Breech Presentation at a District Level Hospital

Introduction:The term Breech Trial has led to obstetricians opting for caesarean section as the mode of delivery for this presentation; even in poor countries. The concerns of this approach are the resultant increase in caesarean section rates and their associated complications; particularly in under-resourced countries; which are faced with financial and human resource expertise constraints. Method: This was a retrospective chart review of women who presented at term with a singleton breech presentation at the antenatal and in labour; from January 2005 - December 2007. Results:There was a total of 19;197 deliveries; of which 466 were singleton term breech deliveries; giving a rate of 2.4. Of the 297 women who had antenatal care and had been allocated to planned caesarean section; 271 had the planned operation. There were no neonatal deaths in the planned caesarean section group. The emergency caesarean section group and the group in which no decision was made on the mode of delivery; were associated with a higher maternal complication rate than those who had planned caesarean sections. The highest neonatal complication rate was in those who had unplanned vaginal delivery. Conclusion: In a district hospital in South Africa; the mode of delivery is usually a planned caesarean section. Unplanned vaginal deliveries are associated with significant perinatal mortality

The effect of restructuring of health care services on caesarean section rates

Objective: To examine the anticipated changes in caesarean section (CS) rates following the restructuring of maternity health care services from regional to district level. Hypothesis: A change in provision of maternity services from regional to district level results in a decrease in CS rates. Method: A retrospective audit was undertaken of CS rates 3 months before (1 April-30 June 2001) and 3 months after (1 August-31 October 2001) the 'down-scaling' of obstetric services from regional to district level at Addington Hospital; Durban; South Africa. In addition; the booking status of patients; indication for CS; appropriateness of CS decision; and perinatal outcome were evaluated. Results: The total number of deliveries before and after the restructuring of health care services decreased 2070 to 1409. Despite this 32 reduction in the total number of deliveries; the CS rate was essentially unchanged following the restructuring of the obstetric service (24.6 vs. 22.9). The proportion of CS for complicated high-risk cases decreased from 9.62 to 4. The perinatal mortality rate decreased from 84.5/1000 to 59.4/1000 deliveries. An inappropriate decision for CS was made in one-third of the cases. Conclusion: The restructuring of the health service and decrease in the number of high-risk patients seen should have resulted in a decrease in CS rate. Lack of change in the latter may suggest possible influence of the skill of health care providers