Fetal outcome in emergency versus elective cesarean sections at Souissi Maternity Hospital, Rabat, Morocco

Introduction Perinatal mortality rates have come down in cesarean sections, but fetal morbidity is still high in comparison to vaginal delivery and the complications are more commonly seen in emergency than in elective cesarean sections. The objective of the study was to compare the fetal outcome and the indications in elective versus emergency cesarean section performed in a tertiary maternity hospital. Methods This comparative cross-sectional prospective study of all the cases undergoing elective and emergency cesarean section for any indication at Souissi maternity hospital of Rabat, Morocco, was carried from January 1, to February 28, 2014. Data were analyzed with emphasis on fetal outcome and cesarean sections indications. Mothers who had definite antenatal complications that would adversely affect fetal outcome were excluded from the study. Results There was 588 (17.83%) cesarean sections among 3297 births of which emergency cesarean section accounted for 446 (75.85%) and elective cesarean section for 142 cases (24.15%). Of the various factors analyzed in relation to the two types of cesarean sections, statistically significant associations were found between emergency cesarean section and younger mothers (P < 0.001), maternal illiteracy (P = 0.049), primiparity (P = 0.005), insufficient prenatal care (P < 0.001), referral from other institution for pregnancy complications or delivery (P < 0.001), cesarean section performed under general anesthesia (P < 0.001), lower birth weight (P < 0.016), neonatal morbidity and early mortality (P < 0.001), and admission in neonatal intensive care unit (P = 0.024). The commonest indication of emergency cesarean section was fetal distress (30.49%), while the most frequent indication in elective cesarean section was previous cesarean delivery (47.18%). Conclusion 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.


Introduction
Cesarean section delivery represents the most important operation in obstetrics and its incidence is on the rise throughout the world [1]. This increasing rate does not seem to improve the overall fetal outcome but is linked with increased morbidity and costs [2][3][4].
According to WHO, cesarean section rate greater than 15% is not justified in any region in the world [5,6]. Cesarean section can be done as an elective as well as emergency procedure. This study was therefore undertaken to compare the fetal outcome and the indications in elective versus emergency cesarean sections in a tertiary maternity hospital.

Study design and location:
We conducted a comparative crosssectional prospective study from January 1, to February 28, 2014 at Souissi maternity hospital of Rabat, Morocco.
Inclusion and exclusion criteria: All mothers undergoing cesarean section for any indication during the study period were included, except those who had definite antenatal complications that would adversely affect neonatal outcome.
Data collection: Data were prospectively collected for each birth by the attending pediatric resident: inpatient registration number, referral status, maternal socioeconomic status, maternal age and blood group, maternal weight and height, gravidity and parity, prenatal care (the number of prenatal visits and obstetric ultrasonography was retrieved), history of miscarriage or infertility, previous perinatal death, maternal  surgery were also comparable between the two groups. Table   1 shows maternal, pregnancy, delivery, and newborn characteristics.

Maternal data:
The youngest woman included in the study was 16 year old and the oldest was 46 years old. Elective cesarean sections were globally performed in older mothers with a mean age of 31.5 ± 6.54 years. On the other hand, emergency cesarean sections were performed in younger mothers with a mean age of 27.8 ± 6.07 years. This difference in the ages of mothers was statistically significant (P < 0.001). There were also statistically more primiparous mothers in emergency cesarean group than in elective cesarean group (P = 0.005), since 42.15% of mothers were primiparous in emergency cesarean group and only 28.87% were primiparous in elective cesarean group. Also, elective versus emergency cesarean was statistically associated with gestational diabetes mellitus (P = 0.003) and gestational hypertension (P = of emergency cesarean sections versus 2.11% of elective cesarean sections and the difference was statistically significant (P < 0.001).
All mothers who underwent elective cesarean section were operated under regional anesthesia, while general anesthesia was given to 8.52% of mothers who underwent emergency cesarean section.
Moreover, there was a statistically significant relationship between emergency cesarean section versus elective cesarean section regarding maternal illiteracy (P = 0.049). On the contrary, there was no significant difference in elective versus emergency cesarean groups in terms of marital status, area of residency, incidence of maternal chronic disease, multiple pregnancy, prelabor rupture of membranes greater than 18 hours, malpresentation, or chorioamnionitis.

Discussion
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 [1]. 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 [8,9]. 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 [10]. During the study period, the incidence of cesarean section at Souissi maternity hospital was found to be 17.83% and the overall cesarean section delivery rate was 24 were emergency cesarean sections [14]. In another study conducted in Australia in 2005, the incidence of cesarean section was 28.3% of which 35.8% were elective and 64.14% were cesarean emergency sections [15]. In Nigeria, Onankpa et al.
reported a cesarean section rate of 8.4%. Of these, 19.4% were elective and 80.6% were emergency cesarean sections. As stated by the authors, cesarean section deliveries are not readily accepted by the mothers in their country which explains such low rate of cesarean section deliveries [16]. As previously reported by Al Nuiam et al., significant difference was found between emergency cesarean delivery and younger mothers and low parity in this study [17]. The relationship of age with the type of cesarean section is difficult to decipher. 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. 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. In this study, cesarean section delivery was performed on primiparous mothers in 38.95% of cases.
Other studies found a slightly higher rate. It was 42% for Kambo et al. and 55.48% for Adhikeri et al. [18,19].
Overall, fetal complications were higher in emergency cesarean group. Fetal morbidity was 28.23%. Of this, 90.36% cases were contributed by the emergency cesarean group and 9.64% were elective cesarean group. The major cause of fetal morbidity was respiratory morbidity followed by birth asphyxia, seen mainly in emergency group. Prematurity, birth asphyxia, respiratory morbidity, and admission in neonatal intensive care unit were significantly more frequent in emergency cesarean group than in elective cesarean group. Other studies have reported similar facts [11,14,16]. De Luca et al. found in their study that there was less fetal morbidity in elective cesarean group than in emergency cesarean group section but perinatal mortality and respiratory morbidity were similar in both groups [20]. This was contrary to the findings of Miller et al. [21]. They reported in their study that birth asphyxia was less common in emergency cesarean section than in elective cesarean section. This is difficult to explain except for the fact that in their study emergency cesarean section was most often Roth-Kleiner et al. found that severity of respiratory morbidity was higher in newborns after elective cesarean section than in emergency cesarean section, probably because of the changes occurring to the fetal lungs when the mother gets into labor [24].
Those findings do not correlate with ours though. Moreover, elective repeat cesarean section has been implicated in the development of pulmonary hypertension of the newborn [25]. Furthermore, a common cause of fetal complications is infant respiratory distress syndrome which is a function of gestational age [26].
Inappropriately timed cesarean delivery has been known to result in this complication. According to a study by Morrison et al., a significant reduction in neonatal respiratory morbidity can be obtained if elective cesarean section is performed during the 39th week of pregnancy [27]. Perinatal mortality was 10.2 per 1000 births and was only observed in emergency cesarean group. There was one early neonatal death in this group due to hypoxic encephalopathy, as also found in Cebeku et al. study [28]. This was in spite of the fact that all antenatal complications that might predispose to adverse fetal outcomes were excluded from the study.
Studies from developed countries have reported a perinatal mortality for cesarean section deliveries of less than 10 per 1000 births [14]. In developing countries, Onankpa et al. reported that perinatal mortality was 11 per 1000 among the cesarean deliveries [16]. Ali et al. reported a perinatal mortality for cesarean section deliveries of 10 per 1000 which was similar to our findings [12]. In both these studies the perinatal mortality was higher in emergency cesarean group.
In our study, the most frequent reason for cesarean section was a previous cesarean delivery (35.84%) which is similar as in literature [14,15,29].

Conclusion
Emergency cesarean sections showed significantly more fetal complications than elective cesarean sections in this study. The high incidence of emergency cesarean section found emerges from insufficient prenatal care and poor referral system. 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.

What is known about this topic
• Fetal complications are more commonly seen in emergency than in elective cesarean sections; • To our knowledge, no previous study has evaluated fetal outcome in emergency versus elective cesarean sections in Morocco.

What this study adds
• Emergency cesarean sections showed significantly more fetal complications than elective cesarean sections in this study; Page number not for citation purposes 6 • Incidence of emergency cesarean was high in this study due to insufficient prenatal care and poor referral system; • 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.

Competing interests
The authors declare no competing interest.

Authors' contributions
This work was carried out in collaboration between all authors. All