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Research on indications for cesarean section for first-borns at Hanoi Obstetrics and Gynecology Hospital in 2021 - 2

LIST OF TABLES

Table 1.1. Rate of cesarean section in some countries 14

Table 1.2. Rate of cesarean section for primiparous pregnancies in Vietnam 15

Table 3.1. General MLT rate in 2021 at Hanoi Obstetrics and Gynecology Hospital 21

Table 3.2. Rate of first and second child MLT in MLT group 21

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Table 3.3. Age table of pregnant women group MLT first child 22

Table 3.4. MLT ratio of the number of children distributed by occupation 22

Table 3.5. Body mass index of the subject group before pregnancy 23

Table 3.6. Gestational age distribution table of the study group 23

Table 3.7. Number of fetuses 24

Table 3.8. Rate of MLT indications in primiparous mothers 24

Table 3.9. MLT 26 timing

Table 3.10. Rate of MLT in the genital tract group 27

Table 3.11. Rate of MLT in first-borns at 27

Table 3.12. Weight distribution of large fetus group after MLT 28

Table 3.13. Rates of causes of fetal distress 28

Table 3.14. Rate of MLT in first-borns due to fetal adnexa 29

Table 3.15. Postoperative Apgar table of TSS at 1st and 5th minutes 30

Table 3.16. Table of postoperative complications 31

Table 3.17. Average hospital stay after surgery 32

Table 4.1. Rate of MLT due to genital tract causes 37

Table 4.2. Rate of MLT due to pelvic 38

Table 4.3. Table of MLT rates due to hypertrophic CCTC 38

Table 4.4. Rate of MLT because CTC does not progress in the genital tract group 39

LIST OF CHARTS

Figure 3.1. Proportion of MLT indications number 26

Chart 3.2. Indications for MLT in first child due to maternal illness 29

Figure 3.3. Distribution of first-time mothers due to social causes 30

Chart 3.4. Fetal gender 31

LIST OF IMAGES

Figure 1.1. Horizontal diagram through the uterus 3

Figure 1.2. Method of cesarean section at the lower uterine segment 9

PROBLEM STATEMENT

Caesarean section (C-section) is the removal of the fetus and its appendages from the uterine cavity through an incision in the abdominal wall and an incision in the uterine wall. C-section has a long history dating back hundreds of years BC. C-section has been increasingly improved, along with the continuous development of medicine, the advent of antibiotics and anesthesia and resuscitation techniques, aseptic and sterilization techniques have increased the success rate of C-section, reducing the rate of complications for mothers and newborns [1,2].

In fact, cesarean section is only really appropriate in cases where vaginal birth is not possible. In recent years, as society has developed and the quality of life has improved, each family only has one or two children, so people often care about reproductive health, the health of the mother and newborn. There is also the notion that cesarean section is "safer", "the child is smarter", some cases request cesarean section on request to choose a "good" day and time. Pregnant women believe that they "have the right to choose the way of giving birth as they wish". Under such psychological pressure, obstetricians may passively decide to perform a cesarean section.

The rate of cesarean section in many countries around the world has increased rapidly in the past 20 years, especially in developed countries. A study by Quinlan JD et al. (2015) found that the rate of cesarean section in developed countries was: Italy 38.2%, Mexico 37.8%, Australia 30.3%, the United States 30.3%, Germany 27.8%, Canada 26.3%, Spain 25.9% and the United Kingdom 22.0%[3]. A study by Begum T. et al. (2017) in Bangladesh showed that the rate of cesarean section was 35.0%[4].

Currently, first-time MLT is of interest to obstetricians because if the rate of first-time MLT increases, it will increase the rate of MLT in general, and complications due to MLT such as placenta previa, placenta accreta, pregnancy implanted in old cesarean scar, infertility due to cesarean scar defect, uterine rupture... will also increase. Therefore, controlling and giving the right indications for MLT is necessary to contribute to reducing the rate of MLT in general and the rate of MLT in people with uterine scars for subsequent births, thereby causing the rate of MLT to tend to increase.

Therefore, I conducted the study "Research on indications for cesarean section for first-borns at Hanoi Obstetrics and Gynecology Hospital in 2021" with two objectives:

1. Describe the characteristics of the group of primiparous pregnant women at Hanoi Obstetrics and Gynecology Hospital in 2021

2. Comments on some indications and results of primary MLT at Hanoi Obstetrics and Gynecology Hospital in 2021


1.1. Brief history of MLT

CHAPTER 1 OVERVIEW


Cesarean section is a surgery to remove the fetus, placenta, and amniotic membranes from the uterus through an incision in the abdominal wall and the uterine wall is intact.

In Vietnam, in the early 60s of the 20th century, cesarean section was first applied in the obstetrics department of Bach Mai hospital (Hanoi) using the classical method. Later, Professor Dinh Van Thang performed a transverse cesarean section to remove the fetus and this method is now widely applied throughout the country.

1.2. Anatomical and physiological changes in the uterus during pregnancy [5]

1.2.1. Changes in the body of the uterus

The body of the uterus is the part that changes the most during pregnancy and labor. The egg nests in the uterine lining and the uterine lining becomes the ectoplasm. Here the placenta, chorionic membrane, and amniotic sac are formed to contain the fetus inside. During labor, the uterus gradually changes to form the birth canal for the fetus to come out. To meet that need, the body of the uterus changes in size, position, and properties.


Figure 1.1. Horizontal diagram through the uterus

(Source: Frank H. Netter. MD Atlas of Human Anatomy – Medical Publishing House)

1997)

Before pregnancy, the uterus weighs about 50 - 60g. After the fetus and placenta are delivered, the uterus weighs about 900 - 1200g. The weight of the uterus increases mainly in the first half of pregnancy.

Normally, before pregnancy, the uterine muscle is about 1cm thick. During the 4th - 5th month of pregnancy, the thickest layer of the uterine muscle is about 2.5cm and the uterine muscle fibers grow 3 - 5 times wider and up to 40 times longer.

In the first weeks of pregnancy, the uterus enlarges due to the effects of estrogen and progesterone. But after 12 weeks, the uterus increases in size mainly due to the fetus and its appendages growing, causing the uterus to increase accordingly. Before pregnancy, the uterine cavity capacity is from 2 - 4ml. When pregnant, the uterine cavity capacity increases to 4000 - 5000ml. In cases of multiple pregnancies or polyhydramnios, the uterine cavity capacity can increase even more. Before pregnancy, the uterus measures about 7cm, and by the end of pregnancy, it is up to 32cm.

In the first 3 months, because the anterior and posterior diameters grow faster than the transverse diameters, the uterus is round. The lower part is larger and can be felt through the vaginal fornix. Because the fetus does not occupy the entire uterine cavity, the uterus is asymmetrical, extremely large above and extremely small below.

During the last 3 months, the shape of the uterus depends on the position of the fetus in the uterine cavity. When not pregnant, the uterus is located at the bottom of the pelvis in the pelvis, when pregnant, the uterus grows and moves into the abdominal cavity.

As the uterus grows, it stretches the broad ligament and the round ligament. In the first month, the uterus is below the pubic symphysis. From the second month onwards, the uterus grows on average 4cm above the pubic symphysis each month.

1.2.2. Changes in the cervix and uterine isthmus

The peritoneum in the body of the uterus adheres tightly to the myometrium. During pregnancy, the peritoneum enlarges and expands along the myometrium. In the isthmus of the uterus, the peritoneum can be easily separated from the myometrium, the boundary between the two areas is the line of peritoneal adhesion. This is the boundary to distinguish the body of the uterus from the lower uterine segment. Cesarean section is often performed in the lower uterine segment so that the peritoneum can be covered after closing the incision in the myometrium.

Before pregnancy, the uterine isthmus is a small ring 0.5-1cm long. When pregnant, the uterine isthmus widens and lengthens into the lower uterine segment and is up to 10cm long. The lower uterine segment does not have a layer of intervertebral muscle in the middle, so it is very fragile and prone to bleeding when there is placenta previa.

1.3. Indications for cesarean section in primiparous mothers.

Can be divided into two types of indications:

- Active MLT indications.

- MLT indications in labor.

1.3.1. Indications for elective cesarean section

The group of indications set out during the pregnancy monitoring period includes:

1.3.1.1. Maternal indication

* Causes due to the pelvis:

- A narrow pelvis is a pelvis with all diameters reduced equally in both the upper and lower waist. In particular, the protruding-back diameter is less than 8.5cm.

- Distorted pelvis (skewed pelvis or asymmetrical pelvis) is based on the Michaelis rhombus. Normally, the Michaelis rhombus has a superior-inferior diagonal (from the posterior spine of the 5th lumbar vertebra to the top of the gluteal spine) of 11cm long and a horizontal diagonal (from the posterior superior iliac spine) of 10cm long. These two diagonals are perpendicular to each other. The superior-inferior diagonal divides the horizontal diagonal into two equal parts, each side is 5cm long. The horizontal diagonal divides the superior-inferior diagonal into two parts: 4cm above and 7cm below. If the pelvis is distorted, these two diagonals intersect unequally, are not perpendicular, and the rhombus is formed by two non-isosceles triangles.

- The funnel-shaped pelvis is wide at the upper waist and narrow at the lower waist. Diagnosis is based on measuring the diameter of the ischial tuberosity. If the diameter of the ischial tuberosity is less than 9cm, the fetus will not be delivered, so CLT is indicated.

* Uterine group:

- Surgical scars on the uterine body before this pregnancy such as: uterine fibroid enucleation scar, hysterectomy scar, uterine preservation suture scar in cornual pregnancy.

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