On admission, assessment was carried out for the mode of delivery.

Favorable factors for vaginal delivery;

i. Average size of baby with weight less than 3000 g.

ii. Pelvis quite roomy

iii. Mother’s age between 20 to 30 years

iv. Cervix is favorable –soft, more than 3 cm. dilated and effaced.

v. Frank breech

vi. Progress of labour is normal

vii. Forceps should be kept ready for delivery of the after coming head if required

C-section is indicated in cases of

i. Big Baby->3.500g.

ii Contracted pelvis

iii Compound presentation

iv Footling presentation

v. Cord presentation

vi. Hyperextension of head

vii. Uterine dysfunction

viii. Unfavorable cervix

ix. Previous child suffering from birth trauma

x. Too premature baby as chances of head injury during vaginal delivery are more

Associated Maternal and Fetal indications-

i. Previous C-section

ii. Placenta Previa

iii. Fetal distress

iv. Pregnancy induced hypertension

v. Intra uterine growth retardation

vi. Elderly primigravidae ,age more than 35 years

Scoring technique for assessment of mode of delivery -Zatuchni and Andros Score (5).

In this method absolute indication for C-section is excluded.

S.N.	Factor	0	1	2
(1)	Parity	Primipara	Multipara	-
(2)	Gestational age (weeks)	39		37
(3)	Estimated weight (kg)	3.5 (8 Ibs)	3-3.5 (7 to 7 Ibs and 12 oz)	3 (7 Ibs)
(4)	Previous breech with weight greater than 2.5 kg.	None	One	2
(5)	Cervical dilation	3	3	4
(6)	Station of breech	-3 or high	-2	-1 or low

Inferences:-

Score; 3 or less –C-section

Score; 4- Reassess during labour

Score; 5 to 11-Vaginal delivery

Westin Breech Risk Scoring System-1977

This scoring system was not used in this study as it requires X-Ray pelvimetry which is not the policy of the institute because of ill effects.

On analysis of the collected data it has been revealed that there were 33 percent cases of 32 -36 weeks of gestational age out of these 72.7 and 27.3 percent were delivered by vaginal and C-section respectively. In case of 37 and above weeks 50 percent delivered by vaginal (26%) and C-section(74%) while under 32 weeks of gestational age 94.1 %vaginal and only 5.9%by C-section.

Maximum 61 percent cases belong to 20-25 years of mothers out of these 50.8 percent vaginal delivery and 49.2percent by C-section while in case of 26-30 years of age 70.8 vaginal and 29.2 by C-section and in cases of above 30 years of age 40 percent vaginal and 60 percent C-section. Authors further noted that mothers whose age were under 20 years, 60 %and 40% were C-section and vaginal delivery respectively. Age of mothers did not seem to play an important role in the mode of delivery .In the present study there were 3 cases of elderly primaepara, two of them delivered by C-section and third an encephalic baby vaginally. Douglas and Stromme in 1976 consider elderly primaepara, an indication for C-section .

The parity played a major role in the management .Conventionally, primigravida with breech is considered to be an indication for C-section. Zatuchni-Andros (5) ,noted that primigravidae as a disfavor able factor for vaginal breech delivery. However, Collea et.al. (22) found that parity per se should not be a selecting factor. Even so the C-section rate continues to be higher for primigravidae as borne out in the present study.

On further analysis it has been revealed that in primigravidae 61.70 percent were C-section and 38.30 percent vaginal delivery in comparison to multigravidae where 33.96 percent C-section and 66.04 percent delivered vaginally this indicate that higher percentage of vaginal delivery in multigravidae was higher because of the maternal pelvis had stood the taste of a previous delivery. Higher percentage of C-section in primigravidae shows the trend of primae with breech towards C-section. C-section (9) is indicated in Breech presentation.

Type of breech on mode of delivery:

Frank breech is most suitable for vaginal delivery .In the present study 55.4 percent of frank breech was delivered vaginally .Footling presentation was at a higher risk. There were 5 cases of cord prolapsed, one was delivered by emergency C-section, another was breech extraction, and the remaining three were presented with intrauterine death. One case of footling was of encephalic baby. One case of footling presented with abruption placenta and IUD baby.

There were 63.82 percent emergency C-section and the rest 36.17 % were elective or scheduled C-section where trial of labour was not given (Table-I).On analysis of reasons of elective C-section, it was noted that 35.29 percent were because of previous LSCS, 23.52 5%in big baby or contracted pelvis, 17.64 %PIH, 11.64 percent early primigravidae, and 5.88 percent each for post datism and bad obstetric history /precious pregnancy(Table-II).

TABLE –I: INCIDENCE OF CAESAREAN SECTION

Elective Caesarean Section	17 (36.17)
Emergency Caesarean Section	30 (63.82)
Total	47 (100.0)

Figures in parenthesis indicate percentage.

TABLE – II: REASONS FOR ELECTIVE CAESAREAN SECTION

Previous LSCS	6 (35.29)
Big baby or contracted pelvis	4 (23.52)
PIH	3 (17.64)
Elderly Primigravida	2 (11.64)
Post datism	1 (5.38)
Bad obstetric History / Previous Pregnancy	1 (5.38)
Total	17 (100.0)

Figures in parenthesis indicate percentage

As far as causes for emergency C-section concerned (Table –III) revealed that 40% because of contracted pelvis, 26.66% non progress of labour, 6.66 % each in footling presentation ,extended head, eclampsia, and PIH. Authors further found that 3.33 % each were in cord prolapsed and placenta previa.

TABLE – III: INCIDENCE OF EMERGENCY CAESAREAN SECTION

INDICATION	No. of Cases
Contracted Pelvis	12 (40.0)
Non progress of Labour	8 (26.66)
Footing presentation	2 (6.66)
Extended Head	2(6.66)
Eclampsia	2 (6.66)
PIH	2 (6.66)
Cord prolapse	1 (3.33)
Placenta Praevia	1(3.33)
Total	30(100.0)

Figures in parenthesis indicate percentage

C-section birth rise in Mumbai: One in four children in Mumbai (19) is delivered by C-section. But this is not only worrying aspect high lightened in the latest United Nations Development Programme (UNDP) report on the city’s human development. The reasons that the report attributes to the trend are equally eye opening :unscrupulous doctors who want to save time even while multiplying their fees as well as pregnant women who “fear that their husbands might lost interest in them following vaginal expansion” that could follow a natural birth.

Dr. Smita Allahabadia, a city based Gynecologist who practiced in Central Mumbai, backs the UNDP observations.’ Women are worried about taking pain and feel it will affect their sexual life .They insist on C-section and are aware of study which suggest there is no way to repaired and restore vaginal muscles”. She also added this changing trend may be because of “Patients are educated, carrier oriented who delay marriage and pregnancy. More ever they are aware of every consequences of every treatment and complication. They participate in their own treatment”. Dr. Rekha Daver, the head of Gynecology department, J.J. Hospital Mumbai, concedes that cases of C-section are as high as 50 %among women hailing from the middle –and –upper –middle class families. Dr. Duru Shah, former president of the federation of O.B.G. socities of India, too, concedes that about 50% C-section deliveries of the women belongs to upper classes and the 20% of the rest classes.

According to the UNDP report, of the total hospital based live births in Mumbai, around 20 -25 %are by C-section. “This is alarming, given the fact that the W.H.O., the umbrella organization that decides public health policy for it’s various member countries, insist that only 10 -15 %of the births would require surgical deliveries.

Of the record, many doctors state that the percentage of C-section deliveries in private hospitals is too high for comfort. Consider the allegations made by an NGO. Birth India, which promotes natural delivery, on it’s web –site;” The C-section rate in India’s urban area’s is approximately 50% and is estimated to be as high as 80%or more in some private hospitals”(19).

According to a published in the open accesses medical journal, Public Library of Science, July 2008, higher C-section could be the results of delayed child birth among women. The researcher further stated that this could be because of advanced age is associated with “impaired uterine function, resulting in a reduced degree of spontaneous contraction’ need for a natural birth.

UNDP report further pointed out that what about unscrupulous doctors advising patients to undergo C-section instead of time consuming wait for the patients womb to contract enough for a natural delivery? Health researcher and activist Ravi Duggal is convinced that the increasing number of C-section is mainly due to commercial gains that doctors aim at.”Although there are certain families that insist on having children on an auspicious time and during vacations and insist on C-section ,there is no denying that doctors who are commercial minded leading to an increase in C-sections”.

The medical fraternity refuses; however, to take the blame. Dr. Allahabadia insists that patients with low threshold for pain want the C-section. Dr. Points that C-sections are real life savers.

Cultural particularities are at play, too the sharp rise in demand for C-section in Brazil is tied to the belief that vaginal delivery could compromise sexual; enjoyment among both women and their partners. Study further reveals that women believed they would receive higher quality care if they delivered by C-section, a perception held by women and health providers alike in many countries, including Egypt and India (20).

Until a decade back, it was believed that in every three children born in the US was delivered by C-section, but health activists now believe the number of women giving birth by C-section is up 50 % (20).

A survey conducted by WHO warned that a shift towards modernization resulted in increase in C-section birth .This is not necessarily good thing .The UN health agency warned that the woom in unnecessary surgeries is jeopardizing women health(20) (Lancet).The report revealed that unwanted C-section are costlier than the natural birth and raise the risk of complications for the mothers(20) .Hence the efforts must be made to bring awareness in the community because natural birth is the ideal one .Any C-section is to be performed in the interest of the mother and child –and that too after a careful evaluation.

From above findings and discussions the authors reached to the conclusion that the factors like parity, type of breech, gestational age, pelvic size, and architure need to be carefully considered while dealing with breech presentation to decide on the mode of presentation.

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Received on 10.08.2009

Modified on 29.06.2011

Accepted on 01.08.2011

Research J. Pharmacology and Pharmacodynamics. 4(2): March - April, 2012, 94-97