in elec ve group. The complica ons like PPH, puerperal pyrexia, high spinal block, rectus sheath hematoma and wound infec on were seen in emergency cesarean group in our study. Various studies showed different complica ons. In the study 19 done by Ghazi et al in Pakistan, maternal complica ons were higher in cs group, the most common being postopera ve anaemia. In the study by Santhanalakshmi et 20 al , the most common maternal complica ons in emergency group were primary hemorrhage and bladder injury. This difference in the pa ern of maternal complica ons in various studies may be due to difference in indica ons of cesarean sec on, level of care provided in different hospitals and designa on of service provider.

Subedi A et al
There were no cases of maternal mortality in either group in our study. This may be due to efficient management of cases in our center, as well as short study dura on. In the study by 16 Gurunule AA, the incidence of maternal mortality in emergency cs was 0.3% and no mortality in elec ve group. Various studies showed that maternal mortality was higher 17,21,22 in emergency group than in elec ve group. Such differences may be due to the fact that elec ve cases are performed on prearranged me with op miza on of both maternal and fetal condi ons whereas emergency ones are done due to unseen maternal and fetal risks, predisposing to increased risk of complica ons.
Regarding fetal outcome, emergency cesarean sec on was associated with poor Apgar score and increased NICU admission, as majority of emergency cs were done for fetal indica ons. However these findings were not significant 9 sta s cally. In the study by Schindu P et al, 11.4% of emergency cs and 9.8% of cases in elec ve group had poor perinatal outcome but this finding was not significant. 11,17,23 Similar results were depicted by other studies as well. There were no cases of perinatal mortality in our study.

CONCLUSION
The rate of cesarean sec on is high in a ter ary care centre. Emergency cesarean is always associated with increased maternal and perinatal complica ons than in elec ve cesarean ones.

RECOMMENDATIONS
Since we are aware of the fact that cesarean sec ons are always associated with increased maternal and perinatal risks than vaginal delivery, this study recommends in reducing cesarean delivery in both the emergency or elec ve ones by revisi ng our indica ons for cesarean sec ons, decreasing our fear of li ga ons, by standardizing the skills of instrumental delivery of the nursing staffs, doctors and also encouraging pa ents to have regular antenatal care so that any complica ons can be caught earlier and treated before it's too late.

LIMITATION OF STUDY
This study was done for a short dura on of me. The sample size of study popula on was also small and there was significant difference in the number of pa ents in emergency and elec ve group. So the differences seen were not sta s cally significant in most of our findings. So the findings cannot be generalized.

ACKNOWLEDGEMENT
We would like to thank first the Ins tu on Review Commi ee for gran ng us the permission to conduct the study. We would also like to express our gra tude to the hospital administra on for allowing us to conduct the study in the department of Obstetrics and Gynecology of Manipal Teaching Hospital. We also like to acknowledge the help received from our students and residents.