RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE,
BENGALURU, KARNATAKA.
SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Ms. SWILLY. P MENONPEACE COTTAGE,
MAKUTTI,
PUTHAN KUNNU,
SULTHAN BATTERY ,
KERALA -691566
2. / NAME OF THE INSTITUTION / M.S RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH, BANGALORE
3. / COURSE OF STUDY AND SUBJECT / M.Sc NURSING
OBSTETRICS AND
GYNAECOLOGICAL NURSING.
4. / DATE OF ADMISSION / 29-07-2011
5. / TITLE OF THE STUDY: “TREND OF CAESAREAN SECTION AND POST CAESAREAN MATERNAL OUTCOME.”
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION
During natural childbirtha woman will experience the most beautiful sensations, she will ever feel. Allis necessaryto experiencingthe fullness of joy and pleasure of giving birth. Why give up the most amazing feeling a woman will ever have the privileged of experiencing, just to relieve a few moments of pain that will soon be forgotten? Pain in childbirth is not like other types of pain. Although it can be overwhelming without the proper moral and physical support,it is totally double and satisfying withproper preparation,the rightatmosphereandthe right kind of help, especiallyfrom an expert who has helped hundreds of women give birth naturally. It is been noticed that the child birth has becoming a matter of due to the over medicalization of their bodies. One of the current example of this is the cesarean delivery1.
Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through the abdominal wall (laparotomy) and the uterine wall (hysterectomy). Because the words "cesarean" and "section" are both derived from verbs that mean to cut, the phrase "cesarean section" is a tautology. Consequently, the terms "cesarean delivery" and "cesarean birth" are preferable2.
Factors effecting choice of delivery are Socio economic status, cultural factors, fear and anxiety of delivery process, myths and believes, lack of pain perception, clinical factors, maternal or fetal causes, institutional factors, economic incentives , risk minimizing behaviors, risk factors such as age, size of child, parity, previous caesarean section3.
The outcome of minor complications during the operation can cause uterine rupture infection, blood clots, nerve injury, bladder injury, organ injury, anaesthesia reaction (allergy), anaesthesia failure which means a woman might feel some pain during the ,stroke, blood vessel injury, damage to the intestines ,hypertension complications, wound breakdown. lung or heart failure .Other complications can occur to the foetus , fractures to long bones or the skull, scratches, scrapes and cuts, serious nerve or brain damage possible complications from a caesarean section can include any or all of the following: Infections in the mother or infant, separation of the scar on the uterus from a previous caesarean section, haemorrhoids, constipation ,minor bleeding, urinary tract infection ,an allergic skin reaction ,abnormal or painful scar tissue, increased risk of death, admission to ICU, blood transfusion and hysterectomy, including ante partum caesarean section without medical indications3 .
Currently, cesarean deliveries are performed for a variety of fetal and maternal indications. The indications have expanded to consider the patient’s wishes and preferences. Controversy surrounds the current rates of cesarean delivery in developed countries and its use for indications other than medical necessity. Caesarean section is a life-saving procedure firmly ensconced in obstetric practice. With the advances in anaesthetic services and improved surgical techniques, the morbidity and mortality of this procedure have come down considerably. This has, albeit wrongly, emboldened obstetricians to perform more and more caesarean sections, generating a universal upswing that has hit both developing and developed countries. Unfortunately, given our economic constraints, India is hardly equipped to handle the repercussions of such an unprecedented increase in surgical interventions4.
In today’s situation when the access to the analyzed recent scenario states that due to recent advancement in the medical and surgical fields of obstetrics and gynecological technology and treatment modalities, it is making an easy way for the women to choose the delivery modes based on the obstetric care that is growing day by day for a women to go for caesarean section and it has been rising the rates over the world 5.
The national family health survey data shows that the consistent increase has been observed in the rate of cesarean section deliveries in most form of deliveries are common in high tech cities of Karnataka ,Kerala , Andhra Pradesh, Goa states with marked demographic transition as well as high institutionalized births have inflated rates of cesarean deliveries. The trends in caesarean deliveries and increasing preference by the medical professionals point towards the growing medicalization of women’s health 6.
6.1 NEED FOR THE STUDY
The studies throw light on current trends in caesarean delivery in developed and developing countries including India, increase use of medical technologies during child birth and competency leads to great increase from moving away from naturality of birth process7.
A collaborative study done by the Indian Council of Medical Research (ICMR) in 1980, the escalating rates of Caesarean sections in teaching hospitals in India compared the rates between 1993-94 and 1998-99, with data from 30 medical colleges/teaching hospitals .The overall rate showed an increase from 21.8 per cent in 1993-94 to 25.4 per cent in 1998-99. What was alarming was that 42.4 per cent were primigravida’s and 31 per cent had come from rural areas. Because of the rise in primary Caesarean sections, there is a proportionate rise in repeat sections as well. Between 1990 and 1992 the repeat rate was between 30 and 45 per cent in teaching hospitals in Madurai and Chennai 8.
In a study over a two-year period in an urban area of India, the total Caesarean section rates even in the public and charitable sectors were 20 and 38 per cent respectively. In the private sectors, the rate was an unbelievable 47 per cent. A similar study from an affluent part of Chennai showed that almost every other woman (45 per cent) had a Caesarean section these rates cannot be justified 9.
The rate of Caesarean section is relatively higher in Kerala and Goa .A 1995 study in Thiruvananthapuram, Kerala, found that the Caesarean section rate in the private sector (30 per cent) was three times that of the public sector (10 per cent). In addition, in Andhra Pradesh, Bihar, Gujarat, Karnataka, Punjab and Uttar Pradesh the chance of having a Caesarean is four or more times higher in private institutions as compared to public ones. This raises the question of whether this life-saving surgical intervention is being motivated by monetary profit in several states .Public perception of Caesarean sections has seen a swing from a “failure of obstetric care” to being “safe for mother and child.” There have been occasions where an obstetrician has been manhandled for a poor outcome and blamed needlessly for not having performed a Caesarean section. At the same time media glare has fallen unfavourably on the rise in rates of these procedures9.
There is a substantial increase in the number of caesarean delivery .Concerning this WHO gives recommendations revised in 1994 guidelines of caesarean rates proportion should range from 5-15% but still it is increasing over the times which have no good for mother and child10.
A Global survey conducted by WHO on maternal and prenatal health 2004-2008 from and found that out of 286,565 delivery 27.7% were caesarean section out of which 9.5% were without medical indication according to medical records10.
A hospital based retrospective study was carried out in a tertiary government-run hospital in Karnataka specializing in Obstetrics & Gynaecology & all deliveries conducted from Jan 1st 2009 to Dec 31st 2009 were included. There were 7543 deliveries in the study period, with 1756 being Caesarean section, giving a rate of 23.27%. The studies states that there is an increasing trend of caesarean section from 2005 (20.24%) to 2009 (23.27%)11 this study highlight the relationship between caesarean section and severe maternal out come more specifically to analyze the risk of caesarean section and maternal out come and the present fact about the important factors that are present for the choose of the caesarean section and to find the rates of caesarean section and the future impact of this intervention 11.
6.2. REVIEW OF LITERATURE
The studies throw light on current trends in caesarean delivery in developed and developing countries including India, increase use of medical technologies during child birth is the existing cause for carrying such intervention4.
There are a substantial increase in the number of caesarean delivery .Concerning this WHO recommendations on guidelines of caesarean rates proportion from 5-15% but still it is increasing over the time which have no good for mother and child 10.
A multi country, facility-based survey that is conducted by using cluster sampling design to obtain samples a total of 24 countries and 373 health facilities participated in this study . a total of 286,565 deliveries were analyzed. The overall caesarean section rate was 25.7% and a total of 1 1.0 percent of all deliveries were caesarean section without medical indication ,either due to maternal request or in the absence of other recorded indications . Compared to spontaneous vaginal delivery, caesarean section deliveries are of increased risk of death, admission to ICU, blood transfusion and hysterectomy, including antepartum caesarean section without medical indications12.
Caesarean Awareness Month was initiated by the International Caesarean Awareness Network to bring attention to the high number of caesareans performed in the United States and the lack of access to medical care for VBAC. The caesarean rate rose to 32.9 per cent in 2009,another record high for the U.S. The percentage ofcaesarean births has been rising steadily for over a decade, and is up nearly 60% since 1996 despite evidence of the increased risk of maternal and neonatal mortality when healthy women agree to a scheduled surgery13.
In a study conducted regarding awareness and perceptions of and attitudes towards caesarean delivery among antenatal of 317 women interviewed 304 (96%) had heard of the operation; however only 43 (13.5%) could mention specific indications for it. Vaginal delivery was preferred by 296 (93.3%) while 11 (3.5%) preferred planned caesarean delivery; the remaining 10 (3.2%) were undecided. Although 164 (51.7%) perceived it as being dangerous to the mother and baby, 287 (90.5%) were willing to undergo the operation when indicated; 19 (6%) would refuse the operation even when indicated. Almost all the women, 311 (98.1%), wanted caesarean section to be part of client education at the antenatal clinic and 314 (99.1%) wanted to be informed about the specific indication before surgery14.
A study conducted regarding Caesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa, shows Median caesarean delivery rate was 8.8% among 83 439 births. Caesarean deliveries were performed in only 95 (73%) facilities and were influenced by previous caesarean, preeclampsia, induced labour, referral status, and higher health facility classification scores15.
A review of 1683 caesarean sections performed at one hospital in a 3-year period (1977-79) showed that the caesarean section rate had trebled since 1967-79, the rates being 16.9% and 5.8%. The main indications for caesarean section responsible for this rise were dystocia, breech presentation and a previous caesarean section. After the operation 23.3% of received antibiotics. If the caesarean section rate is to fall, the biggest impact can be made by planning vaginal delivery in selected patients with a previous caesarean section and by improving the management of no progressive labour16.
STATEMENT OF THE PROBLEM
‘‘A RETROSPECTIVE STUDY TO ASSESS TREND OF CAESAREAN SECTION AND POST CAESAREAN MATERNAL OUTCOME AT SELECTED HOSPITALS , BANGALORE’’
6.3. OBJECTIVES
· To identify the trend of caesarean section.
· To assess post caesarean maternal out come.
· To correlate between rate of caesarean section and maternal outcome.
· To find the association between caesarean section rates with selected socio demographic variables.
· To find association between post caesarean maternal outcome with selected socio demographic variable
6.4. HYPOTHESES
• There will not be significant relationship between trend in caesarean sections and post caesarean maternal outcomes.
• There will not be significant co-relation between trend and selected socio demographic variables.
• There will not be significant association between post caesarean maternal outcome and selected socio demographical variables.
6.5. OPERATIONAL DEFINITONS
CAESAREAN SECTION: refers to an operative procedure where by the fetuses are delivered through an incision on the abdominal and uterine walls.
TREND: refers to the general direction in which caesarean section rate is increasing or changing.
POST CAESAREAN MATERNAL OUTCOME: Refers to the condition of the mother after caesarean section delivery such as Postpartum Hemorrhage, anesthetic hazards, infections, wound complications, scar rupture.
6.6. ASSUMPTIONS
• There may be exponential raise in caesarean section rates.
• Medical and technological advancement in operative procedures may influence the mother to choose caesarean section.
• Fear and pain perception of labour process may influence mother to choose caesarean section.
6.7. DELIMITATIONS
The Study is delimited to
• One month period of data collection.
7. MATERIALS AND METHODS
7.1. SOURCE OF DATA :
· Medical records from selected hospitals
7.2. METHODS OF DATA COLLECTION
7.2.1. TYPE OF STUDY APPROACH
v Retrospective Approach
7.2.2. RESEARCH DESIGN
Retrospective Study Design
7.2.3. VARIABLES:
Study variables:
Rates of Caesarean Section and Post Caesarean Maternal Outcome from Hospital Records.
Attribute variables:
Age ,educational qualification, occupation ,parity, family income, previous caesarean section, place of delivery, duration of hospital stay, no of caesarean section .
7.2.4. SAMPLING TECHNIQUE
Simple Random Sampling Technique
7.2.5. SAMPLE AND SAMPLE SIZE
500 Record Survey from selected hospital
7.2.6. SELECTION CRITERIA:
Inclusion criteria
• Number of deliveries during the past 5 years
§ Hospitals that provide the records for analysis.
§ Records availability during data collection period.
§ Who are undergone caesarean sections during the study period.