European Journal of Cardiovascular Medicine

Caesarean section is commonly performed surgery in obstetrics. As medical science and especially obstetrics has evolved over the recent years, there has been a parallel and steady increase in the rate of caesarean births. Primary caesarean section means first caesarean section done in the patients who had delivered vaginally once or more. Multipara means a women delivered at least once.1

Barber et al found that 50% of the increase in cesarean deliveries at their institution was attributed to an increase in primary cesarean deliveries2 Understanding the factors leading to primary cesarean deliveries is essential to reducing the total cesarean rate. According to the latest data from 150 countries, currently 18.6% of all births occur by cesarean section, ranging from 6% to 27.2% in the least and most developed regions, respectively3. Asia and Northern America were the regions with the highest and lowest average annual rate of increase 6.4% and 1.6%, respectively3.

Primary caesarean deliveries are an important target for reduction in numbers, because they lead to an increased risk   for   a   repeat   caesarean   delivery. Delivery   by caesarean   section   is   most   frequently   performed   in nulliparous for dystocia with suspected cephalopelvic disproportion.  At the same time the abnormalities most common in multipara such as transverse lie, placenta praevia are encountered less often than in former. One of the primary causes of rising trend in the rates of cesarean sections is the increase  in  number  of  such  deliveries  in primigravida.   However, an   upward   trend   of   primary caesareans among parous women has also contributed to the elevated rates.1

There is worldwide trend of increase in caesarian section rates. With improved safety following, introduction of modern anesthesia, higher antibiotics and blood transfusion facilities the indications for caesarian section are liberalized to include dystocia, fetal distress, placenta previa, BOH, and others. Caesarian section is considered as a safer alternative to prolonged and difficult vaginal operative delivery to reduce maternal and perinatal morbidity and mortality4.

It is a common belief amongst public that once a mother delivers her child or children normally, all her subsequent deliveries will be normal. As a result such multiparous mothers often neglect routine antenatal checkup5.It is for these reasons that one attention has been directed to the indication for caesarean section in women who have previously delivered vaginally6.

Need for the study:

The present study focuses on the various indications for caesarean section in multiparous women who had delivered vaginally earlier and their outcome. The present study evaluates the proportion of primary caesarean sections occurring in multipara  in a  tertiary care  hospital and their indications. This   study   also   assesses   the maternal   and   perinatal outcomes of these women.

AIMS AND OBJECTIVES:

Primary: To evaluate the incidence of primary cesarean section among multiparous women with previous vaginal delivery.

Secondary: To study maternal and fetal outcome.

INCLUSION CRITERIA:

Multiparous women,

• Who underwent cesarean section for the first time who had a vaginal delivery previously
• Term gestation.
• Singleton pregnancy.

EXCLUSION CRITERIA:

• Previous cesarean section or hysterotomy, myomectomy or septal resection
• Multiple pregnancy
• Primigravida
• Gestational age <37 weeks

This is a retrospective study of 160 cases of primary cesarean section in multiparous women from may 2022 to November 2022, done in the Department of Obstetrics and Gynecology, Government General Hospital, Kadapa.

DATA SOURCE: Data collected from patients casesheets  department of Obstetrics and Gynecology, Government General Hospital, Kadapa.

STATISTICAL ANALYSIS:

Descriptive statistics was applied and data was analyzed by percentages and chi square test.

METHODOLOGY:

Information regarding age, socioeconomic status, details about previous pregnancy, antenatal care and booking status was collected. Information regarding Complete general physical examination, systemic examination and obstetric examination was collected. Routine and relevant investigations such as Hb gm/dl, blood Grouping and Rh typing, VDRL, HIV, HBsAg, GST and urine analysis for albumin, sugar, Microscopy were all noted. Ultrasound with fetal Doppler study was noted whenever found necessary.

Cardiotocographic monitoring graphs were observed during labour to assess fetal wellbeing. Details like, duration of labour, indication for cesarean delivery, color of liquor, abnormality of III stage, puerperium; weight of baby, maturity, APGAR and congenital malformation are recorded. Maternal complications like postpartum hemorrhage, anemia, pre-eclampsia, hydramnios, antepartum hemorrhage and intra-

uterine growth retardation were noted. Neonatal morbidity like low birth weight, meconium aspiration syndrome and birth asphyxia were noted.

Table1: Frequency of primary cesarean section in multipara.

The frequency of primary cesarean section in multiparous women is 7.2% of total cesarean sections and 3.1 % of the total number of deliveries during the study period. Frequency of cesarean section among total multiparous women is 5.9%.

Table no 2: Age distribution

Table 3:  Gravidity and Parity distribution

In this study, 24% patients had spontaneous onset of labour, while 45% underwent induction of labour. Incidence of cesarean section was more among induced labour patients.

Anemia, antepartum hemorrhage, malpresentations and hypertensive disorders of pregnancy are frequently encountered in multiparous women. Malpresentations were more frequently associated accounting for 26.3%. Anemia (Hb% < 10gm%) was observed in 10.6% cases and antepartum hemorrhage was encountered in 8.1% cases, hypertensive disorder of pregnancy in 18.1% patients had eclampsia. Some patients in the study had 2 or more complications.

Majority of cases 143 (89.4%) underwent emergency cesarean section and only 17(10.6) cases had elective cesarean section. Among160 cesarean section 56 patients underwent tubectomy. In the study all cesarean sections were lower segment cesarean sections.

Among malpresentations most common was breech presentation accounting for 32(76.1%) cases followed by transverse lie were 5 (11.9%), face 2(4.8%), brow, oblique lie and compound presentation 1(2.4%) each.

Table 4: Significant intraoperative finding in study

postoperative morbidity was present in 31(19.4%) patients, among them urinary tract infection 12(7.5%) and pyrexia 10(6.3%) were more common. Others were paralytic ileus 4(2.5%), wound infection 3(1.9%) and respiratory tract infection 2(1.3%).

In the study majority of the babies weighed in the range of 3.1 to 3.5 kg. Birth weight weighing <1.5 kg was three and > 4 kg was one.

This is a retrospective study undertaken to analyze 160 cases of caesarean section done for first time in multiparous women.

There were 5173 deliveries, around 2208 caesarean section which represented 42.7% of all deliveries.

Incidence of primary caesarean section in parous women is 3.1% of all deliveries and accounted for 7.2% of all sections done.

Table 5: Incidence of cesarean section in multipara among different studies

Most common indication of cesarean section were fetal distress 46(28.8%), malpresentations 42(26.3%), cephalopelvic disproportion 31(19.4%) and antepartum hemorrhage 13(8.1%).

Table 6: Indications for primary caesarean section in multiparous women compared to other studies.

Multiparity is a problem associated with poverty, ignorance, illiteracy and lack of knowledge of the available antenatal care and family planning methods. A multipara who has earlier delivered vaginally may still require a caesarean section for safe delivery and they are actually associated with high maternal and fetal morbidity.

This study reemphasizes the need for proper antenatal care and vigilance in the management of labor. Negligence in which, most of the time needs operative interventions for the good outcome of both mother and baby both.

Previous vaginal delivery gives the patient as well as her relatives a false sense of security. The fact that a multipara has had one or more vaginal deliveries should be regarded as an optimistic historical fact, not as diagnostic criteria for spontaneous delivery of the pregnancy at hand.

Primary cesarean in parous woman is not uncommon, although constituting only a small percentage of the total deliveries. Good intra-partum and postpartum care can eliminate maternal deaths. Hence a multiparous woman in labour requires the same attention as that of primigravida.

Improvement of antenatal care in multipara with early identification of high risk pregnancies, good quality of emergency obstetric care, adoption of integrated and composite approach to improve the health status of women, and lastly health education and counseling for adoption of small family norms are some of the measures to be undertaken for reducing the maternal morbidity and mortality in multipara.

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