Why do pregnant women prefer cesarean birth? A qualitative study in a tertiary care center in Southern Thailand.

BACKGROUND: Increasing worldwide rates of cesarean section are of global concern. In recent years, cesarean births upon maternal request have become a hotly debated issue. Hence, this study aimed to explore maternal reasons for cesarean preference without medical indications. METHODS: A descriptive qualitative study was conducted, using in-depth interviews with 27 pregnant women who preferred cesarean birth, attending antenatal care in Songklanagarind Hospital from September 2018 to June 2019. Data were analyzed using content analysis. RESULTS: Maternal reasons for cesarean preference were classified into six main categories: fear of childbirth, safety concerns related to health risk perceptions, negative previous birth experiences, positive attitudes toward cesarean birth, access to biased information and superstitious beliefs in auspicious birth dates. Most women had more than one reason for opting cesarean birth. CONCLUSION: Several reasons for cesarean birth preference have been elucidated. One striking reason was superstitious beliefs in auspicious birth dates, which are challengable for obstetricians to deal with. Obstetricians should explore the exact reasons why women request cesarean birth in order to prevent or diminish unnecessary cesarean births.

An in-depth analysis of maternal mortality in a quaternary university hospital in Southern Thailand: A 16-year experience.

OBJECTIVE: To perform an in-depth analysis and evaluate the causes of maternal deaths in a university hospital in Southern Thailand. METHODS: A retrospective descriptive study was conducted. Medical records of all women who died during pregnancy or within 42 days of termination of pregnancy at Songklanagarind Hospital from January 2006 to December 2021 were reviewed. RESULTS: There were 51 910 live births during the 16-year period and 68 maternal deaths (31 of direct cause, 36 of indirect cause, and one of unknown cause). The maternal mortality ratio was 131 per 100 000 live births. There was a decreasing trend in the maternal mortality ratio, especially during the past 4 years. The leading causes of death were cardiac disease (n = 17), hypertensive disorders in pregnancy (n = 9), and postpartum hemorrhage (n = 7). The most common indirect causes of maternal death were cardiac disease, hematologic disease, and dengue hemorrhagic fever. There was a decreasing trend in indirect to direct deaths ratios during three study periods. Ratios in 2006 to 2010, 2011 to 2015, and 2016 to 2021 were 1.6, 1.4, and 0.5, respectively. CONCLUSIONS: The three leading causes of death were cardiac disease, hypertensive disorders in pregnancy, and postpartum hemorrhage. Improvements in the quality of obstetric care at all hospital levels are required.

A comparative study of cost of care and duration of management for first-trimester abortion with manual vacuum aspiration (MVA) and sharp curettage.

OBJECTIVE: This study compared the hospital charges, duration of in-hospital procedures, clinical course and complications between manual vacuum aspiration (MVA) and sharp curettage. MATERIALS AND METHODS: A prospective observational study was conducted during the May 2007-April 2008 period in Songklanagarind Hospital, Thailand. Forty cases of pregnancy ≤9 weeks of gestation, with conditions of an incomplete abortion, a blighted ovum or missed abortion were treated with either MVA or sharp curettage. Both groups were compared in terms of demographic and obstetric data, hospitalization cost, clinical course and complications. RESULTS: The obstetric data of both groups showed that the median parity was two, with a median gestation age of 8 weeks. The median total hospital expenditure was 54.67 USD for patients using the MVA technique and 153.97 USD for the sharp curettage group (p < 0.01). The median duration of in-hospital care in the MVA group was significantly less than that of the sharp curettage group, 4 versus 20 h, respectively (p < 0.01). 90 % of patients in the MVA group had only one visit compared with 72.5 % in the sharp curettage group (p = 0.04). No complications needing further curettage or treatment in either group were noted. CONCLUSION: The use of MVA in the management of a first-trimester abortion is practical, safe, cheap and time-saving.

The effect of vacuum operator's experience on Apgar scores.

OBJECTIVE: To determine the effect of a vacuum operator's experience on Apgar scores. METHODS: A historical cohort study was conducted. All women who delivered by vacuum extraction between January 2003 and December 2007 at Songklanagarind Hospital were recruited. Vacuum operators were divided into two groups: staff doctors and residents. Comparisons of Apgar scores and rates of low Apgar scores (≤7) between the two groups were studied. A multivariate logistic regression analysis was used to control confounding variables for low Apgar scores. RESULTS: The percentages for the procedure performed by the staff doctors and residents were 76.9 and 23.1%. At 1 min, the rates of low Apgar scores in the staff and resident groups were 6.7 and 24.1% (p<0.001), and at 5 min, the rates of low Apgar scores were 0.6 and 5.2% (p<0.001). Multivariate logistic regression analysis showed that the operator's experience was an independent risk factor for low Apgar scores. The residents had a 2.9-fold increased risk of low Apgar scores at 1 min compared with the staff doctors (adjusted odds ratio 2.9; 95% confidence interval 1.7-6.8). In the resident group, the third year residents had the lowest risk of low Apgar scores. CONCLUSIONS: The vacuum operator's experience was an independent risk factor for low Apgar scores. Improvement of the residency training program is mandatory.

Validation of modified World Health Organization classification for pregnant women with heart disease in a tertiary care center in southern Thailand.

PURPOSE: To validate the modified World Health Organization (WHO) classification in pregnant women with congenital and acquired heart diseases. PATIENTS AND METHODS: The database of pregnant women with heart disease, who delivered at Songklanagarind Hospital between January 1995 and December 2016, was retrieved from the Statistical Unit, Department of Obstetrics and Gynecology, along with the Hospital Information System of Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University. Each patient was retrospectively classified according to the modified WHO classification of maternal cardiovascular risk. Comparison of maternal and fetal outcomes among the modified WHO classes were analyzed using the chi-square test or Fisher's exact test and one-way ANOVA test. A p-value of <0.05 was considered statistically significant. RESULTS: A total of 331 cases were studied: 157 cases with congenital heart disease and 174 cases with acquired heart disease. There were 48, 173, 32 and 78 cases in the modified WHO class I, II, III and IV, respectively. Congestive heart failure was the most common complication. The overall maternal mortality rate was 3.6%, all of which were in the modified WHO class IV. Maternal cardiovascular events occurred in 24.2% of cases, increasing rates with higher modified WHO class: 4.2%, 15.0%, 25.0% and 56.4% in class I, II, III and IV, respectively (p<0.001). Adverse fetal outcomes including preterm delivery, low birth weight, small for gestational age and neonatal intensive care unit admission were also significantly increased in class III and IV (p<0.05). CONCLUSION: The modified WHO classification is useful not only for obtaining a cardiovascular risk assessment in pregnant women with heart disease but also for predicting adverse fetal outcomes. It must, therefore, be implemented into routine care service at all levels of health care systems.

Ten years of experience with Norplant implantation in southern Thailand.

PURPOSE: This study investigated clinical and contraceptive characteristics of a group of southern Thai women who had two consecutive Norplant implantations at Songklanagarind Hospital. METHODS: Seventy reinsertions were performed from 251 original Norplant implantations during the years 1986-1996. Four women had an exposed capsule within 3 months after reinsertion, and two of them subsequently had to have the capsule removed due to infection. RESULTS: Following implantation, the recipients had gradually increased body mass index and systolic blood pressure, which returned to baseline 6 months after discontinuance after 10 years of implantation. Long-term continuation rates were 76.7% and 74.0% at the end of the first and second 5-year periods, respectively. CONCLUSION: The failure rate was 1.8% during the second period compared to 1.1% during the first period.

Spontaneous intra-abdominal bleeding during pregnancy.

Two cases of spontaneous hemoperitoneum caused by ruptured uterine vessels plexus during the second and third trimester of pregnancy were reported. All presented with acute abdominal pain. Emergency exploratory laparotomy and suture-ligation were performed One case had a recurrent intra-abdominal bleeding. The outcomes were good. One infant had complications from prematurity and both were discharged in good condition.

Clinical practice guideline for cesarean section due to cephalopelvic disproportion.

OBJECTIVES: To evaluate the effect of the Clinical Practice Guideline (CPG) for cesarean section due to Cephalopelvic Disproportion (CPD) on physician compliance, pregnancy outcomes and cesarean section rate. The study also wants to identify factors associated with physician non-compliance. MATERIAL AND METHOD: 455 medical records of women undergoing a cesarean section due to CPD from January 1, 2002 to December 31, 2003 were reviewed The CPG was implemented on January 1, 2003. The pregnant outcomes of women who delivered from January 1, 2002 to December 31, 2002 were used for comparison. The outcome measurements were physician compliance, pregnancy outcomes and cesarean section rates. Multivariate logistic regression analysis was used to identify factors associated with physician non-compliance. Independent variables included private care, parity, maternal height, Bishop score, maternal age and estimated fetal weight. RESULTS: The compliance rate was 83%. Physician compliance in private practice was lower than in non-private practice (76.6% VS 92.4%). Pregnancy outcomes were not different between the two periods. The cesarean section rates before and after implementation of the CPG were 8.4% and 8.5%, respectively. Private practice, poor Bishop score and estimated fetal weight < or = 3500 g were significant predictors of physician non-compliance. CONCLUSION: The compliance rate was high, but the cesarean section rate due to CPD did not significantly change within a one year period There was no adverse outcome. Physician non-compliance was more common in private practice. Poor Bishop score and high estimated fetal weight were significant predictors.

Prenatal diagnosis of complete trisomy 9: a case report and review of the literature.

Complete trisomy 9 is a very rare chromosome aneuploidy, associated with specific patterns of multisystem dysmorphism and a wide spectrum of congenital anomalies. We present a case of complete trisomy 9 with prenatal sonographic findings in the second trimester. The combination of sonography and karyotyping from cordocentesis enabled us to establish the prenatal diagnosis. An additional clinical feature of this syndrome that has not been reported previously is an aortopulmonary communication. A review of the literature specifically dealing with prenatal sonographic findings with complete trisomy 9 is also presented.

Effect of a clinical practice guideline on physician compliance.

OBJECTIVES: To evaluate the effect of a clinical practice guideline for cesarean section due to dystocia on physician compliance, pregnancy outcome, and cesarean delivery rates, and to identify factors associated with physician non-compliance. DESIGN: A cross-sectional study. SETTING: A university hospital, Southern Thailand. STUDY PARTICIPANTS: All 719 medical records of women undergoing a cesarean section due to dystocia (failure to progress; cephalopelvic disproportion) before and after implementation of the guideline, from 1 January 1998 to 31 December 2000. INTERVENTION: A clinical practice guideline for cesarean section due to dystocia was implemented on 1 June 1999. MAIN OUTCOME MEASURES: Physician compliance, pregnancy outcomes, and cesarean section rates. Multivariate logistic regression was used to identify factors associated with physician non-compliance. Independent variables consisted of maternal age, height, parity, type of service, and birthweight. RESULTS: Physician compliance with the guideline was 89.2%. Maternal complications were less in the period after implementation of the guideline. Fetal outcomes were not different between the two periods. The cesarean section rates due to dystocia decreased after implementation of the guideline, from 10.7% in 1999 to 8.6% in 2002. Private practice, maternal short stature, and birthweight > or = 3500 g were significant predictors of physician non-compliance. CONCLUSIONS: Physician compliance was high. A clinical practice guideline can reduce the cesarean section rates due to dystocia without increasing adverse outcomes. Physician non-compliance was more common in women with well known risk for cephalopelvic disproportion, and private practice.