A retrospective study of emergency caesarean sections performed for prolonged labour in primiparous singleton pregnancies delivered in the Maltese islands

Abstract

Evidence suggests that changing institutional practice to provide more time before caesarean birth for slow progress reduces the rate of caesarean delivery in nulliparous women (A. Caughey et al., 2014). Morton et al. carried out a retrospective observational study of all caesarean deliveries in Sydney, Australia between 1989 and 2016. The rates and indications for emergency and elective caesarean deliveries were the primary outcome measures. Their sample size was 147722 births, with caesarean sections accounting for 25.3% of the deliveries. They observed a substantial increase in the rate of caesarean delivery during their study period. Emergency CS rose from 8.7% to 11.4%, whereas elective CS rates nearly doubled from 10% to 19%. Emergency caesarean delivery for slow progress increased from 3.4% to 5.5% of all births. Next most common indication for this intervention was suspected intrapartum fetal compromise (Morton et al., 2020). The authors concluded that the observed outcomes are due to a rise in the number of procedures conducted for poor labour progress, breech presentation, or repeat caesarean section. The trend of increasing emergency procedures performed for poor labour progress warrants additional investigation. Studies of recent data from the Consortium on Safe Labour in the United States (A. B. Caughey et al., 2014) recommend that the active first stage of labour should be redefined to 6 cm of cervical dilatation (Cohen and Friedman, 2015). This is based on the observation that most consistent and rapid progress could be witnessed beyond this threshold. At less than 6 cm dilation, half of all caesarean births for slow progress were performed (A. B. Caughey et al., 2014). Other researchers have discovered that a substantial proportion of caesarean sections for poor progress are initiated before this point, implying that some of these operations are unnecessary (Zhang, Troendle, et al., 2010; C. Riddell et al., 2017). An emergency caesarean section is defined as an operative delivery performed despite the plan for a vaginal delivery from the onset of labour, or for an acute emergency such as placental abruption. The two categories of emergency caesarean indications are slow progress and others like a suspected intrapartum fetal compromise. First and second-stage protraction and arrest disorders, including failed instrumental delivery and unsuccessful induction of labour may result in poor progress. Fetal distress, late deceleration on CTG (cardiotocograph) and fetal bradycardia are indicators of fetal compromise. All other caesarean deliveries are categorised as planned or elective and are decided by an obstetrician during antenatal visits. Planned indications include macrosomia, big baby, CPD (cephalo-pelvic disproportion), high head, short stature, LGA (large for gestational age), malpresentation including breech and compound presentations, malposition, placental problems such as placenta previa, AMA (advanced maternal age), maternal request, STD (sexually transmitted disease), other maternal comorbidities and fetal anomalies.