|Year : 2016 | Volume
| Issue : 4 | Page : 175-179
Maternal and fetal outcomes following cesarean deliveries: A cross-sectional study in a tertiary health institution in North-Western Nigeria
DC Nnadi1, S Singh1, Y Ahmed1, S Siddique2, S Bilal2
1 Department of Obstetrics and Gynecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Pathology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||21-Dec-2016|
D C Nnadi
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
Background: Cesarean 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 maternal and early neonatal outcomes of CS in a Tertiary Hospital in Nigeria. Materials and Methods: This is a 2-year cross-sectional study of all CS deliveries performed at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, North-Western Nigeria, from July 01, 2009, to June 30, 2011. 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, anesthesia, indications, cadre of a surgeon, and feto-maternal outcomes were documented in a proforma. Statistical analysis was carried out using the EPI INFO 3.5.1 (CDC Atlanta Georgia, USA). Results: There were 4462 deliveries out of which 504 (11.3%) were by CS. The age range of the subjects was between 15 and 50 years, and the mean age was 28.7 (3.05) years. Most of the subjects 75.2% (379/504) were multigravida while the primigravida constituted 3.1% (16/504). CS was performed for emergency reasons in 57.1% (288/504) while elective CS constituted 42.9% (216/504) of cases. The most frequent indication for emergency CS was obstructed labor 25.7% (30/288) and previous CS 39.8% (86/216) for elective CS. There were 514 babies delivered during the study of which 98.1% (504/514) were singletons while 1.9% (10/514) was multiple gestations. The maternal complication rate was 13.3% (67/504), and the main complication was hemorrhage 59.7% (40/67). Complications were more frequent with emergency CS compared to elective surgery (Chi-square test [χ2 ] =6.633, df = 1, P < 0.01) and with junior compared to senior residents (χ2 = 15.9, df = 1, P < 0.001). There was also a significant relationship between the fetal Apgar scores and the type of CS. The low 1 st and 5 th min Apgar scores were more frequent with emergency cases compared to elective CS (χ2 = 30.60, df = 1, P < 0.001; χ2 = 4.62.df = 1, P < 0.003). There were 10 maternal and 60 perinatal deaths. Conclusion: The CS rate in this study was 11.3%. Obstructed labor and previous CS among multigravida were the most frequent indications. Maternal and perinatal complications were more frequent with emergency CS and in the referred cases.
Keywords: Caesarean section, Nigeria, outcome, Sokoto
|How to cite this article:|
Nnadi D C, Singh S, Ahmed Y, Siddique S, Bilal S. Maternal and fetal outcomes following cesarean deliveries: A cross-sectional study in a tertiary health institution in North-Western Nigeria. Sahel Med J 2016;19:175-9
|How to cite this URL:|
Nnadi D C, Singh S, Ahmed Y, Siddique S, Bilal S. Maternal and fetal outcomes following cesarean deliveries: A cross-sectional study in a tertiary health institution in North-Western Nigeria. Sahel Med J [serial online] 2016 [cited 2020 Feb 29];19:175-9. Available from: http://www.smjonline.org/text.asp?2016/19/4/175/196355
| Introduction|| |
Cesarean section (CS) represents the most significant operative intervention in obstetrics practice. This procedure has tremendously improved maternal and fetal outcomes of pregnancy globally.  The origin of CS is lost in antiquity and mythology.  The indications and rates of CS delivery vary from country to country and from hospital to hospital though the overall incidence of CS shows a rising trend worldwide. The increasing use of CS as a mode of delivery is due to improved safety of the procedure as a result of increasing use of antibiotics, blood availability, and improved anesthetic techniques.  In Nigeria, CS rates range from 6.4% to 33.5% of total deliveries while, in Sokoto, a rate of 9.9-10.3% has been reported. ,,,, In some countries, medical indications for CS have been replaced by mundane reasons such as social reasons, tocophobia, astrological (parents want the child to be born under favorable heavenly bodies constellations), and on maternal request. ,
Despite the safety of CS, the procedure, especially in low-resource settings still poses challenges to the clinician. In the neonate, CS is associated with increased incidence of respiratory distress, high incidence of admission to the neonatal Intensive Care Unit, prolonged hospitalization, low Apgar scores at birth, iatrogenic prematurity, and transient tachypnea of the newborn. 
It is well-documented that CS carries a much higher maternal mortality and morbidity as compared to a vaginal delivery.  In Nigeria, 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 outcomes. This study determined the indications, maternal and fetal outcomes of CS in a tertiary hospital. It is envisaged that the information provided may lead to an improvement on this obstetric service.
| Materials and methods|| |
This is a 2-year cross-sectional study of all CSs performed for various indications at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria, from July 01, 2009, to June 30, 2011.
The UDUTH, Sokoto, is a 600 beds capacity Tertiary Health Institution situated in the North-Western region of Nigeria. It provides tertiary healthcare services to Sokoto, Kebbi, Zamfara, and Niger states. It also receives referrals from the Niger Republic, a neighboring country. The predominant ethnic group is the Hausa/Fulani it acts as a major referral center for high-risk obstetric cases from health institutions located within and outside the environs. About 4000 deliveries take place annually in the hospital. The Obstetrics and Gynaecology Department has two labor suites, one each for the booked patients and referred cases. There is a functional obstetrics theater, and a special care baby unit attached to the main labor room. The hospital runs residency programs in obstetrics and gynecology, surgery, internal medicine, pediatrics, public health among other specialties. The institution is accredited for both the undergraduate and postgraduate medical training. Most of the clientele of the hospital belong to the middle- and low-income status.
A cross-sectional study carried out over a period of 2 years (July 01, 2009, to June 30, 2011). All patients who had CS at any time within the 24 h period were noted and followed up till discharge. Consent for the research was obtained verbally and in written forms. Women who had caesarean hysterectomy following uterine rupture were excluded from the study.
Relevant information such as the sociodemographic variables, type of CS, indications, type of anesthesia given, nature and types of anterior abdominal wall and uterine incisions, cadre of surgeon, postpartum blood loss, fetal and maternal outcomes were extracted from the case notes and operation files and documented in a proforma. The duty residents were informed about the study and were trained to fill the proforma. Parameters of fetal outcome were determined by Apgar scores at birth, neonatal intensive care admission, and perinatal mortality. The adverse maternal outcome was determined by complications of surgery such as hemorrhage, surgical site wound infections (SSI), sepsis, and anemia among others. Statistical analysis of the results was carried out using the EPI INFO 3.5.1 (CDC, Atlanta Georgia, USA). The results were expressed in frequencies, means, percentages, tables, figures, and charts. The Chi-square test (χ2 ) was used for association at P = 0.05 at 95% confidence interval. The Hospital's Ethical and Research Committee approved the study.
| Results|| |
During the study period, there was a total of 4462 deliveries out of which 504 were through caesarean operations. This gave a CS rate of 11.3%. The age distribution of the subjects is shown in [Table 1]. The age range of the subjects was between 15 and 50 years, and the mean age was 28.7 (3.05) years. Teenage mothers aged 16-19 years made up 7.5% (38/504) of the CS cases while elderly mothers aged between 45 and 50 years constituted 0.8%. About 67.9% (342/504) of the patients were booked for antenatal care while 32.1% (162/504) received antenatal care elsewhere. The parity distribution of the subjects was shown in [Table 2]. Most of the subjects were multigravida 75.2% (379/504) while the primigravida constituted 3.1% (16/504). CS was performed for emergency reasons in 57.1% (288/504) while elective CS constituted 42.9% (216/504) of cases.
The most common indications for emergency CS were prolonged obstructed labor 25.7% (30/288) and preeclampsia/eclampsia 10.7% (31/288) while the least common indications were fetal malpresentation 1.5% (4/288) and breech in labor at term 1.5% respectively. Previous CS was the most common indication for elective CS 39.8% (86/216), followed by breech at term 17.6% (38/216) while the least indication was placenta previa 2.8% (6/216) as depicted in [Figure 1]. There was no case of cesarean delivery on maternal request.
General anesthesia was utilized in 53.2% (268/504) of cases, spinal 43.5% (219/504), and combined general and spinal anesthesia in 3.3% (17/504) of cesarean operations. This option is practiced when spinal anesthesia fails or when patients develop respiratory distress during surgery. Epidural anesthesia was not used in any case.
There were 514 babies delivered by CS during the period of study. Of these, 98.1% (504/514) were singletons while 1.9% (10/514) was multiple gestations. The sex distribution of the neonates showed a preponderance of males 55.5% (280/514) over females 44.5% (234/514) with a male:female sex ratio of 1.2:1 as seen in [Table 3].
The main complications of surgery are shown in [Table 4]. The birth weight of the neonates is shown in [Table 5]. The Apgar scores are shown in [Table 6].
During the study, there were 60 perinatal deaths, thus giving a perinatal mortality rate of 119.1/1000. The majority (81.7% [49/60]) of them were peripartum and early neonatal deaths. Some of the perinatal deaths 8.3% (5/60) were observed in multiple gestations, especially in situations where the second twin had been retained.
|Table 5: Comparison of Apgar score birth weight of the neonates babies delivered by elective and emergency CS |
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There were 10 maternal deaths associated with CS deliveries during the study period, giving a case fatality rate of 19.8/1000. The main causes of death were puerperal sepsis following prolonged obstructed labor 60% (6/10) and complications of eclampsia 30% (3/10). Only one patient died from postpartum hemorrhage. Eight of the maternal deaths were from referred patients while 20% (2/10) were from patients who had received antenatal care at this center. The causes of death among these latter two patients were uncontrollable postpartum hemorrhage related to coagulation failure and complications of eclampsia, respectively. The causes of death were based on the clinical findings before death as there was no postmortem examination.
| Discussion|| |
The CS rates in this center range from 9.9% to 10.3% from previous retrospective studies. , However in this prospective review, a rate of 11.3% was observed. This shows an upward trend but is within the World Health Organization (WHO) acceptable range of 10%-15%. The WHO in 1985 stated that "there is no justification for any region to have a CS rate higher than 10-15%."  Rates more than 15% are considered to cause more harm than good. Countries with CS rates <10% are considered to show underuse while those with rates from 10% to 15% are considered to have adequate use of CS.  CS rates in Nigeria range from 6.4% to 33.2%. ,,
Emergency CSs constituted 57.1% (288/504) of all CSs in this study compared to elective surgery 42.9% (216/504). In the previous reviews from this center, emergency CS constituted 78.2-86.4% of cesarean deliveries, respectively. , The most common indications for emergency CS were prolonged obstructed labor 25.7% (30/288) and preeclampsia/eclampsia 10.7% (31/288) while the least common indications were fetal malpresentation and breech in labor at term 1.5% (4/288). Previous CS is the most common indication for elective CS worldwide.  Due to the absence of continuous intrapartum electronic fetal monitoring to give early signs of uterine scar dehiscence in many resource-poor countries, there will always be a low threshold for repeat CS.  There is usually no sufficient time given to women with a previous CS to attempt vaginal birth. ,
In contrast to a previous study from this center, where there was a high rate of CS in the primigravida due to cephalo-pelvic disproportion,  the highest rate of caesarean operation was seen in the multigravida 75.2% (379/504) and the grand multiparous women 21.6% (109/504) in this study. This was mainly due to disproportion from fetal malposition and malpresentation and also due to the high practice of repeat elective CS.
In the current study, CS was associated with maternal complications in 13.3% (67/504) of cases, this is low compared to the 20.4% observed in a previous study from this institution and 39.3%, 44.4% reported from Benin City and Maiduguri, respectively. ,, The major complication in this study was postpartum hemorrhage 59.7% (40/67) as opposed to sepsis from previous studies. ,, This may be related to relatively high number of CS deliveries performed by resident doctors in training in the institution. Proper supervision and adequate attention to hemostasis should be encouraged. Similarly, uterine atony and hence postpartum hemorrhage is a major complication of prolonged obstructed labor which is the main indication for emergency CS in this study.
Maternal complications of surgery were more when the procedure was performed by a junior resident compared to a senior resident (χ2 = 6.685, df = 1, P < 0.01). The CS mortality rate of 19.8/1000 in this study is also lower than the 28.7/1000 in previous reviews from this center, but it is still high compared to the 7.8/1000 and 15.6/1000 reported from the South-South region of Nigeria. ,, This is due to the higher number of referred patients who present for emergency surgery with complications of prolonged labor. The major cause of death was sepsis following prolonged obstructed labor as reported in other reviews. ,, The most common infecting organisms were Escherichia More Details coli and Klebsiella species in our center, which tend to resist the conventional antibiotics.  Previous authors have reported that Staphylococcus aureus was the most commonly isolated bacteria in SSI following CS.  Prolonged membrane rupture, multiple digital vaginal examinations and late referral of these patients were the main contributing factors to sepsis. Correct use of partograph in the peripheral health centers would have detected labors that were deviating from the normal course and facilitated early referral.
In 1952, Virginia Apgar proposed her score ("Apgar scores") as a means of evaluating the physical condition of infants' shortly after delivery and of predicting neonatal survival.  A low Apgar score at 5 min is commonly indicative of a neonate that is not well oxygenated and at greater risk of death. In this study, birth asphyxia as determined by low neonatal Apgar scores (0-5), were associated more with emergency CS compared to the elective procedure (χ2 = 30.6, df = 1, P < 0.001, χ2 = 4.623, df = 1, P < 0.03). There were 60 perinatal deaths, thus giving a perinatal mortality rate of 119.1/1000 births. Majority 81.7% (49/60) of them were peripartum and early neonatal deaths. In a previous study from this center, the perinatal mortality rate following CS was 111/1000. 
| Conclusion|| |
CS rate in this study is 11.3%. Obstructed labor and previous CS were the main indications for surgery. The major maternal complication was postpartum hemorrhage while the case fatality rate was 19.8/1000. The perinatal mortality rate was 119/1000. The outcome of cesarean delivery was worse with those patients who received antenatal care elsewhere and with those that had emergency surgery.
We recommend that tertiary institutions should have an outreach enlightenment program for the community and traditional birth attendants in particular on the benefits of hospital supervised delivery and early referral of obstetric cases. Similarly, proper supervision of resident doctors during surgery is advocated.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]