Concerns about Validity of Caesarian Section for Foetal Distress with No Risk in Mother – Baby

Research Article

Austin J Obstet Gynecol. 2017; 4(2): 1072.

Concerns about Validity of Caesarian Section for Foetal Distress with No Risk in Mother – Baby

Chhabra S* and Mandar K

Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Maharashtra, India

*Corresponding author: Chhabra S, Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Kasturba Health Society, Sevagram, Wardha, Maharashtra, India

Received: June 20, 2017; Accepted: August 08, 2017; Published: August 16, 2017

Abstract

Background: Diagnosis of Foetal Distress (FD) is nonspecific, because of low positive predictive value. Many times after interventions, infant is in good condition at birth with normal Apgar score or umbilical cord blood pH or both. Equally true is that some babies are limp, sometimes still born at Cesarean Birth (CB) for FD. It is essential to understand modalities of authentic, timely diagnosis of FD, causes of true FD in women without risk.

Aim: Study was done to know frequency of diagnosis of intrapartum FD and appropriateness of caesarian section in cases with no risk factors.

Methods: Analytical study of 252 women admitted to labour area with term gestation, vertex presentation, no apparent risk for FD, were enrolled. Diagnosis of FD was made by intrapartum intermittent foetal heart auscultation (IFHA) and/ or Non-Stress Test (NST) and/or intrapartum presence of meconium in liquor amnii.

Results: There was no still birth, 211 (83.74%) babies were vigorous at birth after C Birth for FD, 41(16.26%) were admitted to Neonatal Intensive Unit (NICU), 40 (97.56%) recovered completely with one neonatal death, (2.43% of NICU admissions, 0.39% of 252 CS) due to severe birth asphyxia because of congenital heart disease in baby, missed during pregnancy. CS for unexplained FD accounted for 2.74% of births (9186), 7.44 % of CS (3385). Apgar scores had poor correlation with perinatal asphyxia, umbilical cord blood pH.

Conclusion: In around 66% women CS for FD without any risk factor, there was no abnormality, even during CS. Babies were vigorous at birth, obviously, over diagnosis of FD, through conventional diagnostic modalities. Research is needed for authentic diagnostics for non- reassuring fetal status, non conventional or unknown risk factors, responsible for fetal asphyxia which leads to diagnosis of FD.

Keywords: Caesarean Section; Fetal Distress; Validity; Risk Factors

Introduction

Background

Years back, Parer and Livingston [1] reported that the lack of clear definition of Fetal Distress (FD) compounded the difficulty in making an accurate diagnosis and initiation of appropriate treatment. The situation continues to be the same. ACOG [2] in its guidelines described the term FD as imprecise, which resulted in inappropriate action, such as an unnecessary urgent delivery under general anaesthesia. Diagnosis of FD is nonspecific because of low positive predictive value even in high-risk populations. Many a times after interventions, the infant is in good condition at birth, with normal Apgar score or umbilical cord blood pH or both. Equally true is the fact that some babies are limp, sometimes still born at Cesarean Birth (CB) for FD. It is essential to understand the modalities for authentic timely diagnosis of FD and causes of true FD without risk factors in mothers and/or baby.

Objectives

Present study was done to know the frequency of diagnosis of intrapartum FD, appropriateness of Caesarean Section (CS) performed for FD in cases with no risk factors, during pregnancy or labour and causes missed during pregnancy as well as at onset of labour but evident during birth.

Materials and Methods

The present prospective study was carried out over 2 years at a rural referral institute. Approval of the ethics committee of the institute, and informed consent from the study subjects were taken, for enrolment of the mother, foetus and the newborn in the study. It was an observational analytical study of women admitted to the labour area with term gestation with no apparent risk factor for FD. There were 9186 births during the study period, 5801 (63.15%) vaginal & 3385 (36.85%) by CS. Of the 3385 CS, 2370 (70.01% of all CS) were emergency CS and 948 (40% of all emergency CS) were for FD, 73.42% (696 of 948) had some or other risk factor diagnosed during pregnancy or at the time of admission to labour area and the remaining 252 (26.58% of CS for FD) women had no risk factor. So CS for unexplained FD accounted for 2.74% of all births (9186) and 7.44% of all CS (3385). These 252 women were admitted to the labour area with term, singleton pregnancy with vertex presentation. They were monitored with intrapartum Intermittent Foetal Heart Auscultation (IFHA), Non-Stress Test (NST), and for the presence of meconium in liquor amni. Women who were diagnosed as intrapartum FD and intervened by CS were the study subjects. Diagnosis of FD was made by IFHA and/or NST, & /or intrapartum presence of thick meconium in liquor amni. A tool was made for recording the details of the cases. No separate protocol was provided to clinicians but similar modalities of monitoring and recording were adopted in all the cases. Detailed information at admission to labour area, demographic profile, physical, obstetric examination, NST, IFHA & meconium in liquor amnii were recorded. NST results were categorized as reactive or nonreactive according to recent ACOG guideline [3]. IFHR was done in all the cases with hand held digital Doppler, half hourly in active first stage & every 5 minutes during second stage of labour, in accordance with joint AAP & ACOG guidelines [4]. FHR was interpreted as mild Tachycardia > 160, Severe Tachycardia > 180, mild bradycardia < 110, moderate bradycardia < 100 and < 80bpm severe diagnosed as FD. CS for FD was performed for persisting bradycardia or persisting tachycardia. During CS, the intraoperative details, meconium in liquor amnii, abnormalities of placenta & umbilical vessels, details of condition of the newborn at birth. Apgar scores at 1, 5, 10 minutes and resuscitative measures needed for the baby were recorded. Umbilical cord blood PH immediately after the delivery of the neonate was done. PH of 7.2-7.36 was considered normal, 7.2 to 7.0, as moderate and < 7.0 as severe acidosis. Neonatal Intensive Care Unit (NICU) admission & interventions if any were recorded. Postpartum follow up of newborn was done for 7 days (Table 1).