Caesarean sections in Cyprus
There is an increasing trend globally for delivery by caesarean section. Many factors contribute to this, and we need to explore the reasons and cause for this rate. There are many misconceptions regarding this, as well as an increasing trend for delivery by caesarean section by maternal request and action needs to be taken to correct this trend.
Cord around the neck found on routine antenatal ultrasound is not an indication for a caesarean section. Studies in about 180,000 pregnancies have shown that up to 29% of pregnancies have cord around the neck by term and that there is no effect on perinatal outcome or mode of delivery. Furthermore, an ultrasound before delivery was not a good predictor of cord around the neck due to a high percentage of false positives.
Short-sightedness again has not been shown to be a risk factor for retinal detachment and women should not opt for elective caesarean section.
Pelvic disproportion has long been proven a difficult diagnosis as X-ray pelvimetry, vaginal examination for pelvic assessment cannot predict the performance and outcome in labour. The vast majority of obstructed labours are due to foetal malpositions, as opposed to true cephalopelvic disproportion.
This brings us to another issue regarding large for gestational date babies. The size of the baby is not so much of an issue, as is the position of the head in the pelvis. Therefore, “large babies” are not an indication for caesarean section.
Foetal head position and specifically occipito-posterior position (OP) antenatally is of no significance as most OP babies turn during labour and those who do not, may deliver vaginally anyway. You may get failure to progress and secondary arrest with malpositions but you will only find this out during labour, therefore an elective caesarean is not indicated.
Reduction of amniotic fluid as pregnancy approaches term is a natural process and has no impact on the baby’s outcome. An abnormally reduced liquid volume in combination with other factors such as reduced growth and reduced umbilical diastolic flows and resistance, may affect our decision to induce labour but an outright decision for caesarean is not always necessary.
Maternal request is an important issue as we are faced with the common practice of trying to convince women not to have a caesarean and try for a vaginal delivery. Our role as obstetricians is to explore their concerns. It has been proven that 90% of women requesting a caesarean have a specific reason for the request. We need to find out what that is and tackle it. In most cases we can reassure and counsel them accordingly with evidence-based data. And of those who make the request 90-95% will change their mind in a fully informed way.
Moving to the emergency caesarean sections in labour is most often performed in women who have not entered the active stage of labour. This can be prevented by avoiding the use of uterotonic drugs too early in the process of labour. There is minimal stress on the baby during the latent stages of labour so this period can be expectantly managed until adequate cervical maturation and correct foetal position takes place. At the onset of labour, active management can take place, thus optimising labour efficiency and avoiding misdiagnosis of secondary arrest in the latent stage.
Timing for delivery or induction of labour should be carefully assessed, if there is margin for expectant management without compromising foetal health then induction of labour should be delayed as much as possible towards or even after the expected due date. Natural onset of labour is the most efficient way of cervical ripening, and better labour efficiency.
In summary, we really need to carefully assess the decisions regarding elective caesarean sections, the timing of induction of labours, and the management during labour, without compromising patient or foetal health. I firmly believe that by taking these points into careful consideration we can easily drop down our caesarean section rates to almost half.