Can we reduce the caesarean section rate?

Caesarean section rates continue to be an issue of great concern to many midwives, obstetricians, women, and society as a whole. With an increase in women requesting caesarean sections, the responsibility for the caesarean section rate needs to be re-defined. There is a need to improve the routine information collection on all aspects of childbirth. There is also a need to adopt standard classification systems so that comparisons and improvement of care can take place. Caesarean section rates should no longer be thought of as being too high or too low, but rather whether they are appropriate or not, after taking into consideration all the relevant information. This will require statutory, standardized collection of information. Maternal satisfaction has now become one of the most significant outcome factors after childbirth and must be taken into consideration when implementing any changes in childbirth. Finally, caesarean section rates must no longer be considered in isolation from other changes taking place in society.

Using the medical audit cycle to reduce cesarean section rates.

OBJECTIVE: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates. STUDY DESIGN: A retrospective medical audit of all deliveries from 1984 to 1988 was performed. The groups of women contributing most to the overall cesarean section rate were identified. Strategies for labor management directed at the primary indication for cesarean section (dystocia) were developed and introduced. The effect was monitored prospectively from 1989 through 1992. Data were analyzed with the chi 2 test. RESULTS: A total of 21,125 deliveries were studied. After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate. CONCLUSION: Effective medical audit of labor management can reduce cesarean section rates.

Is amniotic fluid quantitation of value in the diagnosis and conservative management of prelabour membrane rupture at term?

This study examined the hypothesis that ultrasound quantitation of amniotic fluid depth is of value in the diagnosis and management of prelabour rupture of the membranes (PROM) at term. The deepest vertical pool was measured in 151 consecutive patients with a history of suspected PROM for at least 10 h before labour. In 100 patients the diagnosis of PROM was confirmed by the collection of amniotic fluid at the vulva. There was no difference in mean depth of amniotic fluid in 100 patients with confirmed PROM, compared with 51 in whom PROM was not confirmed (48.5 mm SD 16.4 vs. 60.1 mm SD 16.5); the frequency of oligohydramnios (fluid depth less than 30 mm) was 5% and 5.8% respectively. There was no relation between ultrasound amniotic fluid quantitation and the onset of labour, the duration of labour nor the frequency of oxytocin augmentation in labour. The results show that ultrasound quantitation of amniotic fluid is of no value in the diagnosis and conservative management of PROM at term.

Successful outcome after antepartum expulsion of placenta and fetus into the abdominal cavity; a case report.

Spontaneous rupture of the uterus before labour is a rare event associated with a high incidence of maternal and fetal death. We report a case of spontaneous uterine rupture at 34 weeks' gestation in a patient's second pregnancy. The case is unusual because both the mother and baby survived despite the expulsion of the placenta with the fetus into the abdominal cavity prior to laparotomy.

Laser excision rather than vaporization: the treatment of choice for cervical intraepithelial neoplasia.

We are concerned that the use of ablative therapy in the treatment of cervical intraepithelial neoplasia may lead to a failure to diagnose early invasive carcinoma. In view of this, since June 1986, 196 patients considered suitable for laser vaporization were treated by a shallow laser excision cone biopsy instead. The mean age of the women treated was 31 years, and the mean length of the excised specimen, measured after fixation, was 14 mm. All procedures were completed in the colposcopy clinic and took no longer to perform than vaporization. The complication rate was low, and an excellent specimen was available for pathologic examination. In this series, histology on the excised cone revealed that two patients had microinvasive carcinoma and one had adenocarcinoma in situ. In addition, 16 patients had a lesion two or three grades worse on the laser excision biopsy than was predicted by the colposcopically directed biopsy. Because of the inaccuracy of colposcopic biopsy, we now recommend a small laser excision cone biopsy as the treatment of choice for all patients with cervical intraepithelial neoplasia.