MATERNAL AND FETAL OUTCOMES IN

ELECTIVE AND EMERGENCY

CAESAREAN SECTION

Conducted by
Dr. Fathia Gamode Saleh Shaib Elain

Supervised by:
Dr. fuod Ali Zekri
MD, Pisa University Italy
Libyan Board in Obstetrics and Gynecology
Italian Diploma in Gynecology

Consultant obstetrics & gynecology department, Tripoli University

Dr. Maha Shinshin

MDh Arab board Obstetrician &Gynecology

T.M.C

This dissertation is submitted fulfillment for certification by the Arab board of

medical specialization in Gynecology and Obstetrics 2021
 Certificate
The work presented in this dissertation was carried out by Dr. Fathia Gamode Saleh
Shaib Elain ,During the training In department of obstetrics and gynecology in Tripoli
Medical Center under my supervision .

1
 Table of contents

Subject Page
Certification 1
List of content 2
List of abbreviation 3
List OF tables 4
List OF figures 5
Acknowledgment 6
Abstract 7
Aim of study 7
Material and methods 7
introduction 11
Result 21
Discussion 33
Conclusion and recommendation 38 -37
References 39
Arabic summary 45

2
LIST OF ABBREVIATIONS

Term Abbreviation

Cesarean Section C/S

Elective Cesarean Section Elective c/s

Emergency Cesarean Section Emergency c/s

Nursery intensive care unit NICU

Intrauterine fetal death IUFD

Fetal distress FD

Respiratory distress syndrome RDS

Bad obstetric history BOH

Parity P

Preeclampsia PET

Postpartum hemorrhage PPH

Spinal anesthesia SA

General anesthesia GA

Diabetes Mellitus DM

Urinary tract infection UTI

3
 List of tables
Table number Title Page number

1 maternal age 22

2 Distribution of gestational age 23

3 Distribution of parity 24

4 Indication of cesarean section. 25

5 Type of anesthesia 26

6 Neonatal outcome . 27

7 Apgar score 28

8 neonatal admission 29

9 neonatal complications 30

10 Intraoperative maternal complications. 31

11 postoperative maternal complications. 32

4
 List of figures
Figure Title Page
number number
1 Type of cesarean section 21

2 Maternal age 22

3 Gestational age of the women … 23

4 Distribution of parity 24

5 Type of anesthesia 26

6 Neonatal outcome 27

7 NICU admission 29

8 Neonatal complications 30

9 Intraoperative complications … 31

10 Postoperative complications 32

5
 Acknowledgment

To ‘Allah’ the most Gracious and the most merciful, who directed us through the way,
To Dr. Maha Shinshin for his huge efforts of directing and supervising me to
achieve this adequate work.

To my husband and all my family And friends ,they supported me and encouraged
me to finish this work. To all my staff members and my colleagues, who helped me in
my work. I thank all of them and wish you the best in their lives.

Dr. Fathia Gamode Saleh Shaib Elian

6
 Abstract
Back ground:
Cesarean section delivery represents the most important operation in obstetrics and its
incidence is on the rise throughout the world .
This increasing rates of cesarean section (CS) are increasing worldwide leading to an
increased risk for maternal and neonatal complications in the subsequent pregnancy and
labor.

Aims of study :
T he purpose of this study is to compare the maternal and neonatal outcome and
complications in two groups of pregnant women undergoing elective and emergency
cesarean section.

MATERIALS AND METHODS

was prospective study. It was conducted at the department of obstetrics and gynecology
in Tripoli Medical Center TMC. A total of 600 pregnant women who underwent an
elective and emergency cesarean section were randomly selected and analyzed The data
was collected by using pretested questionnaire, which consisted of three section.

1- maternal characteristics ( maternal age, , parity, gestation age, indication of

cesarean section , types of anesthesia )
2- neonatal morbidity outcome (outcome of baby alive or died, Apgar score, cause of
NICU admission, length of stay in nursery and neonatal complication).
3- maternal morbidity outcome (intraoperative injury ,spinal headache, postpartum
hemorrhage PPH ,Anemia , postoperative fever and wound infection).

7
 Result:
The proportion of elective and emergency caesarean was 40.8% and 59.2% respectively.
All of the complications were significantly higher in emergency group in terms of both
maternal and fetal outcome.
There was 600 cesarean sections of which emergency cesarean section accounted for
355(59.2%) and elective cesarean section for 245 cases ( 40.8%). The mean age of the
patients was found to be 31 ± 6 years. The mean gestational age was found to 38.3 ± 1.5.
The frequency of complications was higher in emergency group than elective cesarean
section group. Our result demonstrate that with appropriate prenatal care, adequate
preoperative cares, surgical techniques and careful postoperative care emergency
cesarean section were safe. Of the various factors analyzed in relation to the two types of
cesarean sections, statistically significant associations were found between emergency
cesarean section and ,indication of cesarean section . The commonest indication of
emergency cesarean section was fetal distress ( 33.8%), while the most frequent
indication in elective cesarean section was previous cesarean delivery ( 55.1%).

Conclusion:
The planned operation (Elective cesarean section ) often does better in morbidity than
one performed as an emergency cesarean section due to all complication rate is high in
emergency cesarean section than in elective cesarean section .

8
Definition of terms:

Cesarean section delivery is defined as the birth of a fetus, living or dead through an
incision on the abdominal and uterine wall. The removal of the fetus from the abdominal
cavity as in case of either ruptured uterus or abdominal ectopic pregnancy is excluded.
Cesarean section delivery was classified as elective c/s if the decision to perform the
operation was made before the onset of labor and after preoperative preparation at a
prearranged time during office hours to ensure the best quality of obstetrics, anesthetic,
neonatal, and nursing services.
even when labor started before the operation (regular contractions with cervical
dilatation). All others were considered as emergency cesarean deliveries.
Parity was the number of previous pregnancies ending after 20 completed weeks of
gestation including stillbirth.
prenatal care: A woman was considered to have received adequate prenatal care when
she had 3 or more visits for prenatal care during her pregnancy and prenatal care was
considered insufficient if there were less than 3 visits for prenatal care during the course
of the pregnancy.
Birth weight was defined as the first measurement of body weight, usually in the first
hour of life.
Gestational age was calculated using the first day of last maternal menstrual period if it
was known, or estimated by obstetric sonography, or with the Dubowitz score.
Fetal macrosomia was defined as birth weight above the 90th percentile of the Leroy
and Lefort curve.
Prematurity: was defined as a birth occurring before 37 completed weeks of gestation.
Post-term: was defined as 42 or more weeks of gestation.
Birth asphyxia was defined as a low Apgar score of less than 7 at 5 minutes (1)

9
Respiratory morbidity : was defined by the presence of tachypnea or chest retractions
regardless of the etiology.
Fresh stillbirth was defined as the intrauterine death of a fetus during labor or delivery.
Early neonatal mortality included any death that occurred within the first 7 days of life.
Perinatal mortality was defined as the sum of all stillbirths and early neonatal deaths.

10
Introduction
Cesarean sections are one of the most performed surgical procedures all over the world
(2 ) can be a life-saving intervention when medically indicated, but this procedure can also

lead to short-term and long-term health effects for women and children.The present study
was conducted to determine the maternal & neonatal outcome and complications in two
groups of pregnancy among women with elective and emergency cesarean section. So
that measures can be taken to reduce morbidity and mortality in near future.
The prevalence of maternal mortality and maternal morbidity is higher after CS than after
vaginal birth. Although caesarean section (CS) can be a life-saving intervention for
mothers and children, it can also lead to short-term and long-term health consequences.
C/S is associated with an increased risk of uterine rupture, abnormal placentation, ectopic
pregnancy, stillbirth, and preterm birth

The term" cesarean section" denotes the delivery of fetus , placenta , the membranes
through a surgical incision in the abdominal and uterine walls. This definition exclude the
obsolete operation of vaginal cesarean section in which transvaginal access to the fetus is
achieved by incising the anterior lip of the cervix and lower uterine segment .The term
also excludes the operation involving the recovery, through an abdominal incision, of a
fetus lying free in the abdominal cavity after secondary implantation or uterine rupture.
The correct term for the surgical delivery of a previable infant is hysterotomy(3) . The
maternal mortality rate was high, most often because of hemorrhage & infection.
However, advances in surgical & anesthetic techniques, safe blood transfusions, & the
discovery of effective antibiotics have led to a dramatic decline in the mortality rate (3)
.The rates vary widely by country, health care facility, and delivering physician, partly
because of differing perceptions of its benefits and risks by health care providers as well
as by pregnant women(4).

In the past 30years the rate of caesarean section has steadily increased from 5% to more
than 20% the reason being, avoidance of mid-forceps and vaginal breech deliveries ,use
of fetal monitoring during labour and the belief that caesarean section will reduce
perinatal mortality(5). A caesarean section is a life-saving surgical procedure when
certain complications arise during pregnancy and labor, However, it is a major surgery
and is associated with immediate maternal and perinatal risks and may have implications
for future pregnancies as well as long-term effects that are still being investigated (6-8) .
11
For the patient who is about to give birth, caesarean section carries considerable
disadvantage when compared with normal vaginal delivery. This is not only in terms of
the pain & trauma of an abdominal operation, but also because of the possible associated
complications which cannot be totally avoided(9) . Like all surgical procedures caesarean
section is also not risk free and it has some inherent risk factors associated(10,11)

Emergency cesarean section was defined as the one performed as soon as possible after
the decision of operation was made without prior pre-operative preparation.
Elective cesarean was defined as the one performed after proper planning and
preoperative preparations.

Indications for cesarean section:

Cesarean section is used in cases where vaginal delivery either feasible or would impose
undue risks to the mother or baby.

1.Repeated cesarean section.

2.Cephalopelvic disproportion/Dystocia.

3.Mal position , mal presentation.

4.Fetal distress.

5.Failure to progress in labor.

6.Diabetes mellitus.

7.Bad obstetric history.

8..Multiple gestation .

9.Placental problems.( placenta preavia , abruptio, accreta).

10.Preeclampsia, eclampsia.

11. umbilical cord Prolapse .

12. fetal abnormality (hydrocephalus ) (12) .

12
13.Maternal request

14. cervical cancer and active herpes infection.

Antenatal counseling and documentation:

One of the goals of prenatal care is to reduce pregnancy complications which may
warrant emergency cesarean section

It is very important to document the discussion of risk and benefits of both vaginal
delivery and cesarean section with patient careful.

Counseling the patient with regard to the likelihood of success is also important and
review of the previous is a necessary part of this counseling..

Wherever possible the records of delivery leading to the cesarean section should be
reviewed by asking a copy of the case notes for possible extension of incision or other
complication or if any doubt about the type of uterine scar used Full informed consent
must always be obtained prior to operation as long as the indication for delivery is
discussed in appropriate and considerate manner..

The national consent form require both the risk benefits to be discussed with patient and
recorded in on the consent form common medical practice is highlight risks not benefits ,
It is suggest that top copy of the form should be offered to the patient.

13
Types of cesarean section :
The type of cesarean section is based on the type of incision of the uterus.

1. Medline vertical incision :

The midline vertical incision could be in lower segment of the uterus commonly, it
starts in the lower segment as a small buttonhole incision until the uterine cavity is
reached and is extended upward. The midline incision is reserved for specific
indication because of difficulty in making the incision increase blood loss, inadequate
approximation at closure, increased postoperative morbidity, and inability to offer a
trial of vaginal delivery in the next pregnancy due to possible higher incidence of scar
rupture (13) .

2-lower uterine segment incision:

Lower segment cesarean section involves a horizontal incision on the lower segment
after reflecting the visceral peritoneum , this is the commonest cesarean section
procedure. The abdomen is opened by a low midline, par median and, more commonly
by a P fannenstiel (supra pubic horizontal) incision and the peritoneal cavity opened .
The bladder is reflected from the lower segment and transverse incision is made on lower
uterine segment, care being taken not to injure the fetus. The presenting part is delivered
through the lower segment .A forceps can be used to assist delivery in a cephalic
presentation(13) .

Classification of cesarean section:

Caesarean section is further divided into two sub-types as far as the urgency of operation
is concerned. Elective caesarean section refers to “those occasions where a cesarean is
conducted as a result of advanced planning”(14) .It also refers to a decision made more
than 24 hours before delivery. An elective cesarean, due to its non-emergency situation,
may be perceived by the woman giving birth as a calm and positive experience.
Emergency cesarean section ,on the other hand, is defined as any cesarean delivery that is
not planned or scheduled(15) . A cesarean operation is considered an emergency if
14
decisions are made during the 24 hours before the delivery because of deteriorating fetal
or maternal health before the onset of labor(15) .

Indications for this non-elective caesarean section are usually evident only after the onset
of labor, either in the early stage or after a woman has been in labor for a while. Since
time is critical in this operation, several studies attempted to set the standard interval time
from the date and time of decision to carry out the cesarean section to the date and time
of delivery of the baby. The present acceptable delivery interval is 30 minutes, although
other studies have found out that even beyond this period, as long as it does not exceed
75 minutes, emergency caesarean section outcomes are still favorable (16,17) .

this classification is used to help communication between obstetric , midwifery and

anesthetic team for discussion of most appropriate method of anesthesia . The decision
whether to perform general anesthesia or regional is important and based on many
indication .Including how urgent the delivery need to be as well as the medical and
obstetric history of women(18) . Regional anesthetic is almost always safer for the women
and baby but sometimes general anesthetics is safer for one or both. Elective caesarean
may reduce the incidence of emergency caesarean that is associated with high maternal
morbidity and mortality (19) .

Elective caesarean section is generally done around 38-39 weeks as the incidence of
tachypnoea of the newborn is much less after this gestation. However, the medical or
obstetric condition determines the gestation at which the elective caesarean section is
planned – the main principle being to carry out the caesarean section as late as possible in
gestation without compromising the maternal or fetal health(20) .It is seen that morbidity
and mortality are associated more with emergency procedures than with elective
procedures (21) . In elective caesarean section mother is well prepared preoperatively, and
all criteria for surgery are tried to meet with availability of trained staff, and both
maternal and fetal complications are undoubtedly less(22) . The major threats to a women
undergoing emergency caesarean section are complications of anesthesia and surgery .In
emergency caesarean section there is lack of facilities to meet all the criteria of surgery,
the procedure has to be done in deficient circumstances, and elective caesarean section
adversely affects the outcome. Both maternal and fetal complication are understandably
more common in emergency cases (23-24) .The aspect of complications relating to the
delivery being an emergency or an elective caesarean section, was investigate .They
found an increased incidence in severe maternal morbidity (deep venous
15
thromboembolism, amniotic fluid embolism, major puerperal infection, severe
hemorrhage, uterine rupture and inversion and events requiring operative intervention
after delivery) in emergency compared to elective caesarean section. Cesarean sections
have long been practiced as an obstetric surgical procedure that contributes to reducing
fetal complications. And though it is classified as a major procedure, the incidence of
cesarean section has considerably increased over the years all over the world (25)
.Nevertheless , its advantages do not justify its continuous increase since it carries
considerable disadvantages when compared with normal vaginal delivery. According to
some studies, cesarean section requires a longer recovery time and operative
complications such as lacerations and bleeding may occur at rates varying from 6% for
elective cesarean to 15% for emergency cesarean (26,27) .Though advances in the field
have reduced maternal complications considerably, the problem of fetal morbidity after
cesarean section still persists. And as much as is practical, everything points to the
advantages that can be derived from an elective cesarean as compared to one that is
undertaken as an emergency (28) . In fact, most evidence indicates that caesarean section
has much higher risk than labor.

There is currently no evidence that elective caesarean is safer than vaginal delivery..
Therefore, obstetric care providers should continue to advocate for vaginal delivery as
the optimal mode of birth(29) .

The risks of a cesarean delivery:

A cesarean delivery is becoming more common delivery type worldwide ,but it’s still a
major surgery that carries risks for both mother and child. Vaginal birth remains the
preferred method for the lowest risk of complications. The risks of a cesarean delivery
include:

• bleeding
• blood clots &DIC.
• breathing problems for the child, especially if done before 37 weeks of pregnancy
• increased risks for future pregnancies
16
 • infection
• injury to the child during surgery
• longer recovery time compared with vaginal birth
• surgical injury to other organs
• adhesions, hernia, and other complications of abdominal surgery

Types of anesthesia

Various options are available for anesthesia during a cesarean.

Discuss these with a healthcare provider. Options include the use of general anesthesia,
epidural block, or spinal block. When general anesthesia is used, the patient will be put to
sleep for the operation.

With an epidural or spinal block, only the lower half of the body will be numb. During an
epidural block, the doctor injects numbing medication into a space in the spine either
with or without a tube that can deliver additional medication as needed.

During a spinal block, the doctor injects the medication directly into the spinal fluid.

Technique for cesarean section:

Antibiotic prophylaxis is used before an incision.
The uterus is incised, and this incision is extended with blunt pressure along a
cephalad- caudad axis(30). The infant is delivered , and the placenta is then removed.
The surgeon then makes a decision about uterine exteriorization. Single-layer uterine
closure is used when the mother does not want a future pregnancy . when
subcutaneous tissue is 2 cm thick or more ,surgical suture is used(31). Caesarean
section can be performed with single or double layer suturing of the uterine
incision(31) .

17
 A Cochrane review came to the result that single layer closure compared with double
layer closure was associated with a statistically reduction in mean blood loss(32) .
Standard procedure includes the closure of the peritoneum, However, research
question this may not be needed , with some studies indicating peritoneal closure is
associated with longer operative time and hospital stay(33)

Recovery after cesarean section:

Following a C-section, a woman and her infant can expect to remain in the hospital for
2–4 days.

The new mother is likely to experience pain at the site of the incision, cramping, and
bleeding with or without clots for 4–6 weeks. The severity of these symptoms will vary
for different women who have undergone the operation but should improve fairly quickly
as time passes.

Visit a doctor with any concerns about the severity of these symptoms or if they continue
for longer than expected. The doctor will assess recovery during postoperative visits.
These are good opportunities to discuss progress and questions.

Healthcare providers will recommend restricting physical activity on returning home.

Until a doctor says that resuming normal activity is safe, typically 4–6 weeks after
surgery, they routinely recommend that patients avoid strenuous exercise, lifting heavy
objects, placing anything in the vagina.During the recovery period, a woman can take the
following steps:

• maintain hydration by drinking plenty of water

• take any medications as directed
• rest when necessary
• provide support to the incision and abdomen with the use of a pregnancy belt or
pillow

18
Maternal complications:
Maternal complication are increased with all cesarean compared with vaginal
deliveries(34) .
Cesarean section has higher maternal surgical risks for the current and subsequent
pregnancy. This is balanced against lower rates of perineal injury and short-term pelvis
floor disorder for mother ,death attributable solely to cesarean section is rare in Unites
States .Even so, numerous studies attest to increase mortality risk(35). Principles among
these complication ,infection ,hemorrhage, and thromboembolism . Anesthetic
complication, which also rarely include death, have greater incidence with cesarean
compared with vaginal delivery(36) . Adjacent organ may be injured as the bladder
laceration and bowel damage. Other complication include hysterectomy, and re-
hospitalization for infection or wound complication longer initial hospital stays, and
greater rates of uterine rupture or abnormal placenta implantation in subsequent
pregnancies(37) . Placenta accrete is abnormal placental adherent to the uterus, increta
:invades the myometrium , or percreta :invades serosa and adjacent organ, or accrete
:villi attached to the myometrium . Most significant maternal morbidity after cesarean
section occur in subsequent pregnancies in women with placenta accrete ,which has now
become the most common reason for cesarean hysterectomy in developing countries
Infertility which may result when adhesion distort tissue of the ovaries ,tube.

Neonatal complication:
Cesarean sections have long been practiced as an obstetric surgical procedure that
contributes to reducing fetal complications. And though it is classified as a major
procedure, the incidence of cesarean section has considerably increased over the years all
over the world (38). Increase incidence of respiratory distress syndrome, hypoglycemia
,needs NICU admission , increases the rate of respiratory death(40),Potentials for early
delivery and complicated preterm delivery may be ,inadvertently ,carried out ,if due-date
calculation is inaccurate ,one study found that the increased of complication risk if be
repeated of elective cesarean section when performed even few day before the
recommended 39week(41) . Cesarean section associates with less risk of fetal trauma skin
laceration , which is the most common(39)..

19
The overall fetal complications rate was higher in emergency cesarean section than in
elective cesarean section. Early recognition and referral of mothers who are likely to
undergo cesarean section may reduce the incidence of emergency cesarean sections and
thus decrease fetal complications.

20
Results:
Type of cesarean section
The total number of the patient were included in this study were 600, out of which
245patients had elective cesarean section 40.8%, and 355 patients had emergency
cesarean section 59.2%.

cesarean Section

[]
Elective c/s
[]
Emergency c/s

Figure1: Type of cesarean section

21
maternal age
The mean age of pregnant women in this study was 31 ± 6 years , with youngest age was
19 years and oldest age was 44 years .the maximum number of patients was between 20-
30 yr (46.8 %).

In elective caesarean section less than 20 years was about 1.2% , 20 - 30 yrs was 41.2% ,
31- 40 yr was 51.5 % and more than 40 yr was about 6.1 % , while in emergency
caesarean section those less than 20 years were 3.9% , 20 - 30 yr were 50.7% , 31- 40 yr
were 40.3 % and more than 40ys made 5.1 %

Table 1 : maternal age

Maternal Age Elective c/s Emergency c/s Total

< 20 yr 3 (1.2%) 14 (3.9%) 17 (2.9%)

20-30 yr 101 (41.2%) 180 (50,7%) 281 (46.8%)
31-40 yr 126 (51.5%) 143 (40.3%) 269 (44.8%)
>40 yr 15 (6.1%) 18 (5.1 %) 33 (5.5%)
Total 245 (100%) 355 (100%) 600 (100%)

60.00%
50.70% 51.50%

50.00%
41.20% 40.30%
40.00%

30.00%
Elective c/s

20.00% Emergency
c/s
10.00% 6.10% 5.10%
3.90%
1.20%
0.00%
<20 yr 20-30 yr 30-40 yr > 40 yr

Figure 2: Maternal age

22
Gestational Age
The present study showed that the maximum gestational age was 42 weeks and the
minimum gestational age was 30 weeks with mean of 38.3 ±1.5, most of women were
term between 37- 40 weeks (81.8%).

Table 2:Gastitional age

Gestational Age Elective c/s Emergency c/s Total

<37 wk 9 (3.7%) 43 (12.1%) 52 (8.7%)

37-40wk 229 (93.5%) 262 (73.8%) 491 (81.8%)

>40wk 7 (2.8%) 50 (14.1%) 57 (9.5%)

Total 245 (100%) 355 (100%) 600 (100%)

[]
100.00%

90.00%
73.80%
80.00%

70.00%
Elective c/s
60.00%

50.00% Emergency
c/s
40.00%

30.00%
12.10% 14.10%
20.00%
3.70% 2.80%
10.00%

0.00%
<37 wk 37 -40wk >40wk

Figure 3:Gestational age of the women

23
parity distribution:
Regarding the parity distribution , most of the patient 57.2% were multipara ,the
maximum parity was 8 and the minimum parity was 1 with mean was 2 ±1.7.

In elective caesarean section group 27.3% were primigrivida & Para one and 72.7%
were multipara ,whereas in the emergency caesarean section group 53.5% were
primigrivida & para one and 42.8 % were multipara.

Table 3- parity distribution:

parity Elective c/s Emergency c/s Total

PG- p1 67 (27.3%) 190 (53.5%) 257 (42.8%)

P2-P7 178 (72.7%) 165 (46.5%) 343 (57.2%)

Total 245 (100%) 355 (100%) 600 (100%)

80.00% 72.70%

70.00%

60.00% 53.50%
46.50%
50.00%
Elective c/s
40.00% Emergency
27.30%
30.00%

20.00%

10.00%

0.00%
PG-p1 p2-p7

Figure 4: Distribution of parity

24
Indication of cesarean section:
Most common indication for cesarean section in general was previous caesarean section
33%. Among those who had elective caesarean sections most indication was for previous
caesarean section 55.1% and precious pregnancy 8.6% and mal presentation 7% ,while
in emergency caesarean section group was a fetal distress 33.8% , previous caesarean
section 17.7% and failure to progress 16.6% were the main indications .

Table 4:Indication of cesarean section

Indication Elective c/s Emergency c/s Total
Pervious pregnancy 21 (8.6%) 11 (3.1%) 32 (5.3% )
Infertility & BOH
Previous c/s 135 (55.1%) 63 (17.7%) 198 (33%)
Mal presentation 17 ( 7% ) 28 (7.9%) 45 (7.5%)
Twine pregnancy 5 ( 2% ) 13 (3.7 %) 18 ( 3% )

Hydrocephaly 15 ( 6% ) 14 (3.9% ) 29 (4.8% )

FD 0 ( 0% ) 120 (33.8%) 120 (20%)
Failure to progress 0 ( 0%) 59 (16.6%) 59 (9.8%)
macrosomia 10 (4.1%) 11 (3.1%) 21 (3.5%)
Oligo hydrominas 15 (6.1%) 5 (1.4% ) 20 (3.3%)
PET 5 (2%) 13 (3.7%) 18 (3 %)
Placenta previa 12 (5%) 4 (1.1%) 16 (2.7%)
Abruptio placenta 0 (0%) 7 (2%) 7 (1.2%)
DM 6 (2.4%) 2 (0.6%) 8 (1.3%)
Cord prolapse 0 (0%) 3 (0.8%) 3 (0.5%)
Rupture uterus 0 (0%) 1 ( 0.3%) 1 (0.2%)

others 4 (1.6%) 1 (0.3%) 5 (0.9%)

Total 245 (100%) 355 (100%) 600 (100%)

25
Type of anesthesia
Most of the patients 77.5% had spinal anesthesia and 22.5% had general anesthesia
,among those who had general anesthesia 23.4% had emergency cesarean section and
21.2% belonged to the elective cesarean section group, while in spinal anesthesia 76.6%
had emergency surgery and 78.8% belonged to the elective cesarean section group, the
association between anesthesia and type of caesarean was not statistically significant

Table 5 : Type of anesthesia

Type of Elective c/s Emergency c/s total
anesthesia
GA 52 (21.2%) 83 (23.4%) 135 (22.5%)
SA 193 (78.8%) 272 (76.6%) 465 (77.5%)
Total 245 (100%) 355 (100%) 600 (100%)
78.80%
76.60%
80.00%

70.00%

60.00%

50.00%
Elective c/s
40.00% Emergency c/s

30.00% 23.40%
21.20%

20.00%

10.00%

0.00%
GA SA

Figure 5 :Type of anesthesia

26
Neonatal outcome:

In the current study, approximately 98.2% of the neonates were alive at birth , neonatal
death &still birth reported in 10 cases 1.7% and IUFD in 1 cases 0.2 % . Neonatal
outcome in the elective group, 99.6% were alive births and only 0.4% were neonatal
&still birth deaths .While in the emergency group, there were 97.2% live births and 2.5%
neonatal deaths & still birth.

Table 6: Neonatal outcome

Neonatal outcome Elective c/s Emergency c/s Total

alive 244 (99.6%) 345 (97.2%) 589 (98.2%)
Neonatal death 1 (0.4%) 9 (2.5%) 10 (1.7%)
&still birth
IUFD 0 (0%) 1 (0.3%) 1 (0.2%)
Total 245 (100%) 355 (100%) 600 (100%)

99.60%97.20%
100.00%
90.00%
80.00%
70.00%
60.00%
Elective c/s
50.00%
Emergeny c/s
40.00%
30.00%
20.00%
10.00% 0.40% 2.50% 0% 0.30%
0.00%
alive neonatal death IUFD

Figure 6: neonatal outcome

27
Apgar score
The newborns in the group with the elective cesarean section had considerably better
Apgar score index in the first minute and fifth minute than in emergency group.

Table 7 : Apgar score

Abgor score Elective c/s Emergency c/s Total

First minute
<7 2 (0.8% ) 38 (10.7%) 40 (6.7%)
>7 243 (99.8%) 317 (89.3%) 560 (93.3%)
Total 245 (100%) 355 (100%) 600 (100%)

After 5 minute
<7 1 (0.4%) 16 (4.5%) 17 (2.8%)
> 7 244 (99.6%) 339 (95.5) 583 (97.2%)
Total 245 (100%) 355 (100%) 600 (100%)

Admission to NICU:
Among those neonate who need admission, the duration may range from less than 7 days
or more than 7day ,although 83.8% of newborn had no nursery admission ,only 7.3% in
elective cesarean section and 12.4% in emergency cesarean section stay in nursery
intensive care unit about 7 days . but 6.1% in elective cesarean section and 5.9% in
emergency cesarean section stay more than 7 days in nursery Almost of them cases of
congenital Hydrocephaly they need arrangement of neurosurgery..

28
Table8: Neonatal admission

outcome of the Elective c/s Emergency c/s Total

baby

No admission 212 (86.6%) 291 (82%) 503 (83.8%)

1-7day 18 (7.3%) 44 (12.4%) 62 (10.3%)

>7day 15 (6.1%) 20 (5.6%) 35 (5.9%)

Total 245 (100%) 355 (100%) 600 (100%)

86.65%
90.00% 82%
80.00%

70.00%

60.00%
Elective c/s
50.00%
Emergency c/s
40.00%

30.00%

20.00% 12.40%
7.30% 6.10% 5.60%
10.00%

0.00%
No admision 1-7 day >7day

Figure 7:Neonatal admission

29
Neonatal complications
Majority of those neonatal had no complication 84.3%, while the remaining show birth
asphyxia, respiratory distress syndrome RDS, meconium aspiration, neonatal sepsis ,
more common in emergency than elective cesarean section .
Table9: Neonatal complications
complication Elective c/s Emergency c/s Total
No complication 215 (87.8%) 291 (82%) 506 (84.3%)
Birth asphyxia 1 (0.4%) 9 (2.5%) 10 (1.7%)
RDS 12 (4.9%) 30 (8.5%) 42 (7%)
Meconium aspiration 0 (0%) 8 (2.3%) 8 (1.4%)
CongenitalHydrocephaly 15 (6.1%) 14 (3.9%) 29 (4.8%)
Neonatal sepsis 2 (0.8%) 3 (0.8%) 5 (0.8%)
Total 245 (100%) 355 (100%) 600 (100%)
87.80%
82%

90.00%

80.00%

70.00%

60.00%

50.00%

40.00% Elective c/s

30.00% Emergency c/s

8.50%

20.00%
6.10%
4.90%

3.90%
2.50%

2.30%

0.80%
0.80%
0.40%

0.00%

10.00%

0.00%

Figure 8: Neonatal complication

30
Intraoperative maternal complications:
The most complication found was excessive bleeding presented more in emergency
groups 11.5% while in elective groups was 4.9% ,extension of uterine incision found in
9.1% of emergency cesarean section ,whereas in elective cesarean section 3.3% ,bladder
injury was seen in emergency groups only found about 1.2% , Only one cesarean
hysterectomy was performed in elective group 0.4% because of placenta previa accrete
that lead to uterine atony and heavy bleeding , the result was statistically not significant
with (p- value =1).
Table 10: Intraoperative maternal complications:
complication Elective c/s Emergency c/s Total
Without complication 222 (90.6%) 279 (78.6%) 501 (83.5%)
Bleeding 12 (4.9%) 41 (11.5%) 53 (8.8%)
Extension of uterine incision 8 (3.3%) 32 (9.1%) 40 (6.7%)
Bladder injury 2 (0.8%) 3 (0.8%) 5 (0.8%)
Hysterectomy 1 (0.4%) 0 (0%) 1 (0.2%)
Total 245 (100%) 355 (100%) 600 (100%)
90.60%

78.60%

100.00%

80.00%

Elective c/s
60.00%
Emergency c/s

40.00%
11.50%

9.10%
4.90%

3.30%

0.80%
0.80%

0.40%
0.00%

20.00%

0.00%
Without Bleeding Extension of Bladder injery Hystrectomy
complication utrine incision

Figure 9: intraoprative complication.

31
postoperative maternal complications:
Regarding postoperative complication anemia was more frequent in emergency cesarean
section group 40.3% of cases as compare to 27.8% of cases in elective cesarean section
group, wound infection contributed about 8.1% in emergency cesarean section as
compared to 4.1% in elective cesarean section, the PPH contributed to 24 cases 6.8% in
emergency cesarean section as compared to 5 cases 2% in elective cesarean section, the
results was statistically significant with above all complications, the less complications
were in spinal headache and Postpartum fever. There was no case of thromboembolism
in both groups.
Table 11: postoperative maternal complications
complication Elective c/s Emergency c/s Total
Without complication 152 (62%) 128 (36.1%) 280 (46.7%)
PPH 5 (2%) 24 (6.8%) 29 (4.8%)
anemia 68 (27.8%) 143 (40.3%) 211 (35.1%)
Spinal headach 7 (2.9%) 18 (5.1%) 25 (4.1%)
Post partum fever 3 (1.2%) 13 (3.6%) 16 (2.7%)
Wound infection 10 (4.1%) 29 (8.1%) 39 (6.5%)
Total 245 (100%) 355 (100%) 600 (100%)
62%

70%

60%
40.30%
36.10%

50%
27.80%

40%

30%
Elective c/s
8.10%

20%
6.80%

Emergency c/s
5.10%

4.10%
3.60%
2.90%

1.20%

10%
2%

0%

Figure10: post operative complication

32
Discussion:
Caesarean section is one of the most commonly performed procedures for women over
the worth. There are well documented risks for the women and her infants with caesarean
section birth, both in the current pregnancy and in a subsequent pregnancy (34) almost a
third of women in many developed countries experiencing caesarean section when they
give birth . It is generally accepted that a planned operation (Elective c/s) often does
better in morbidity than one performed as an emergency.

It is therefore essential, to compare the outcomes of the deliveries in both situation. We

then excluded women who would not be eligible for “cesarean delivery at maternal
request,” as defined by the NICHD(34A).Specifically, we excluded preterm births, multiple
gestations, women diagnosed with placenta previa, and those with a prior myomectomy.
Preterm births were defined as <37 completed weeks of gestation. Also, to eliminate
cases in which the mode of delivery was influenced by antepartum complications, we
excluded cases of abruption, antepartum bleeding, stillbirth, and uterine rupture.

In some study of a hospital based prospective study at centers (24) of nine counters showed
that maternal complications were increased by caesarean section but elective caesarean
section may reduce neonatal complications(35) . The incidence of caesarean section in our
hospital during the study period is 45.2%,out of which 59.2% were emergency caesarean
section and 40.8% were elective caesarean section. this increased in the rate because our
hospital being referral center receives complicated cases of the catchment area . In our
study 46.8% women were in the age group of 20-30 years, with mean age was found to
be 25 ± 6 years. . On the other hand, it is accepted that the older mothers tend to have
more previous cesarean section deliveries, which may automatically require elective
cesarean section ,so the Majority of patient 51.5% in the elective cesarean section group
were in the age group of 31-40years. . However the high incidence of emergency
cesarean section in younger mothers may indicate the tendency of the attending
obstetrician to allow vaginal deliveries in these mothers as long as this is feasible with a
view to preserving their future reproductive performances and only resorting to cesarean
section delivery when there is a threat to either the mother or the fetus. The relationship
of age with the type of cesarean section is difficult to decipher. Although cesarean
section delivery was performed on multipara mothers in 57.2% of cases, in contrary in to
other study done by Adhikeri et al (36) whose found majority of cesarean section done in
primiparous women. In the index study 93.5% had term elective caesarean section and
33
73.8% had term emergency caesarean section. Those caesarean section were done under
spinal anesthesia 77.5% . In our study shows 59.2% emergency cesarean section and
40.8% elective cesarean section, and the most common indication for elective cesarean
section was previous cesarean section 55.1% ,while in emergency caesarean section the
most common indication was F.D 33.8% followed by previous caesarean section 17.7%,
this result was similar to study done by Daniel Suja et al (12) who stated that most of the
elective caesarean section were done for previous cesarean section and an emergency
caesarean section group F.D and previous caesarean section were the main indications, .
There are well documented risks for the women and her infants with caesarean section
birth, both in the current pregnancy and in a subsequent pregnancy(34)while in study
done by Najem et al (37) they found the common indication was the same indication for
elective and emergency group and was repeated caesarean section.

Maternal intraoperative and postoperative complication were more common in

emergency cesarean section cases as compared to elective ones. In our study overall
intraoperative complication were more for emergency group 21.4 % when compared to
elective group 9.4% . Among intraoperative complication massive hemorrhage was the
most common complication ,which occurred due to uterine atony and abnormal
adherence of placenta or as result to varicosity of uterus .

A study from Lahore showed that intra operative hemorrhage was the most common
complication in cesarean section being responsible for two maternal deaths in that
series(38) .

screening of scarred obstetrical population, placental localization and elective caesarean

section by expert person capable of handling the complications (38) .

The result of uterocervical extension in our study was 6.7%, being significantly more
common during emergency than elective caesarean section .The reported incidence of
bladder injury at the time caesarean section around 0.8%. Most injuries occur in the
dome of the bladder and rarely involve the trigone . Bladder injuries occur as a result of
a number of factors, including surgical difficulty encountered while developing the
bladder flap over the lower uterine segment. The difficult is usually caused by scar tissue
from previous surgery (39) ,bladder injury seen in elective and emergency caesarean
section 0.8% in our study.

34
Regarding postoperative complications were significantly more in emergency group
63.9% when compared to elective group 38%, conclusions were obtained in other study .

The commonest postoperative complication was anemia in both groups, it found in

majority of cases 40.3% in emergency caesarean section group ,while in patients of
elective caesarean section group anemia was found in 27.8%, this justified that
emergency caesarean section associated with greater blood loss and may need for blood
transfusion . This is because the emergency caesarean sections which may come up at
nights when the very skilled hands have gone, but the elective caesarean section is
better planned and performed by more competent personnel’s with higher and better
skills.) .wound infection was the second postoperative complication seen in our study
8.1% and 4.1% in emergency and elective caesarean section respectively ,these result
similar to study done by Suwal et al (40) whose found in their trial that wound infection
rate as 6.58% vs 3.44% in emergency and elective caesarean section respectively. This
finding could be attributable to the fact that in emergency cases membrane rupture and
multiple vaginal examinations are frequent, and postpartum hemorrhage PPH is the third
complication post cesarean section 6.8% in emergency group and 2% in elective group.
post natal fever was found to be 3,6% in emergency caesarean section and 1.2% for
elective caesarean section. The only anesthetic complication seen in both the groups was
spinal headache which contributed to 5.1% in emergency compare to 2.9% in elective
groups. This difference was not statistically significant, there were no maternal death
during period study in both groups .Only one case cesarean hysterectomy was performed
in elective group with case of placenta previa accreta (grade 4) assiated with uterine
atony and heavy bleeding .

In our study of neonatal outcome in the elective group 99.6% were live births and only
0.4% were perinatal deaths ,and in the emergency group there were 97.2% live births,
2.5% perinatal deaths . Similarly fetal complications were higher in emergency cesarean
group where fetal morbidity was 18 %, of these cases were contributed by the emergency
cesarean group and 12.2% were elective cesarean group.

The major cause of fetal morbidity was a respiratory problems. Prematurity, birth
asphyxia, respiratory morbidity, and admission in neonatal intensive care unit were a
significantly more frequent in emergency cesarean group than in elective cesarean group.
Other studies have reported similar facts ( 41,42,43) . Others no as De Luca et al (44) whose
found in their study that there was less fetal morbidity in elective cesarean group than in
35
emergency cesarean group section but perinatal mortality and respiratory morbidity were
similar in both groups .

Also our data revealed that the neonatal outcome was less favorable in emergency
caesarean section, with more cases with APGAR score of <7 (10.7%), than in patients
with elective caesarean section 0.8%. These findings were in contrary to the findings of
previous studies.(45,46) .While admission to a NICU 12.4% of emergency group required
less than 7days than 7.3% in elective group , This was significant as duration of NICU
stay was one of our study criterions to assess the fetal morbidity so caesarean delivery
was associated with an increase in fetal morbidity and admissions to the NICU for 7 days
or longer even after adjustment for preterm delivery (47)

36
Conclusion:
The purpose of this study was to compare the short-term outcomes of women who deliver
by cesarean without labor ( Elective c/s) with those who deliver by cesarean after labor or
vaginal birth (Emergency c/s). We considered both maternal and neonatal complications.
Our hypothesis was that planned cesarean birth is associated with a lower risk of
maternal and neonatal complications than either vaginal birth or cesarean after the onset
of active labor.

Emergency caesarean sections are unavoidable, But we can definitely bring down the
rates of emergency caesarean section by proper selection of cases for induction of labor
and by initiating active management of labor. This study is to highlight the fact that
caesarean sections done as an emergency for any indication has its share of problems to
the mother and hence caution must be exerted in proper planning of the cases. Education
of patients , improving antenatal facilities and of primary health provider, early referral
and good transport system and improved diagnostic skills are suggested to reduce the
number of emergency caesarean section and thus decrease the risks and complications
associated with such cases.

Study design:
Study design: This study is prospective study.
Study setting: It was conducted at the department of obstetrics and gynecology in
Tripoli Medical Center TMC

Study period: during the year 2019

Study population: total 600 pregnant women who underwent a cesarean section because
of different indications were randomly selected for this study

Statistical analysis:
Statistical analysis was performed using the Statistical Program for Social Sciences(
SPSS version 16) that used for data entry and analysis. Descriptive statistics were used
and all results are presented as frequencies, mean ± standard deviation and percentage.
Student t-test was used for quantitative comparative data where appropriate.

37
Recommendations:
.

Firstly, In Caesarean Section The Proper planning can help obstetric practitioners to
avoid complications and all obstetricians should be skilled in the performance of this
surgical technique and be acknowledgeable in the management of intraoperative
complications, which constitute a major contributor in the maternal and prenatal
morbidity and mortality statistics.

Secondly,
the proportion of emergency operations needs to be reduced, either by
allowing more patients to give birth by the vaginal birth or by planning elective
procedures.

Lastly, during the antenatal management of each pregnancy risk factors must be
carefully assessed and early recognition and referral of mothers who are likely to undergo
cesarean section may reduce the incidence of emergency cesarean sections and thus
decrease maternal and fetal complications.

38
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44
 ‫ملخص البحث‬

‫خلفية الدراسة‪:‬‬
‫أصبحت الوالدة بالعملية القيصرية تمثل نسبة كبيرة من العمليات‪,‬حيث أن نسبة حدوث مضاعفات والوفيات لكل من‬
‫األم والطفل أكثر من العمليات المخطط لها مسبقا‪.‬‬

‫أهداف الدراسة‪:‬‬
‫مقارنة بين األسباب والمضاعفات الناتجة أثناء وبعد العمليات الطارئة والمخطط لها لكل من األم والطفل‪.‬‬

‫نوع الدراسة‪:‬‬
‫هده الدراسة مستقبلية (استطالعية)‪.‬‬

‫المكان‪:‬‬
‫تمت الدراسة في قسم أمراض النساء والتوليد مركز طرابلس الطبي‪.‬‬

‫طرق وأدوات البحث‪:‬‬

‫الدراسة ذات طابع استباقي (مستقبلية) وكانت في قسم أمراض النساء والتوليد مركز طرابلس الطبي من شهر يناير‬
‫إلي شهر أغسطس ‪ ,2019‬وتم تجميع البيانات والمعلومات من المرضي وملفاتهم بالقسم بواسطة استبيان ‪,‬حيث‬
‫شملت الدراسة ‪ 600‬مريضة من اللواتي أجريت لهن عمليه قيصريه قسموا إلي مجموعتين‪ :‬األولي تضمنت (‪)245‬‬
‫عمليه قيصريه مخطط لها مسبقا والثانية (‪ )355‬عمليه قيصريه طارئة حيث أجريت المقارنة بين العمليات‬
‫المخططة لها مسبقا والعمليات الطارئة من ناحية المضاعفات الناتجة أثناء وبعد العملية ومقارنة حالة الطفل العامة‬
‫بعد العملية‪.‬‬

‫تم تسجيل البيانات والمعلومات والتي تشمل عمر األم وعمر الجنين أثناء العملية وعدد الوالدات السابقة وأسباب‬
‫العملية القيصرية ‪,‬ونوع التخدير أثناء العملية والمضاعفات أثناء وبعد العملية القيصرية كالنزيف أثناء العملية‬
‫‪,‬وأصابه الرحم والمثانة البولية بتمزق أثناء العملية القيصرية‪,‬استئصال الرحم‪ ,‬وفقر الدم الناتج عن العملية‬
‫القيصرية ونزيف ما بعد الوالدة‪,‬التهاب الجرح‪,‬وارتفاع الحرارة بعد العملية والصداع الناتج عن التخدير النصفي ‪.‬‬
‫باإلضافة إلي نتائج حديثي الوالدة من حيث (نتيجة الطفل حديثي الوالدة حيا أو ميتا ‪ ,‬نتيجة أبغار‪,‬مدة اإلقامة في‬
‫عناية حديثي الوالدة والمضاعفات الناتجة بعد العملية القيصرية) ‪.‬‬

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 ‫النتائج‪:‬‬

‫اتضح من دراستنا خالل تحليل اإلحصائيات التي جمعت خالل العمليات القيصرية أن هناك تأثير كبير لنوع‬
‫العملية سواء كانت طارئة أو مخطط لها مسبقا علي مجريات سير العملية القيصرية ومضاعفاتها البسيطة والكبيرة‬
‫أثناء العملية الجراحية بحيث تكون نسبة المضاعفات أكثر مع العمليات الطارئة بفارق معتد بها إحصائيا كما وجد أن‬
‫هناك تأثير واضح ومعتد بها إحصائيا لعوامل الخطورة والمضاعفات الحاصلة بعد العملية الجراحية لالم والطفل‪.‬‬

‫الوسائل اإلحصائية‪:‬‬
‫تمت مقارنة النتائج باستخدام اختبار الكاي سكوير‪.‬‬

‫االستنتاج‪:‬‬
‫أن إجراء العمليات بطريقة مخطط لها مسبقا مع تحديد عوامل الخطورة أثناء فترة الحمل يساهم في تقليل نسبة‬
‫المضاعفات المتوقعة أثناء العمليات الطارئة‪.‬‬

‫التوصيات‪:‬‬
‫ان من الموصي به أن يتم إجراء العمليات القيصرية في ظروف مخطط لها مسبقا أفضل بكثير ودلك‬

‫باعتبار أن نسب المضاعفات الجراحية الحاصلة أثناء العمليات القيصرية تكون اعلي عند إجرائها في الظروف‬
‫الطارئة‬

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 ‫نبذة عن قسم النساء والوالدة مركز طرابلس الطبي سابقا (المستشفي الجامعي طرابلس )‬

‫يعتبر مركز طرابلس الطبي من الركائز الطبية المتقدمة في مجال تقديم الخدمات الطبية إلي جانب انه مركز تعليمي‬
‫طبي متقدم لتأهيل وتدريب العناصر الطبية والطبية المساعدة‪..‬‬

‫حيث تم افتتاح القسم مع افتتاح المركز عام‪1996‬م بسعة سريريه ‪ 120‬سرير وأمراض النساء حوالي ‪ 70‬سرير‬
‫حيث وصلت معدل حاالت الوالدة بالقسم من ‪ 15-12‬ألف حالة والدة في العام وعمليات القيصرية تتجاوز ‪2000‬‬
‫عملية في العام ‪.‬حيث يقدم خدمة جليلة للمواطنين في مدينة طرابلس وضواحيها وفق اإلمكانيات المتاحة بجهود نخبة‬
‫كبيرة من العناصر الطبية والطبية المساعدة ذات الكفاءة المهنية العالية ‪....‬‬

‫والقسم حاليا تحت الصيانة‬

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 ‫السيد \رئيس المجلس العلمي لتخصص النساء والتوليد بالمجلس العربي لالختصاصات الصحية‬

‫تحية الطبية ‪:‬‬

‫نفيدكم بان الطبيبة فتحية القمودي صالح شائب العين المسجلة بالمجلس العلمي لتخصص النساء والتوليد‬
‫بالمجلس العربي لالختصاصات الصحية قد أجرت البحث العلمي مركز طرابلس الطبي تحت إشراف د‪ .‬مها شنشن‬

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