ANATOMY OF FEMALE GENITAL ORGAN
GROSS ANATOMY
The uterus is a thick walled hollow muscular-organ shaped like a pear, situated in the pelvis between the bladder in front and the rectum behind.
Position: Its normal position is one of the ante version and ante flexion. The uterus usually inclines to the right (dextrorotation) so that the cervix directed to the left (Laevorotation) and comes in close relation with the left ureter.
Measurements and Parts
Its dimension vary but the nulliparous organ measures approximately 8 cm (31/4) overall length, 6 cm (21/2 inch) across it widest part 4 cm (1/2) from before backwards in the thickest part.
Its weight 45 to 55 gm. The wall is 1 to 2 cm thick, so the length of the normal uterine cavity, including the cervical canal, is not less than 7 cm and may be
7.5 to 8.0 cm.
The uterus is made up of a body or corpus, isthmus and cervix. The part of the body situated above the level of insertion of the fallopian tubes is described as fondues, especially during pregnancy.
The area of insertion of each fallopian tube is termed the cornu. The cavity of the uterus is triangular in shape when seen from the front, but is no more than a slit when seen from the side. It communicates with the vagina through the cervical canal and with the lumen of the fallopian tube at cornu.
Structure
The whole of the fondues, the anterior wall as low as isthmus, and the posterior wall as low as the attachment of the vagina to the cervix are covered with peritoneum which is so intimately connected with the underlying muscle that it cannot be stripped away.
The side of the uterus between the attachment of the two leaves of the broad ligament, the lower anterior uterine wall, and the whole of the cervix except for the posterior aspect of its supra vaginal part, are devoid of peritoneum.
The main mass of the uterine wall is composed of involuntary muscie fibres which for the most part run obliquely in a crisscross spiral fashion. The more superficial fibers, however, are arranged longitudinally and are continuous with those forming the outer coats of the elastic tissues are mixed with the muscle in varying amounts. Internal to the muscle layers, there is a mucous membrane which is directly applied to the muscle without an intervening sub mucosa, so its glands often dip into the fibro muscular tissue.
Isthmus
The isthmus is an annular zone, no more than 0.1-0.5 cm from top to bottom in the non-pregnant uterus, which lies between the cervix and the corpus.
The obvious constriction between the uterine cavity and the cervical canal is the anatomical internal OS and the isthmus is below this. The junction between the isthmus and the cervical canal proper, which is recognized microscopically, is the internal OS. The mucous membrane of the isthmus is intermediate in structure and function between that of the corpus and that of the cervix.
The importance of the isthmus is that it is the area which during late pregnancy and labour becomes the lower uterine segment.
Cervix8
The cervix is barrel-shaped, measuring 2.5 to 3, 5 cm from above downwards. Half of it projects into his vagina (vaginal cervix or portio virginal’s) while half is above the vaginal attachment (supravaginal cervix).
The vaginal part is covered with squamous epithelium continuous with that of the vagina. The supravaginal part is surrounded by pelvic fascia except on its posterior aspect where it is covered with the peritoneum of the pouch of Douglas.
A spindle shaped canal, disposed centrally, connects the uterine cavity with vagina. The upper part of the cervix is composed mainly of involuntary muscle, many of the fibres being continuous with those in the corpus. The lower half has a thin peripheral layer of muscle (the external cervical muscle) but is otherwise entirely composed of fibrous and collage nous tissue. The mucous membrane lining the canal (end cervix) is thrown into folds which consist of anterior and posterior columns from which radiate circumferential fold to give the appearance of tree trunk and branches, hence the name arbor vitae.
Vascular Connection8
Arterial Supply.
- Uterine Artery
- Ovarian Artery
Venous
- Pam inform plexus in the broad ligament
- Uterine vein
- Ovarian vein
- Vaginal plexus
- Vertebral plexus
Lymphatic
Cervix
- Paracervical Plexus
- Obturator nodes
- External iliac and internal iliac
- Sacral nodes
Corpus8
· The same as the cervix.
· Also the aortic nodes via lymphatic accompanying the ovarian vessels.
· Superficial inguinal nodes via lymphatic in the round ligament.
Nerves8
The nerve supply of the uterus is derived principally from the sympathetic system and part by from the parasympathetic system.
Sympathetic components are from segments T5 and T6 in the case of motor nerves, and from segments T 10 to L1 in the case of sensory nerves. The somatic distribution of uterine pain is that of the abdomen supplied by T10 to L-i Spinal Segment (sensory). The somatic distribution of uterine pain is that area of the abdomen supplied by T10 to L1. The parasympathetic system is represented on either side by the pelvic nerve which consists of both motor and sensory fibers S2, S3, S4 and ends in the ganglia of Frankenhauser. The cervix is insensitive to touch, heat and also when it is grasped by any instrument.
The uterus too, is insensitive to handling and even to incision over its wall.
RELATION8
Anterior
The upper part of the uterus has the uterovesical pouch and either intestine or bladder in front of it.
The lower part is closely associated with the base of the bladder from which it is separated only by loose connective tissue.
Posterior:
Posterior lays the pouch of Douglas (uterorectal pouch) with coils of intestine. The vagina! Cervix also has the posterior fornix behind it.
Laterally:
Laterally are the broad ligament and its contents, especially the uterine artery which runs up by the side of the uterus, giving branches at different levels. Attachment of the Mackenrodt’s ligament extends from the internal OS down to the supravaginal cervix and lateral vaginal wall.
As the ureter pass forwards to reach the base of the bladder the ureter lies only 1-2cm to the side of the supravaginal cervix.
The uterine artery crosses the ureter almost at right angle to the ureter at the
level of the internal OS. Here it gives off a descending branch to supply the
lower cervix, and a circular branch the circular artery of the cervix, from which
arise the anterior and posterior azygos arteries to the vagina.
CAESAREAN SECTION 9-12
A caesarean section refers to the delivery of a fetus, placenta and membranes through an abdominal and uterine incision. The first documented caesarean section on a living person was performed in 1610. The patient died 25 days after since the time, numerous Advances have made a safe procedure, in order for the practitioner to perform this common operation safely, he or she must be aware of the indications, risk, operative technique and potential complications of the procedure.
Indication
Caesarean section is used in cases where original vaginal delivers either is not feasible or would impose undue risk to the mother or baby. Some of the indications for caesarean section are clear and straightforward, whereas others are relatives in some cases, fine Judgments is necessary to determine whether caesarean section or vaginal delivery would be better. It is not practical to list all possible indication. However, hardly any obstetric complication has not been dealt with by caesarean section. The fallwing indications are currently common.
EMERGENCY CAESAREAN SECTION
When the operation is performed due to unforeseen complication arising either during pregnancy or during labour without wasting time following the decision, it is said to be ’emergency’.
Indication
1) Cord prolapsed with the child still alive and cervix not dilated
2) Severe preeclampsia
3) Failed induction of labour
4) Fetal distress in the first stage of labour
5) Failed trial of labour
6) Failed trial of forceps
7) Malpresentation during labour
8) Obstructed labour
9) Prolong labour.
10) Ante partum hemorrhage
ELECTIVE CAESAREAN SECTION
When the operation is done at a prearranged time during pregnancy to ensure best surgical conditions, it is said to be ‘elective’.
Indications
Ø Cephalopelvic disproportion
Ø Previous two Caesarean sections
Ø Successful repair of vesicovaginal fistula
Ø Placenta praevia posterior type II, III and IV
Ø Proven intrauterine growth retardation
Ø Persistent malpresentation
Ø Cervical stenosis
Ø Vaginal stenosis
Ø Patient with bad obstetric history
Ø Elderly primigravida with breech presentation
Ø Ovarian tumour complicating pregnancy at term if it cannot be pushed up from the front of the presenting part
Ø Cases of fibroid which occupy the pelvis persists in advance to the
presenting part
Ø Many cases of diabetes mellitus
Ø TYPES OF CAESAREAN SECTION
The types of Caesarean sections in modern use are:
1) Lower segment Caesarean section
2) Classical Caesarean section
1) Lower segment Caesarean section
In this operation, the extraction of the baby is done through an incision made in the lower segment through a transperitoneal approach. It is the only method practiced in present day obstetrics and unless specified, Caesarean section means lower segment operation.
Advantage
a) The myometrial incision is positioned entirely in the thin lower segment
b) The incisional site is less vascular than the upper segment
c) A tower segment incision is easier to close than an upper segment wound
d) There is lower likelihood of postoperative ileus
e) Complications and risk of rupture/dehiscence in vaginal birth after Caesarean (VBAC) trials are less
Potential complications
a) The length of the incision is limited is limited by the width of the lower uterine segment
b) Problem with premature deliveries
c) Problem with abnormal presentations
d) Risk of vessel injury
e) The angles may be difficult to suture, exposure may be limited and extension or vessels injury are common
f) Haemorrhage and haematoma may form at the wound angles
g) Extension of the wound into the vagina, bladder or broad ligament
h) Ureteric injury is possible
2) Classical Caesarean section
In this operation, the baby is extracted through an incision made in the upper segment of the uterus. Its indications in present day obstetrics are very much limited, and the operation is only done under forced. Circumstances, such as:
a) Preterm delivery with poorly formed lower segment
b) Placenta praevia with large vessels in lower segment
c) Premature rupture of membranes, poor lower segment and transverse lie
d) Transverse lie with back inferior
e) Large cervical fibroid
f) Severe adhesions in lower segment reducing accessibility
g) Postmortem Caesarean section
Advantages
a) There is no limitation in uterine incision length
b) Entry is rapid as neither cervix or bladder dissection is required
c) Access to the transverse lie is excellent
Potential complications
a) Closing of the incision may be difficult
b) There is greater blood loss with this technique than with a transverse incision
c) Poor uterine closure/healing is impossible
d) Adhesion of bowel to wound incision and/or postoperative ileus is more likely than with transverse incisions
e) There is an increased risk of scar rupture/dehiscence with a VBAC trial
Extra peritoneal Caesarean section
This procedure, designed for use in infected or potentially infected patient, was introduced before the modern era of antibacterial agents and blood transfusion. The procedure is time-consuming and may not be effective in preventing spillage into the peritoneal cavity, because the peritoneum often is perforated even by the expert. Although the operation was virtually discarded more than 20 years ago, the question has recently been raised whether it might not be applicable for the potentially infected patient, At present, most obstetricians perform caesarean hysterectomy if the uterus is frankly infected; if it is only potentially infected, they perform lower cervical Caesarean section with prophylactic antibiotic coverage.
ANAESTHESIA USED
DURING CAESAREAN SECTION12-15
Whatever might be the choice of anaesthesia, it is important for the obstetric surgeon to review in advance the circumstances of the projected operation with the anesthesiologist. In instances of patients with preexisting medical problems, a preoperative anaesthesia consultation is best obtained at a time when the patient is remote from term, and not in labour. Such preliminary visits are strongly indicated for individuals with congenital or acquired cardiac disease, serious medical complications (e.g. advanced diabetes mellitus), hereditary disorders likely to result in complications (e.g. Marfan’s or Ehlers-Danlos syndrome), and patients receiving anticoagulants of antihypertensive, those with prior back surgery or prior anaesthesia complications and for other complicated or unusual cases.
Anaesthesia for Caesarean section
1) Regional anesthesia
a) Epidural
b) Spinal
2) General anaesthesia
3) Local anaesthesia and analgesia
For the safety of the patient, epidural or spinal anaesthesia is usually best for caesarean delivery if the clinical circumstance permit. The patient “remains awake, members of the family may be present, and the potentially dangerous issues of intubation and airway management are avoided. Unfortunately, epidural anaesthesia is neither always available nor indicated if frank fetal distress, severe maternal hemorrhage or other-problems develop.
1) Regional anesthesia
Regional anaesthesia is generally considered to be the technique of choice. It allows the parturient to be awake and the father to be present, reduces blood loss, is associated with less maternal risk of pulmonary aspiration of gastric contents or hypoxia from failed endotracheal intubation, and reduces neonatal drug effects. The major hazard of the regional analgesic technique is blockade of sympathetic fibres and a decrease in vascular resistance, venous pooling and hypertension. However, this can be greatly alleviated by elevation of the patient’s right hip to avoid compression of the vena cava by the gravid uterus when the patient is lying on the operating table. In addition, the anaethesiologist may rotate the operating table 15-20 degrees to the left to rotate the uterus away from the vena cava, and the patient is given a rapid infusion of Ringer’s lactated solution. One may utilize 5-10 mg ephedrine intravenously for a mild vasopressin effect.
a) Lumbar epidural block
Lumbar epidural blockade may be utilized for Caesarean section analgesia and for providing adequate analgesia for operative delivery.
Advantages
a) Hypotension is less likely to occur
b) Anaesthesia is more controllable if an epidural catheter is placed because additional anesthetic doses can be given if necessary
c) Headache does not occur postoperatively because the Duran is not punctured
Disadvantages
a) It is not easy to perform
b) It is not indicated in cases of acute urgency or fetal distress or severe maternal hemorrhage
c) Spinal anaesthesia
Advantages
a) Simpler technique to perform
b) Immediate onset of analgesia so that there is no waiting for the block to become effective
Disadvantages
a) A more profound and rapid onset of hypotension
b) More frequent nausea and vomiting
c) Spinal headache occurs more frequently
d) Spinal anaesthesia is contraindicated in anaemia, shock and severe hemorrhage.
2) General anaesthesia
General anaesthesia is indicated for Caesarean section delivery when regional techniques cannot be used because of coagulopathy, hypovolaemia, or urgency. Some prefer to be ‘put-to-sleep’ and refuse regional techniques.
Advantages
a) Greater cardiovascular stability (i.e. hypotension from sympathetic blockade)
b) It is speedy in its action
c) Simple to perform
d) The patient has no unpleasant memories of the procedure
e) It is used suitable in case of titanic uterine contraction and constriction ring
Disadvantages
a) During induction, vomiting from full stomach results in dangerous
Aspiration
b) If anesthesiologist is not skilled at passing endotracheal tube, it results in maternal asphyxia which is dangerous to the baby and mother
c) Many drugs cross the placenta barrier. So, use of anaesthetic drugs, analgesic or hypnotics may affect the fetus either directly crossing the placenta or indirectly.
3) Local anaesthesia
Local anaesthesia still has a useful place in situations where general anesthetic service is inadequate.
Advantages
Shock is reduced to a minimum and pulmonary complication is very rare. Again, the liver and kidneys suffer no toxic damage and cardiac muscle is not, in any way, affected. Uterine tone is good throughout, and this also diminishes hemorrhage. Cases of heart disease are regarded as usually suitable.
Disadvantages
It takes time to secure adequate anaesthesia and often fails to achieve it completely so that the patient, already frightened, finds that she has to suffer, also a certain amount of pain. But, now local anaesthesia during Caesarean section is not practiced.
PREPARATION FOR
CAESAREAN SECTION12-14, 16-18
GENERAL PREPARATION
Before doing operation, written permission for operation under general or spinal anesthesia must be sought from patient’s guardian. Blood is sent for grouping and cross-matching. If facilities are available, hemoglobin percentage (Hb %) is to be done. When patient is anaemic and where blood loss prior to operation has been acute, blood should be transfused before operation. A supply of compatible blood should be assured. Intravenous Ringer’s lactate solution be started. Abdominal wall and vulva are shaved. Stomach should be empty. In case of elective operation, patient is given nothing-by-mouth eight hours prior to operation to relieve the full stomach. Patient transferred to operating theatre must be in the left lateral position with a wedge under the right buttock. Premedication with antacid is standard. In theatre, the operating table must also be kept in left lateral tilt position until after delivery,
SKIN INCISION
After the anesthesiologist has indicated that the patient is ready, fetal heart sound is checked, abdomen and thigh are painted with antiseptics. The patient is now draped for operation. The surgeon’s attention is then directed to the abdomen for the initial skin incision.
A number of types of skin incision are possible. The choice depends on gestational age, indication, necessity for a classical section and the presence of previous scars. A low transverse incision is preferred for its cosmetic appeal and a lesser chance of wound dehiscence and hernia. If other operative procedures have to be combined, a lower vertical incision is preferred for better exposure. A minimum length of 15 cm is needed. Excision of a previous scar is essential for better healing and cosmetic results. If a classical Caesarean section is contemplated, a midline or paramedian incision that can be extended above the umbilicus if needed should be used.
PROCEDURE FOR LOWER SEGMENT CAESAREAN SECTION
Position of the patient during operation should be dorsal with a left lateral tilt of 10-15 degrees. General or spinal anaesthesia may be given according to the case. A transverse Pfannenstiel incision is given two-finger breadth above the symphysis pubis. Incision should be 15 cm in length.
The choice of incision is based upon the urgency of the operation. For elective procedure, Pfannenstiel incision is preferred; it is given for cosmetic purpose.
During emergency procedure, sub umbilical right par median and midline incision is to be given. After sharp dissection of rectus sheath, splitting of rectus muscle peritoneum is reached. The peritoneum is now picked up and incised in the upper-third of the peritoneum. Now, abdominal cavity is entered. A Doyne’s retractor is introduced. The anterior surface of uterus is now in view. It should be noted whether there is any dextrorotation. If present, dextrorotation is corrected. The loose peritoneum over the lower uterine segment is lifted up and incised transversely. By means of finger dissection through loose arcolar tissue the bladder is separated from the anterior surface of the uterus inferior for a distance of 3-5 cm. The bladder is held away by retractor. The lower segment is exposed, and a short incision made through it, down to the fetal membrane. The incision in the lower segment can be made large by finder traction with very little bleeding. The membranes are ruptured if intact. The Doyne’s retractor is removed. The head is delivered by hooking the hand with until the palm is placed below the head. As the head is drawn to the incision line, the assistant applies pressure on the fundus. As soon as the shoulders are delivered, an intravenous infusion containing about 20 units of oxytocin per litre is allowed to flow at a brisk rate of 10 mlmin until the uterus contracts are satisfactory, after which the rate can be reduced. Bolus doses of 5 to 10 units are avoided due to associated hypotension. The rest of the body is delivered slowly. The cord is cut ir between two clamps and baby is handed over to the nurse. The uterine incision is observed for any vigorously bleeding sites. These should be promptly clamped with sponge-holding forceps, or similar instruments. Most surgeons recommend that the placenta be removed promptly manually, unless it is separating spontaneously. Fundal massage begun as soon as the fetus is delivered reduces bleeding and hastens delivery of the placenta.
Repair of the uterus
After delivery of the placenta, the uterus may be lifted through the incision into the draped abdominal wall, and the fundus covered with a moistened laparotomy pack. Although some clinicians prefer to avoid this latter step. Uterine exteriorization often has advantages that outweigh any disadvantages. The relaxed, atonic uterus can be recognized quickly and massage applied. The incision and bleeding points are visualized more easily and repaired; especially if there have been extensions laterally. Adnexal exposure is superior, and thus, tubal sterilization is easier.
The principal disadvantages are from discomfort and vomiting caused by faction in the woman given spinal or epidural analgesia. Neither febrile morbidity nor blood appears to be increased in woman undergoing uterine exteriorization prior to repair. Immediately after delivery and inspection of the placenta, the uterine cavity is inspected and wiped out with a gauze pack to remove avulsed membranes, verminx, clots or other debris. The upper and lower cut edges and each angle of the uterine incision are examined carefully for bleeding vessels. The uterine incision is closed with one or two layers of continuous 0 or #1 absorbable suture. Traditionally, chromic suture is used.
Abdominal closure: All packs are removed, and the gutters and cul-de-sac are emptied of blood and amniotic fluid by gentle suction. After the sponge and instrument counts are found to be correct, the abdominal incision is closed. Many omit peritoneal edge approximation. Now-a-days, both the visceral and parietal peritoneum is left open because it reduces operating time and postoperative adhesion. The rectus muscles are allowed to fall into place, and the subfascial space is meticulously checked for homeostasis. The overlying rectus fascia is closed wither with interrupted nonabsorbable sutures that are placed lateral to the fascial edges and no more than 1 cm apart, or by continuous, nonlocking suture of a long-lasting absorbable or permanent type. The subcutaneous tissue usually need not be closed separately. The skin is closed with vertical mattress sutures of 3-0 or 4-0 silk or equivalent suture or skin clips.
POSTOPERATIVE CARE
First 24 hours
a) The patient is observed meticulously for at least 6 to 8 hours; periodic check-up of pulse, blood pressure, amount of vaginal bleeding and behaviour of the uterus are mandatory
b) Patient .is given nothing-by-mouth until bowel sound appears
c) Intravenous fluid, 5% dextrose or Ringer’s lactate drip, is continued until at least 2 to 2.5 litres of the solution has been infused
d) Oral feeding in the form of plain water or coconut water or clear soup may be given after 6 hours, if condition permits
e). Blood transfusion is helpful in anaemic mothers for a speedy postoperative recovery; blood transfusion is required if the blood loss is more than average during the operation and also if the Caesarean section is done in anemic patient or with history of antepartum hemorrhage
f) Prophylactic parenteral antibiotic injection, cephradine 500 mg
intravenous , 6-hourly, along with or without injection metronidazole
500 mg intravenous, 8-hourly for 24 hours and then oral antibiotics
for another 5 days
g) Injection pethidine hydrochloride 75 mg is administered when patient comes round and may have to be repeated if patient feels pain; diclofenac sodium suppository may be used
h) Injection oxytocin 5-10 unit intravenous drip may be given slowly through separate channel for 24 hours to prevent postpartum hemorrhage
i) Ambulation: The patient can sit on the bed; she is encouraged to move her legs and ankles and to breathe deeply to minimize leg vein thrombosis and pulmonary embolism.
j) The baby is put to the breast as early as possible
From second day
a) Antibiotics are given in oral form
b) Analgesics are given either in oral or in suppository form
c) Diet from liquid to semisolid or even solid food may be given as patient’s preference
d) Catheter is removed, and patient is encouraged to drink plenty of water or liquid diet by mouth and get out of bed to evacuate the bladder
e) On sixth or seventh day
The abdominal skin stitches are to be removed on the sixth (in transverse) or seventh day (in longitudinal)
DISCHARGE
The patient is discharged on the day following removal of the stitches.
Advice on discharge
a) To avoid heavy lifting for six weeks
b) To return for postnatal check-up after six weeks
c) To take contraceptive measures
d) To avoid pregnancy for two years
e) To come for regular antenatal check up in her next pregnancy; she must be admitted into hospital two weeks before her expected date of delivery for observation.
COMPLICATIONS OF CAESAREAN SECTION10-14
MATERNAL COMPLICATIONS
Immediate complications
a) Hemorrhage: Primary hemorrhage is related either to the operations. It is mostly related to uterine atony. The average loss which may be one liter is too much for the patient, especially with preexisting anaemia.
b) Shock: When Caesarean section with hemorrhage.
c) Anesthetic hazards: Mostly occur during emergency operation. The hazards are cardiac arrest, aspiration gastric contain. The result may be aspiration atelectasis or aspiration pneumonitis (Mendelson’s. Syndrome).
d) Sepsis: Still remains one of the commonest complications, especially with emergency Caesarean section, prolonged rupture of membrane, obstructed labour and frequent internal examination.
e) Thrombosis: Leg vein thrombosis and pulmonary embolism are likely to occur following Caesarean section.
f) Wound complications: Abdominal wound sepsis is quite common, The complications detected on removing skin stitches are:
Ø Sanguineous or frank pus
Ø Haematoma
Ø Dehiscence (peritoneal coat intact)
Ø Burst abdomen involving the peritoneal coat
g) Intestinal obstruction: The obstruction may be mechanical due to adhesions or bands, or paralytic ileus following peritonitis.
h) Secondary postpartum hemorrhage.
Remote complications
1) Gynecological
a) Menstrual irregularities
b) Chronic pelvic pain
c) Backache
2) General surgical complications
a) Incisional hernia
b) Intestinal obstruction due to bands and adhesion
3) Future pregnancy
a) Risk of rupture scar
b) Scar endometriosis
FETAL COMPLICATIONS
a) Iatrogenic prematurity is common
b) Increased risk of respiratory distress syndrome (RDS)
Objectives of the present study
General:
Is to analyze the indication of emergency caesarean section of the patients admitted in Dhaka Medical College Hospital.
Specific:
1. To detect the indication of emergency caesarean section cases,
2. To find out the complication in the emergency caesarean section cases.
3. To know the outcomes of mother and fetus in emergency caesarean section.
4. To determine the proportion of emergency caesarean section among all caesarean section cases.
5.
METHODOLOGY:
Type of study- Cross sectional
Place of study – Dept. of Gynae & Obs in Dhaka Medical College Hospital.
Period of Study- The study will be conducted over a period of 6 months. From 1st January 2009 to 1st July 2009.
STUDY POPULATION:
All the emergency caesarean section cases admitted at Dhaka Medical College Hospital during the period of study.
SAMPLE SIZE
415 cases were selected for the study.
Which was calculated by this formula-?
Sample size (n) =
Here, z= 1.95 (95% confidence limit where value of ‘t’ is 1.95)
p = .47 (the prevalence rate of disease)
q = .53 (1-p, proportion of persons not affected by the disease)
d = .05 (Acceptable standard error, which range from 5
(0.05) to 25 (0.25)
Sample size (n) =
=378.88
Additional 10% of 378.88 =37.88
So sample size for study will be (378+37) = 415
SAMPLING TECHNIQUE
Purposive
DATA COLLECTION INSTRUMENT
Prepared questionnaire.
ETHICAL CONSIDERATION
The patient will be informed about purpose and nature of the study and
potential benefit or risk of it. Before collection of data it will be ensured to
maintain the confidentiality of her data and informed consent will be taken from
the patient or her legal guardian. Before starting the study permission will be taken
from the ethical committee of the institute.
DATA COLLECTION METHOD
Data will be collected by investigator herself.
The case will be diagnosed by history, examination findings, and investigation. After admission name, age, address, occupation, socioeconomic condition of the patient will be recorded. Details menstrual history, past obstetrical history like para, history of any abortion will be taken. At the time of admission patient’s condition like anaemia, temperature, pulse, blood pressure, edema, jaundice, condition of heart, condition of lungs will be recorded. Prr-abdominal examination and pervaginal examination will be done.
Indication of operation, Intra-operative, postoperative complications and fetal outcome will be noted. All information will be recorded in the predesigned questionnaire.
Procedure of data analysis
After collection of required information data will be checked, processed and edited by computer and statistical analysis will be done using appropriate formula.
RESULTS
Table-I Type of Caesarean section (n-415)
Caesarean section no. (%)
Elective 42 (10.12%)
Emergency 373 (89.87%)
Table-I shows that out of 415 pregnant women, 42 (10.12%) underwent elective Caesarean section and 373 (89.87%) emergency.
Table-II. Age of the Caesarean section subjects
Age (years) Elective Emergency
(n=42) (n=373)
No. (%) No. (%)
Up to 20 8 (19.04) 70 (18.76)
21-30 27 (64.28) 287 (76.94)
>30 7 (16.66) 16 (4.28)
Mean + SD 25.13 + 5.64 24.31+3.94
Range 18.0-39.0 18.0-36.0
Age distribution of elective and emergency Caesarean section women shows that 8 (19.04%) and 70 (18.76%) were in age group < 20 years, 27 (64.28%) and 287 (76.94%) in age group 21-30 years and rest 7 (66.66%) and 16 (4.28%) were in age group >30 years. Respectively. In both the groups, maximum number of women belonged to age group 21-30 years, followed by <20 years and 24.31+3.94 years. Respectively (Table-II)
Table -III. Educational status of the study subjects
Education Elective Emergency (n=42) (n=373)
No. (%) No. (%)
Primary 8 (19.04) 12 (3.21)
Secondary 20 (47.61) 112 (30.0)
SSC 14 (33.33) 179 (47.98)
HSC 0 48 (12.86)
Graduate and above 0 14 (3.75)
Illiterate 0 8 (2.14)
Table-III shows educational status of the study women of electively and emergency Caesarean section. In elective group, maximum number of women had secondary (47.61%) level of education and in emergency group SSC (47.98%).
Table-IV. Residence of the study subjects
| Residence | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
||
| Urban | 30 | (71.42) | 317 | (84.98) |
| Semi urban (slum) | 8 | (19.04) | 44 | (11.70 |
| Rural | 4 | (9.52) | 12 | (3.21) |
Table-IV shows residential status of elective and emergency Caesarean section women. Thirty (71.12%) and 317 (84.98%) were from urban areas, 8 (19.04%) and 44 (11.79%) from semi urban (slum) and 4 (9.52%) and 12 (3.21%) from rural areas, respectively.
Table-V. Occupation of the study subjects
| Occupation | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
||
| Housewife | 40 | (95.23) | 346 | (92.76) |
| Daylabourer | 2 | (4.76) | 12 | (3.21) |
| Serviceholde | 0 | 15 | (4.02) | |
Table-V shows that 40 (95.23%) women of elective group were housewives, 2 (4.76%) day labourer and none service holder. In the emergency group, 346 (92.76) were housewives, 12 (3.2%) daylabourers and 15
(4.02%) serviceholders.
Table-VI. Socioeconomic status of the study subjects
| Socioeconomic status | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
| Poor(<Tk.3,000/month) | 3 (7.14) | 0 |
| Low middle(Tk.3,000-6,000/
month) |
30 (71.72) | 171 (45.84) |
| Mobile(Tk6,001-10,000/
month) |
8 (19.04) | 193 (51.74) |
| Rich(>Tk. 10,000/month) | 1 (2.38) | 9 (2.41) |
Table-VI shows that most of the women of elective group were from low middle class income (71.42%) and in emergency group from middle income (51.74%)
Table VII. Built and nutritional status of the study subjects
| Parameters | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
|||||
| Built and nutrition | |||||||
| Poor | 3 | (7.14) | 11 | (2.94) | |||
| Average | 36 | (85.71) | 283 | (75.87) | |||
| Obese | 3 | (7.14) | 79 | (21.17) | |||
| Height (cm) | |||||||
| <130 | 3 | (7.14) | 0 | ||||
| 130-150 | 27 | (64.28) | 242 | (64.87) | |||
| >150 | 13 | (28.57) | 131 | (35.12) | |||
| Weight (kg) | |||||||
| Mean+SD | 58.00+8.11 | 61.69+10.53 | |||||
| Range | 45.0-70.0 | 38.0-83.0 | |||||
Table VII shows that built and nutritional status was poor in 3 (7.14%) and 11 (2.94%) average in 36 (85.7%) and 283 (75.87%) and obese in 3 (7.14%) and 79 (21.17%) women of elective and emergency groups, respectively.
Height was <130 cm in 3 (7.14%) and 0, 130-150 cm in 27 (64.28%) and 242 (64.87%) and > 150 cm in 12 (28.57%) and 131 (35.12%) respectively. Mean (+ SD) weight was 58.00+8. 11 and 61. 69+ 10.53 kg, respectively.
Table VIII. Gravidity of the study subjects
| Gravida | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
||||
| Primi | 20 | (47.61) | 138 | (36.99) | ||
| 2nd | 14 | (33.33) | 171 | (45.84) | ||
| 3rd | 8 | (19.04) | 41 | (10.99) | ||
| 4th or more | 0 | 23 | (6.16) | |||
Table- VIII shows that 20 (47.61%) women of elective group and 138 (36.99%) of emergency group were primigravida, the rest 22 (52.38%) women of elective and 235 (63.00%) of emergency group were multigravidae.
Table-IX. Gestational age and status of ANC
| Parameters | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
||
| Gestational age (weeks) | ||||
| Mean+SD | 39.40+1.33 | 39.12+1.23 | ||
| Range | 37.042.0 | 35.0-41.0 | ||
| Antenatal care | ||||
| Once | 3 | (7.14) | 7 | (1.87) |
| Twice | 11 | (26.19) | 33 | (8.84) |
| Thrice | 13 | (30.95) | 93 | (24.84) |
| More than thrice | 15 | (35.71) | 240 | (64.34) |
Table – IX shows that mean (± SD) gestational age of elective and emergency groups were almost equal, i.e. 39. 40 ± 1.33 and 39. 12 ± 1.23 weeks, respectively. Antenatal care shows significant variation between the two study groups.
Table X. Past history of any disease
| History | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
|||
| Past history | |||||
| Present | 0 | 19 | (5.09) | ||
| Absent | 42 | (100.0) | 364 | (97.58) | |
| Hypertension | 13 | (68.42) | |||
| (on medication) | |||||
| Operative treatment | 3 | (15.78) | |||
| Bronchial asthma | 3 | (15.78) | |||
Table-X shows that none of the women of elective group had any history of any disease or operation. In emergency group, out of 19 women, 13 (68.42%) were suffering from hypertension and were on medication, 3 (15.74%) had operative treatment and 3 (15.78%) was suffering from bronchial asthma.
Table XI. Obstetric history
| History | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
||
| AbortionOne
Two None |
60
36 |
(14.28)(85.71) | 150
358 |
(4.02)(95.97) |
| MROne
Two None |
03
39 |
(7.14)(92.85) | 150
358 |
(4.02)(1.07)
(94.97) |
| IUDOne
None |
339 | (7.14)(92.85) | 4369 | (1.07)(98.92) |
| Neonatal deathOne
None |
042 | (100.0) | 15358 | (4.03)(95.97) |
| Caesarean sectionYes
No Number of Caesareansection One Two |
933
6 3 |
(21.42)(78.57)
(66.66) (33.33) |
160213
142 18 |
(42.89)(57.10)
(88.75) (11.25) |
Table-XI shows that 6 (14.28%) women of elective group compared to 19 (5.09%) women of emergency group had history of abortion. History of MR was present in 3 (7.14%) of elective group compared to 15 (4.02%) in emergency group. History of IUD was present in 3 (7.14%) of elective and 4 (1.07%) of emergency group. History of neonatal death was absent in elective group compared to 15 (4.02%) in emergency group. Significantly more women had history of Caesarean section, i.e. 9 (21.42%) in elective group and 160 (42.89%) in emergency group. Out of 9 women of elective group with history of Caesarean section, 6 (66.66%) had one and 3 (33.33%) two Caesarean sections, and out of 160 women of emergency group, 142 (88.75%) had one and 18 (11.25%) two Caesarean sections.
Table XII. Presenting complaints
| Complaints | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
| Pain | 11 (26.19) | 112 (30.02) |
| Per vaginalwatery discharge | 0 | 15 (4.02) |
| Less fetal movement | 0 | 7 (1.8) |
| Others | 0 | 4 (1.07) |
| None | 31 (73.80) | 235 (63.00) |
Pain was the main presenting complains in both elective (26.7%) and emergency (30.02%) group. Other complaints in emergency group was 15 (4.02%) per vaginal watery discharge, 7 (1.8%) less fetal movement and 4 (1.07%) others. In elective group, other than pain, there were no other complaints.
Table-XIII: Indications for caesarean section
| Indications | Elective (N=42) No. (%) | Emergency (N=373) No. (%) |
| Fetal distress | 0 | 130 (34.85) |
| Eclampsia with complications | 0 | 45 (12.02) |
| Obstructed labour | 0 | 30 (2.04) |
| Premature rupture of membrane | 0 | 30 (8.04) |
| Prolonged labour | 0 | 10 (2.68) |
| Friled induction | 0 | 52 (13.94) |
| Transverse lie | 5 (11.90) | 1 (0.26) |
| Bad obstetric history | 9 (21.42) | 7 (1.87) |
| Contracted pelvis | 4 (9.52) | 1 (0.26) |
| Placenta praevia | 10 (23.80) | 1 (0.26) |
| Elderly primi | 3 (7.14) | 1 (0.26) |
| Twin pregnacy with high blood pressure | 8 (19.3) | 7 (1.87) |
| Unfavourable cervix | 0 | 7 (1.87) |
| Oligohydramnios | 0 | 12 (3.21) |
| Breech Presentation | 2 (4.76) | 12 (3.21) |
| Twin pregnancy with breech presentation | 0 | 5 (1.34) |
| Antipartum haemorrhage | 0 | 17 (4.55) |
| History of 2 previous c/s | 4 (9.51) | 5 (1.34) |
Table-XIV Neonatal weight and Apgar score
| Parameters | Elective(N=42)
No (%) |
Emergency(n=385)
No. (%) |
| Birth weight (kg) | ||
| Mean + SDRange | 2.5-4.02.0-4.02.97+ 0.40 | 0.95+0.42 |
| Birth Weight | ||
| Normal(2.5-4.0kg)
Low (<2.5 kg) |
42 (100.0)0 | 373 (96.88)12 (3.11) |
| Apgar score (5-mnute) | ||
| Mean+ SD | 9.73+0.69 | 9.72+0.69 |
| Range | 8.0-10.0 | 8.0-10.0 |
In this study, 12 women of emergency caesarean section had twin pregnancies. One baby of each twin pregnancy were low birth weight (<2.5kg) babies. Mean (+SD) birth weight of elective (n=42) and emergency (n=385) groups were (2.97+0.40 and 2.95+0.42kg, and Apgar score (5-minute) were 9.73+0.69 and 9.72+0.69, respectively (Table XIV)
Table XV. Hospital
| HospitalStay (days) | Elective (n=42)No. (%) | Emergency(n=373)
No. (%) |
| Mean +SDRange | 5.33+0.885.0-8.0 | 5.87+1.005.0-7.0 |
Table-XV shows that mean (+SD) hospital stay of elective and emergency groups were almost equal, i.e. 5.33+0.88 and 5.87+1.00 days, respectively.
Maternal Condition during Puerperium
| Condition | Elective(n=42)
No. (%) |
Emergency(n=373)
No. (%) |
| Normal | 40 (95.23) | 333 (89.27) |
| Pyrexia | 1 (2.38) | 18 (4.82) |
| Urinary tract infection | 1 (2.38) | 8 (2.14) |
| Post partum Hemorrhage | 0 |